HomeMy WebLinkAboutMINUTES - 10072014 - D.7RECOMMENDATION(S):
CONSIDER the possible development of a program by the County’s Health Services Department that implements
involuntary assisted outpatient treatment (AOT) services in Contra Costa County, as recommended by the Family and
Human Services Committee.
FISCAL IMPACT:
Potential costs of $0-8 million, to be determined based on if, and how, the Board of Supervisors would choose to
implement such a program. A financial analysis is located on pages 140-143 of the attached AOT/Laura’s Law work
group report.
BACKGROUND:
At its June 3, 2013 meeting, the Legislation Committee received information from staff and the public about “Laura’s
Law” and related bills.
The Assisted Outpatient Treatment Demonstration Project Act (AB 1421), known as Laura’s Law, authored by
Assembly Member Helen Thomson, was signed into California law in 2002 and is authorized until January 1, 2017.
Laura’s Law is named after a 19 year old woman working at a Nevada County mental health clinic. She was one of
three individuals who died after a shooting by a psychotic individual who had not engaged in treatment.
Like many counties across California, Contra Costa County is grappling with the challenge of how to best serve
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 10/07/2014 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I Supervisor
Candace Andersen, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Karen Mitchoff, District IV
Supervisor
Federal D. Glover, District V
Supervisor
Contact: Cynthia Belon (925)
957-5201
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the
Board of Supervisors on the date shown.
ATTESTED: October 7, 2014
, County Administrator and Clerk of the Board of Supervisors
By: June McHuen, Deputy
cc: Health Services Director, Behavioral Health Director, CAO
D.7
To:Board of Supervisors
From:William Walker, M.D., Health Services Director
Date:October 7, 2014
Contra
Costa
County
Subject:OPTIONS FOR PROGRAM RELATED TO INVOLUNTARY ASSISTED OUTPATIENT TREATMENT /
LAURA’S LAW
BACKGROUND: (CONT'D)
residents living with severe mental illness who are not currently engaging in treatment and/or experiencing
repetitive emergency and hospital visits.
AB1421 provides court-ordered intensive outpatient services for individuals with severe mental illness who
refuse voluntary treatment yet are also at risk for self-harm or grave disability. AB1421 outlines the target
population, eligibility criteria, service goals and requirements, per Welfare and Institutions Code (WIC) section
5346. These programs, known as Assisted Outpatient Treatment (AOT), attempt to address a gap in the
continuum of treatment for these individuals.
The Contra Costa County Board of Supervisors first considered the AB1421 legislation during its July 9, 2013
meeting. At this meeting, the Board decided to refer the matter of possible development of an AOT program by
the County’s Behavioral Health Division to the Family and Human Services (F&HS) Committee of the Board of
Supervisors.
Contra Costa Behavioral Health Services and other stakeholders formed a work group to engage the community in
developing strategies around addressing the needs of the target population defined by the AB1421 legislation. The
result of this work group’s efforts are summarized in the March 10, 2014 Family and Human Services Committee
Report. In the report, recommendations were to engage the AB1421 treatment population through Outreach and
Engagement, Education, and to pilot an AOT program.
At the March 10, 2014 meeting of the F&HS Committee, staff were directed to bring to the full Board of
Supervisors a report on how an AOT program could be implemented in Contra Costa County. With the majority
of public speakers requesting a "full 45-person Laura's Law program" rather than the 10-person pilot program
suggested in the staff report, the F&HS Committee further directed staff to meet with all the affected County
Departments to determine the cost of implementing a full AOT program and provide an analysis of the ability of
the County to launch such a program. If the costs were too prohibitive for a full program initially, then staff could
suggest a phased in approach to bring it to a full program, with the idea of initially providing the most robust AOT
program that the County could afford to address the needs of the AB1421 population.
Contra Costa Behavioral Health Services staff invited the former work group members, as well as consumers of
mental health services and representatives from the affected departments, to form the AOT work group. The AOT
work group was formed with participation from stakeholders in alignment with the AB1421 legislation to make
the final recommendations to the Board of Supervisors on the engagement of the AB1421 target population in
mental health treatment that includes but is not limited to AOT, as depicted on page 7 of the attached report, in
Contra Costa County.
The attached report documents the AOT work group's decision process, as well as their final recommendations of
programs and services to be considered by the Contra Costa County Board of Supervisors.
CONSEQUENCE OF NEGATIVE ACTION:
No action by the Board on this matter would maintain the status quo.
CLERK'S ADDENDUM
Speakers: Don Edward Green, resident of Lafayette; Nancy Seibert, NAMI; Lauren Rettag, resident of
Danville; Nancy Mazzanti, resident of Danville; Tess Paoli, resident of Concord; Connie Steers, resident of
Concord; Randall Haear, California Psychiatric Association; Mark Stryker, resident of Moraga; Gloria
Dulick, resident of Discovery Bay; David Kahler, resident of Concord; Anthony Khalil, resident of Brentwood;
Janice Khalil, resident of Brentwood; Fran Martin, resident of Concord; Charles Madison, resident of Walnut
Creek; Karen Cohen, resident of Walnut Creek; Sharon Madison, resident of Walnut Creek; Peter Tobias,
resident of Pleasanton; Susan Gendron, resident of Walnut Creek; Monica White, resident of Orinda; Kris
Widmer, resident of Antioch; Linda Dunn, NAMI; Douglas Dunn, NAMI; Teresa Pasquini, resident of El
Sobrante; Candy DeWitt, resident of Alameda; Alejandro Levin, resident of Walnut Creek; Liliana Maculus
Levin, resident of Walnut Creek; Nestor Vaschetto, resident of Walnut Creek; Zena Potash, M.D.; Ralph
Hoffman, resident of Walnut Creek; Brenda J. Crawford, resident of Walnut Creek; Mike Conklin, Sentinels of
Freedom; Peter Mantas; Victor E. Zelidon, resident of Pittsburg; Mariana Moore, Human Services Alliance of
Contra Costa; Irene Needoba, resident of Orinda.
DIRECTED staff to return to the Board within 90 days with a proposed model to implement a 37 person
Assisted Outpatient Treatment program, with the following financial information provided: a. The amount of
reserve funds being set aside in MHSA funding, in particular that above the legal requirement; b. The start up
costs for implementation of the program, initial funding; c. Data on what the costs of the 37 offenders are to
the County for the last five years (i.e. incarceration, medical services); d. How many of the 37 persons are
receiving SSI or SSDI; e. A proposed budget for 2015/16 FY implementation of the program, to include: the
housing element, thorough identification of court costs from Public Defender, information from the state on
what is reimbursable to the court system, and County Counsel costs; f. Information from other counties
regarding what their actual cost savings are by implementing a program g. The impacts of implementing the
program on next years County budget; h. A process identified of how the costs will be tracked; i. Any known or
possible/probable grant funds that might be applied for.
ATTACHMENTS
AOT Work Group Report 2014
AOT Work Group Recommendations 2014
Mental Health Commission Comments
Public Comment_Lori Hefner
Public Comment_CA Assoc of Psyc. Techs
Contra Costa County Health Services:
Report on the AOT Workgroup
Recommendations
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Table of Contents
Introduction .................................................................................................................................................. 5
Summary of the AOT Workgroup ................................................................................................................. 8
AOT Workgroup Overview ........................................................................................................................ 8
AOT Workgroup Participants .................................................................................................................... 8
Approach to Meeting Facilitation ........................................................................................................... 10
Pre-Meeting Interviews with AOT Workgroup Participants ................................................................... 10
Summary of AOT Workgroup Meetings .................................................................................................. 11
Meeting 1: June 10, 2014 .................................................................................................................... 11
Meeting 2: June 17, 2014 .................................................................................................................... 12
Meeting 3: June 24, 2014 .................................................................................................................... 14
Meeting 4: July 8, 2014 ...................................................................................................................... 17
Meeting 5: July 15, 2014 ..................................................................................................................... 19
Meeting 6: August 28, 2014 ............................................................................................................... 20
Approach to Addressing Assisted Outpatient Treatment (AOT)............................................................. 23
Limitations........................................................................................................................................... 27
AB1421 Target Population .......................................................................................................................... 29
AB1421 Eligibility Criteria ........................................................................................................................ 29
Identifying Contra Costa’s AB1421 Target Population ........................................................................... 30
Recommendations that Directly Serve the Target Population ................................................................... 34
In Home Outreach Team (IHOT) ......................................................................................................... 34
Psychiatric Emergency and Hospital Transitions ................................................................................ 34
Full Service Partnership Expansion ..................................................................................................... 35
Assisted Outpatient Treatment (AOT) ................................................................................................ 36
Other Recommendations ........................................................................................................................ 38
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Assisted Outpatient Treatment .................................................................................................................. 39
Current and Planned AOT Programs in California................................................................................... 39
Implementation Considerations for Contra Costa County ..................................................................... 39
Program Considerations ..................................................................................................................... 39
Funding Considerations ...................................................................................................................... 42
Conclusion ................................................................................................................................................... 45
Next Steps ............................................................................................................................................... 46
Appendices .................................................................................................................................................. 47
Appendix A: California Welfare and Institutions Code Section 5345-5349.5 (“Laura’s Law”) ............... 48
Appendix B: Meeting 1 Materials ........................................................................................................... 60
Appendix C: Meeting 2 Materials ........................................................................................................... 77
Appendix D: Meeting 3 Materials ......................................................................................................... 117
Appendix E: Meeting 4 Materials .......................................................................................................... 129
Appendix F: Meeting 5 Materials .......................................................................................................... 137
Appendix G: In-Home Outreach Team (IHOT) Budget Detail ............................................................... 141
Appendix H: Psychiatric Emergency Hospital Transitions Budget Detail .............................................. 142
Appendix I: Court Costs Associated with AOT ...................................................................................... 143
Appendix J: Budget Summary of all Programs and Services ................................................................. 144
List of Tables
Table 1: AOT Workgroup Participants .......................................................................................................... 9
Table 2: Estimated AOT Cost Impacts ......................................................................................................... 27
Table 3: Number of adults with 2 hospitalizations in 36 months ............................................................... 31
Table 4: Number of adults with 2 hospitalizations in 12 months ............................................................... 32
Table 5: Amendments to Consider in Adopting AB1421 ............................................................................ 40
Table 6. AOT Allowable Funding Sources .................................................................................................... 42
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Introduction
Contra Costa Behavioral Health Services (CCBHS) is the safety net provider for thousands of residents
living with mental illness. Its stated mission is to care for and improve the health of all people in Contra
Costa County with special attention to those who are most vulnerable to health problems . Like many
counties across California, Contra Costa County is grappling with the challenge of how to best serve
residents living with severe mental illness who are not currently engaging in treatment and/or
experiencing repetitive emergency and hospital visits.
In 2002, the California State Assembly passed the Assisted Outpatient Treatment Demonstration Project
Act (AB1421). AB1421, also known as “Laura’s Law,” was developed in response to the 2001 Nevada
County shooting of a mental health worker by a man who was not receiving treatment.
AB1421 provides court-ordered intensive outpatient services for individuals with severe mental illness
who refuse voluntary treatment yet are also at risk for self-harm or grave disability. AB1421 outlines the
target population and eligibility criteria per Welfare and Institutions Code (WIC) Section 5346, and the
service goals and requirements of AB1421 programs (see Appendix A). These programs, known as
Assisted Outpatient Treatment (AOT), attempt to address a gap in the continuum of treatment for these
individuals.
The Contra Costa County Board of Supervisors first considered the AB1421 legislation during its July 9,
2013 meeting. At this meeting, the Board decided to:
Refer to the Family and Human Services Committee of the Board of Supervisors the
matter of considering the possible development of a program by the County’s Behavioral
Health Division that implements involuntary assisted outpatient treatment services,
similar to AB1421, also known as Laura’s Law, in Contra Costa County, as recommended
by the Legislation Committee.
CCBHS and other stakeholders formed a workgroup to engage the community in developing strategies
around addressing the needs of the target population defined by the AB1421 legislation. The result of
this workgroup’s efforts are summarized in the March 10, 2014 Family and Human Services (F&HS)
Committee Report. In the report, recommendations to engage the AB1421 treatment population
included Outreach and Engagement, Education and Coordination with the Consumer’s Support Network,
and to pilot an AOT program.
At the March 10, 2014 meeting of the F&HS Committee staff was directed to bring to the full Board of
Supervisors in June a report of how an AOT program could be implemented in Contra Costa County.
With the majority of public speakers requesting a "full 45 person Laura's Law program" rather than the
10-person pilot program suggested in the staff report, the F&HS Committee further directed staff to
meet with all the affected County Departments to determine the cost of implementing a full AOT
program and provide an analysis of the ability of the County to launch such a program. If the costs were
too prohibitive for a full program initially, then staff could suggest a phased in approach to bring it to a
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full program, with the idea of initially providing the most robust AOT program that the County could
afford to address the needs of the AB1421 population.
CCBHS staff invited the former workgroup members as well as mental health consumers and
representatives from the affected departments to form the AOT workgroup. The AOT workgroup was
formed with participation from stakeholders in alignment with the AB1421 legislation to make the final
recommendations to the Board of Supervisors on the engagement of the AB1421 target population in
mental health treatment that includes but is not limited to AOT, as depicted on the next page, in Contra
Costa County.
The report documents the AOT workgroup's decision process, as well as their final recommendations of
programs and services to be considered by the Contra Costa County Board of Supervisors
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1
1 Courtesy of Jo Robinson, Director of Community Behavioral Health Services, City and County of San Francisco.
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Summary of the AOT Workgroup
AOT Workgroup Overview
CCBHS sought to create an AOT workgroup
aligned with the AB1421 legislation in which AOT
workgroup members would collaborate across
departments and agencies to address questions
about the Adult System of Care and the challenge
of how to engage the AB1421 identified target
population. The department retained Resource
Development Associates (RDA) to facilitate this
AOT workgroup in addressing these issues and to
allow the group to collectively investigate a range
of program models that includes, but is not
limited to, AOT.
RDA worked with CCBHS staff to convene
stakeholders, prepare for and facilitate a series of
planning meetings, and synthesize the resulting
materials into a report to be presented to the
Board of Supervisors. Each successive meeting
built on the work previously done and resulted in
the development of programs and services that
address the engagement of people with serious
mental illness experiencing frequent crisis events
and who are not engaging in voluntary mental
health services. Figure 1 summarizes the purpose
of each meeting that was conducted with the AOT
workgroup:
AOT Workgroup Participants
AB1421 requires that local mental health departments enact a service planning and delivery process
involving groups who would provide, receive, or be affected by AB1421 programs. In regards to those
who are required to participate in the process, AB1421 states:
The local director of mental health shall consult with the sheriff, the police chief, the
probation officer, the mental health board, contract agencies, and family, client, ethnic,
and citizen constituency groups as determined by the director.
Meeting 6
Verify Report to the Board of Supervisors
Meeting 5
Identify programs and
services to address needs of
target population
Decision to add
Meeting 6
Meeting 4
Continuation of AOT discussion
Meeting 3
Discussion of AB1421
legislation AOT discussion
Meeting 2
Identify the Target Population
Meeting 1
AOT Workgroup Kickoff
Figure 1: AOT Workgroup Overview
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In Contra Costa County, stakeholders in the AOT workgroup included members of the Contra Costa
County Behavioral Health staff, other County staff, the Mental Health Commission, the courts, County
Counsel, contracted providers, consumers, and family members of consumers. CCBHS identified and
selected participants from a range of groups, perspectives, and geographies, as well as CCBHS and
community providers and those who are peripherally engaged in the mental health system, including
the courts, county counsel, and public defender, to participate in the AOT Workgroup. Below is a list of
those who participated in the workgroup and their affiliation:
Table 1: AOT Workgroup Participants
AB1421 Defined Group
Affiliation Position and Agency AOT Workgroup Participant
Contra Costa County
Behavioral Health Services
Staff:
Director of Behavioral Health
Services Cynthia Belon, LCSW
Adult/Older Adult Program Chief,
Behavioral Health Services Victor Montoya
Medical Director, Behavioral Health
Services Ross Andelman, MD
Transition Team Manager,
Behavioral Health Services Michaela Mougenkoff, MFT
Forensic Mental Health Program
Manager David Siedner, LMFT
Psychiatric Emergency Services,
Behavioral Health Services Julie Kelley, MSW, MPH
Other County Staff:
Conservator’s Office Suzanne Davis, MFT
Chief Public Defender Robin Lipetzky
Assistant County Counsel Steven Rettig
Emergency Medical Services
Director Joe Barger, MD
County Sheriff: Captain, Office of the Sheriff Jeff Nelson
Mental Health
Commission: Mental Health Commission Lauren Rettagliata
Superior Court, State of
California:
Director of Court Programs and
Services Magda Lopez
Contracted Providers:
Program Director, Fred Finch TAY
Services Fanshen Thompson, LCSW
Director of Clinical Services,
Rubicon Programs Inc. Anne Cevallos, MSW, ASW
Consumers:
Program Coordinator, Office of
Consumer Empowerment Susan Medlin
Ashley Baughman
Tess Paoli
Connie Steers
Family Members of
Consumers:
Douglas Dunn
Sharon Madison
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Approach to Meeting Facilitation
In order to carry-out this workgroup, the facilitation team developed clear goals and objectives for each
meeting, based on the achievements and questions from prior meetings, and utilized activities to
promote engagement and to move the group towards a set of recommendations. The RDA team
facilitated meetings and AOT workgroup sessions, prepared materials and background information for
committee participants, and managed communication with CCBHS leadership and workgroup
participants between meetings. The foundation to this approach was informed by the main question of:
What is the appropriate mix of programs and services, including but not limited to AOT,
that will address the needs of the target population defined by AB1421 in Contra Costa
County?
Pre-Meeting Interviews with AOT Workgroup Participants
Prior to the first planning meeting, the facilitation team conducted an interview with each member of
the AOT workgroup, with the exception of the Behavioral Health Director, Cynthia Belon, LCSW, and the
Adult/Older Adult Chief, Victor Montoya, who were not interviewed. The team used a consistent set of
questions in order to yield information about the participants’ experience with and in the mental health
system and the AB1421 target population, their expectations and any concerns regarding the
workgroup, and their perspectives on AOT and other program models the AOT workgroup might
consider. The following summary provides key findings from the pre-meeting interviews:
AOT workgroup participants all had differing levels of understanding about the AB1421
legislation and its implications. AOT workgroup participants had different levels of knowledge
and understanding about the AB1421 legislation and its implications, regardless of their
stakeholder affiliation. In addition, there was a lack of understanding about the target
population and service requirements defined in AB1421.
AOT workgroup participants agreed that there is a problem with engaging the individuals
defined in the AB1421 legislation. When provided the definition of the target population as
stated in the AB1421 legislation, AOT workgroup participants all felt that there was a problem in
how the mental health system engages those individuals in mental health treatment. Specific
concerns expressed included the lack of awareness of mental illness and the difficulty in
engaging those that don’t recognize the need for services, the stigma of seeking services, and
that it can be difficult to access services, especially during periods of significant symptoms.
Many workgroup participants felt that AOT may be the best option presently available to
engage the target population in treatment. During this point in the process, AOT workgroup
participants expressed that AB1421 and AOT may not be ideal but provided a viable option for
how to reach out and engage the target population in treatment.
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Some workgroup participants expressed concern that people with mental illness are ending
up in jails or psychiatric emergency services at increasing rates. Some workgroup participants
expressed the belief that AOT could help get people into services and out of jails and hospitals,
while simultaneously decreasing costs.
Summary of AOT Workgroup Meetings
Meeting 1: June 10, 2014
The AOT workgroup held its first meeting on Tuesday June 10, 2014. At this meeting, RDA helped to
facilitate introductions of AOT workgroup members and inform them about the AOT workgroup. The
second-half of Meeting 1 included an overview of the AB1421 legislation, AOT in both the state and
national contexts, evidence-based and promising service delivery models with demonstrated efficacy, as
well as a review of the CCBHS programs and services systems map for adult consumers.
Meeting 1 Objectives:
Introduce AOT workgroup members to each other and to the AOT workgroup.
Establish a set of ground rules and working norms for the AOT workgroup.
Develop a baseline understanding about the AB1421 legislation, including the target population,
service requirements, and service goals as stated in the legislation.
Provide literature of the evidence-based practices with documented efficacy relevant to the
AB1421 identified target population.
Meeting 1 Rationale:
The purpose of Meeting 1 was to help establish a baseline understanding for all AOT workgroup
participants about the AB421 legislation and evidence-based practices with documented efficacy
relevant to the AB1421 identified target population that would allow the group to move forward into
subsequent work sessions. Specific regard was also taken in this meeting to build rapport among AOT
workgroup participants to allow them to work more comfortably together in the context of addressing
such a complex and emotional topic.
Meeting 1 Accomplishments:
After AOT workgroup members introduced themselves, the facilitators asked the group to reflect on
what participants had in common and what participants were hopeful to contribute to the workgroup.
Participants noted that each participant was committed to growing a mental health system that is more
respectful and suitable for consumers and their family members to receive services in the community.
However, participants also discussed that the current mental health system may not entirely understand
the needs of all consumers and how to address the needs of those eligible for AOT under AB1421. All
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participants spoke to the commitment of AOT workgroup participants, whether personal or
professional, to caring for mental health consumers and wanting to be thoughtful in their approach to
this issue.
The second half of the meeting resulted in specific questions and follow up items requested by AOT
workgroup participants. After reviewing the AB1421 legislation in a power point presentation given by
the lead facilitator, Dr. Roberta Chambers, AOT workgroup participants requested the full legislation of
AB1421 for their review. In addition, AOT workgroup participants requested county-specific data on the
target population defined by the AB1421 legislation, as well as expressed a desire to further explore
other evidence-based and promising service delivery models with demonstrated efficacy for how to
address the needs of the AB1421 identified target population.
Meeting 1 materials are included in Appendix B on page 58.
Meeting 2: June 17, 2014
In Meeting 2 on June 17, 2014, AOT workgroup participants began to identify the target population
defined by the AB1421 legislation and applied this to the population of Contra Costa County. The result
of this presentation is included in greater discussion in the section of the report titled “Identifying the
Target Population” on page 28. CCBHS utilization data was presented and workgroup participants
developed additional questions to be answered through a second data request. After reviewing the data
and responding to participant questions about the data, AOT workgroup participants reviewed the Adult
System of Care Map to identify the service strengths and gaps in their current system.
Meeting 2 Objectives:
Review the AB1421 legislation that defines the target population.
Interpret CCBHS data on the population that meets the AB1421 criteria, and identify additional
questions to be answered through a second data request.
Develop a common understanding of the characteristics defining the County’s AB1421 identified
target population.
Identify the strengths and challenges of the current Adult System of Care.
Meeting 2 Rationale:
The purpose of interpreting CCBHS data on the AB1421 identified target population allowed AOT
workgroup participants to:
1. Understand the criteria used to determine eligibility for assisted outpatient treatment in
California.
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2. Identify the number of individuals possibly implicated in the implementation of an AOT program
by applying the AB1421 criteria to CCBHS service utilization data.
3. Provide foundational knowledge to all AOT workgroup participants of what types of current
services and programs that are currently offered by CCBHS so that AOT workgroup participants
can better identify gaps in the adult mental health system that may result in frequent crisis
events and lack of voluntary engagement.
Meeting 2 Accomplishments:
AOT workgroup participants interpreted CCBHS data on utilizers of emergency medical and psychiatric
emergency services (EMS and PES, respectively) over the previous 36 and 12 months. Through their
discussion of the data, AOT workgroup participants developed several more questions that required
further investigation by CCBHS and RDA. Some of their questions include:
What are the number of individuals included in the target population who have been placed in
involuntary settings under the Lanterman-Petris-Short Act (LPS)?
What proportion of PES visits and hospitalizations were voluntary and involuntary?
To what extent have these individuals engaged in voluntary services near the time they were
hospitalized?
The data needed to answer the AOT workgroup’s additional questions, specifically about the
proportions of hospitalizations that were voluntary or involuntary and the number of involuntary
placements under the LPS Act, were not available in this time frame.
In the second half of the AOT workgroup meeting, participants appraised the Adult System of Care map
for its strengths and challenges. AOT workgroup participants identified the following strengths in Contra
Costa County’s Adult System of Care. Please note that this list is taken directly from the meeting notes.
Creation of a new transition team to help mental health clients move between different levels of
care more seamlessly.
Broad collaboration with a variety of community-based organizations (CBOs) to provide mental
health services, respite, shelter, other health services, and peer and family member supports.
Increasing use of evidence-based practices for mental health intervention including a prodromal
model for youth, Full Service Partnership (FSP), and trauma-informed systems of care.
Included in the AOT workgroup’s discussion was the identification of some of the challenges facing the
Adult System of Care. The challenges listed below were taken directly from the meeting notes.
Lack of dedicated outreach and engagement to mental health consumers other than homeless
outreach teams.
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Lack of housing in the county (a major limiting factor to increasing participation in FSP as a
required component to that level of service).
Shortage of FSP services and slots across the county.
Lack of peer supports across the entire continuum of mental health services, and specifically in
PES and hospital settings.
Overall, AOT workgroup participants felt that the Adult System of Care was comprehensive and meeting
the needs of the majority of consumers in Contra Costa County. The AOT workgroup acknowledged the
need to identify interventions specifically for the AB 1421 target population.
Meeting 2 materials are included in Appendix C on page 76.
Meeting 3: June 24, 2014
The focus of Meeting 3 was to engage in a deeper discussion on Assisted Outpatient Treatment (AOT) as
defined by the AB1421 legislation and to facilitate a conversation between AOT workgroup participants
on the strengths of challenges of implementing such a program. In Meeting 3 on June 24, 2014, AOT
workgroup participants were debriefed on the Community Living Room Conversation and Community
Forums held regarding AOT and explored the implications of AOT in Contra Costa County. Materials
from the Community Living Room Conversations are included in Appendix D.
Meeting 3 Objectives:
Debrief AOT workgroup on Community Forums and Community Living Room Conversations
about AOT.
Discuss implications of AOT in Contra Costa County.
Meeting 3 Rationale:
The purpose of Meeting 3 was to ensure that AOT workgroup participants were fully informed of
previous and concurrent efforts to engage the Contra Costa community in conversation on AB1421 and
AOT. In addition, this workgroup set out to thoroughly address the considerations for implementing an
AOT program prior to the consideration of other programs and services.
Meeting 3 Accomplishments:
After debriefing the Community Living Room Conversations, the AOT workgroup participated in a
facilitated discussion about the perceived benefits and challenges of implementing AOT in Contra Costa
County. Below is a summary of the AOT workgroup’s findings on the benefits and challenges that were
taken directly from the meeting notes:
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Perceived Benefits of AOT:
Expanded and continuous outreach and engagement for a hard to reach2 target population.
Access to a treatment team and coordinated treatment plan upon entry into the program.
Peers and family members are embedded in different types of team s, i.e. outreach and
engagement.
Judicial review as part of civil commitment have added protections for consumers.
Multiple opportunities for consumers to choose voluntary services prior to entering into the
legal system.
Reduction in the need for conservatorship.
Potential cost savings to law enforcement, emergency medical, and psychiatric emergency
services.
Perceived Challenges of AOT:
Lack of information regarding the cost savings and cost avoidance associated with implementing
AOT.
Potential lack of access for those with private health insurance or coverage.
Limited availability of resources, especially housing, to achieve all of the program objectives
outlined by the AB1421 legislation.
Potential civil rights implications by mandating treatment through a court order.
Preexisting housing resources are limited for Contra Costa County consumers.
Identifying the right type of judge and program manager to carry-out AOT as defined by CCBHS
and stakeholders.
In the second half of Meeting 3, AOT workgroup participants were asked what other range of programs
and services they should consider in Meeting 4 that would meet the needs of the target population in
addition to AOT. RDA facilitated a brainstorming session to gather all of the AOT workgroup’s input to
develop a comprehensive list of programs, services, and suggestions to improve the Adult System of
Care.
2 Hard to reach in this context refers to people who have difficulty accessing mental health services or are less
likely to receive them in traditional settings.
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The following is a list of all of the AOT workgroup’s ideas to consider moving forward presented in no
particular order:
1. Outreach and Engagement
a. Access Line Triage Program to deploy outreach team, as needed, based on Access Line
calls.
b. In Home Outreach Team to provide in-home outreach services to consumers and their
families.
c. Outreach Team- unspecified.
2. PES and Hospital Transitions
a. PES/Hospital Discharge Follow-up Outreach to connect with consumers upon PES or
hospital discharge to help them connect to non-emergency behavioral health services.
b. Peer Mentor Hospital Release Program to provide peer mentors inside the hospital to
support discharge planning.
3. Full Service Partnership
a. Expand capacity.
b. Increase available housing.
c. Provide additional resources to existing FSP teams.
d. Provide more intensive follow-up to current FSPs who are hospitalized.
e. Change the FSP referral process so that there is a coordinated and centralized process to
ensure that those with the greatest need receive FSP services.
4. Assisted Outpatient Treatment
a. Include outreach and education services to potential AOT recipients.
5. Mobile Crisis Services to provide clinical staff along with law enforcement.
6. Expanded Patient Advocate Program to work with consumers and family members to support
consumer rights, including access to treatment.
7. CCBHS Systems Navigators to support individuals and their families to access behavioral health
services and move between services and levels of care.
Other Suggestions:
1. Expand and broaden continuum of housing options
2. More residential AOD treatment
3. Provide more trauma groups
4. Increase shelter beds
5. Family to family groups
6. Supported employment, vocational, and volunteer programs
7. WRAP groups
8. Benefits case management
9. Recreation therapists
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Systems-level considerations to support the target population:
1. Review accounting systems to support cross-allocation of costs across multiple funding streams.
2. Reduce barriers to accessing services and increase the ease of entering and receiving services.
3. Increase consumer and family involvement throughout the process and system, including both
increased consumer and family involvement in services being received as well as increased
numbers of consumer and family staff positions.
4. Improve integration and collaboration between systems.
Meeting 3 materials are included in Appendix D on page 119.
Meeting 4: July 8, 2014
On July 8, 2014, AOT workgroup participants gathered for their fourth meeting. Meeting 4 was intended
to address levels of support by the AOT workgroup for the other programs and services that would meet
the needs of the target population. However, the AOT workgroup had remaining questions and items for
discussion related to AOT. In continuing the efforts to thoroughly address the implications of AOT, the
facilitation team continued the AOT workgroup’s discussion and included additional information about
the allowable and unallowable funding sources for implementing AOT as well as types of costs
associated with implementing AOT and areas of potential savings. After continuing their discussion of
AOT and the allowable and unallowable funding sources, AOT workgroup participants were asked to
rate their level of support in recommending an AOT program to the Board of Supervisors.
Meeting 4 Objectives:
Continue discussion on the implications of implementing an AOT program in Contra Costa
County.
Receive presentation on the allowable and unallowable funding sources for implementing AOT
as well as types of costs associated with implementing AOT and areas of potential savings.
Develop recommended programs and services, including but not limited to AOT, to be included
in the report to the Board of Supervisors.
Meeting 4 Rationale:
In continuing the discussion of AOT and the implications for implementation as well as AOT funding, AOT
workgroup participants were able to use data-driven decision making to inform their level of support in
recommending an AOT program for the Board of Supervisors’ approval.
Meeting 4 Accomplishments:
Although Meeting 4 was intended to develop consensus among AOT workgroup participants around the
other programs and services (including but not limited to AOT), the AOT workgroup decided it needed
additional time to discuss their agreements and disagreements on AOT specifically. The AOT workgroup
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showed their level of support through a series of discussions and voting exercises after an in-depth
discussion of AOT program and after receiving information on AOT funding as AOT is defined by AB1421.
Below is a summary of the workgroup’s agreements and disagreements on AOT by levels of support at
the end of the meeting:
Neutral/Uncertain/Had Questions:
Many of the AOT workgroup participants who were unsure of their support or felt neutral about
supporting AOT had many questions about the logistics of implementing a program aligned with the
AB1421 legislation. The following concerns of AOT workgroup participants were taken directly from the
meeting notes:
Costs of implementing AOT.
Having the resources to adequately meet demand.
Questions about the potential to reach the target population by increasing the level of voluntary
services before resorting to AOT.
Supports AOT:
AOT workgroup participants who supported the implementation of AOT discussed several different
aspects that show promise to meet the needs of the target population. For those members in support of
AOT, their perspectives directly from the meeting notes are included below:
Recognition that AOT outlined by AB1421 is not a perfect program but is the most viable option
available to meet the needs of the target population.
Implementation reports from Nevada County and New York (Kendra’s Law) show promise to
reduce health care costs for the target population.
Consumers considered for AOT have several opportunities to accept voluntary treatment before
being court ordered.
Not in Support of AOT:
AOT workgroup participants who were not in support of AOT had similar concerns to those participants
who were still uncertain or neutral in their position. In addition to having more questions about AOT’s
implementation, AOT workgroup participants who were not in support of AOT added the following
taken directly from the meeting notes:
Trauma from past experience with the mental health system may get in the way of consumers
engaging in treatment voluntarily. Requiring consumers through a court order to engage in
treatment risks enhancing that individual’s trauma with the treatment system.
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Additional voluntary programs are needed to enhance the continuum of crisis services prior to
implementing AOT.
High level of concern about the civil rights implications of the individual’s choice to engage in
treatment for their mental illness.
Before moving forward in the next meeting to conduct a final assessment of the AOT workgroup’s
support for recommending AOT, AOT workgroup participants requested additional follow-up by RDA to
the Mental Health Services Oversight and Accountability Commission (MHSOAC) and to the other larger
counties considering or moving forward with implementing AOT.
Meeting 4 materials are included in Appendix E on page 129.
Meeting 5: July 15, 2014
Following the continued discussion of AOT in Meeting 4, the AOT workgroup met on July 15, 2014 in
Meeting 5 to discuss programs and services to be considered for recommendation to the Board of
Supervisors, including but not limited to AOT. AOT workgroup participants also agreed on the need for
an additional meeting to verify the final report that will be submitted to the Board of Supervisors.
Meeting 5 Objectives:
Agree on timeline for reporting.
Assess levels of support for recommended programs and services to meet the needs of the
target population identified by AB1421 in Contra Costa County.
Agree on the recommended programs and services for the Board of Supervisor’s consideration.
Meeting 5 Rationale:
In Meeting 5, RDA assessed the AOT workgroup participants’ levels of support for programs and services
including but not limited to AOT as an essential step for preparing this report on their recommendations
to the Board of Supervisors. We also wanted to ensure that participants understood what the next steps
were before finalizing the report on their recommendations to address the needs of the AB1421
identified target population.
Meeting 5 Accomplishments:
AOT workgroup participants discussed programs and services that were being considered for
recommendation. The AOT workgroup considered the following programs and services:
Outreach and Engagement – In-Home Outreach Team (IHOT) model
Psychiatric Emergency Services and Hospital Transitions – Peer Mentor Hospital Release and
Follow-up Program
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Enhance the resources to expand availability of Full Service Partnerships (FSPs)
Expanded Patient Advocacy Program
Mobile Crisis Services
Systems navigators
Following a discussion of other programs and services, AOT workgroup participants were asked to show
their level of support of each of the programs and services, including AOT, to be forwarded as a
recommendation to the Board of Supervisors. The voluntary programs to serve the target population
received broad group support. However, there was less consensus about whether or not AOT would be
useful instead of or in addition to these other voluntary programs and services. Although AOT did not
receive the same level of consensus as the other programs and services, the majority of county
employees either deferred their vote or stated they were still neutral. There were additional concerns
about focusing that level of resources on a smaller sub-population of people with mental illness.
However, all of the county employees agreed that they would support the direction of the Board of
Supervisors.
With one exception, the participants representing consumers and family members of consumers
supported the recommendation of including AOT as described in AB1421 as a program that would
address the needs of the identified target population. AOT workgroup participants decided it was
important to also discuss the parameters to consider if implementation of AOT were to result at some
point in Contra Costa County.
Meeting 5 materials are included in Appendix F on page 137.
Meeting 6: August 28, 2014
Between Meeting 5 and August 22, 2014, RDA worked with CCBHS leadership to develop the draft
report on the AOT workgroup’s recommendations for programs and services to address the needs of the
AB1421 identified target population in Contra Costa County. In Meeting 6 on August 28, 2014, AOT
workgroup participants provided RDA and CCBHS feedback on the report. Dr. Chambers facilitated the
session, noting each AOT workgroup participant’s feedback into the relevant sections of the report.
Once feedback was collected, Dr. Chambers facilitated the AOT workgroup to develop consensus about
what pieces of feedback to include in the final draft of the report for submission to the Board of
Supervisors.
Meeting 6 Objectives:
Collect AOT workgroup feedback on the draft AOT workgroup Process Report.
Review detailed budgets of program and services costs.
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Determine the revisions to be made to the AOT workgroup Process Report prior to submission
to the Board of Supervisors.
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Meeting 6 Rationale:
The purpose of Meeting 6 was to verify the AOT workgroup Report with AOT workgroup members
before their recommendations were finalized and submitted to the Board of Supervisors. The process of
collectively editing the draft report ensured an accurate portrayal of the AOT workgroup meetings and
their recommendations to the Board of Supervisors.
Meeting 6 Accomplishments:
In Meeting 6, AOT workgroup participants provided their feedback on the draft AOT Workgroup Process
Report and developed consensus on the revisions to be made to the final report. In addition, the AOT
workgroup reviewed the detailed budgets of both voluntary and involuntary programs included in this
report. AOT workgroup participants also received information related to the court process and costs
associated with AOT for Contra Costa County. The AOT workgroup discussed the need to establish a
collaborative court model3 for use in a possible AOT program and the number of hours a court would
need to dedicate to AOT while ensuring compliance to AB1421. Although the AOT workgroup agreed on
the need to use a collaborative court model for AOT, it was unsure about the number of hours needed
for the court process associated with the program. The AOT workgroup indicated it may be unlikely that
a full-time/40-hour per week court is needed for AOT. This report reflects the AOT workgroup’s revisions
and additional input as a result of its discussion and as agreed upon in the August 28, 2014 meeting.
3 Collaborative courts-also known as problem-solving courts- combine judicial supervision with rehabilitation services that are
rigorously monitored and focused on recovery to reduce recidivism and improve individual outcomes.
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Approach to Addressing Assisted Outpatient Treatment (AOT)
This workgroup was specifically designed to address the implications of implementing AOT as described
in AB1421 as well as other programs and services that would address the needs of the identified target
population as defined in the legislation. RDA integrated both research and reflection on AOT at multiple
points throughout this AOT workgroup. Discussion of AOT within the AOT workgroup was iterative and
required different forms of follow up and guidance from multiple sources to help fully inform workgroup
participants about the implications in implementing AOT as described in AB1421. RDA approached the
discussion and consensus building around recommending AOT in the following ways:
Pre-Meeting Interview with AOT Workgroup Participants:
In order to assess the knowledge and understanding of AOT workgroup participants prior to beginning
the workgroup meetings, RDA conducted interviews with each of the participants, with the exception of
the Behavioral Health Director, Cynthia Belon, LCSW, and the Adult/Older Adult Chief, Victor Montoya,
who were not interviewed. We included the following questions:
This AOT workgroup is intended to address the needs of consumers who are currently
experiencing a disproportionately high level of crisis interventions, 5150s and hospitalizations,
but are not engaged in treatment in between these interventions. Can you describe your level of
familiarity with this population? What are the challenges in serving this population?
AB1421 involves a collaboration between behavioral health services and the judicial system
(courts, county counsel, public defender). How would you rate your familiarity with these
systems on a scale of 1-5?
If you could make one change to the current system to address this needs of this population
(consumers who are currently experiencing a disproportionately high level of crisis intervention
due to 5150s and hospitalizations, but are not engaged in treatment in between these
interventions), what would it be?
What does assisted outpatient treatment (AOT) mean to you?
a. What about AOT might benefit this population?
b. Are there aspects of AOT that concern you?
The results of the interviews allowed the facilitation team to address the various levels of understanding
about the AB1421 legislation within the AOT workgroup, as well as to understand the range of positions
participants may have had upon entering the AOT workgroup.
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Meeting 1:
In a presentation titled Building the Foundation, Dr. Roberta Chambers of RDA led the AOT workgroup
into a discussion of the AB1421 legislation. In the presentation, Dr. Chambers provided the AB1421
guidelines on the following:
AB1421 Eligibility Criteria, Welfare and Institutions Code 5346
AB1421 Service Goals, Welfare and Institutions Code 5348
AB1421 Service Requirements, Welfare and Institutions Code 5348
After reviewing the AB1421 legislation, RDA helped to contextualize how AOT is being approached
across the nation prior to focusing on the development of AB1421 in California. Dr. Chambers presented
information on the states that have laws authorizing AOT and three bills being considered by the House
of Representatives that would enhance access to resources for the implementation of AOT programs or
supplement programs and services to address the needs of the target population discussed throughout
this process. The three House of Representative bills discussed include:
H.R. 4302: Protecting Access to Medicare Act of 2014 (passed)
H.R. 3717: Helping Families in Mental Health Crisis Act (proposed)
H.R. 4574: Strengthening Mental Health of Our Communities Act of 2014 (proposed)
In order to illustrate the response to AOT in California specifically, Dr. Chambers reviewed California
Counties that had either implemented AOT as defined by AB1421 or were considering the
implementation of AOT. Nevada County and Yolo County were the only two counties in California that
had moved into full implementation of AB1421 at the beginning of workgroup meetings. Orange County
had also moved to pass AB1421 in May of 2014 but is not yet implementing the program. However, over
the duration of Contra Costa County’s AB1421 Workgroup, San Francisco and Los Angeles counties both
approved implementation of AB1421.
The following materials were also provided to each AOT workgroup participant for their review in
between Meeting 1 and Meeting 2:
Laura’s Law (AB1421) Functional Outline: The Laura’s Law Functional Outline was developed by
the Mental Illness Policy Org. to help translate AB1421 into the terms commonly understood at
the level of County Program Managers and other interested stakeholders.
Meeting 2:
In Meeting 2, Dr. Chambers followed up with questions from AOT workgroup participants regarding
funding sources for AOT. The following information was provided to the AOT workgroup:
Service costs for AOT (FSP/ACT)
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o DHCS (formerly DMH) has issued a ruling that MHSA and Medi-Cal funds can pay for
FSP/ACT services, regardless of legal status.
Court/Legal Costs for AOT
o The CA Attorney General has issued a position that MHSA and Realignment funds
cannot pay for court/legal costs associated with AOT.
o Currently, Yolo and Nevada County use General Funds to pay for court and legal costs.
H.R. 4302: Protecting Access to Medicare Act of 2014
o Provides funding for AOT pilot projects through a competitive grant program.
H.R. 3717: Helping Families in Mental Health Crisis Act
o Requires states include AOT in the state Medicaid plan.
Dr. Chambers utilized the next portion of Meeting 2 to present synthesized findings on the research that
has been conducted on the outcomes of AOT programs. The findings presented to the workgroup were
the result of an expansive review of the current literature available on both individual and systems level
outcomes evaluation of AOT programs. For the entire set of findings related to the research on
outcomes of AOT programs, please refer to the presentation for Meeting 2 located in Appendix C.
AB1421 defines the target population for any AOT program that is implemented as a result of the
legislation. RDA used the target population definition described in AB1421 and helped the AOT
workgroup to apply that definition to CCBHS data. This process to define the target population as
described by AB1421 is discussed in greater detail in the “Identifying the Target Population” on page 28
of this report.
To help support the learning of AOT workgroup participants about AB1421, AOT, and other programs
and services that may meet the needs of the target population and are evidence-based with
demonstrated efficacy, the following materials were distributed to AOT workgroup participants in
Meeting 2:
AB1421 Bill Text: The complete AB1421 Bill Text was provided to AOT workgroup participants at
their request from Meeting 1. The AB1421 Bill Text encompasses the requirements for AOT as it
was considered for this AOT workgroup.
AOT – The Nevada County Experience: Nevada County prepared a presentation on their
experiences with implementing AOT. This presentation provided AOT workgroup participants
with additional perspectives to consider on the implications of implementing AOT.
In-Home Outreach Team (IHOT) Program Description: In-Home Outreach Team (IHOT) program
was developed by San Diego as part of their Mental Health Services Act (MHSA) Innovation Plan.
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This program developed targeted outreach to individuals who may encounter additional barriers
to seeking mental health treatment by sending outreach teams into their homes. Individuals’
eligible to refer a consumer for additional outreach and engagement was expanded to include
family members of consumers.
San Diego County IHOT 9-Month Report: This report provides an interim outcomes on the
evaluation of IHOT.
Meeting 3:
At Meeting 3, AOT workgroup participants discussed the implications of implementing AOT in Contra
Costa County. AOT workgroup participants were provided the notes and supplemental materials from
the County’s Community Living Room Conversations that focused on education to the community about
AB1421 and AOT.
Meeting 4:
Dr. Chambers provided additional information about the funding rules and regulations in the
implementation of AOT during Meeting 4. The following summarizes allowable funding sources for
various components to an AOT program as described by AB1421:
Full Service Partnership Services:
Any funding source that currently funds FSP/ACT services, including MHSA. If FSP services were
to be funded by MHSA:
o Funds must be derived from the Community Services and Supports (CSS) component.
o A plan update would be required and include a Community Program Planning (CPP)
process, 30 day public posting, public hearing, and Board of Supervisor approval.
o The costs associated with AOT implementation cannot reduce or eliminate voluntary
programs (i.e. must be monies not currently allocated to existing programs.)
Housing:
MHSA funds for housing associated with FSP participation, MHSA housing, or other non-mental
health housing subsidies.
County Counsel:
General Fund or other non-mental health funding
o MHSA and/or Realignment funds cannot be used for legal costs associated with AOT
implementation.
Public Defender:
General Fund
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o MHSA and/or Realignment funds cannot be used for legal costs associated with AOT
implementation.
Court:
General Fund
o MHSA and/or Realignment funds cannot be used for legal costs associated with AOT
implementation.
Other AOT costs were also included in this portion of the presentation and included in Meeting 4
materials in Appendix E.
Dr. Chambers also introduced information on AOT impacts on costs, including cost savings and
avoidance. However, according to the literature available, it is noted that there may be an increase in
the costs of some services while a potential reduction in others as a result of implementing AOT.
Literature of other AOT programs indicates the following AOT cost increases and potential reductions:
Table 2: Estimated AOT Cost Impacts
Materials provided to AOT workgroup participants in Meeting 4 included:
SB585 Bill Text: SB585 clarifies how funds generated under Proposition 63 of 2004 – the Mental
Health Services Act – can be expanded to provide mental health treatment services under AOT
programs defined by AB1421.
Meeting 5:
In Meeting 5, the AOT workgroup continued its discussion and reflection on the information provided
about AOT as defined by AB1421. Levels of support to recommend AOT to the Board of Supervisors was
assessed at the conclusion of the presentation of the materials discussed in the previous steps.
Limitations
AOT workgroup participants noted the following limitations during this project: 1) Some of the AOT
workgroup members had participated over the past twelve months in an initial workgroup focusing on
AOT. During that time, they had the opportunity to develop an in-depth understanding of AOT. Due to
Estimated AOT Cost Increases Categories of Potential AOT Cost
Reductions
Full Service Partnership Services
Housing
County Counsel
Public Defender
Court
Psychiatric Emergency Services
Psychiatric Hospitalization
Emergency Room
Jail
Law Enforcement
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the short timeline for this AOT workgroup process and the introduction of new workgroup members, as
cited in the AB1421 legislation, workgroup members had varying levels of understanding of AOT and this
timeline did not allow for as in-depth an educational experience. 2) Additionally, identifying the target
population as defined by AB1421 is complex because the criteria set forth in the legislation is both
historical and predictive and represents querying CCBHS utilization data that is atypical for what has
been required in program planning in the past. Despite CCBHS’ dedication of resources to query the
data, not all of the data requested was available in this timeframe.
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AB1421 Target Population
The eligibility criteria set forth in AB1421 describes a population of adults with serious mental illness
who are experiencing repeated crisis events and are not engaging in mental health services on a
voluntary basis. The workgroup discussed the reasons why someone in such a high level of distress may
not voluntarily engage in mental health services. There were three main considerations discussed by
the AOT workgroup, all of which are present in the literature about mental illness.
Potential Barriers to Voluntarily Engaging in Mental Health Treatment:
1. A percentage of people with serious mental illness don’t have an awareness that they are ill and
don’t recognize the need for mental health treatment. This is more common in those with
schizophrenia, bipolar, and other psychotic disorders.
2. Some adults with mental illness, specifically those with repeated crisis and hospital events, may
have experienced trauma and/or stigma related to seeking or receiving mental health services
and therefore may avoid engaging in mental health treatment.
3. Some adults may experience difficulty accessing or navigating the mental health system as a
result of barriers to access, limited resources or capacity issues, or “falling through the cracks”
when moving between levels of care.
AB1421 Eligibility Criteria
AB1421 sets forth the following eligibility criteria that must be met for enrollment in an assisted
outpatient treatment program:
The person is 18 years of age or older.
The person is suffering from a mental illness.
There has been a clinical determination that the person is unlikely to survive safely in the
community without supervision.
The person has a history of lack of compliance with treatment for his or her mental illness, in
that at least one of the following is true:
o At least 2 hospitalizations within the last 36 months
o One or more acts of serious and violent behavior toward himself or herself or another,
or threats, or attempts to cause serious physical harm to himself or herself or another
within the last 48 months.
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The person has been offered an opportunity to participate in a treatment plan by the director of
the local mental health department, or his or her designee, provided the treatment plan
includes all of the services described in Section 5348, and the person continues to fail to engage
in treatment.
The person's condition is substantially deteriorating.
Participation in the assisted outpatient treatment program would be the least restrictive
placement necessary to ensure the person's recovery and stability.
In view of the person's treatment history and current behavior, the person is in need of assisted
outpatient treatment in order to prevent a relapse or deterioration that would be likely to result
in grave disability or serious harm to himself or herself, or to others, as defined in Section 5150.
It is likely that the person will benefit from assisted outpatient treatment.
Identifying Contra Costa’s AB1421 Target Population
Projecting the number of people who may be qualify for an assisted outpatient treatment program
requires estimating the number of individuals who are likely to meet the above criteria. While some of
the criteria are clear (e.g. the person is 18 years of age or older), some of the criteria are predictive and
less easily estimated (e.g. the person is unlikely to survive safely in the community without supervision).
In the following section, we present data from Contra Costa County’s Behavioral Health Services
database, the methodology and assumptions for estimating the target population, and the projected
number of individuals likely to meet the eligibility criteria set forth in the legislation. Please note that
this data was extracted from the Practice Support Program (PSP) data system and includes utilization
data from Contra Costa Regional Medical Center and contracted hospitals. Those who are dual eligible
with Medi-Cal and Medicare may be underrepresented in this data.
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First, we looked at how many adults had at least two hospitalizations within the past 36 months,
presented in Table 3. Seven hundred and seven (707) adults had at least two hospitalizations within
the past 36 months in Contra Costa County.
Table 3: Number of adults with 2 hospitalizations in 36 months
# of Hospitalizations in 36 months # of Individuals
2 376
3 155
4 82
5 43
6 20
7 9
8 8
9 5
10 3
11 2
12 1
13 1
14 1
20 1
Total 707
The criteria set forth in the AB1421 legislation lists two separate criteria: 1) 2 hospitalizations in the last
36 months or 2) One or more acts of serious and violent behavior toward himself or herself or another,
or threats, or attempts to cause serious physical harm to himself or herself or another within the last 48
months. For the purpose of estimating the number of people likely to be eligible from historical data, we
relied on the first criteria of 2 hospitalizations within the last 36 months more than the second criteria
because the PSP system does not have the ability to query whether or not an incident would meet the
criteria.
We then looked at the predictive criteria of:
There has been a clinical determination that the person is unlikely to survive safely in the
community without supervision, and
The person's condition is substantially deteriorating.
Adults with serious mental illness who are unlikely to survive in the community without supervision and
who are substantially deteriorating have likely experienced hospitalization more recently than 36
months. Therefore, we narrowed the population to people with at least two hospitalizations within the
past 12 months to anticipate how many people are likely to qualify for the above listed predictive
criteria.
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Table 4: Number of adults with 2 hospitalizations in 12 months
# of Hospitalizations in 12 months # of Individuals
2 130
3 44
4 18
5 5
6 2
7 1
8 1
9 1
10 1
Total 203
Table 4 shows that 203 adults had at least two hospitalizations within the last 12 months , providing an
estimate of how many people are likely to meet the criteria of at least two hospitalizations within the
past 36 months and who are unlikely to survive in the community without supervision and be
substantially deteriorating. This methodology assumes that those individuals with a substantial number
of hospitalizations within the 36 month time frame would be represented in the group of individuals
who had at least 2 hospitalizations in the last 12 months.
Of these 203 individuals:
53% are male and 47% female.
22% are transition age youth (ages 18-24), 69% are 25-60 years old, and 9% are seniors age 60
and above.
41% are Caucasian, 33% African American, 15% Latino, 5% Asian/Pacific Islander, 1% Native
American, 3% Other non-white, and 3% race/ethnicity unknown.
59% had a primary diagnosis of schizophrenia or other psychotic disorders, 34% mood disorders,
1% an anxiety disorder, 1% an impulse disorder, and 5% had a primary diagnosis of other
conditions that were the focus of clinical attention.
31% live in West County, 30% in East County, 23% in Central County, 5% in South County, and
11% were from out of county.
To establish the estimated target population in Contra Costa likely to be eligible, we removed the 11% or
22 adults who are not Contra Costa County residents. This adjusts the total from 203 to 181 adults in
Contra Costa County.
Of the 181 adults who are likely to meet the criteria of at least two hospitalizations within the past 36
months and who are unlikely to survive in the community without supervision and be substantially
deteriorating, we then look to the criteria about service engagement, including:
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The person has a history of lack of compliance with treatment for his or her mental illness.
The person has been offered an opportunity to participate in a treatment plan by the director of
the local mental health department, or his or her designee, provided the treatment plan
includes all of the services described in Section 5348,4 and the person continues to fail to engage
in treatment.
Participation in the assisted outpatient treatment program would be the least restrictive
placement necessary to ensure the person's recovery and stability.
CCBHS, specifically the Chief of Adult and Older Adult Services, then reviewed the cases of the 181
identified individuals to determine which individuals would meet the AOT criteria. In this case review,
the Chief of Adult and Older Adult Services reviewed the service utilization history (e.g. face sheets) of
the 181 individuals to determine if each individual would likely fit the criteria for AOT as it is defined in
the AB1421 legislation. Of the 181 individuals:
28 are no longer accessing mental health services and have not had subsequent hospitalizations.
13 are currently in stable placements and doing well.
29 are currently enrolled in FSP programs.
37 would likely pass a clinician assessment to determine eligibility for AOT.
76 would likely benefit from and engage in FSP services but are unlikely to qualify for AOT.
The workgroup requested that the CCBHS re-review utilization data to ensure that people who are dual
eligible with Medicare and Medi-Cal were taken into account. Upon the secondary review, CCBHS
identified two additional dual eligible individuals who would likely pass a clinical assessment to
determine eligibility for AOT, bringing the total number of eligible individuals to 37. CCBHS noted that
there was a fair representation of dual eligible individuals in the first case review.
Therefore, the number of people who are likely to qualify for AOT services in Contra Costa based on
the eligibility criteria set forth in the legislation is 37 individuals. Additionally, the 29 individuals
enrolled in FSP services with at least 2 hospitalizations in the past 12 months would likely benefit from a
review of current FSP practices to identify if there are adjustments to their FSP services that w ould
reduce hospitalizations. There are also 76 individuals not receiving FSP services who have been
determined to likely benefit from and engage in FSP services voluntarily were they available.
4 For the entire service goals listed in WIC Section 5348, please refer to Appendix A.
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Recommendations that Directly Serve the Target Population
In Home Outreach Team (IHOT)
Description: The IHOT are mobile teams that provide in-home outreach and engagement services to
individuals with Severe Mental Illness (SMI) who are reluctant to seek outpatient mental health services,
and to their family members or caretakers. IHOT collaborates with family members and service
providers, all of whom can refer clients and family members to IHOT for outreach and engagement to
facilitate follow up services that may include 1) Outpatient specialty mental health services, 2) Crisis
intervention, 3) Acute care, 4) Alternatives to psychiatric hospitalization, 5) Conservatorship, and 6) Case
management services. The overall goal of IHOT is to develop rapport and a relationship with the
identified client so as to increase the individual awareness as to the benefits in managing his/her
symptoms and behaviors by choosing to participate in outpatient mental health services, rehabilitation
and recovery services or non-clinical support services. This program is targeted to increase family
member satisfaction with the mental health system of care, as well as to reduce the effects of untreated
mental illness in individuals with Serious Mental Illness (SMI) and their families.
Rationale: The purpose of the IHOT team is to provide an avenue for family members and other
professionals to request support for their loved one who is struggling with mental illness and is unlikely
to present to a mental health treatment setting for services. The model includes engaging the individual
with mental illness in services while simultaneously providing support to family members. Evaluation
data from San Diego’s IHOT program suggest that the model has been successful in engaging at least
50% of the individuals referred in mental health services.
Level of Support: The AOT workgroup had broad-based support for implementing the IHOT program to
meet the needs of the target population.
Cost: $735,395.10. Please see Appendix G on page 141 for budget detail.
Psychiatric Emergency and Hospital Transitions
Description: The psychiatric emergency and hospital transitions program provides outreach and
engagement services to people who present to psychiatric emergency services and/or are hospitalized
at the Contra Costa Regional Medical Center (CCRMC). In the proposed model, an interdisciplinary team
including professional, peer, and family staff would be co-located at PES and the inpatient unit to begin
engagement in services prior to discharge. Team members would also provide follow-up to individuals
who were discharged from the hospital prior to engagement with the transition team. This is an
expansion of the existing transitions team program and adds peer and family staff as well as co -location
at CCRMC.
Rationale: The psychiatric emergency and hospital transitions program is intended to engage people
who present to psychiatric emergency services and/or are hospitalized at CCRMC to facilitate
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engagement in outpatient services following discharge and interrupt the cycle of repetitive
hospitalizations by establishing linkages and relationships prior to discharge. This model may also
reduce the trauma associated with involuntary services and improve the likelihood that the individual
will follow-up with CCBHS after discharge. Peer support provided in psychiatric emergency and hospital
settings has a growing body of evidence, mainly from Arizona and Alameda County. Also, this type of
program is currently being developed in counties across the state, including Alameda County, in
response to meeting the needs of the population set forth in AB 1421.
Level of Support: The AOT workgroup had broad-based support for implementing psychiatric
emergency and hospital transitions program to meet the needs of the target population. However,
there was mild disagreement about whether or not the program should include non-professional staff.
Cost: $520,396.85. Please see Appendix H on page 142 for budget detail.
Full Service Partnership Expansion
Description: The Full Service Partnership (FSP) is a required category of service described in the MHSA
that uses a “whatever it takes” model to support individuals with serious mental illness who meet the
following criteria5:
1. Their mental disorder results in substantial functional impairments or symptoms, or they have a
psychiatric history that shows that, without treatment, there is an imminent risk of
decompensation with substantial impairments or symptoms.
2. Due to mental functional impairment and circumstances, they are likely to become so disabled
as to require public assistance, services, or entitlements.
and
3. They are in one of the following situations:
a. They are unserved and one of the following:
i. Homeless or at risk of becoming homeless.
ii. Involved in the criminal justice system.
iii. Frequent users of hospital or emergency room services as the primary resource
for mental health treatment.
b. They are underserved and at risk of one of the following:
i. Homelessness.
ii. Involvement in the criminal justice system.
iii. Institutionalization.
5 Welfare and Institutions Code, section 5600.3(b)
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The FSP model involves a collaborative relationship between County (or contracted provider) and
consumer, as well as family when appropriate, through which the County plans for and provides the full
spectrum of community services so that the consumer can achieve the goals identified in their individual
services and supports plan (ISSP). The full spectrum of community services includes a variety of mental
health and non-mental health services (i.e. housing, food, clothing) as well as afterhours support.6
Rationale: The FSP target population includes individuals with serious mental illness who are
experiencing significant distress and difficulty functioning as a result of their mental illness and are
frequently accessing hospital and emergency room services for mental health treatment. The primary
difference between individuals that would qualify for FSP compared to AOT is the ability to voluntarily
engage in services. FSP is based on the Assertive Community Treatment model, which has the strongest
evidence base of any mental health service, and has been demonstrated to reduce negative outcomes
related to homelessness, arrest, and use of psychiatric emergency services while increasing independent
living, employment, education, and level of functioning.
Level of Support: The AOT workgroup had broad-based support for expanding voluntary FSP program
capacity to meet the needs of the target population. However, some AOT workgroup members
expressed the concern that expanding FSP would only support those who were able and willing to
voluntarily engage, and that AOT was still a necessary consideration.
Cost: $3,653,472.00 including $2,850,000.00 for 76 FSP slots at $37,500 each and $803,472 for housing
at $881 per month per individual.
Estimated Need: It is likely that 76 individuals from the target population would benefit from and
engage in voluntary FSP services.
Assisted Outpatient Treatment (AOT)
Description: AOT refers to categories of mental health services ordered by a court; AB1421 does not
include provisions to provide medication without consent.
According to AB1421, AOT services in California must:
Outreach and engagement services
Coordination and access to medications, psychiatric and psychological services, and substance
abuse services
Supportive housing or other housing assistance
Vocational rehabilitation
Veterans' services
6 California Code of Regulations, Title 9, § 3620. Full Service Partnership Service Category.
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Family support and consultation services
Parenting support and consultation services
Peer support or self-help group support, where appropriate
Age, gender, and culturally appropriate services7
Additionally, AB1421 mandates that outreach and engagement services be provided to family members
who live with a person with serious mental illness and people likely to come into cont act with people
with serious mental illness, like physicians and law enforcement.8
Rationale: There are limited options available to counties in California to intervene with individuals with
serious mental illness who are not voluntarily engaging in mental health services and are at risk of
negative outcomes, including homelessness, jail, incarceration, and death. Prior to AB1421, options
included 5150 (up to a 72 hour hold), 5250 (up to a 14 day hold), 5270 (up to a 30 day hold), and LPS
conservatorship, which is required for anyone in a locked psychiatric facility but can also be
implemented in community settings. AB1421 provides another option for counties to support
individuals with the highest level of need who are not willing or able to voluntarily engage in mental
health services and are at serious risk of negative outcomes.
Level of Support: The AOT workgroup was unable to achieve consensus on AOT, and this
recommendation had the least amount of group support. While there were a small number of
participants who were opposed to AOT implementation and most of the consumer and family member
representatives expressed strong support for AOT, the majority of AOT workgroup participants were
neutral or expressed ambivalence about AOT. For the AOT workgroup members who were undecided,
many were unsure if AOT was necessary and wondered if there weren’t other solutions that should be
tried first to serve the target population. There were additional concerns about diverting that level of
resources to a smaller sub-population of people with mental illness. However, all county staff expressed
their commitment to implement the Board of Supervisors’ directions.
Cost: $2,721,735.65 - $3,191,807.29 including $1,387,500 for 37 FSP slots at $37,500 each; $391,164 for
housing at $881.00 per month per individual; and $943,071.65 - $1,413,143.29 for legal costs. Please
note that the legal costs are estimated based on the need to create a new court calendar and hire
additional county counsel and public defender staffing as the three departments don’t have existing
capacity to absorb AOT into current court calendars or staff workload. Additionally, the AOT workgroup
did not reach consensus on the number of weekly hours a court for AOT would need to operate, but it
may be unlikely that a full-time/40-hour per week court is needed. Court costs are indicated by a range
to show costs with a 20-hour per week court (low-end estimate) and 40-hour per week court (high-end
estimate) for AOT.
7 Welfare and Institutions Code Section 5348
8 Ibid.
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The budget detail for court costs associated with AOT is included in Appendix I on page 143.
Estimated Need: It is likely that 37 individuals from the target population would benefit from and be
eligible for AOT services.
Other Recommendations
The group also discussed programs and services that would likely benefit a larger population of people
with mental illness to voluntarily engage and prevent or reduce the need for voluntary services.
Specifically, the AOT workgroup believed that it would be useful to improve access to services, increase
consumer and family involvement throughout the process and system, improve integration and
collaboration between systems, as well as a financial review. Suggestions include:
Mobile Crisis Services9 to provide trained clinical staff at the critical juncture during which law
enforcement responds to a report of a mental health crisis to minimize the ineffective and costly
placement of individuals in hospitals and jails when a therapeutic intervention and/or treatment
is available.
Expanded patient advocacy to provide trained patient advocates to support individuals in
understanding their rights as a consumer and to access needed services.
Systems navigators to facilitate entry into behavioral health services as well as care transitions
between service providers and levels of care.
Trauma support groups to help consumers address the trauma associated with their
experiences of stigma and of past events, particularly mental health crisis events.
Review of accounting systems to ensure that costs and revenue are allocated to the
appropriate cost centers and that savings are re-invested.
9 CCBHS has received limited funding through Senate Bill (SB) 82 in 2014 for three Full Time Eq uivalencies (FTEs) to
provide mobile crisis services.
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Assisted Outpatient Treatment
Current and Planned AOT Programs in California
Nevada and Yolo County are the only two counties in California to have implemented AOT at the time of
report. During this AOT workgroup, the Boards of Supervisors for San Francisco, Orange, and Los
Angeles Counties passed resolutions adopting AOT and directed the behavioral health departments to
develop and implement AOT programs.
Nevada County has served 76 individuals in their AOT program since 2008. There is an average
of 5 individuals with an AOT court order at any given time in the County. Nevada County also
estimates that the cost per person in AOT is approximately $25,000.
Yolo County currently has an AOT program with capacity for 5 individuals. Utilization data
suggests that at any time, 2-3 individuals are enrolled in AOT.
Los Angeles County expects to receive 500 AOT referrals for year and will maintain capacity for
300 individuals to receive AOT services. They have also budgeted for 60 crisis residential
treatment (CRT) beds for AOT referred and enrolled individuals. This AOT program expansion,
including the CRT, is estimated at $7.8 million annually. This estimate includes expected Medi-
Cal revenue but does not include court and legal fees.
Orange County has planned an AOT program to serve 120 individuals and estimates that costs
will range from $5.8 - $6.1 million annually. This estimate includes expected Medi-Cal revenue
and public defender and county counsel costs but does not include court costs. They anticipate
a per person cost of $35,000- $40,000 annually.
San Francisco has passed the AOT resolution but has not yet estimated the number of
individuals to be served. The County is planning to engage in the community program planning
process required by MHSA during FY 2014-15 and implement AOT in FY 2015-16. They
anticipate a per person cost of $35,000- $40,000 annually for mental health services. Legal and
court costs are not yet determined.
Implementation Considerations for Contra Costa County
Program Considerations
If the Board of Supervisors chooses to adopt AB1421 and authorize AOT, the AOT workgroup
recommends that the county consider the same amendments to its authorization that San Francisco
made when adopting AB1421. The following table lists the San Francisco amendments along with the
AOT workgroup’s agreements and/or modifications.
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The County Mental Health Director (“Director”) shall create a Care Team consisting of:
Table 5: Amendments to Consider in Adopting AB1421
San Francisco Board of Supervisors Amendment AOT Workgroup Modifications
A forensic psychiatrist, who will be the
designated licensed mental health treatment
provider responsible for clinical evaluation of the
referred individual;
A general psychiatrist, who will be the designated
licensed mental health treatment provider
responsible for clinical evaluation of the referred
individual.
A peer specialist, who will be a person with
mental illness, who can provide lived experience
to help the Referred individual engage into
treatment; and
Consider as written.
A family liaison, who will be a person who has
had a family member with mental illness, who
can provide lived experience to educate the
family.
Consider as written.
The Care Team shall work closely with the
Referred Individual and the individual requesting
the AOT petition to maximize all opportunities
within AOT to engage individuals who meet AOT
criteria into voluntary treatment.
Consider as written.
Referral to AOT provides to key opportunities for
voluntary engagement of individuals meeting
AOT criteria prior to a court hearing:
i. Immediately after the request for
petition and before the filling of a
petition with the court; and
ii. After the filing of a petition and before
the conclusion of the court hearing on
the petition.
At each of these opportunities, the Care Team
shall make every attempt to engage the Referred
Individual into voluntary treatment.
Consider as written.
The Referred Individual shall at all times have the
opportunity to voluntarily participate in a Full
Service Partnership (“FSP”) which is the
collaborative relationship between the City and
the Referred Individual and, when appropriate,
the Referred Individual’s family, through which
the City plans for, and provides, the full spectrum
of community services so that the client can
achieve the identified goals. The City shall
provide FSP services that conform to the
requirements of California Code of Regulations
Title 9, Section 3200.13c, defining FSP, or any
Consider as written.
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successor provisions.
The Care Team shall work closely with the
Referred Individual and the individual initiating
the petition in an effort to engage the Referred
Individual into a FSP as preferred alternative to
court-ordered treatment.
Consider as written.
All evaluations of the Referred Individual shall be
conducted in the least restrictive setting.
Consider as written.
The Referred Individual may not be transported
for evaluation by a peace, probation, or parole
officer, unless there is probably cause to believe
that the individual meets the criteria required by
California Welfare and Institutions Code §5150,
or there is no other means to safely transport the
Referred Individual.
Consider as written.
The AOT Team shall also ensure that individuals
referred for AOT who do not meet AOT criteria
are evaluated for, and connected to, the
appropriate level of mental health treatment.
Consider as written.
In addition, AOT workgroup participants made the following recommendations in AOT workgroup
Meeting 5:
AOT participation is limited to only those consumers who absolutely need it the most.
Opportunities for consumer choice be maximized and supported, wherever appropriate and
allowable.
Creation of an interdisciplinary team includes clinical as well as peer counselor and family
liaison.
Adoption of the collaborative court model for an AOT program. This is the model used in AOT in
Nevada County and other states, and represents a shift away from an adversarial court process
to a one where the judge and other professionals work in partnership with the consumer.
Selection of a judge and other AOT involved professionals who are willing to embrace the
collaborative court model and work together in service of the consumer and their wellness and
recovery.
Referred individuals be transported by law enforcement for a mental health evaluation only if
the individual meets 5150 criteria.
Required program evaluation be performed by an external evaluator.
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The AOT workgroup representative from County Counsel also suggested an assessment to understand
the risks and liabilities associated with AOT should be considered prior to implementation of an AOT
program in Contra Costa County.
Funding Considerations
AOT Funding Sources
AOT has two main categories of service costs. This includes the costs associated with mental health
services and the costs associated with the legal system, including the court, public defender, and county
counsel. The Attorney General and the Department of Health Care Services (formerly Department of
Mental Health) have issued statements that MHSA dollars can be used to fund the mental health
services associated with AOT but that MHSA dollars cannot be used to fund any legal or court costs.
Table 6. AOT Allowable Funding Sources lists the allowable funding sources for the general expense
categories associated with AOT.
Table 6. AOT Allowable Funding Sources
Category Allowable Funding Sources
Full Service
Partnership
(FSP)
Services
Any funding source that currently funds FSP/ACT services, including MHSA.
If FSP services were to be funded by MHSA:
A plan update would be required and include a CPP process, 30 day public
posting, public hearing, and Board of Supervisor approval.
The costs associated with AOT implementation cannot reduce or eliminate
voluntary programs
(i.e. must be monies not currently allocated to existing programs.)
Housing MHSA funds for housing associated with FSP participation, MHSA housing, or other non-
mental health housing subsidies.
County
Counsel
General Fund or other non-mental health funding
MHSA and/or Realignment funds cannot be used for legal costs associated
with AOT implementation.
Public
Defender
General Fund
MHSA and/or Realignment funds cannot be used for legal costs associated
with AOT implementation.
Court General Fund
MHSA and/or Realignment funds cannot be used for legal costs associated
with AOT implementation.
Use of MHSA Funds for AOT Service Costs
If MHSA funds are used for AOT, all activities must be in accordance with the MHSA legislation, including
the rules governing MHSA programs and expenditures as well as the MHSA principles of:
Recovery, Wellness, and Resiliency Focused
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Client and Family Driven
Cultural Competence
Integration
Collaboration
The following questions about MHSA funding and AOT emerged from the AOT workgroup, and RDA
sought guidance from the Mental Health Services Oversight and Accountability Commission (MHSOAC).
Questions and responses are below.
“If a Board adopts assisted outpatient treatment which results in an expansion of existing Full
Service Partnership programs, is a community program planning process required (or suggested)
before increasing the number of existing Full Service Partnership slots available that would be
used for AOT?” The MHSOAC response was that a Community Program Planning process would
be required.
“Can MHSA prudent reserves be used to expand existing Full Service Partnership services as part
of an AOT program?” The MHSOAC response was no. Prudent reserve can only be used to
sustain programs when revenue is low.
“AB1421 states that implementation of AOT cannot reduce the availability of voluntary
services. If a county has unspent funds and currently has more money allocated to programs
than is anticipated to come in, the county may have funding in the current or next year to
support an expansion of existing Full Service Partnership services for AOT, but will run out of
unspent money and/or reserves within 2-3 years and have to reduce voluntary programs as a
result. How should one apply the AB1421 legislation around not reducing voluntary programs in
this situation?” The MHSOAC is researching this question and was unable to provide a response.
Cost Savings and Cost Avoidance
The question of cost savings and cost avoidance is important as the County evaluates the potential
benefits and investment in AOT. The general assumptions about cost savings and cost avoidance as well
as the categories which are likely to experience cost savings and/or avoidance are based on the Nevada
County experience and the evaluation of existing Full Service Partnership programs throughout the
state. Nevada County’s AOT program and Full Service Partnership programs throughout California
demonstrate cost reductions in the following categories:
Psychiatric Emergency Services
Psychiatric Hospitalization
Emergency Room
Jail
Law Enforcement
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While it is reasonable to anticipate cost savings as a result of implementing AOT in Contra Costa County,
there is not adequate information from comparable California counties to reliably quantify or estimate
what the actual cost savings amount would be. Unfortunately, the only county with actual cost savings
data is Nevada County; it is unlikely that these costs and cost savings would be applicable to a larger,
Bay Area County. San Francisco, Orange, and Los Angeles Counties have communicated to RDA and
CCBHS that they are not attempting to estimate cost savings or avoidance with any detail but will collect
data, as required by DHCS, to assess actual cost savings after the first year of implementation. Orange
County has stated that they expect the cost savings from AOT to be commensurate with the cost savings
associated with FSP services, and LA County is expecting that the costs of AOT legal costs will be entirely
offset by cost avoidance derived from decreased need for criminal and civil processes.
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Conclusion
CCBHS sought to create an AOT workgroup in which County staff, service providers, consumers, family
members and others could collaboratively investigate how the County could respond to the group of
adults with serious mental illness who are experiencing repeated crisis events and are not engaging in
mental health services on a voluntary basis. RDA worked with CCBHS staff to convene stakeholders,
prepare for and facilitate a series of planning meetings, and synthesize the resulting materials into this
report to be presented to the Board of Supervisors. Each successive meeting built on the work
previously done and resulted in the development of programs and services that address the
engagement of people with serious mental illness experiencing frequent crisis events who are not
engaging in voluntary services.
The AOT workgroup developed the following recommendations informed by data provided by CCBHS:
1. Develop an IHOT program based on the San Diego model to provide support for consumers and
their families to engage in voluntary mental health services.
2. Enhance the supports to transition from PES and the hospital through an interdisciplinary team
co-located at CCRMC.
3. Expand the number of FSP spots for 76 consumers who are likely to voluntarily engage.
4. Consider the development of a 37 person AOT program. If the board chooses to adopt the 1421
legislation, the AOT workgroup recommends:
a. Limit AOT participation to only those consumers who absolutely need it the most.
b. Opportunities for consumer choice be maximized and supported, wherever appropriate
and allowable.
c. Creation of an interdisciplinary team that includes clinical as well as peer counselor and
family liaison.
d. Selection of a judge and other AOT involved professionals who are willing to embrace
the collaborative court model and work together in service of the consumer and their
wellness and recovery.
e. Referred individuals only be transported by law enforcement for a mental health
evaluation only if the individual meets 5150 criteria.
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Next Steps
The estimated timeline for completion of the following tasks is approximately four to nine months. The
AOT workgroup expresses its commitment to implement the Board’s directions as efficiently as possible .
The AOT workgroup also recognizes that there are people who are in need of additional programs and
seeks to balance that sense of urgency with a commitment to establish programs in a sustainable and
reliable fashion compliant with applicable regulations that are likely to meet the desired outcomes. If
the board chooses to move forward with an AOT program, the following steps would be necessary:
Pass a board resolution adopting the AB1421 legislation and issue a finding that no voluntary
mental health program serving children or adults would be reduced as a result of the
implementation.
Develop a workgroup to plan, design, and implement a collaborative process with CCBHS, the
Courts, County Counsel, and the Public Defender.
Hire and train new and selected staff.
Engage in outreach efforts, as set forth in the AB1421 legislation, to educate people likely to
come into contact with the AB1421 population including family members, primary care
physicians and other service providers, law enforcement, homeless service providers, and other
relevant parties.
If the board would like to consider the use of MHSA funding for any of the recommendations,
engage in a Community Program Planning (CPP) process, as described in the MHSA legislation
and Welfare and Institutions code, to develop an amendment to the three year program and
expenditure plan. Given that CCBHS just completed a CPP process for the MHSA Three-Year
Program and Expenditure Plan, the workgroup requests that any relevant information about the
target population or stakeholder input from that process be considered and inform a CPP
process for a plan amendment as permitted by regulation.
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Appendices
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Appendix A: California Welfare and Institutions Code Section 5345 -5349.5
(“Laura’s Law”)
WELFARE AND INSTITUTIONS CODE
SECTION 5345-5349.5
5345. (a) This article shall be known, and may be cited, as Laura's
Law.
(b) "Assisted outpatient treatment" shall be defined as categories of outpatient services that have
been ordered by a court pursuant to Section 5346 or 5347.
5346. (a) In any county in which services are available as provided in Section 5348, a court may order a
person who is the subject of a petition filed pursuant to this section to obtain assisted outpatient
treatment if the court finds, by clear and convincing evidence, that the facts stated in the verified
petition filed in accordance with this section are true and establish that all of the requisite criteria set
forth in this section are met, including, but not limited to, each of the following:
(1) The person is 18 years of age or older.
(2) The person is suffering from a mental illness as defined in paragraphs (2) and (3) of subdivision (b)
of Section 5600.3.
(3) There has been a clinical determination that the person is unlikely to survive safely in the
community without supervision.
(4) The person has a history of lack of compliance with treatment for his or her mental illness, in that
at least one of the following is true:
(A) The person's mental illness has, at least twice within the last 36 months, been a substantial factor
in necessitating hospitalization, or receipt of services in a forensic or other mental health unit of a state
correctional facility or local correctional facility, not including any period during which the person was
hospitalized or incarcerated immediately preceding the filing of the petition.
(B) The person's mental illness has resulted in one or more acts of serious and violent behavior toward
himself or herself or another, or threats, or attempts to cause serious physical harm to himself or herself
or another within the last 48 months, not including any period in which the person was hospitalized or
incarcerated immediately preceding the filing of the petition.
(5) The person has been offered an opportunity to participate in a treatment plan by the director of
the local mental health department, or his or her designee, provided the treatment plan includes all of
the services described in Section 5348, and the person continues to fail to engage in treatment.
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(6) The person's condition is substantially deteriorating.
(7) Participation in the assisted outpatient treatment program would be the least restrictive placement
necessary to ensure the person's recovery and stability.
(8) In view of the person's treatment history and current behavior, the person is in need of assisted
outpatient treatment in order to prevent a relapse or deterioration that would be likely to result in
grave disability or serious harm to himself or herself, or to others, as defined in Section 5150.
(9) It is likely that the person will benefit from assisted outpatient treatment.
(b) (1) A petition for an order authorizing assisted outpatient treatment may be filed by the county
mental health director, or his or her designee, in the superior court in the county in which the person
who is the subject of the petition is present or reasonably believed to be present.
(2) A request may be made only by any of the following persons to the county mental health
department for the filing of a petition to obtain an order authorizing assisted outpatient treatment:
(A) Any person 18 years of age or older with whom the person who is the subject of the petition
resides.
(B) Any person who is the parent, spouse, or sibling or child 18 years of age or older of the person who
is the subject of the petition.
(C) The director of any public or private agency, treatment facility, charitable organization, or licensed
residential care facility providing mental health services to the person who is the subject of the petition
in whose institution the subject of the petition resides.
(D) The director of a hospital in which the person who is the subject of the petition is hospitalized.
(E) A licensed mental health treatment provider who is either supervising the treatment of, or treating
for a mental illness, the person who is the subject of the petition.
(F) A peace officer, parole officer, or probation officer assigned to supervise the person who is the
subject of the petition.
(3) Upon receiving a request pursuant to paragraph (2), the county mental health director shall
conduct an investigation into the appropriateness of the filing of the petition. The director shall file the
petition only if he or she determines that there is a reasonable likelihood that all the necessary elements
to sustain the petition can be proven in a court of law by clear and convincing evidence.
(4) The petition shall state all of the following:
(A) Each of the criteria for assisted outpatient treatment as set forth in subdivision (a).
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(B) Facts that support the petitioner's belief that the person who is the subject of the petition meets
each criterion, provided that the hearing on the petition shall be limited to the stated facts in the
verified petition, and the petition contains all the grounds on which the petition is based, in order to
ensure adequate notice to the person who is the subject of the petition and his or her counsel.
(C) That the person who is the subject of the petition is present, or is reasonably believed to be
present, within the county where the petition is filed.
(D) That the person who is the subject of the petition has the right to be represented by counsel in all
stages of the proceeding under the petition, in accordance with subdivision (c).
(5) The petition shall be accompanied by an affidavit of a licensed mental health treatment provider
designated by the local mental health director who shall state, if applicable, either of the following:
(A) That the licensed mental health treatment provider has personally examined the person who is the
subject of the petition no more than 10 days prior to the submission of the petition, the facts and
reasons why the person who is the subject of the petition meets the criteria in subdivision (a), that the
licensed mental health treatment provider recommends assisted outpatient treatment for the person
who is the subject of the petition, and that the licensed mental health treatment provider is willing and
able to testify at the hearing on the petition.
(B) That no more than 10 days prior to the filing of the petition, the licensed mental health treatment
provider, or his or her designee, has made appropriate attempts to elicit the cooperation of the person
who is the subject of the petition, but has not been successful in persuading that person to submit to an
examination, that the licensed mental health treatment provider has reason to believe that the person
who is the subject of the petition meets the criteria for assisted outpatient treatment, and that the
licensed mental health treatment provider is willing and able to examine the person who is the subject
of the petition and testify at the hearing on the petition.
(c) The person who is the subject of the petition shall have the right to be represented by counsel at all
stages of a proceeding commenced under this section. If the person so elects, the court shall
immediately appoint the public defender or other attorney to assist the person in all stages of the
proceedings. The person shall pay the cost of the legal services if he or she is able.
(d) (1) Upon receipt by the court of a petition submitted pursuant to subdivision (b), the court shall fix
the date for a hearing at a time not later than five days from the date the petition is received by the
court, excluding Saturdays, Sundays, and holidays. The petitioner shall promptly cause service of a copy
of the petition, together with written notice of the hearing date, to be made personally on the person
who is the subject of the petition, and shall send a copy of the petition and notice to the county office of
patient rights, and to the current health care provider appointed for the person who is the subject of the
petition, if any such provider is known to the petitioner. Continuances shall be permitted only for good
cause shown. In granting continuances, the court shall consider the need for further examination by a
physician or the potential need to provide expeditiously assisted outpatient treatment. Upon the
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hearing date, or upon any other date or dates to which the proceeding may be continued, the court shall
hear testimony. If it is deemed advisable by the court, and if the person who is the subject of the
petition is available and has received notice pursuant to this section, the court may examine in or out of
court the person who is the subject of the petition who is alleged to be in need of assisted outpatient
treatment. If the person who is the subject of the petition does not appear at the hearing, and
appropriate attempts to elicit the attendance of the person have failed, the court may conduct the
hearing in the person's absence. If the hearing is conducted without the person present, the co urt shall
set forth the factual basis for conducting the hearing without the person's presence.
(2) The court shall not order assisted outpatient treatment unless an examining licensed mental health
treatment provider, who has personally examined, and has reviewed the available treatment history of,
the person who is the subject of the petition within the time period commencing 10 days before the
filing of the petition, testifies in person at the hearing.
(3) If the person who is the subject of the petition has refused to be examined by a licensed mental
health treatment provider, the court may request that the person consent to an examination by a
licensed mental health treatment provider appointed by the court. If the person who is the subject of
the petition does not consent and the court finds reasonable cause to believe that the allegations in the
petition are true, the court may order any person designated under Section 5150 to take into custody
the person who is the subject of the petition and transport him or her, or cause him or her to be
transported, to a hospital for examination by a licensed mental health treatment provider as soon as is
practicable. Detention of the person who is the subject of the petition under the order may not exceed
72 hours. If the examination is performed by another licensed mental health treatment provider, the
examining licensed mental health treatment provider may consult with the licensed mental health
treatment provider whose affirmation or affidavit accompanied the petition regarding the issues of
whether the allegations in the petition are true and whether the person meets the criteria for assisted
outpatient treatment.
(4) The person who is the subject of the petition shall have all of the following rights:
(A) To adequate notice of the hearings to the person who is the subject of the petition, as well as to
parties designated by the person who is the subject of the petition.
(B) To receive a copy of the court-ordered evaluation.
(C) To counsel. If the person has not retained counsel, the court shall appoint a public defender.
(D) To be informed of his or her right to judicial review by habeas corpus.
(E) To be present at the hearing unless he or she waives the right to be present.
(F) To present evidence.
(G) To call witnesses on his or her behalf.
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(H) To cross-examine witnesses.
(I) To appeal decisions, and to be informed of his or her right to appeal.
(5) (A) If after hearing all relevant evidence, the court finds that the person who is the subject of the
petition does not meet the criteria for assisted outpatient treatment, the court shall dismiss the
petition.
(B) If after hearing all relevant evidence, the court finds that the person who is the subject of the
petition meets the criteria for assisted outpatient treatment, and there is no appropriate and feasible
less restrictive alternative, the court may order the person who is the subject of the petition to receive
assisted outpatient treatment for an initial period not to exceed six months. In fashioning the order, the
court shall specify that the proposed treatment is the least restrictive treatment appropriate and
feasible for the person who is the subject of the petition. The order shall state the categories of assisted
outpatient treatment, as set forth in Section 5348, that the person who is the subject of the petition is
to receive, and the court may not order treatment that has not been recommended by the examining
licensed mental health treatment provider and included in the written treatment plan for assisted
outpatient treatment as required by subdivision (e). If the person has executed an advance health care
directive pursuant to Chapter 2 (commencing with Section 4650) of Part 1 of Division 4.7 of the Probate
Code, any directions included in the advance health care directive shall be considered in formulating the
written treatment plan.
(6) If the person who is the subject of a petition for an order for assisted outpatient treatment
pursuant to subparagraph (B) of paragraph (5) of subdivision (d) refuses to participate in the assisted
outpatient treatment program, the court may order the person to meet with the assisted outpatient
treatment team designated by the director of the assisted outpatient treatment program. The
treatment team shall attempt to gain the person's cooperation with treatment ordered by the court.
The person may be subject to a 72-hour hold pursuant to subdivision (f) only after the treatment team
has attempted to gain the person's cooperation with treatment ordered by the court, and has been
unable to do so.
(e) Assisted outpatient treatment shall not be ordered unless the licensed mental health treatment
provider recommending assisted outpatient treatment to the court has submitted to the court a written
treatment plan that includes services as set forth in Section 5348, and the court finds, in consultation
with the county mental health director, or his or her designee, all of the following:
(1) That the services are available from the county, or a provider approved by the county, for the
duration of the court order.
(2) That the services have been offered to the person by the local director of mental health, or his or
her designee, and the person has been given an opportunity to participate on a voluntary basis, and the
person has failed to engage in, or has refused, treatment.
(3) That all of the elements of the petition required by this article have been met.
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(4) That the treatment plan will be delivered to the county director of mental health, or to his or her
appropriate designee.
(f) If, in the clinical judgment of a licensed mental health treatment provider, the person who is the
subject of the petition has failed or has refused to comply with the treatment ordered by the court, and,
in the clinical judgment of the licensed mental health treatment provider, efforts were made to solicit
compliance, and, in the clinical judgment of the licensed mental health treatment provider, the person
may be in need of involuntary admission to a hospital for evaluation, the provider may request that
persons designated under Section 5150 take into custody the person who is the subject of the petition
and transport him or her, or cause him or her to be transported, to a hospital, to be held up to 72 hours
for examination by a licensed mental health treatment provider to determine if the person is in need of
treatment pursuant to Section 5150. Any continued involuntary retention in a hospital beyond the initial
72-hour period shall be pursuant to Section 5150. If at any time during the 72-hour period the person is
determined not to meet the criteria of Section 5150, and does not agree to stay in the hospital as a
voluntary patient, he or she shall be released and any subsequent involuntary detention in a hospital
shall be pursuant to Section 5150. Failure to comply with an order of assisted outpatient treatment
alone may not be grounds for involuntary civil commitment or a finding that the person who is the
subject of the petition is in contempt of court.
(g) If the director of the assisted outpatient treatment program determines that the condition of the
patient requires further assisted outpatient treatment, the director shall apply to the court, prior to the
expiration of the period of the initial assisted outpatient treatment order, for an order authorizing
continued assisted outpatient treatment for a period not to exceed 180 days from the date of the order.
The procedures for obtaining any order pursuant to this subdivision shall be in accordance with
subdivisions (a) to (f), inclusive. The period for further involuntary outpatient treatment authorized by
any subsequent order under this subdivision may not exceed 180 days from the date of the order.
(h) At intervals of not less than 60 days during an assisted outpatient treatment order, the director of
the outpatient treatment program shall file an affidavit with the court that ordered the outpatient
treatment affirming that the person who is the subject of the order continues to meet the criteria for
assisted outpatient treatment. At these times, the person who is the subject of the order shall have the
right to a hearing on whether or not he or she still meets the criteria for assisted outpatient treatment if
he or she disagrees with the director's affidavit. The burden of proof shall be on the director.
(i) During each 60-day period specified in subdivision (h), if the person who is the subject of the order
believes that he or she is being wrongfully retained in the assisted outpatient treatment program
against his or her wishes, he or she may file a petition for a writ of habeas corpus, thus requiring the
director of the assisted outpatient treatment program to prove that the person who is the subject of the
order continues to meet the criteria for assisted outpatient treatment.
(j) Any person ordered to undergo assisted outpatient treatment pursuant to this article, who was not
present at the hearing at which the order was issued, may immediately petition the court for a writ of
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habeas corpus. Treatment under the order for assisted outpatient treatment may not commence until
the resolution of that petition.
5347. (a) In any county in which services are available pursuant to Section 5348, any person who is
determined by the court to be subject to subdivision (a) of Section 5346 may voluntarily enter into an
agreement for services under this section.
(b) (1) After a petition for an order for assisted outpatient treatment is filed, but before the conclusion
of the hearing on the petition, the person who is the subject of the petition, or the person's legal
counsel with the person's consent, may waive the right to an assisted outpatient treatment hearing for
the purpose of obtaining treatment under a settlement agreement, provided that an examining licensed
mental health treatment provider states that the person can survive safely in the community. The
settlement agreement may not exceed 180 days in duration and shall be agreed to by all parties.
(2) The settlement agreement shall be in writing, shall be approved by the court, and shall include a
treatment plan developed by the community-based program that will provide services that provide
treatment in the least restrictive manner consistent with the needs of the person who is the subject of
the petition.
(3) Either party may request that the court modify the treatment plan at any time during the 180-day
period.
(4) The court shall designate the appropriate county department to monitor the person's treatment
under, and compliance with, the settlement agreement. If the person fails to comply with the treatment
according to the agreement, the designated county department shall notify the counsel designated by
the county and the person's counsel of the person's noncompliance.
(5) A settlement agreement approved by the court pursuant to this section shall have the same force
and effect as an order for assisted outpatient treatment pursuant to Section 5346.
(6) At a hearing on the issue of noncompliance with the agreement, the written statement of
noncompliance submitted shall be prima facie evidence that a violation of the conditions of the
agreement has occurred. If the person who is the subject of the petition denies any of the facts as stated
in the statement, he or she has the burden of proving by a preponderance of the evidence that the
alleged facts are false.
5348. (a) For purposes of subdivision (e) of Section 5346, a county that chooses to provide assisted
outpatient treatment services pursuant to this article shall offer assisted outpatient treatment services
including, but not limited to, all of the following:
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(1) Community-based, mobile, multidisciplinary, highly trained mental health teams that use high staff-
to-client ratios of no more than 10 clients per team member for those subject to court-ordered services
pursuant to Section 5346.
(2) A service planning and delivery process that includes the following:
(A) Determination of the numbers of persons to be served and the programs and services that will be
provided to meet their needs. The local director of mental health shall consult with the sheriff, the
police chief, the probation officer, the mental health board, contract agencies, and family, client, ethnic,
and citizen constituency groups as determined by the director.
(B) Plans for services, including outreach to families whose severely mentally ill adult is living with
them, design of mental health services, coordination and access to medications, psychiatric and
psychological services, substance abuse services, supportive housing or other housing assistance,
vocational rehabilitation, and veterans' services. Plans shall also contain evaluation strategies, which
shall consider cultural, linguistic, gender, age, and special needs of minorities and those based on any
characteristic listed or defined in Section 11135 of the Government Code in the target populations.
Provision shall be made for staff with the cultural background and linguistic skills necessary to remove
barriers to mental health services as a result of having limited-English-speaking ability and cultural
differences. Recipients of outreach services may include families, the public, primary care physicians,
and others who are likely to come into contact with individuals who may be suffering from an untreated
severe mental illness who would be likely to become homeless if the illness continued to be untreated
for a substantial period of time. Outreach to adults may include adults voluntarily or involuntarily
hospitalized as a result of a severe mental illness.
(C) Provision for services to meet the needs of persons who are physically disabled.
(D) Provision for services to meet the special needs of older adults.
(E) Provision for family support and consultation services, parenting support and consultation services,
and peer support or self-help group support, where appropriate.
(F) Provision for services to be client-directed and that employ psychosocial rehabilitation and
recovery principles.
(G) Provision for psychiatric and psychological services that are integrated with other services and for
psychiatric and psychological collaboration in overall service planning.
(H) Provision for services specifically directed to seriously mentally ill young adults 25 years of age or
younger who are homeless or at significant risk of becoming homeless. These provisions may include
continuation of services that still would be received through other funds had eligibility not been
terminated as a result of age.
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(I) Services reflecting special needs of women from diverse cultural backgrounds, including supportive
housing that accepts children, personal services coordinator therapeutic treatment, and substance
treatment programs that address gender-specific trauma and abuse in the lives of persons with mental
illness, and vocational rehabilitation programs that offer job training programs free of gender bias and
sensitive to the needs of women.
(J) Provision for housing for clients that is immediate, transitional, permanent, or all of these.
(K) Provision for clients who have been suffering from an untreated severe mental illness for less than
one year, and who do not require the full range of services, but are at risk of becoming homeless unless
a comprehensive individual and family support services plan is implemented. These clients shall be
served in a manner that is designed to meet their needs.
(3) Each client shall have a clearly designated mental health personal services coordinator who may be
part of a multidisciplinary treatment team who is responsible for providing or assuring needed services.
Responsibilities include complete assessment of the client's needs, development of the client's personal
services plan, linkage with all appropriate community services, monitoring of the quality and follow
through of services, and necessary advocacy to ensure each client receives those services that are
agreed to in the personal services plan. Each client shall participate in the development of his or her
personal services plan, and responsible staff shall consult with the designated conservator, if one has
been appointed, and, with the consent of the client, shall consult with the family and other significant
persons as appropriate.
(4) The individual personal services plan shall ensure that persons subject to assisted outpatient
treatment programs receive age-appropriate, gender-appropriate, and culturally appropriate services,
to the extent feasible, that are designed to enable recipients to:
(A) Live in the most independent, least restrictive housing feasible in the local community, and, for
clients with children, to live in a supportive housing environment that strives for reunification with their
children or assists clients in maintaining custody of their children as is appropriate.
(B) Engage in the highest level of work or productive activity appropriate to their abilities and
experience.
(C) Create and maintain a support system consisting of friends, family, and participation in community
activities.
(D) Access an appropriate level of academic education or vocational training.
(E) Obtain an adequate income.
(F) Self-manage their illnesses and exert as much control as possible over both the day-to-day and
long-term decisions that affect their lives.
(G) Access necessary physical health care and maintain the best possible physical health.
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(H) Reduce or eliminate serious antisocial or criminal behavior, and thereby reduce or eliminate their
contact with the criminal justice system.
(I) Reduce or eliminate the distress caused by the symptoms of mental illness.
(J) Have freedom from dangerous addictive substances.
(5) The individual personal services plan shall describe the service array that meets the requirements
of paragraph (4), and to the extent applicable to the individual, the requirements of paragraph (2).
(b) A county that provides assisted outpatient treatment services pursuant to this article also shall
offer the same services on a voluntary basis.
(c) Involuntary medication shall not be allowed absent a separate order by the court pursuant to
Sections 5332 to 5336, inclusive.
(d) A county that operates an assisted outpatient treatment program pursuant to this article shall
provide data to the State
Department of Health Care Services and, based on the data, the department shall report to the
Legislature on or before May 1 of each year in which the county provides services pursuant to this
article.
The report shall include, at a minimum, an evaluation of the effectiveness of the strategies employed by
each program operated pursuant to this article in reducing homelessness and hospitalization of persons
in the program and in reducing involvement with local law enforcement by persons in the program. The
evaluation and report shall also include any other measures identified by the department regarding
persons in the program and all of the following, based on information that is available:
(1) The number of persons served by the program and, of those, the number who are able to maintain
housing and the number who maintain contact with the treatment system.
(2) The number of persons in the program with contacts with local law enforcement, and the extent to
which local and state incarceration of persons in the program has been reduced or avoided.
(3) The number of persons in the program participating in employment services programs, including
competitive employment.
(4) The days of hospitalization of persons in the program that have been reduced or avoided.
(5) Adherence to prescribed treatment by persons in the program.
(6) Other indicators of successful engagement, if any, by persons in the program.
(7) Victimization of persons in the program.
(8) Violent behavior of persons in the program.
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(9) Substance abuse by persons in the program.
(10) Type, intensity, and frequency of treatment of persons in the program.
(11) Extent to which enforcement mechanisms are used by the program, when applicable.
(12) Social functioning of persons in the program.
(13) Skills in independent living of persons in the program.
(14) Satisfaction with program services both by those receiving them and by their families, when
relevant.
5349. This article shall be operative in those counties in which the county board of supervisors, by
resolution or through the county budget process, authorizes its application and makes a finding that no
voluntary mental health program serving adults, and no children's mental health program, may be
reduced as a result of the implementation of this article. To the extent otherwise permitted under state
and federal law, counties that elect to implement this article may pay for the provision of services under
Sections 5347 and 5348 using funds distributed to the counties from the Mental Health Subaccount, the
Mental Health Equity Subaccount, and the Vehicle License Collection Account of the Local Revenue
Fund, funds from the Mental Health Account and the Behavioral Health Subaccount within the Support
Services Account of the Local Revenue Fund 2011, funds from the Mental Health Services Fund when
included in county plans pursuant to Section 5847, and any other funds from which the Controller
makes distributions to the counties for those purposes. Compliance with this section shall be monitored
by the State Department of Health Care Services as part of its review and approval of county
performance contracts.
5349.1. (a) Counties that elect to implement this article, shall, in consultation with the State
Department of Health Care Services, client and family advocacy organizations, and other stakeholders,
develop a training and education program for purposes of improving the delivery of services to mentally
ill individuals who are, or who are at risk of being, involuntarily committed under this part. This training
shall be provided to mental health treatment providers contracting with participating counties and to
other individuals, including, but not limited to, mental health professionals, law enforcement officials,
and certification hearing officers involved in making treatment and involuntary commitment decisions.
(b) The training shall include both of the following:
(1) Information relative to legal requirements for detaining a person for involuntary inpatient and
outpatient treatment, including criteria to be considered with respect to determining if a person is
considered to be gravely disabled.
(2) Methods for ensuring that decisions regarding involuntary treatment as provided for in this part
direct patients toward the most effective treatment. Training shall include an emphasis on each
patient's right to provide informed consent to assistance.
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5349.5. (a) This article shall remain in effect only until January 1, 2017, and as of that date is repealed,
unless a later enacted statute that is enacted on or before January 1, 2017, deletes or extends that date.
(b) The State Department of Health Care Services shall submit a report and evaluation of all counties
implementing any component of this article to the Governor and to the Legislature by July 1, 2015.
The evaluation shall include data described in subdivision (d) of Section 5348.
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Appendix B: Meeting 1 Materials
Contra Costa County Behavioral Health Care Services
AB1421 Planning Work Group
Meeting #1
June 10, 2014, 2:00 - 5:00pm
Agenda
TIME TOPIC PRESENTER
2:00 I. Convening Cynthia Belon, LCSW, Behavioral Health Services
Background
Role of Planning Committee
2:15 II. Introductions Roberta Chambers, PsyD, RDA
Jane Stallman, Center for Strategic Facilitation The Facilitation Team
Participant Introductions
3:00 III. Facilitation Process Overview Jane Stallman, Center for Strategic Facilitation
Working Norms
Process Overview
Report Out on Participant Interviews
Questions & Answers
3:30 B R E A K (10 minutes)
3:40 VI. Building the Foundation Roberta Chambers, PsyD, RDA
AB1421 Overview
National/State Landscape
Evidence-based and Promising Service
Delivery Models
Systems Map
Questions & Answers
4:55 VII. Recap & Close Jane Stallman, Center for Strategic Facilitation
Meeting Recap
Next Work Session
Adjourn
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Working Together Effectively
Meeting Norms for the Contra Costa County AB1421 Planning Process
To build our ability to work together we…
Agree to participate. This is complex work. If we had an easy solution it would already
be implemented. Each of us has something important to contribute.
Learn from others’ questions and comments. No one has the perfect answer. By
putting together various insights and wisdom, we’ll be able to come up with solutions that
invite support.
Focus on interests, not positions – It is difficult to agree on positions, easier to
generate solutions that take into account all the interests identified.
Try to see the whole picture – not just the part that concerns you the most.
Be open to the possibility that with our combined intelligence, experience and
commitment, we will find ways to address the challenges in front of us.
Be open to all the various outcomes and not the outcome you may assume to be true
or most likely.
To show respect and courtesy, we agree to…
Have one person speak at a time.
Focus on one process, one content at a time – stay on the agenda.
Express disagreement with ideas, not people.
Keep your comments short – if you take up a lot of time, others won’t have any time to
share their experience, ideas and insights.
Be on time. Arrive on time and be back on time from breaks.
Use the parking lot for questions that are not on the agenda or will not serve the
greater good of the meeting, but should ultimately be addressed.
Turn off electronics or at minimum put on vibrate (step out if you need to take a call).
Practice “Step Up, Step Back” in order to make room for participation by all.
Acknowledge and address fears among participants as they come up in the process.
To promote understanding, we agree to…
Assume good intentions – really hearing one another as genuine participants in
solving a challenging problem.
Use inquiry more than advocacy. Inquiry allows us to understand more deeply.
Ask for clarification vs. assuming what another person means or intends to say.
Uncover underlying assumptions – your own as well as others’.
Based on working norms developed by Jane Stallman
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Mental Health Acronyms Reference Guide
Acronym Meaning Definition
Crisis and
Hospital
Services
PES
Psychiatric
Emergency
Services
A Psychiatric Emergency Services (PES) unit is designed to
provide accessible, professional, cost-effective services to
individuals in psychiatric and/or substance abuse crisis,
and strive to stabilize consumers on site and avoid
psychiatric hospitalization whenever possible. A PES
provides emergency/urgent walk-in and police-initiated
evaluation and crisis phone service 24 hours a day, 7 days
a week.
IPU Inpatient Unit
An inpatient unit, also called acute inpatient psychiatric
unit, provides 24 hour mental health services to individuals
with acute psychiatric conditions. Acute inpatient services
are short-term and targeted towards individuals who are
often high-utilizers of PES or other community resources.
Services provided in these settings are tailored to the
individual’s needs and may include but are not limited to:
medication evaluation and management; psycho-
educational groups; group and individual counseling;
family interventions; and substance use.
CSU
Crisis
Stabilization
Unit
Crisis Stabilization Unit services are provided to individuals
who are in psychiatric crisis whose needs cannot be
accommodated safely in the residential service settings.
CSUs can be designed for both voluntary and involuntary
consumers who are in need of a safe, secure environment
that is less restrictive than a hospital. The goal of the CSU
is to stabilize the consumer and re-integrate him or her
back into the community quickly. The typical length of stay
in a CSU is 23 hours. Consumers in CSUs receive
medication, counseling, referrals, and linkage to ongoing
services.
PHF Psychiatric
Health Facility
A psychiatric health facility is defined to mean a health
facility that provides 24-hour inpatient care for patients
with severe mental health needs whose physical health
needs can be met in an affiliated hospital or in outpatient
settings. Services include, but are not limited to:
psychiatry; clinical psychology; psychiatric nursing; social
work; rehabilitation; and medication evaluation and
management.
Residential
Services
MHRC
Mental Health
Rehabilitation
Center
Mental health rehabilitation center means a 24–hour
program which provides intensive support and
rehabilitation services designed to assist adults with
mental disorders who would otherwise have been placed
in a state hospital or another mental health facility to
develop the skills to become self–sufficient and capable of
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increasing levels of independent functioning.
CRT
Crisis
Residential
Treatment
An alternative to hospitalization, CRTs provide intensive
mental health and behavioral supports to resolve the
consumer’s current crisis and develop skills to reduce the
likelihood of future crisis events. CRT’s use a short stay
model, generally 5-14 days, through which consumers
have access to integrated professional staff, medication
evaluation and management, individual and group
therapy, and life skills support.
ART / TR
Adult
Residential
Treatment /
Transitional
Residential
ART/TR represents a wide a variety of transitional living
programs designed to meet the needs of multiple
populations who do not required locked or institutional
settings for treatment. Lengths of stay range from three to
eighteen months and focus on assisting individuals in
addressing any issues that lead to their enrollment in the
program and develop a strategy for returning to a more
independent setting.
Outpatient
Services
ACT
Assertive
Community
Treatment
Assertive Community Treatment is an evidence-based
team treatment approach designed to provide
comprehensive, community-based psychiatric treatment,
rehabilitation, and support to persons with serious and
persistent mental illness. Among the services ACT teams
provide are: case management, initial and ongoing
assessments; psychiatric services; employment and
housing assistance; family support and education;
substance abuse services; and other services and supports
critical to an individual's ability to live successfully in the
community. ACT services are available 24 hours per day,
365 days per year.
ICM Intensive Case
Management
Intensive Case Management (ICM) is a community based
package of care, aiming to provide long term care for
severely mentally ill people who do not require immediate
admission. Intensive case management is differentiated
from other forms of case management through factors like
a smaller caseload size, team management, outreach
emphasis, a decreased brokerage role, and an assertive
approach to maintaining contact with clients.
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Laura’s Law (AB 1421)
A Functional Outline
Assisted Outpatient Treatment Investigations
Only the county mental health director, or his or her designee, may file a petition with
the superior court in the county where the person is present or reasonably believed to
be present. The following persons, however, may request that the county health
department investigate whether to file a petition for the treatment of an individual:
1) Any adult with whom the person resides;
2) An adult parent, spouse, sibling, or adult child of the person;
3) If the person is an inpatient, the hospital director;
4) The director of a program providing mental health services to the person in
whose institution the person resides;
5) A treating or supervising licensed mental health treatment provider; or
6) The person’s parole or probation officer.
On receiving a request from a person in one of the classes above, the county mental
health director is required to conduct an investigation. The director, however, shall only
file a petition if he or she determines that it is likely that all the necessary elements for
an AOT petition can be proven by clear and convincing evidence. The availability of
assisted outpatient services for the anticipated length of the order (up to six months)
must be established by the court before ordering assisted outpatient treatment. Thus a
county mental health director who does not believe the requisite qualified services are
available is precluded from filing a petition.
Assisted Outpatient Treatment Criteria
A person may be placed in assisted outpatient treatment only if, after a hearing, a court
finds that all of the following have been met. The person must:
1) Be eighteen years of age or older;
2) Be suffering from a mental illness;
3) Be unlikely to survive safely in the community without supervision, based on a
clinical determination;
4) Have a history of non-compliance with treatment that has either:
A. Been a significant factor in his or her being in a hospital, prison or jail at
least twice within the last thirty-six months or;
B. Resulted in one or more acts, attempts or threats of serious violent
behavior toward self or others within the last forty-eight months;
5) Have been offered an opportunity to voluntarily participate in a treatment plan
by the local mental health department but continues to fail to engage in
treatment;
6) Be substantially deteriorating;
7) Be, in view of his or her treatment history and current behavior, in need of
assisted outpatient treatment in order to prevent a relapse or deterioration that
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would likely result in the person meeting California’s inpatient commitment
standard, which is being:
A. A serious risk of harm to himself or herself or others; or
B. Gravely disabled (in immediate physical danger because unable to
meet basic needs for food, clothing, or shelter);
8) Be likely to benefit from assisted outpatient treatment; and
9) Participation in the assisted outpatient program is the least restrictive placement
necessary to ensure the person’s recovery and stability.
Any time spent in a hospital or jail immediately prior to the filing of the petition does not
count towards either the 36 or 48-month time limits in criterion No. 4 above. In other
words, if an individual spent the two months prior to the filing in a hospital, the court can
then look back 38 months (36+2) to see if he or she meets criterion No. 4(A).
Petition for Assisted Outpatient Treatment
The petition must state: (1) that the person is present or believed to be present within
the county where the petition is filed; (2) all the criteria necessary for placement in AOT;
(3) the facts supporting the belief that the person meets all the criteria (4) that the
subject of the petition has the right to represented by counsel.
The petition must be accompanied by an affidavit of a licensed mental health treatment
provider designated by the county mental health director stating that either:
1) The licensed mental health treatment provider examined the person no more than ten
days prior to the submission of the petition, believes that the person meets the criteria
for assisted outpatient treatment, the recommends assisted outpati ent treatment, and is
willing to testify at the hearing; or 2) The licensed mental health treatment provider, or
his or her designee, made appropriate attempts no more than ten days prior to the filing
of the petition to examine the person and the person refused, has reason to suspect the
person meets the criteria assisted outpatient treatment, and is willing to examine the
person and testify at the hearing.
The court must fix a date for a hearing on the petition that is no more than five days
(excluding weekends and holidays) after the petition is filed.
Continuances will only be allowed for good cause. Before granting one, the court shall
consider the need for an examination by a physician, or the need to provide assisted
outpatient treatment expeditiously.
Notice of Hearing
The petitioner must cause a copy of the petition and notice of the hearing to be
personally served on the person who is its subject. The petitioner also has to send
notice of the hearing and a copy of the petition to:
1) The county office of patient rights; and
2) The current health care provider appointed for the person, if known.
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Note: The person subject to a petition may also designate others to receive
adequate notice of the hearings.
Right to Counsel
The person who is subject to the petition has the right to be represented by
counsel at all stages of an AOT court proceeding. If the person elects, the court
shall immediately appoint a public defender or other attorney to oppose the
petition. If able to afford it, the person is responsible for the cost of the legal
representation on his or her behalf.
Settlement Agreements
After an AOT petition is filed but before the conclusion of the hearing on it, the person
who is the subject of the petition may waive the right to a hearing and enter into a
settlement agreement. If the court approves it, a settlement agreement has the same
force and effect as a court order for assisted outpatient treatment.
The settlement agreement must be in writing, agreed to by all parties and the court, and
may not exceed 180 days (note – initial orders by a court after a hearing are for a period
of up to six months, which can be a few days longer). The agreement is conditioned
upon an examining licensed mental health treatment provider stating that the person
can survive safely in the community. It also must include a treatment plan developed by
the community-based program that will provide services to the person.
After entering a settlement agreement, a court designates the appropriate county
department to monitor the person’s treatment under, and compliance with, the
settlement agreement. Only the court can modify settlement agreements, but either
party may request a modification at any time during the 180-day period.
Assisted Outpatient Treatment Hearing
The court will hear testimony and, if advisable, examine the person (in or out of court).
The testimony need not be limited to the facts included in the petition.
If the person fails to appear at the hearing and appropriate attempts to e licit attendance
have failed, the court may conduct the hearing in the person’s absence. However, the
court is prohibited from ordering AOT unless a physician who has reviewed the
available treatment history of the person and personally examined him or her no more
than ten days before the filing of the petition testifies in person at the hearing.
If the person is present at the hearing but has refused and continues to refuse to be
examined and the court finds reasonable cause to believe the allegations in the petition
to be true, it may order the person be taken into custody and transported to a hospital
for examination by a licensed mental health treatment provider. Absent the use of the
inpatient hospitalization provisions of California law, the person may be kept at the
hospital for no more than 72 hours.
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Any person ordered to undergo assisted outpatient treatment who was not present at
the hearing at which the order was issued may immediately petition the court for a writ
of habeas corpus, which is a judicial challenge asserting that, under these
circumstances, the person does not meet the eligibility criteria for AOT. Treatment
under the order may not commence until that petition is resolved in another hearing.
If after hearing all relevant evidence, the court finds that the person does not meet the
criteria for assisted outpatient treatment, the court will dismiss the petition.
If the court finds, by clear and convincing evidence, that the person meets the criteria
for assisted outpatient treatment and there is no appropriate and feasible less restrictive
alternative, the court may order the person to receive assisted outpatient treatment for
up to six months.
The Treatment Plan
In the assisted outpatient treatment order, the court shall specify the services that the
person is to receive. The court may not require any treatment that is not included in the
proposed treatment plan submitted by the examining licensed mental health treatment
provider. The court, in consultation with the county mental health director, must also find
the following:
1) That the ordered services are available from the county or a provider approved by the
county for the duration of the court order;
2) That the ordered services have been offered on a voluntary basis to the person by
the local director of mental health, or his or her designee, and the person has person
has refused or failed to engage in treatment;
3) That all of the elements of the petition have been met; and
4) That the treatment plan incorporated in the order will be delivered to the county
director of mental health, or his or her appropriate designee.
Renewals
If the condition of the person requires an additional period of AOT, the director of
the assisted outpatient treatment program may apply to the court prior to the
initial order’s expiration for an additional period of AOT of no more than 180 days
(initial orders are for a period of up to six months, which can be a few days
longer). The procedures and requirements for obtaining a renewal order are the
same as for obtaining an initial order.
Early Release from Assisted Outpatient Treatment
There are two methods by which someone under an order can establish that he or she
no longer meets the eligibility criteria and should be released from an AOT order:
1) No less than every 60 days the director of the assisted outpatient treatment program
is required to file an affidavit with the court stating that the person still meets the criteria
for placement in the program. Although not explicitly stated in the stat ute, this
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presumably means that anyone who does not meet the criteria must be released from
AOT. The person has the right to a hearing to challenge the assessment. If the court
finds that the person does not meet the criteria, it will void the AOT order.
2) Also, an assisted outpatient may at any time file a petition for a writ of habeas corpus.
At the hearing on this petition the court will determine whether or not the person still
meets the initial AOT eligibility requirements. If not, the person shall be released from
the AOT order.
In either type of hearing the burden of proving that the AOT criteria are still met is on the
director.
Remedy for Non-Compliance with Assisted Outpatient Treatment
A licensed mental health treatment provider can request that one of certain designated
classes of persons (peace officers, evaluation facility attending staff, members of mobile
crisis teams, and other professional persons designated by the county) take a person
under an AOT order to a hospital to be held for an up to 72-hour examination to
determine if he or she meets the criteria for inpatient hospitalization (i.e., that the person
is a danger to self/others or gravely disabled because of a mental illness).
The treatment provider may only make such a request on determining that:
1) The person has failed or refused to comply with the court-ordered treatment,
2) Efforts were made to solicit compliance, and
3) The person may need involuntary admission to a hospital for evaluation.
Any continued involuntary retention in the evaluating facility beyond the initial 72 hours
must be pursuant to the California Code’s provisions for inpatient hospitalization. A
person found not to meet the standard for involuntary inpatient hospitalization during the
evaluation period and who does not agree to stay in the hospital voluntarily must be
released.
Failure to comply with an order of assisted outpatient treatment alone is not sufficient
grounds for involuntary civil commitment. Neither may such non-compliance result in a
finding of contempt of court.
Rights of Persons Subject to Petitions and Orders for Assisted Outpatient
Treatment
A person subject to a petition for assisted outpatient treatment has the right to:
1) Retain counsel or utilize the services of a court-appointed public defender;
2) Adequate notice of the hearings;
3) Have notice of hearings sent to parties designated by the person;
4) Receive a copy of the court-ordered evaluation;
5) Present evidence, call witnesses, and cross-examine adverse witnesses;
6) Be informed of his or her right to judicial review by habeas corpus;
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7) Not be involuntarily committed or held in contempt of court solely for failure to comply
with a treatment order;
8) Be present at the hearing, unless he or she waives this right;
9) Appeal decisions, and to be informed of his or her right to appeal; and
10) Receive the least restrictive treatment deemed appropriate and feasible.
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AB1421 Planning Meeting Feedback Form
Thank you for participating in the Contra Costa County Behavioral Health Services’ AB1421 Planning
Process. We would like to hear about your experience with the Planning Meeting today. Your feedback
will guide future meetings. Please take a few minutes to fill out this anonymous feedback form and
leave it at the registration table before you leave today.
Based on your expectations for the AB1421 Planning Process, please mark to what extent you agree with
the following statements.
Strongly
Disagree Disagree Agree Strongly
Agree
1. The proposed process will strengthen the
behavioral health system in Contra Costa
County.
2. The information presented in today’s meeting
was appropriate and meaningful.
Poor Fair Good Excellent
3. Overall, how would you rate the quality of the
facilitation for the Planning Meeting today?
4. Rate the degree to which you felt the agenda
allowed adequate time for questions and
discussion.
5. Please share any additional comments or suggestions you may have about the AB1421 Planning
Process:
Thank you!
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Appendix C: Meeting 2 Materials
Contra Costa County Behavioral Health Care Services
AB1421 Planning Work Group
Meeting #2
June 16, 2014, 2:00 - 5:00pm
Agenda
TIME TOPIC PRESENTER
2:00 I. Convening Roberta Chambers, PsyD, RDA
Review Progress and Agenda
Follow-up from previous meeting
2:15 II. Defining the Target Population Roberta Chambers, PsyD, RDA
Jane Stallman, Center for Strategic Facilitation Data Review
Questions and Answers
2:45 III. System Overview Roberta Chambers, PsyD, RDA
System Map
Questions and Answers
Strengths and Gaps Group Exercise
Jane Stallman, Center for Strategic Facilitation
3:30 B R E A K (10 minutes)
3:45 VI. Conversations of Significance Jane Stallman, Center for Strategic Facilitation
What are the criteria for a successful
recommendation?
What are other conversations we need
to have?
4:45 VII. Recap & Close Roberta Chambers, PsyD, RDA
Meeting Recap
Next Work Session
Feedback form
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Assembly Bill No. 1421
CHAPTER 1017
An act to add and repeal Article 9 (commencing with Section 5345) of Chapter 2 of Part 1 of Division 5 of the Welfare and
Institutions Code, relating to mental health.
[ Filed with Secretary of State September 28, 2002. Approved by Governor September 28, 2002. ]
LEGISLATIVE COUNSEL'S DIGEST
AB 1421, Thomson. Mental health: involuntary treatment.
Existing law, the Lanterman-Petris-Short Act, makes provision for the involuntary treatment of any
person with a mental disorder who, as a result of the mental disorder, is a danger to others or to himself
or herself, or is gravely disabled.
This bill, until January 1, 2008, would enact the Assisted Outpatient Treatment Demonstration Project
Act of 2002, which would create an assisted outpatient treatment program for any person who is
suffering from a mental disorder and meets certain criteria. The program would operate in counties that
choose to provide the services.
The program would involve the delivery of community-based care by multidisciplinary teams of highly
trained mental health professionals with staff-to-client ratios of not more than 1 to 10, and additional
services, as specified, for persons with the most persistent and severe mental illness. This bill would
specify requirements for the petition alleging the necessity of treatment, various rights of the person
who is the subject of the petition, and hearing procedures. This bill would also provide for settlemen t
agreements as an alternative to the hearing process. This bill would provide that if the person who is the
subject of the petition fails to comply with outpatient treatment, despite efforts to solicit compliance, a
licensed mental health treatment provider may request that the person be placed under a 72-hour hold
based on an involuntary commitment.
This bill would also require each county operating an outpatient treatment program pursuant to the bill
to provide certain data to the State Department of Mental Health, and would impose requirements
upon the department to report to the Legislature, as specified.
The bill would also require the department to develop a specified training and education program for
use in counties participating in the program pursuant to the bill.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the following:
(a) On February 15, 2001, the Rand Corporation released a report, commissioned by the California
Senate
Committee on Rules, titled “The Effectiveness of Involuntary Outpatient Treatment: Empirical Evidence
and the Experience of Eight States,” which is an evidence-based approach to examining and synthesizing
empirical research on involuntary outpatient treatment.
b) Rand’s findings include the following:
(1) Data from the State Department of Mental Health’s Client Data System, documenting about one-half
of all commitments in California, indicate that 58,439 individuals accounted for 106,314 admissions
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person who is the subject of the petition who is alleged to be in need of assisted outpatient treatment. If
the person who is the subject of the petition does not appear at the hearing, and appropriate attempts
to elicit the attendance of the person have failed, the court may conduct the hearing in the person’s
absence. If the hearing is conducted without the person present, the court shall set forth the factual
basis for conducting the hearing without the person’s presence.
(2) The court shall not order assisted outpatient treatment unless an examining licensed mental health
treatment provider, who has personally examined, and has reviewed the available treatment history
of, the person who is the subject of the petition within the time period commencing 10 days before
the filing of the petition, testifies in person at the hearing.
(3) If the person who is the subject of the petition has refused to be examined by a licensed mental
health treatment provider, the court may request that the person consent to an examination by a
licensed mental health treatment provider appointed by the court. If the person who is the subject
of the petition does not consent and the court finds reasonable cause to believe that the allegations
in the petition are true, the court may order any person designated under Section 5150 to take into
custody the person who is the subject of the petition and transport him or her, or cause him or her
to be transported, to a hospital for examination by a licensed mental health treatment provider as
soon as is practicable. Detention of the person who is the subject of the petition under the order
may not exceed 72 hours. If the examination is performed by another licensed mental health
treatment provider, the examining licensed mental health treatment provider may consult with the
licensed mental health treatment provider whose affirmation or affidavit accompanied the petition
regarding the issues of whether the allegations in the petition are true and whether the person
meets the criteria for assisted outpatient treatment.
(4) The person who is the subject of the petition shall have all of the following rights:
(A) To adequate notice of the hearings to the person who is the subject of the petition, as well as to
parties designated by the person who is the subject of the petition.
(B) To receive a copy of the court-ordered evaluation.
(C) To counsel. If the person has not retained counsel, the court shall appoint a public defender.
(D) To be informed of his or her right to judicial review by habeas corpus.
(E) To be present at the hearing unless he or she waives the right to be present.
(F) To present evidence.
(G) To call witnesses on his or her behalf.
(H) To cross-examine witnesses.
(I) To appeal decisions, and to be informed of his or her right to appeal.
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(5) (A) If after hearing all relevant evidence, the court finds that the person who is the subject of the
petition does not meet the criteria for assisted outpatient treatment, the court shall dismiss the
petition.
(B) If after hearing all relevant evidence, the court finds that the person who is the subject of the
petition meets the criteria for assisted outpatient treatment, and there is no appropriate and feasible
less restrictive alternative, the court may order the person who is the subject of the petition to receive
assisted outpatient treatment for an initial period not to exceed six months. In fashioning the order, the
court shall specify that the proposed treatment is the least restrictive treatment appropriate and
feasible for the person who is the subject of the petition. The order shall state the categories of assisted
outpatient treatment, as set forth in Section 5348, that the person who is the subject of the petition is
to receive, and the court may not order treatment that has not been recommended by the examining
licensed mental health treatment provider and included in the written treatment plan for assisted
outpatient treatment as required by subdivision (e). If the person has executed an advance health care
directive pursuant to Chapter 2 (commencing with Section 4650) of Part 1 of Division 4.7 of the Probate
Code, any directions included in the advance health care directive shall be considered in formulating the
written treatment plan.
(6) If the person who is the subject of a petition for an order for assisted outpatient treatment pursuant
to subparagraph (B) of paragraph (5) of subdivision (d) refuses to participate in the assisted outpatient
treatment program, the court may order the person to meet with the assisted outpatient treatment
team designated by the director of the assisted outpatient treatment program. The treatment team
shall attempt to gain the person’s cooperation with treatment ordered by the court. The person may be
subject to a 72-hour hold pursuant to subdivision (f) only after the treatment team has attempted to
gain the person’s cooperation with treatment ordered by the court, and has been unable to do so.
(e) Assisted outpatient treatment shall not be ordered unless the licensed mental health treatment
provider recommending assisted outpatient treatment to the court has submitted to the court a written
treatment plan that includes services as set forth in Section 5348, and the court finds, in consultation
with the county mental health director, or his or her designee, all of the following:
(1) That the services are available from the county, or a provider approved by the county, for the
duration of the court order.
(2) That the services have been offered to the person by the local director of mental health, or his or her
designee, and the person has been given an opportunity to participate on a voluntary basis, and the
person has failed to engage in, or has refused, treatment.
(3) That all of elements of the petition required by this article have been met.
(4) That the treatment plan will be delivered to the county director of mental health, or to his or her
appropriate designee.
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(f) If, in the clinical judgment of a licensed mental health treatment provider, the person who is the
subject of the petition has failed or has refused to comply with the treatment ordered by the court, and,
in the clinical judgment of the licensed mental health treatment provider, efforts were made to solicit
compliance, and, in the clinical judgment of the licensed mental health treatment provider, the person
may be in need of involuntary admission to a hospital for evaluation, the provider may request that
persons designated under Section 5150 take into custody the person who is the subject of the petition
and transport him or her, or cause him or her to be transported, to a hospital, to be held up to 72 hours
for examination by a licensed mental health treatment provider to determine if the person is in need of
treatment pursuant to Section 5150. Any continued involuntary retention in a hospital beyond the initial
72-hour period shall be pursuant to Section 5150. If at any time during the 72-hour period the person is
determined not to meet the criteria of Section 5150, and does not agree to stay in the hospital as a
voluntary patient, he or she shall be released and any subsequent involuntary detention in a hospital
shall be pursuant to Section 5150. Failure to comply with an order of assisted outpatient treatment
alone may not be grounds for involuntary civil commitment or a finding that the person who is the
subject of the petition is in contempt of court.
(g) If the director of the assisted outpatient treatment program determines that the condition of
the patient requires further assisted outpatient treatment, the director shall apply to the court, prior to
the expiration of the period of the initial assisted outpatient treatment order, for an order authorizing
continued assisted outpatient treatment for a period not to exceed 180 days from the date of the order.
The procedures for obtaining any order pursuant to this subdivision shall be in accordance with
subdivisions (a) to (f), inclusive. The period for further involuntary outpatient treatment authorized by
any subsequent order under this subdivision may not exceed 180 days from the date of the order.
(h) At intervals of not less than 60 days during an assisted outpatient treatment order, the director
of the outpatient treatment program shall file an affidavit with the court that ordered the outpatient
treatment affirming that the person who is the subject of the order continues to meet the criteria for
assisted outpatient treatment. At these times, the person who is the subject of the order shall have the
right to a hearing on whether or not he or she still meets the criteria for assisted outpatient treatment if
he or she disagrees with the director’s affidavit. The burden of proof shall be on the director.
(i) During each 60-day period specified in subdivision (h), if the person who is the subject of the
order believes that he or she is being wrongfully retained in the assisted outpatient treatment program
against his or her wishes, he or she may file a petition for a writ of habeas corpus, thus requiring the
director of the assisted outpatient treatment program to prove that the person who is the subject of the
order continues to meet the criteria for assisted outpatient treatment.
(j) Any person ordered to undergo assisted outpatient treatment pursuant to this article, who was
not present at the hearing at which the order was issued, may immediately petition the court for a writ
of habeas corpus. Treatment under the order for assisted outpatient treatment may not commence
until the resolution of that petition.
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5347. (a) In any county in which services are available pursuant to Section 5348, any person who is
determined by the court to be subject to subdivision (a) of Section 5346 may voluntarily enter into an
agreement for services under this section.
(b) (1) After a petition for an order for assisted outpatient treatment is filed, but before the conclusion
of the hearing on the petition, the person who is the subject of the petition, or the person’s legal
counsel with the person’s consent, may waive the right to an assisted outpatient treatment hearing for
the purpose of obtaining treatment under a settlement agreement, provided that an examining licensed
mental health treatment provider states that the person can survive safely in the community. The
settlement agreement may not exceed 180 days in duration and shall be agreed to by all parties.
(2) The settlement agreement shall be in writing, shall be approved by the court, and shall include a
treatment plan developed by the community-based program that will provide services that provide
treatment in the least restrictive manner consistent with the needs of the person who is the subject
of the petition.
(3) Either party may request that the court modify the treatment plan at any time during the 180-day
period.
(4) The court shall designate the appropriate county department to monitor the person’s treatment
under, and compliance with, the settlement agreement. If the person fails to comply with the
treatment according to the agreement, the designated county department shall notify the counsel
designated by the county and the person’s counsel of the person’s noncompliance.
(5) A settlement agreement approved by the court pursuant to this section shall have the same force
and effect as an order for assisted outpatient treatment pursuant to Section 5346.
(6) At a hearing on the issue of noncompliance with the agreement, the written statement of
noncompliance submitted shall be prima facie evidence that a violation of the conditions of the
agreement has occurred. If the person who is the subject of the petition denies any of the facts as
stated in the statement, he or she has the burden of proving by a preponderance of the evidence
that the alleged facts are false.
5348. (a) For purposes of subdivision (e) of Section 5346, any county that chooses to provide assisted
outpatient treatment services pursuant to this article shall offer assisted outpatient treatment services
including, but not limited to, all of the following:
(1) Community-based, mobile, multidisciplinary, highly trained mental health teams that use high staff-
to-client ratios of no more than 10 clients per team member for those subject to court-ordered
services pursuant to Section 5346.
(2) A service planning and delivery process that includes the following:
(A) Determination of the numbers of persons to be served and the programs and services that will be
provided to meet their needs. The local director of mental health shall consult with the sheriff, the
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police chief, the probation officer, the mental health board, contract agencies, and family, client,
ethnic, and citizen constituency groups as determined by the director.
(B) Plans for services, including outreach to families whose severely mentally ill adult is living with them,
design of mental health services, coordination and access to medications, psychiatric and
psychological services, substance abuse services, supportive housing or other housing assistance,
vocational rehabilitation, and veterans’ services. Plans shall also contain evaluation strategies, that
shall consider cultural, linguistic, gender, age, and special needs of minorities in the target
populations. Provision shall be made for staff with the cultural background and linguistic skills
necessary to remove barriers to mental health services as a result of having limited-English-speaking
ability and cultural differences. Recipients of outreach services may include families, the public,
primary care physicians, and others who are likely to come into contact with individuals who may be
suffering from an untreated severe mental illness who would be likely to become homeless if the
illness continued to be untreated for a substantial period of time. Outreach to adults may include
adults voluntarily or involuntarily hospitalized as a result of a severe mental illness.
(C) Provisions for services to meet the needs of persons who are physically disabled.
(D) Provision for services to meet the special needs of older adults.
(E) Provision for family support and consultation services, parenting support and consultation services,
and peer support or self-help group support, where appropriate.
(F) Provision for services to be client-directed and that employ psychosocial rehabilitation and recovery
principles.
(G) Provision for psychiatric and psychological services that are integrated with other services and for
psychiatric and psychological collaboration in overall service planning.
(H) Provision for services specifically directed to seriously mentally ill young adults 25 years of age or
younger who are homeless or at significant risk of becoming homeless. These provisions may include
continuation of services that would still be received through other funds had eligibility not been
terminated as a result of age.
(I) Services reflecting special needs of women from diverse cultural backgrounds, including supportive
housing that accepts children, personal services coordinator therapeutic treatment, and substance
treatment programs that address gender specific trauma and abuse in the lives of persons with
mental illness, and vocational rehabilitation programs that offer job training programs free of gender
bias and sensitive to the needs of women.
(J) Provision for housing for clients that is immediate, transitional, permanent, or all of these.
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(K) Provision for clients who have been suffering from an untreated severe mental illness for less than
one year, and who do not require the full range of services, but are at risk of becoming homeless
unless a comprehensive individual and family support services plan is implemented. These clients
shall be served in a manner that is designed to meet their needs.
(3) Each client shall have a clearly designated mental health personal services coordinator who may
be part of a multidisciplinary treatment team who is responsible for providing or assuring needed
services. Responsibilities include complete assessment of the client’s needs, development of the client’s
personal services plan, linkage with all appropriate community services, monitoring of the quality and
follow through of services, and necessary advocacy to ensure each client receives those services which
are agreed to in the personal services plan. Each client shall participate in the development of his or her
personal services plan, and responsible staff shall consult with the designated conservator, if one has
been appointed, and, with the consent of the client, shall consult with the family and other significant
persons as appropriate.
(4) The individual personal services plan shall ensure that persons subject to assisted outpatient
treatment programs receive age, gender, and culturally appropriate services, to the extent feasible, that
are designed to enable recipients to:
(A) Live in the most independent, least restrictive housing feasible in the local community, and, for
clients with children, to live in a supportive housing environment that strives for reunification with
their children or assists clients in maintaining custody of their children as is appropriate.
(B) Engage in the highest level of work or productive activity appropriate to their abilities and
experience.
(C) Create and maintain a support system consisting of friends, family, and participation in community
activities.
(D) Access an appropriate level of academic education or vocational training.
(E) Obtain an adequate income.
(F) Self-manage their illnesses and exert as much control as possible over both the day-to-day and long-
term decisions that affect their lives.
(G) Access necessary physical health care and maintain the best possible physical health.
(H) Reduce or eliminate serious antisocial or criminal behavior, and thereby reduce or eliminate their
contact with the criminal justice system.
(I) Reduce or eliminate the distress caused by the symptoms of mental illness.
(J) Have freedom from dangerous addictive substances.
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(5) The individual personal services plan shall describe the service array that meets the requirements of
paragraph (4), and to the extent applicable to the individual, the requirements of paragraph (2).
(b) Any county that provides assisted outpatient treatment services pursuant to this article also
shall offer the same services on a voluntary basis.
(c) Involuntary medication shall not be allowed absent a separate order by the court pursuant to
Sections5332 to 5336, inclusive.
(d) Each county that operates an assisted outpatient treatment program pursuant to this article
shall provide data to the State Department of Mental Health and, based on the data, the department
shall report to the Legislature on or before May 1 of each year in which the county provides services
pursuant to this article. The report shall include, at a minimum, an evaluation of the effectiveness of the
strategies employed by each program operated pursuant to this article in reducing homelessness a nd
hospitalization of persons in the program and in reducing involvement with local law enforcement by
persons in the program. The evaluation and report shall also include any other measures identified by
the department regarding persons in the program and all of the following, based on information that is
available:
(1) The number of persons served by the program and, of those, the number who are able to maintain
housing and the number who maintain contact with the treatment system.
(2) The number of persons in the program with contacts with local law enforcement, and the extent to
which local and state incarceration of persons in the program has been reduced or avoided.
(3) The number of persons in the program participating in employment services programs, including
competitive employment.
(4) The days of hospitalization of persons in the program that have been reduced or avoided.
(5) Adherence to prescribed treatment by persons in the program.
(6) Other indicators of successful engagement, if any, by persons in the program.
(7) Victimization of persons in the program.
(8) Violent behavior of persons in the program.
(9) Substance abuse by persons in the program.
(10) Type, intensity, and frequency of treatment of persons in the program.
(11) Extent to which enforcement mechanisms are used by the program, when applicable.
(12) Social functioning of persons in the program.
(13) Skills in independent living of persons in the program.
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(14) Satisfaction with program services both by those receiving them and by their families, when
relevant.
5349. This article shall be operative in those counties in which the county board of supervisors, by
resolution, authorizes its application and makes a finding that no voluntary mental health program
serving adults, and no children’s mental health program, may be reduced as a result of the
implementation of this article. Compliance with this section shall be monitored by the State Department
of Mental Health as part of its review and approval of county Short-Doyle plans.
5349.1. (a) Counties that elect to implement this article, shall, in consultation with the department,
client and family advocacy organizations, and other stakeholders, develop a training and education
program for purposes of improving the delivery of services to mentally ill individuals who are, or who
are at risk of being, involuntarily committed under this part. This training shall be provided to mental
health treatment providers contracting with participating counties and to other individuals, including,
but not limited to, mental health professionals, law enforcement officials, and certification hearing
officers involved in making treatment and involuntary commitment decisions.
(b) The training shall include both of the following:
(1) Information relative to legal requirements for detaining a person for involuntary inpatient and
outpatient treatment, including criteria to be considered with respect to determining if a person is
considered to be gravely disabled.
(2) Methods for ensuring that decisions regarding involuntary treatment as provided for in this part
direct patients toward the most effective treatment. Training shall include an emphasis on each
patient’s right to provide informed consent to assistance.
(15) 5349.5. This article shall remain in effect only until January 1, 2008, and as of that date is
repealed, unless a later enacted statute that is enacted on or before January 1, 2008, deletes or
extends that date.
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San Diego’s In Home Outreach Team (IHOT) Model
The IHOT are mobile teams that provide in-home outreach and engagement services to individuals with
Severe Mental Illness (SMI) who are reluctant to seek outpatient mental health services, and to their
family members or caretakers. The program utilizes rehabilitation and recovery practices and principles
to provide clients with a variety of services to identify and pursue goals that will improve quality of life,
self-sufficiency and independence by helping the client identify ways to manage their symptoms, their
health and their recovery.
IHOT teams provide the following services to individuals with SMI and their family or caretaker, as
necessary:
In-home assessment,
Crisis intervention,
Case management and support services, including:
o Information and education about mental health services and community resources, and
o Linkages to access outpatient mental health care and rehabilitation and recovery
services.
IHOT collaborates with family members, regionally based providers, and the Psychiatric Emergency
Response Team (PERT), all of whom refer clients and family members to IHOT for outreach and
engagement to facilitate follow up services that may include:
Outpatient specialty mental health services,
Crisis intervention,
Acute care,
Alternatives to psychiatric hospitalization,
Conservatorship and
Case management services.
The overall goal of IHOT is to develop rapport and a relationship with the identified client so as to
increase the individual awareness as to the benefits in managing his/her symptoms and behaviors by
choosing to participate in outpatient mental health services, rehabilitation and recovery services or non-
clinical support services. This program is targeted to increase family member satisfaction with the
mental health system of care, as well as to reduce the effects of untreated mental illness in individuals
with Serious Mental Illness (SMI) and their families.
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Specific IHOT Services
1. Motivational interviewing and other best practices and evidence based practices in outreach
and engagement services.
2. Culturally relevant services to diverse populations to include non-ethnic populations, including
those based on gender (both men and women), and lesbian, gay, bi-sexual, trans-gendered, and
queer/questioning (LGBTQ) persons with a serious mental illness.
3. Culturally-appropriate services offered in the client’s/family’s preferred language. When this is
not possible, IHOT shall arrange for appropriate interpretation services.
4. Coordination of transitional services to appropriate outpatient programs.
5. Outreach and engagement provided in client’s home, in community, in hospital or IMD, or at
other location convenient for the client., and services that include:
a. In-home assessment,
b. Crisis intervention,
c. Case management, and
d. Educational and support services to individuals with SMI and their family or caretaker.
6. Educational and support services to client and family member to increase understanding of
mental health disorders, outpatient services, access to services, and navigating the system of
care.
7. Case management services that include:
a. Linkage, consultation, and placement services,
b. On-call response for after business hours and on weekends,
c. Collaboration with the Public Conservator on behalf of clients on Public Conservatorship,
d. Intensive and as needed outreach and engagement services to persons identified as having
a high priority for this service in the client’s residence, and
e. Individualized, comprehensive and integrated mental health and substance abuse
screening for TAY, Adult and Older Adults, strength-based assessment, goal setting and
outcome focused.
8. Peer and family members services that include:
a. Information and education about mental health, support services and community
resources, linkages to access outpatient mental health care, and other support services and
resources as desired by the client.
b. Linkage and referrals to community based organizations, including – but not limited to –
primary care clinics and alternative healing centers and organizations, faith based
institutions, ethnic organizations and peer run programs such as Clubhouses.
c. Collaboration with local peer and family service providers.
9. Link clients for follow up and care coordination of needed services that may include emergency
interventions, acute care, alternatives to psychiatric, conservatorship and intensive clinical case
management services.
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10. Inter-agency coordination of services with with local Emergency Departments (ED), psychiatric
hospitals, Sheriff’s Department, the jail system, and with older adult programs.
11. After business and weekend hour telephone response, emergency telephone consultation
and/or referral of clients for weekends and evening hours.
12. Flexible fund for clients to meet specific client needs when such needs are deemed critical for a
client’s well-being and no other source of funds is available.
13. Coordinate and integrate client’s care with physical healthcare providers and other resources
that clients need and use in the community.
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AB1421 Planning Meeting Feedback Form
Thank you for participating in the Contra Costa County Behavioral Health Services AB1421 Planning
Process. We would like to hear about your experience with the Planning Meeting today. Your feedback
will guide future meetings. Please take a few minutes to fill out this anonymous feedback form and
leave it at the registration table before you leave today.
Based on your expectations for the AB1421 Planning Process, please mark to what extent you agree with
the following statements.
Strongly
Disagree Disagree Agree Strongly
Agree
1. I understand the intended target population for
this planning process.
2. The system overview presentation provided a
good foundation for the planning process.
3. I found the system map easy to understand by
the end of the meeting.
4. I understand the criteria for making a successful
recommendation to the Board of Supervisors.
5. I believe the conversations we plan to have a
future meetings will be productive and
meaningful for the purposes of this process.
Poor Fair Good Excellent
6. How would you rate the quality of response to
your questions and requests for additional
research made at Meeting #1?
7. Overall, how would you rate the quality of the
facilitation for the Planning Meeting today?
8. Please share any additional comments or suggestions you may have about the AB1421 Planning
Process:
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Thank you!
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Appendix D: Meeting 3 Materials
Contra Costa County Behavioral Health Care Services
AB1421 Planning Work Group
Meeting #3
June 24, 2014, 2:00 - 5:00pm
Agenda
TIME TOPIC PRESENTER
2:00 I. Convening Roberta Chambers, PsyD, RDA
Review Agenda
Data Update
2:05 II. Community Updates
Community Forums
Community Living Room Conversations
Roberta Chambers, PsyD, RDA
2:30 III. Exploring AOT Roberta Chambers, PsyD
3:15 B R E A K (15 minutes)
3:30 IV. Exploring Recommendations Roberta Chambers, PsyD, RDA
Jane Stallman, Center for Strategic Facilitation
4:55 VI. Closing Roberta Chambers, PsyD, RDA
Meeting Recap and Next Steps
Next Work Session (2 weeks)
Feedback form
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Community Living Room Conversation – Event #4 AOT Special Topic
Host Provider: The Hume Center
** 15 of 16 INVITEEs showed up and participated in CLRC Tuesday, June 17, 2014
CCBHI SEGMENT & CLRC Role INVITEE COMMENTS SHARED
Round One - Why
are we here
tonight? Getting to
know you.
FM-MH The system is seriously broken and I'm concerned about it. As part of the Mental Health Commission, I think we can come
together to improve the system. Want to be here to add my voice and to listen to other perspectives. Think the CLRC is a big
opportunity.
Round One - Why
are we here
tonight? Getting to
know you.
FM-Home I care about my brother's health. He lives with mental illness. I'm familiar with the mental health system in France because he had
break down while in France. I have a perspective on two Mental Health systems and France's is superior. I want to be able to
share what he experienced in France.
Round One - Why
are we here
tonight? Getting to
know you.
CON-AOD I've been treated for addiction and substance abuse but I my mental health issues were left untreated. I ended up relapsing
because my mental health was not treated. When I went into treatment again with Oz, they treated both issues. I now feel like a I
have a real chance to stay clean.
Round One - Why
are we here
tonight? Getting to
know you.
CON-MH Cen I'm a mental health consumer with an attitude. I've experienced and witnessed abuses with the 5150 process. Staff can and are
responsible for abuse behind closed doors. I call it the "Mental Harm System." I'm interested in participating to hopefully get
beyond considering it the "Mental Harm System."
Round One - Why
are we here
tonight? Getting to
know you.
FM-AOD I'm active in (AOD) recovery and service work and I own a sober living house. I work with people who are transitioning from
treatment to sober living and I see that people continue to slip. They get dropped through the cracks. These folks were getti ng
medications for mental health issues when they were in treatment, but once they're released from residential treatment, the
meds drop off. They system needs some sort of discharge person who is responsible to make sure the person gets enough
medication until they get to their first doctor appointment.
Round One - Why
are we here
tonight? Getting to
know you.
CON-AOD I was locked up in the system for 8 years. The first two years, I didn’t know I had mental health problems but then I was afraid of
having them. In prison, they treat those with mental health issues real bad. If they knew someone had them, they would pick on
them. When I got out, they were supposed to transfer me with meds to the next institution, but they didn't. The next institut ion
never got the information (HIPPA) and I didn't get any meds. Then I was released with no meds. When I got on parole, they didn't
get any information transfered about my mental health issues. They wouldn't share the information so I went 10 days without my
Lithium. On the street I started smoking weed to deal with it. I finally got into DVR and it was good. But even DVR had problems
getting me my meds. They expected county to have a record of the meds I was taking. One woman I had said "she was too busy
and just told me to go to PES to get meds. I knew when I was going to run out of my meds and tried to get things going. The staff
would just laugh. They didn't take my mental health issues and need for medications seriously. Because of HIPPA, people slip
through the cracks because there is not way to share info on medications. It makes me wonder what do I have to do in order for
someone to get it?
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Round One - Why are we
here tonight? Getting to
know you.
FM-MH My brother had a similar experience as Francisco had. There was no database available that detailed the needs of a patient.
They just told me no information was available. Today getting his medications is still a fight. If it has to be a fight, then people
are going to continue to fall through the cracks. it feels like going to jail or going to PES are the only options. I don't understand
why if it's a medical problem like a heart attack - people would respond immediately. But with mental health issues - it's horrid.
When my brother went into PES, they would not let me see him. He was in there for a while, but he didn't get any treatment.
Then, they released him saying he was "okay." He was so NOT okay. He went home and then had an overdose. Why does
someone have to be dangerous to get help?!
Round One - Why are we
here tonight?
PRO-AOD I work in the jails. When a person starts presenting with mental health issues, we get the run around. Without mental health
medications, the person can't participate in (AOD) treatment. What's hard is that they know that they are out of control but
they can't do anything about it.
Round One - Why are we
here tonight?
CON-AOD It's awful trying to get through to get an appointment to get meds. In treatment, we can only use the phone at certain times. So
we all line up and are hanging on the phone, passing to off to the next person who gets phone priveledges until we finally get
through (to a live person). There's like 6 or 7 people on the phone before one of us actually gets through to get an appointm ent.
And then we don't hang up because we finally get to talk with someone. That's what it takes.
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
FM-AOD The question I have about Laura's Law is . . . Is the law more about 'public safety' or is it more about 'recovery?' I have concerns
about the Health Care Directive and if I we a parents can put specific information into the plan for my daughter. My biggest
concern is about 'Who' will take care of my daughter is she has to do treatment under Laura's Law. Who will be the "Attending
Caregiver?" I want to know who this person is. I need to know it's a person who is a 'coach' or a 'collaborator,' and not someone
who doesn't care about the quality of the treatment. My daughter is so good at NOT looking sick. And she can see right through
cargivers and knows when the person is just 'doing a job,' vs. someone who really cares about her. With the one who is just
doing a job, she manipulates them. This won't help anyone.
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
FM-AOD I read somewhere about Laura's Law and a case report that the the doctor, Tom T. "supposedly" said . . . Is this for real. I just
have to wonder, what's happening in the system? What we think we’re seeing, we're not really seeing at all. Unless someone is
really "trained," what's really happening with people with mental illness gets missed. They can't see what's happening (because
people like my daughter can see right through them and then manipulates the situation.)
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
FM-AOD I want 'Transparency' with this program and people who are 'really in it with them (people like my daughter). I want there to be
patient advocates with them (people like my daughter), who are in there with the consumer - more of them with the clinician.
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
FM-AOD My goal for my dauther is that she will have more "happy moments" and that she will be able to have some "control"over her
life. The worst thing the system can do for her is to take her control away. One example of this is when she has to take like 4 pills
a day. This is a huge trigger. It's a reminder 4 times each and every day that she has no control over her own life. Versus - since
she's been able to get injections. When she gets an injection, it's only one or two times a month that she is reminded of this.
That's 120 times vs. 2.
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Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
FM-Home What I'm concerned about is that whether or not someone (is treated under Laura's Law) is based on someone else's
perspective - not on the facts. I don't want it to be based on someone else's perspective. Some people are book
smart, those who learn it in school. But if the person hasn't 'felt it,' they don't know. How can someone (a clinician)
who sees a consumer for a 15 minute appointment know what's actually happening with the person? They just have
a "perspective" about what the consumer has. How can a clinician know what I need in 15 minutes?
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
FM-AOD When I was sick, my wife saved me. This was a person who really cared about me. (With Laura's Law) there needs to
be someone who loves the consumer, not just someone who's going to 'pass out pills.' I think everyone needs a 'peer
counselor,' someone who gets it. (John passed around photos of his daughter.)
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner AOT
SMC
With AOT, the person/consumer will have case management. Voluntary services will be offered to the person. If the
person is not engaging in the services offered or is NOT benefitting from services, then the case can go to AOT and it
will go to Civil Court.
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner AOT
SMC
In Nevada County, they have a 'collaborative court.' With AOT, everyone who is nominated will be offered voluntary
services. Regarding case management in AOT in Contra Costa, a peer specialist will be offered to the consumer.
Unfortunately CCC has less Family Advocates in Contra Costa County than Peer Soecialists.
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
CON-MH Cen I have concerns about AOT. My passion is to get away from the 5150 process.
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner AOT
SMC
In some cases with AOT, the 5150 process may be used. It would if someone in the household has a concern about
the person being a danger to self or others. With AOT, we don't want to wait for a crisis to happen. We don't want to
have to wait for a 5150. But there could be situations in which an emergency does happen and then a 5150 may be
used.
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
CON-MH Cen I would like to see the 5150 patient to be treated much better than are being treated today. I think I would feel
better about it (AOT) if people were being treated better. Maybe it could be an 'alternative to the 'revolving door' (at
PES).
Round Two - What are some
of your concerns about
Laura's Law and Assisted
Outpatient Treatment?
CON-MH Cen QUESTION: Is a Family Member the only person who can nomiate someone for AOT? I was married and had kids. I
had a job. But I lost it. I lost my husband and kids. I lost my job.
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner AOT
SMC
There are still challenges with FSPs. Even though people have a treatment team, people can still go to PES. But the
person will have 'wraparound' services. 'Triage and Outreach' still need to be put into place. And there will be
support with the 'discharge.' With FSPs today, the person has 'Rapid Access,' after they get out of PES. They are
supported in scheduling an appointment within 24 hours. Also, once the ARC is online, they will offer weekend
coverage.
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DOUG Dunn AOT SMC The key to someone being nominates is that the person has a relationship with the consumer.
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Combination of Questions
Posed for Round Two,
Three and Four
CON-AOD (Coming from working in healthcare) I apologize for the workers in the healthcare industry who are mistreating people. They
should be held accountable for the inappropriate things they do to the consumer when they're in care.
Combination of Questions
Posed for Round Two,
Three and Four
CLRC Parter Who can nominate a person?
Combination of Questions
Posed for Round Two,
Three and Four
FM-MH Peggy directed people to the reading materials provided prior to CLRC. She directed people to page 45 of the "AOT
Summary" document that was also provided to participants that night. This expanded the conversation so participants were
not focusing only on Family Members as individuals who can nominate consumer.
Combination of Questions
Posed for Round Two,
Three and Four
FM-AOD If I have a relationship with a Family Member who lives with me and nominated me, I'd feel betrayed. But if it was a seemless
transition to mental health services, I . . .
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner
AOT SMC
Facilitators directed converation to Subject Matter Consultant David Seidner to address "Criteria to be considered for AOT."
David directed participants to pages 6, 7, and 8 of the "AOT Summary" document that was provided to participants prior to
the event and included in participant packets the night of the event.
Combination of Questions
Posed for Round Two,
Three and Four
PRO-MH I would like more detail on how one defines, "What is of danger?" I got attacked two times over the last two months. The
actions were dismissed and the actions of the consumer were dismissed.
Combination of Questions
Posed for Round Two,
Three and Four
FM-AOD Directed question out of the 'Inner Circle' to Subject Matter Consultants (SMC) in the room. What about a blind study in
Contra Costa? Will there be one?
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner
AOT SMC
There have been several activities happening in the county with regards to AOT in order to be able to present its
recommendations to the Board of Supervisors. An AOT Workgroup mad up of 13 individuals was set up to work through the
issues. They made a presentation to the Health and Human Services sub committee of the the BOS. The Workgroup wants full
implementation of "x" number of slots.
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DOUG Dunn AOT
SMC
Family members want there to be 45 slots and for AOT to be fully implemented. The recommendation will likely be made to
the Board July 22nd with a decision being made as early as July 29th.
Combination of Questions
Posed for Round Two,
Three and Four
CON-Home At what point does the Patients' Rights get involved on behalf of the consumer? It seems that Patients' Rights should get
involved earlier in the process - right from the start, (not just when the case goes to Civil Court.) Patients' Rights should be
involved with the case files. It seems like this would make it a more fluid process. They should be taking care of the seriously
mentally ill consumers from the inside by creating an MOU from the start. I also don't feel the consumer shouldn't have to pay
any legal fees if they have been nominated.
Round Two - Clarifications
about Laura's Law and
Assisted Outpatient
Treatment.
DAVID Seidner
AOT SMC
When a consumer is nominated, an evaluation is performed by a clinician. The person is offered voluntary services. If it's
determined the consumer qualifies for AOT, the case goes to Civil Court. Once the Civil process starts, then the Patients's R ights
person can get involved. When supervision is issued, then it can go to Patients' Rights.
Combination of Questions
Posed for Round Two,
Three and Four
CON-Home It's critical that there be a peer specialist or Patients' Rights person actively involved, someone who understands and has
empathy (for what the consumer is going through).
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Round Two - Clarifications about
Laura's Law and Assisted
Outpatient Treatment.
DAVID Seidner AOT
SMC
Empathy is very important. The consumer must also be offered the opportunity to engage in services multiple times.
Being a part of an FSP will give the consumer more contact (with a team of resources). To date, the actual number of
times of engagement hasn't yet been determined. The other important element is that there will be an ongoing
evaluation of services provided. When/If AOT is implemented, an external agency will be contracted to evaluate the
process and pilot as the county is testing it. This needs to be a group of 'outside experts' who assess the
implementation.
Combination of Questions Posed
for Round Two, Three and Four
FM-MH Where are the resources going to come from? We don't have enough resources not. Where's it coming from? We
desperately need transitional houseing. We need beds today! Where's it going to come from?
Combination of Questions Posed
for Round Two, Three and Four
FM-MH Is it going to come from MHSA (Mental Health Services Act) funding?
Round Two - Clarifications about
Laura's Law and Assisted
Outpatient Treatment.
DOUG Dunn AOT
SMC
The precise funding streams have not been yet determined. I made a presentation at CPAW (Consolidated Planning
Advisory Workgroup) last week. But it will have the be the Board of Supervisors who will determine where funding
comes from.
Combination of Questions Posed
for Round Two, Three and Four
CLRC Parter The county will need to go back to the Board of Supervisors. They will also be working with AOD and Mental Health to
determine possible funding sources.
Combination of Questions Posed
for Round Two, Three and Four
CLRC Parter- Facilitator We shouldn't focus on the funding piece right now, but more so about issues about AOT and treatment.
Combination of Questions Posed
for Round Two, Three and Four
CON-MH Cen But who will pay for it? Will insurance, medi-care or medi-cal pay for treatment?
Combination of Questions Posed
for Round Two, Three and Four
FM-Home The comment "Don't think about the cost" has been circulating in my head. We need to have funding to get people in
the program (AOT). But what I'm concerned about is that the county may NOT have the funds to sustain services once
consumer are in the program. I am concerned about it doing more harm than good if we get them in and then they fall
through the cracks.
Combination of Questions Posed
for Round Two, Three and Four
FM-Home Community dollars are not going to housing today. They aren't going to the people who need it the most. If we go
forward with AOT, I DO NOT want to see the dollars that are allocated to go to "the program" or "providers" to pad
their funding. I want the dollars to go to my brother and others like my brother. I want the program to be "PATIENT
Focused" and for the dollars to go to a provider who is committed to "being in it" with my brother.
BREAK BREAK BREAK
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
FM-AOD Initially I was concerned about coming tonight, but these people (participants in the conversation) "really get it." They
see that the concerns are valid. They get it! Hopefully (the county) will use the 'street smarts' of people who 'get it' to
put the program together. It feels good to be here.
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Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
FM-Home I appreciated hearing from the people who shared their personal experiences. They 'showed up' tonight AND
shared. Hopefully we can use what they shared (as the program is put together).
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
FM-MH What can we do to support this? (AOT)
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
DOUG Dunn AOT
SMC
The critical dates are July 29th, maybe August 5th. It depends on what happens with CCBHS Administration and
what they present to the Board of Supervisors.
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
DAVID Seidner AOT
SMC
What is happening with AOT will be posted online to the public. There are also various groups you can
communicate directly with - the Mental Health Commission, NAMI (National Alliance on Mental Illness), the
Office for Consumer Empowerment (OCE) and Recovery Innovations. I would encourage you to go through the
public venues. You may also send an email directly to Administration - to me David Seidner, Vic Montoya our
Mental Health Program Chief. You could also send it to Peggy Kennedy and/or Teresa Pasquini who are
commissioners of the MHC.
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
FM-MH Speaking as a MHC Commissioner, whoever is interested in pushing AOT forward I would recommend that you
go directly to your Supervisor. If you have 'lived experience' whether you are speaking in favor of Laura's Law
or not in favor - it's important to share what you feel and what your concerns are.
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
FM-MH Go see your Supervisor. If people want to share their email addresses, maybe we could follow up this meeting
on updates about what is happening. We could have the critical dates sent to you all.
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
CLRC Parter We will put this information on our website at Support4Recovery.
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
CLRC Parter I want to piggyback on what others have said. I'm a member of the MHSA Finance Committee and we are
talking about funding issues. I'm also on the Mental Health Commission. We actually just made a
recommendation to support Laura's Law. Our recommendation was based on the multiple community forums
that were held in all regions of the county.
Round Five - What did you learn here
tonight? What was one important thing?
What did you appreciate about the
process?
CLRC Parter There could be 'next steps' with the Community Living Room Partnership. We could implement Action Steps
after this 'Conversation.' We could get an email list going for people who are interested in receiving an update
on what's happening with AOT and critical dates. I'm also the chair of the CCRMC Healthcare Partnership that
meets every Tuesday at the hospital. We'll be convening a "Dream System Design Day" in August. I'd like to
invite anyone who in interested in participating.
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Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CLRC Parter I will send around an list. Anyone who is interested in being on an email list, please sign it and return it back to me. I'll give
the list to Teresa and Kimberly to send out a information about the Board of Supervisors' date.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CON-MH The last concern I want to say is that one of the multiple "harms" that I've experienced is being misdiagnosed. I am
concerned that consumers are being misdiagnosed. It's happened to me multiple times.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
DAVID Seidner
AOT SMC
Personally I would be most hopeful to catch consumers before their first break - or just after. The earlier we get them help,
the better outcomes we can produce. With consumers who are nominated and who have been in the system for a while, it's
a very complex situation because they have many records.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
DAVID Seidner
AOT SMC
What I want to say though is that if a consumer is nomiated who has been in the system, AND they meet all the
requirements of receiving treatment with AOT, the consumer will receive a more thorough examination because the results
will be presented in court. I hope it will result in a more accurate diagnosis, but truthfully, I don't know. There are many
variable.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CLRC Parter When I came tonight, I wondered if the AOT as a controversial Topic might take over our Community Living Room
Conversation model. Just it really didn't. The CLRC is a grass roots effort to get at people's experiences, the 'No Wrong Door'
approach and focus. We could use it with substance abuse issues and mental health issues. You all are the 'experts' in the
community and we can learn from you.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CON-Home My last comment and concern. AOT is very complex. One of the things that concerns me is how people define SMI (Serious
Mental Illness). It feels vague, especially with the possibility of misdiagnosis. I want there to be extra attention and focus
made on "efforts to engage and re-engage consumers." I would want to see WRAP (Wellness Recovery Action Plan)
integrated into the treament plan for the consumer, for providers to really understand WRAP as a Plan Tool.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CON-Home I would want the provider to know "What It Looks Like When I Am Well," what my "Triggers" are. I would want more
engagement to educate consumers about the services of programs like Putnam Clubhouse. I want consumers to be pulled
back in before the situation requiring AOT is called for. And I would want true empathy and understanding for what the
consumer is facing and going through. Many consumers do have anosognosia. We need to focus on how to "appropriately"
engage them.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CON-Home I want to say that AOT is "one Tool" in our bag. It's not the only tool and I want to highlight that it also only touches a very
small number due to the requirements of AOT.
Round Five - What did you learn
here tonight? What was one
important thing? What did you
appreciate about the process?
CLRC Parter-
Facilitator
We've had a great conversation tonight. I want to thank all of you for participating. We do have an Event Evaluation we
would like you to take the time to fill out. It will help us to understand more about what you think and how this process
worked for you.
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Community Living Room Conversation – Event #4 AOT Special
Topic
June 17, 2014 Host Provider: The Hume Center
What Worked! Hopes for Future CLRC Events
I like being here.
The people here really get it. It feels comfortable.
I appreciate people who showed up and shared their
personal experiences tonight. These are the experts.
I was glad to see that a critical topic like AOT didn't
overtake the CLRC process. It worked really well.
That people who had experiences shared and this
information can be used to support developing a
"Patient Focused" program
Everything about tonight worked. The food was
great, the reception outside, the people who are
here.
I liked seeing the (PhotoVoice) framed photos
displayed all over the place and learning more about
this
(consumer and family member) program offered by
the Office for Consumer Empowerment.
Writing down what we said (scribe) was great.
That consumers got to network with providers and
come up with real solutions to meet immediate
needs.
Having Subject Matter Consultants in the room
I want more information about how
to support AOT
I want to know how to get updated
information
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AB1421 Planning Meeting Feedback Form
Thank you for participating in the Contra Costa County Behavioral Health Services AB1421 Planning
Process. We would like to hear about your experience with the Planning Meeting today. Your feedback
will guide future meetings. Please take a few minutes to fill out this anonymous feedback form and
leave it at the registration table before you leave today.
Based on your expectations for the AB1421 Planning Process, please mark to what extent you agree with
the following statements.
Strongly
Disagree Disagree Agree Strongly
Agree
1. I have a greater understanding of Assisted
Outpatient Treatment and its benefits and
concerns.
2. Learning about other community events
regarding AOT will be useful for developing
recommendations.
3. The data and other information we received in
previous meetings informed our discussions
today.
4. I believe the conversations we plan to have at
future meetings will be productive and
meaningful for the purposes of this process.
Poor Fair Good Excellent
5. Overall, how would you rate the quality of the
facilitation for the Planning Meeting today?
6. Please share any additional comments or suggestions you may have about the AB1421 Planning
Process:
Thank you!
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Appendix E: Meeting 4 Materials
Contra Costa County Behavioral Health Care Services
AB1421 Planning Work Group
Meeting #4
July 8, 2014, 2:00 - 5:00pm
Agenda
TIME TOPIC PRESENTER
2:00 IV. Convening Roberta Chambers, PsyD, RDA
Welcome and Introductory Comments
Updates
Jane Stallman, Center for Strategic Facilitation
2:20 V. Review Proposed Ideas from Meeting #3 Roberta Chambers, PsyD, RDA
2:30 VI. Development of Recommendations (Small
Group Activity)
Roberta Chambers, PsyD
Jane Stallman, Center for Strategic Facilitation
3:30 B R E A K (10 minutes)
3:40 VII. Report back to the larger group and
discussion
Roberta Chambers, PsyD, RDA
Jane Stallman, Center for Strategic Facilitation
4:50 V. Closing
Meeting Recap and Next Steps
Next Work Session
Feedback form
Roberta Chambers, PsyD, RDA
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An act to amend Sections 5349, 5801, and 5813.5 of the Welfare and Institutions Code,
relating to mental health, and making an appropriation therefor.
[ Approved by Governor September 09, 2013. Filed with Secretary of
State September 09, 2013. ]
LEGISLATIVE COUNSEL'S DIGEST
SB 585, Steinberg. Mental health: Mental Health Services Fund.
Existing law contains provisions governing the operation and financing of community mental health
services for the mentally disordered in every county through locally administered and locally
controlled community mental health programs. Existing law, the Mental Health Services Act, an
initiative measure enacted by the voters as Proposition 63 at the November 2, 2004, statewide general
election, funds a system of county mental health plans for the provision of mental health services, as
specified.
The act establishes the Mental Health Services Fund, continuously appropriated to and administered
by the State Department of Health Care Services, to fund specified county mental health programs,
including programs funded under the Adult and Older Adult Mental Health System of Care Act. The
Adult and Older Adult Mental Health System of Care Act establishes service standards that require,
among other things, that a service planning and delivery process provides for services that are client
directed and employ psychosocial rehabilitation and recovery principles. The act authorizes the
Legislature to clarify procedures and terms of the act by majority vote.
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Existing law, the Assisted Outpatient Treatment Demonstration Project Act of 2002, known as
Laura’s Law, until January 1, 2017, regulates designated assisted outpatient treatment services,
which counties may choose to provide for their residents. In counties where assisted outpatient
treatment services are available, a person is authorized to obtain assisted outpatient treatment
pursuant to an order if requisite criteria are met, as specified. Under that law, participating counties
are required to provide prescribed assisted outpatient services, including a service planning and
delivery process, that are client directed and employ psychosocial rehabilitation and recovery
principles.
This bill would clarify that services provided under Laura’s Law may be provided pursuant to the
procedures specified in the Mental Health Services Act, thereby making an appropriation.
Because the bill would clarify the procedures and terms of Proposition 63, it would require a majority
vote of the Legislature.
Under existing law, the underlying philosophy for the system of care for adults and older adults
includes clients who should be fully informed and volunteer for all treatments provided, unless
danger to self or others or grave disability requires temporary involuntary treatment.
This bill would include within those exceptions clients who are under court order for treatment, as
specified.
Existing law establishes the Local Revenue Fund, which contains specified accounts and
subaccounts, including the Mental Health Subaccount, the Mental Health Equity Subaccount, and the
Vehicle License Collection Account. Existing law establishes the Local Revenue Fund 2011, which
contains specified accounts and subaccounts, including the Mental Health Account and the
Behavioral Health Subaccount within the Support Services Account.
This bill would, to the extent otherwise permitted under state and federal law, specify that counties
that elect to implement Laura’s Law may pay for those services using funds distributed to counties
from the Mental Health Subaccount, the Mental Health Equity Subaccount, and the Vehicle License
Collection Account of the Local Revenue Fund, funds from the Mental Health Account and the
Behavioral Health Subaccount, within the Support Services Account of the Local Revenue Fund
2011, funds from the Mental Health Services Fund, and any other funds from which the Controller
makes distributions to the counties, for those purposes.
DIGEST KEY
Vote: majority Appropriation: yes Fiscal Committee: yes Local Program: no
BILL TEXT
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS
FOLLOWS:
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SECTION 1.
The Legislature hereby finds and declares that the provisions of this act are consistent with, and
further the intent of, the Mental Health Services Act.
SEC. 2.
Section 5349 of the Welfare and Institutions Code is amended to read:
5349.
This article shall be operative in those counties in which the county board of supervisors, by
resolution or through the county budget process, authorizes its application and makes a finding that
no voluntary mental health program serving adults, and no children’s mental health program, may be
reduced as a result of the implementation of this article. To the extent otherwise permitted under state
and federal law, counties that elect to implement this article may pay for the provision of services
under Sections 5347 and 5348 using funds distributed to the counties from the Mental Health
Subaccount, the Mental Health Equity Subaccount, and the Vehicle License Collection Account of
the Local Revenue Fund, funds from the Mental Health Account and the Behavioral Health
Subaccount within the Support Services Account of the Local Revenue Fund 2011, funds from the
Mental Health Services Fund when included in county plans pursuant to Section 5847, and any other
funds from which the Controller makes distributions to the counties for those purposes. Compliance
with this section shall be monitored by the State Department of Health Care Services as part of its
review and approval of county performance contracts.
SEC. 3.
Section 5801 of the Welfare and Institutions Code is amended to read:
5801.
(a) A system of care for adults and older adults with severe mental illness results in the highest
benefit to the client, family, and community while ensuring that the public sector meets its legal
responsibility and fiscal liability at the lowest possible cost.
(b) The underlying philosophy for these systems of care includes the following:
(1) Mental health care is a basic human service.
(2) Seriously mentally disordered adults and older adults are citizens of a community with all the
rights, privileges, opportunities, and responsibilities accorded other citizens.
(3) Seriously mentally disordered adults and older adults usually have multiple disorders and
disabling conditions and should have the highest priority among adults for mental health services.
(4) Seriously mentally disordered adults and older adults should have an interagency network of
services with multiple points of access and be assigned a single person or team to be responsible for
all treatment, case management, and community support services.
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(5) The client should be fully informed and volunteer for all treatment provided, unless danger to self
or others or grave disability requires temporary involuntary treatment, or the client is under a court
order for assisted outpatient treatment pursuant to Section 5346 and, prior to the filing of the petition
for assisted outpatient treatment pursuant to Section 5346, the client has been offered an opportunity
to participate in a treatment plan on a voluntary basis and has failed to engage in that treatment.
(6) Clients and families should directly participate in making decisions about services and resource
allocations that affect their lives.
(7) People in local communities are the most knowledgeable regarding their particular environments,
issues, service gaps and strengths, and opportunities.
(8) Mental health services should be responsive to the unique characteristics of people with mental
disorders including age, gender, minority and ethnic status, and the effect of multiple disorders.
(9) For the majority of seriously mentally disordered adults and older adults, treatment is best
provided in the client’s natural setting in the community. Treatment, case management, and
community support services should be designed to prevent inappropriate removal from the natural
environment to more restrictive and costly placements.
(10) Mental health systems of care shall have measurable goals and be fully accountable by
providing measures of client outcomes and cost of services.
(11) State and county government agencies each have responsibilities and fiscal liabilities for
seriously mentally disordered adults and seniors.
SEC. 4.
Section 5813.5 of the Welfare and Institutions Code is amended to read:
5813.5.
Subject to the availability of funds from the Mental Health Services Fund, the state sha ll distribute
funds for the provision of services under Sections 5801, 5802, and 5806 to county mental health
programs. Services shall be available to adults and seniors with severe illnesses who meet the
eligibility criteria in subdivisions (b) and (c) of Section 5600.3. For purposes of this act, seniors
means older adult persons identified in Part 3 (commencing with Section 5800) of this division.
(a) Funding shall be provided at sufficient levels to ensure that counties can provide each adult and
senior served pursuant to this part with the medically necessary mental health services, medications,
and supportive services set forth in the applicable treatment plan.
(b) The funding shall only cover the portions of those costs of services that cannot be paid for with
other funds including other mental health funds, public and private insurance, and other local, state,
and federal funds.
(c) Each county mental health program’s plan shall provide for services in accordance with the
system of care for adults and seniors who meet the eligibility criteria in subdivisions (b) and (c) of
Section 5600.3.
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(d) Planning for services shall be consistent with the philosophy, principles, and practices of the
Recovery Vision for mental health consumers:
(1) To promote concepts key to the recovery for individuals who have mental illness: hope, personal
empowerment, respect, social connections, self-responsibility, and self-determination.
(2) To promote consumer-operated services as a way to support recovery.
(3) To reflect the cultural, ethnic, and racial diversity of mental health consumers.
(4) To plan for each consumer’s individual needs.
(e) The plan for each county mental health program shall indicate, subject to the availability of funds
as determined by Part 4.5 (commencing with Section 5890) of this division, and other funds available
for mental health services, adults and seniors with a severe mental illness being served by this
program are either receiving services from this program or have a mental illness that is not
sufficiently severe to require the level of services required of this program.
(f) Each county plan and annual update pursuant to Section 5847 shall consider ways to provide
services similar to those established pursuant to the Mentally Ill Offender Crime Reduction Grant
Program. Funds shall not be used to pay for persons incarcerated in state prison or parolees from
state prisons. When included in county plans pursuant to Section 5847, funds may be used for the
provision of mental health services under Sections 5347 and 5348 in counties that elect to participate
in the Assisted Outpatient Treatment Demonstration Project Act of 2002 (Article 9 (commencing
with Section 5345) of Chapter 2 of Part 1).
(g) The department shall contract for services with county m ental health programs pursuant to
Section 5897. After the effective date of this section, the term grants referred to in Sections 5814 and
5814.5 shall refer to such contracts.
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Appendix F: Meeting 5 Materials
Contra Costa County Behavioral Health Care Services
AB1421 Planning Work Group
Meeting #5
July 15, 2014, 2:00 - 5:00pm
Agenda
TIME TOPIC PRESENTER
2:00 VIII. Convening Roberta Chambers, PsyD, RDA
Welcome and Introductory Comments Jane Stallman, Center for Strategic Facilitation
2:20 IX. Updates, Timeline, and Process Overview
Data
Costs
Report
Roberta Chambers, PsyD, RDA
2:40 X. Development of Recommendations Roberta Chambers, PsyD
Jane Stallman, Center for Strategic Facilitation
3:30 B R E A K (10 minutes)
4:00 XI. Decision-making for Board
Recommendations
Roberta Chambers, PsyD, RDA
Jane Stallman, Center for Strategic Facilitation
4:50 V. Closing
Meeting Recap and Next Steps
Roberta Chambers, PsyD, RDA
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AB1421 Work Group Process & Timeline
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PES and Hospital Discharge Services
The group brainstormed the following PES and Hospital Discharge Services to serve the target
population:
Peer Mentor Hospital Discharge Program
PES/Hospital Discharge Outreach and Engagement Team
When you think of the target population (e.g. 2+ hospitalizations, not engaging voluntarily, likely to
deteriorate), what type of PES and hospital discharge services are the most important to consider?
When does the peer or staff member first make contact with the person? (Ex. In peer mentor
discharge, the peer first meets with the individual at the hospital.)
How long does the staff stay involved? (Ex. In hospital transition programs, the staff generally stays
involved until the person is connected with mental health services.)
What types of staffing are involved? Mental health or medical professionals? Peers? Family? Other?
(Ex. With peer mentors, peer counselors work in partnership with the hospital staff.)
Other important elements?
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Outreach and Engagement
The group brainstormed the following outreach and engagement programs to serve the target
population:
In-Home-Outreach Team (description attached)
Outreach Team, unspecified
When you think of the target population (e.g. 2+ hospitalizations, not engaging voluntarily, likely to
deteriorate), what type of outreach and engagement services are the most important to consider?
Appendix G: Meeting 6 Materials
How does the outreach team become aware of the person? Do they take referrals to try to engage
someone? If so, who can make that referral? (Ex. With IHOT, family members can call the IHOT team
so that the IHOT team can engage the person.)
Where does the outreach team provide services? Streets? Homes? Other service locations? (Ex.
With street outreach, teams usually provide services in parks and other service locations but rarely go
into someone’s home. IHOT teams predominantly go to people’s homes.)
What types of staff are on the team? Mental health or medical professionals? Peers? Family?
Other? (Ex. With IHOT, there are clinical, peer, and family staff. Other outreach models vary.)
Other important elements?
Contra Costa Health Services
Report on the AOT Workgroup Recommendations
REVISED September 19, 2014 | 141
Appendix G: In-Home Outreach Team (IHOT) Budget Detail
Staffing FTE Annual Salary + Benefits Total
Clinician/Program Manager 1 156,975.00$ 156,975.00$
Clinician 1 127,909.00$ 127,909.00$
Case Manager 1 112,080.00$ 112,080.00$
Peer Support Specialist 1 73,555.00$ 73,555.00$
Family Liaison 1 73,555.00$ 73,555.00$
TOTAL STAFFING 5 544,074.00$
Operating Costs Quantity Amount
Office Space 1 22,000.00$ 22,000.00$
Office/Program Supplies $125/month/team 125.00$ 1,500.00$
Computers 5 880.00$ 4,400.00$
Cell Phones 5 600.00$ 3,000.00$
County Car 2 30,000.00$ 60,000.00$
Client Assistance $125/month/team 375.00$ 4,500.00$
TOTAL OPERATING 95,400.00$
Administrative Costs
Administrative Costs 15%95,921.10$
TOTAL ADMINISTRATIVE COSTS 95,921.10$
TOTAL PROGRAM COSTS 735,395.10$
In Home Outreach Team
Contra Costa Health Services
Report on the AOT Workgroup Recommendations
REVISED September 19, 2014 | 142
Appendix H: Psychiatric Emergency Hospital Transitions Budget Detail
Staffing FTE Annual Salary+Benefits Total
Clinician 1 $ 127,909.00 $ 127,909.00
Case Manager 1 $ 112,080.00 $ 112,080.00
Peer Support Specialist 1 $ 73,555.00 $ 73,555.00
Family Liaison 1 $ 73,555.00 $ 73,555.00
TOTAL STAFFING 4 $ 387,099.00
Operating Costs Quantity Amount
Office Space 1 $ 22,000.00 $ 22,000.00
Office/Program Supplies $125/month $ 125.00 $ 1,500.00
Computers 4 $ 880.00 $ 3,520.00
Cell Phones 4 $ 600.00 $ 2,400.00
County Car 1 $ 30,000.00 $ 30,000.00
Client Assistance $500/month $ 500.00 $ 6,000.00
TOTAL OPERATING $ 65,420.00
Administrative Costs
Administrative Costs 15% $ 67,877.85
TOTAL ADMINISTRATIVE COSTS $ 67,877.85
TOTAL PROGRAM COSTS $ 520,396.85
PES/Hospital Transition Team
Contra Costa Health Services
Report on the AOT Workgroup Recommendations
REVISED September 19, 2014 | 143
Appendix I: Court Costs Associated with AOT
Court Costs Detail
Classification Annual Salary + Benefits
(40 hours per week)
Annual Salary + Benefts
(20 hours per week)
Commissioner 238,852.27$ 119,426.14$
Courtroom Clerk II 103,371.36$ 51,685.68$
Court Reporter 144,612.21$ 72,306.11$
Interpreter 113,853.02$ 56,926.51$
Clerk III 76,578.43$ 38,289.22$
Bailiff Costs 210,876.00$ 105,438.00$
0.5 FTE Legal Research Attorney 52,000.00$ 26,000.00$
TOTAL 940,143.29$ 470,071.65$
Appendix J: Budget Summary of all Programs and Services
AOT includes Court Costs at 20 hours per week.
AOT includes Court Costs at 40 hours per week.
Program Service Capacity Annual Cost Cost per Person Notes
In Home Outreach Team IHOT Services 1 team $ 735,395.10 N/A Staffing: Clinical, Case Manager, Peer,
Family
PES/Hospital Transition Team Transition Services 1 team $ 520,396.85 N/A Staffing: Clinical, Peer, Family
FSP Services 76 $ 2,850,000.00 Assumes $37,500 per individual
Housing
76 $ 803,472.00
Assumes 100% need housing @
~$880/month (Average of studio/1
bedroom FMR-30% SSI contribution)
Total $ 3,653,472.00
FSP Services 37 $ 1,387,500.00 Assumes $37,500 per individual
Housing 37 $ 391,164.00
Assumes 100% need housing @
$880/month
Court 37 $ 470,071.65
No existing capacity, requires new
calendar, 20 hours per week
County Counsel 37 $ 248,000.00 Assumes 1 FTE attorney
Public Defender 37 $ 225,000.00
Assumes 1 FTE attorney, .5 FTE
paralegal
Total $ 2,721,735.65
GRAND TOTAL $ 7,630,999.60
Assisted Outpatient Treatment
Full Service Partnership $ 48,072.00
$ 73,560.42
Program Service Capacity Annual Cost Cost per Person Notes
In Home Outreach Team IHOT Services 1 team $ 735,395.10 N/A Staffing: Clinical, Case Manager, Peer,
Family
PES/Hospital Transition Team Transition Services 1 team $ 520,396.85 N/A Staffing: Clinical, Peer, Family
FSP Services 76 $ 2,850,000.00 Assumes $37,500 per individual
Housing
76 $ 803,472.00
Assumes 100% need housing @
~$880/month (Average of studio/1
bedroom FMR-30% SSI contribution)
Total $ 3,653,472.00
FSP Services 37 $ 1,387,500.00 Assumes $37,500 per individual
Housing 37 $ 391,164.00
Assumes 100% need housing @
~$880/month
Court 37 $ 940,143.29
No existing capacity, requires new
calendar, 40 hours per week
County Counsel 37 $ 248,000.00 Assumes 1 FTE attorney
Public Defender 37 $ 225,000.00
Assumes 1 FTE attorney, .5 FTE
paralegal
Total $ 3,191,807.29
GRAND TOTAL $ 8,101,071.24
Assisted Outpatient Treatment $ 86,265.06
Full Service Partnership $ 48,072.00
ASSISTED OUTPATIENT TREATMENT WORK GROUP RECOMMENDATIONSRoberta Chambers, PsyDResource Development Associates October 7, 2014
What is AOT?2Passed in 2002, AB1421 allows local Boards of Supervisors to adopt Assisted Outpatient Treatment (AOT) in their respective counties.AOT provides court-ordered intensive outpatient services for adults with serious mental illness who are experiencing repeated crisis events and are not engaging in mental health services on a voluntary basis. AOT is a civil matter and heard in civil court. It is nota criminal matter and has no involvement with criminal proceedings.AB1421 specifies the eligibility criteria, referral process, and suite of services for an AOT program.
Why should we consider AOT?3There is a sub-group of adults with serious mental illness who don’t engage in needed voluntary services.A percentage of people with serious mental illness don’t have an awareness that they are ill and don’t recognize the need for mental health treatment. Some adults with mental illness may have experienced trauma and/or stigma related to mental health services.Some adults may experience difficulty accessing or navigating the mental health system.There are limited options available to intervene with individuals with serious mental illness who are not voluntarily engaging in mental health services and are experiencing repetitive crisis events and hospitalizations.
AOT in the United States4Across the nation, AOT is an “umbrella” term that refers to court-ordered outpatient mental health services. Each state has different legislation that specifies the eligibility criteria, referral and court process, and specific services for an AOT program.45 states have legislation authorizing AOT. New York is the only state with widespread implementation. Also known as Kendra’s Law, NY’s AOT program authorizes a different set of services than is specified in AB1421.In California, AOT can be likened to:Full Service Partnership* + Legal/Court Involvement*Full Service Partnership is a set of intensive wraparound services that provides “whatever it takes” to serve people with serious mental illness. It is a required set of services within the MHSA.
AOT in California5California counties who have implementedAOT:Nevada County has served 76 individuals in their AOT program since 2008. There is an average of 5 individuals with an AOT court order at any given time in the County. Yolo County currently has an AOT program with capacity for 5 individuals. Utilization data suggests that, at any time, 2-3 individuals are enrolled in AOT. California counties who have adopted but not yet implemented AOT:San Francisco County has passed an AOT resolution but is not planning to implement until FY2015-16 to allow for program planning.Los Angeles County is planning for 500 AOT referrals per year and will maintain capacity for 300 individuals to receive AOT services. Cost estimates are $7.8 million annually. This estimate does not include legal/court costs.Orange County is planning an AOT program to serve 120 individuals and estimates that costs will range from $5.8 - $6.1 million annually. This estimate does not include court costs.California counties who are implementing alternatives to AB1421 and are not planning to implement AOT:San Diego County has implemented an In Home Outreach Team (IHOT) program to engage the “difficult-to-engage” population in mental health services.San Mateo County has implemented an LPS community conservatorship model combined with Full Service Partnership services.
AB 1421 Eligibility CriteriaWelfare and Institutions Code Section 53466The person is 18 years of age or older.The person is suffering from a mental illnessThere has been a clinical determination that the person is unlikely to survive safely in the community without supervision. The person has a history of lack of compliance with treatment for his or her mental illness, in that at least one of the following is true:At least 2 hospitalizations within the last 36 monthsOne or more acts of serious and violent behavior toward himself or herself or another, or threats, or attempts to cause serious physical harm to himself or herself or another within the last 48 months.The person has been offered an opportunity to participate in a treatment plan by the director of the local mental health department, or his or her designee, provided the treatment plan includes all of the services described in Section 5348, and the person continues to fail to engage in treatment.The person's condition is substantially deteriorating. Participation in the assisted outpatient treatment program would be the least restrictive placement necessary to ensure the person's recovery and stability.In view of the person's treatment history and current behavior, the person is in need of assisted outpatient treatment in order to prevent a relapse or deterioration that would be likely to result in grave disability or serious harm to himself or herself, or to others, as defined in Section 5150.It is likely that the person will benefit from assisted outpatient treatment.
AB1421 Service GoalsWelfare and Institutions Code Section 53487The individual’s personal services plan shall ensure that persons subject to assisted outpatient treatment programs receive age-appropriate, gender-appropriate, and culturally appropriate services, to the extent feasible, that are designed to enable recipients to:Live in the most independent, least restrictive housing feasible in the local community, and, for clients with children, to live in a supportive housing environment that strives for reunification with their children or assists clients in maintaining custody of their children as is appropriate.Engage in the highest level of work or productive activity appropriate to their abilities and experience.Create and maintain a support system consisting of friends, family, and participation in community activities.Access an appropriate level of academic education or vocational training.Obtain an adequate income.Self-manage their illnesses and exert as much control as possible over both the day-to-day and long-term decisions that affect their lives.Access necessary physical health care and maintain the best possible physical health.Reduce or eliminate serious antisocial or criminal behavior, and thereby reduce or eliminate their contact with the criminal justice system.Reduce or eliminate the distress caused by the symptoms of mental illness.Have freedom from dangerous addictive substances.
AB 1421 Service RequirementsWelfare and Institutions Code Section 53488Community-based, mobile, multidisciplinary, highly trained mental health teams that use high staff-to-client ratios of no more than 10 clients per team member and include a personal service coordinator.Outreach and engagement servicesCoordination and access to medications, psychiatric and psychological services, and substance abuse services.Supportive housing or other housing assistance.Vocational rehabilitation.Veterans' services.Family support and consultation services.Parenting support and consultation services.Peer support or self-help group support, where appropriate.Age, gender, and culturally appropriate services.
AOT Process9Who can refer an individual to AOT?An adult who lives with the individual; Parent, spouse, adult sibling, or adult child of the individual; Director of an institution or facility where the individual resides; Director of the hospital where the person is hospitalized; Treating or supervising mental health provider; Probation, parole, or peace officer.Who can file a petition for AOT?The mental health director or designee must file the petition and certify that each of the criteria set forth in AB1421are met.What services are included in an AOT order?The mental health professional must provide a written treatment plan to the court. In a collaborative court model, all involved parties (including the consumer) work together to design a treatment plan that meets the specific needs of the individual. The court then orders services, in consultation with the mental health director or designee, that are deemed to be available and have been offered and refused on a voluntary basis.Are family members included as a part of the treatment team?Family members may be included as part of the treatment team, with written permission from the consumer. AOT does not exempt the County from compliance with HIPAA requirements.
AOT Process (cont’d)10What if someone refuses to comply with an AOT order?If an individual refuses to participate, the court can order the individual to meet with the treatment team. If the individual does not meet with the treatment team, he/she can be involuntarily transported to a hospital for examination by a licensed mental health treatment provider. However, the hospital may not hold the individual if they do not meet 5150 criteria.
AOT Funding Considerations11Service costs for AOT Any funding source that currently funds Full Service Partnership services.If services were to be funded by MHSA: There must be funding available. The costs associated with AOT implementation cannot reduce or eliminate voluntary programs. A plan update would be required and include a CPP process, 30 day public posting, public hearing, and Board approval.Court/Legal Costs for AOTThe CA Attorney General has issued a position that MHSA and Realignment funds cannot pay for court/legal costs associated with AOT.Currently, Yolo and Nevada County use County General Funds to pay for court and legal costs.H.R. 4302: Protecting Access to Medicare Act of 2014Provides funding for AOT pilot projects through a competitive grant program.The request for applications is expected to be released this federal fiscal year (2014-15).Grantees would then likely commence services in the following federal fiscal year (2015-16).
FSP and AOT Outcomes 12Do the services provided under AB1421 work when provided on a voluntary basis and when people choose to engage?Full service partnership services, when provided on a voluntary basis, decrease ER visits, psychiatric hospitalizations, admissions to long-term care facilities, arrests, incarceration, and homelessness. Is the court order for AOT necessary or would voluntary Full Service Partnership services effectively serve the target population? The research is inconsistent/inconclusive. Will AOT save money?The research is inconsistent/inconclusive about whether or not AOT specifically results in cost savings. However, the services provided under AOT, such as Full Service Partnership, are consistently associated with cost savings in the literature.It is difficult to predictcost savings in Contra Costa County because there are no comparable counties from which to make assumptions.AOT, as defined in AB1421, is different than AOT implemented outside of California. AOT, within California, has only been implemented in small counties.
AOT Workgroup13
Who participated in the AOT Workgroup?14AB1421 requires that local mental health departments enact a service planning and delivery process involving groups who would provide, receive, or be affected by AB1421 programs including,“the sheriff, the police chief, the probation officer, the mental health board, contract agencies, and family, client, ethnic, and citizen constituency groups as determined by the director.”Contra Costa’s AOT Workgroup included representatives from Behavioral Health, Conservator’s Office, Public Defender, the Superior Court, Law Enforcement, County Counsel, Mental Health Commission, contracted providers, consumers, and family members of consumers.
AOT Workgroup Overview15•AOT Workgroup KickoffMeeting 1• Identify the Target PopulationMeeting 2• Discussion of AB1421 legislation• AOT DiscussionMeeting 3• Continuation of AOT discussionMeeting 4•Identify programs and services•Add Meeting 6Meeting 5• Verify report to the Board of SupervisorsMeeting 6AOT Workgroup Meeting TimelineAOT Workgroup Pre-Meeting Activities:Interviews with AOT workgroup participants, with the exceptions of Director of Behavioral Health Services Cynthia Belon, LCSW, and Adult/Older Adult Mental Health Chief Victor Montoya
AOT Workgroup Recommendations16
Contra Costa’s Target Population17How many people have had at least 2 hospitalizations?707 individuals in the past 36 months203 individuals in the past 12 months181 individuals are Contra Costa residentsBased on a case by case review, how many of the 181 County residents would likely meet AB1421 criteria?28 are no longer accessing mental health services and have not had subsequent hospitalizations.13 are currently in stable placements and doing well. 29 are currently enrolled in FSP programs.76 would likely benefit from and engage in FSP services but are unlikely to qualify for AOT.37 would likely pass a clinician assessment to determine eligibility for AOT.
AOT Workgroup Recommendations18In Home Outreach Team to provide in-home outreach and engagement services to adults with serious mental illness who are reluctant to seek outpatient mental health services, and to their family members or caretakers. ($735,395)IHOT would be a new program for Contra Costa County.Psychiatric Emergency and Hospital Transitions Teamto provide outreach and engagement services to people CCRMC’s PES and inpatient units. ($520,396) PE/HT Team would be an expansion of the existing CCBHS Transitions Team.Full Service Partnership to expand voluntary FSP services to an additional 76 individuals who experience frequent crisis events and are likely to engage on a voluntary basis. ($3,653,472) FSP services would be an expansion of existing FSP services.Assisted Outpatient Treatment to provide court-ordered outpatient services to 37 individuals who experience frequent crisis events and are unlikely to engage on a voluntary basis. ($2,721,735- $3,191,807) $1,778,664 is the service and housing estimate; $943,071.65 - $1,413,143.29* is the court and legal cost estimate.AOT would be a new program for Contra Costa County. *Does not include law enforcement/sheriff costs.
Proposed 37 person AOT Program Budget (20 court hours/week)19Program Service Capacity Annual Cost Cost per Person NotesIn Home Outreach TeamIHOT Services 1 team$ 735,395.10 N/AStaffing: Clinical, Case Manager, Peer, FamilyPES/Hospital Transition TeamTransition Services1 team$ 520,396.85 N/A Staffing: Clinical, Peer, Family Full Service PartnershipFSP Services76 $ 2,850,000.00 $ 48,072.00 Assumes $37,500 per individualHousing76 $ 803,472.00 Assumes 100% need housing @ ~$880/month (Average of studio/1 bedroom FMR‐30% SSI contribution)Total$ 3,653,472.00 Assisted Outpatient Treatment FSP Services37 $ 1,387,500.00 $ 73,560.42 Assumes $37,500 per individualHousing37 $ 391,164.00 Assumes 100% need housing @ $880/monthCourt37 $ 470,071.65 No existing capacity, requires new calendar, 20 hours per weekCounty Counsel37 $ 248,000.00 Assumes 1 FTE attorneyPublic Defender37 $ 225,000.00 Assumes 1 FTE attorney, .5 FTE paralegalTotal$ 2,721,735.65 GRAND TOTAL $ 7,630,999.60
Proposed 37 person AOT Program Budget(40 court hours/week)20Program Service Capacity Annual Cost Cost per Person NotesIn Home Outreach TeamIHOT Services 1 team$ 735,395.10 N/AStaffing: Clinical, Case Manager, Peer, FamilyPES/Hospital Transition TeamTransition Services1 team$ 520,396.85 N/A Staffing: Clinical, Peer, Family Full Service PartnershipFSP Services76 $ 2,850,000.00 $ 48,072.00 Assumes $37,500 per individualHousing76 $ 803,472.00 Assumes 100% need housing @ ~$880/month (Average of studio/1 bedroom FMR‐30% SSI contribution)Total$ 3,653,472.00 Assisted Outpatient Treatment FSP Services37 $ 1,387,500.00 $ 86,265.06 Assumes $37,500 per individualHousing37 $ 391,164.00 Assumes 100% need housing @ ~$880/monthCourt37 $ 940,143.29 No existing capacity, requires new calendar, 40 hours per weekCounty Counsel37 $ 248,000.00 Assumes 1 FTE attorneyPublic Defender37 $ 225,000.00 Assumes 1 FTE attorney, .5 FTE paralegalTotal$ 3,191,807.29 GRAND TOTAL $ 8,101,071.24
Phased in 10 person AOT Program Budget(12 court hours/week)21Program Service Capacity Annual Cost Cost per Person NotesIn Home Outreach TeamIHOT Services 1 team$ 735,395.10 N/AStaffing: Clinical, Case Manager, Peer, FamilyPES/Hospital Transition TeamTransition Services1 team$ 520,396.85 N/A Staffing: Clinical, Peer, Family Full Service PartnershipFSP Services76 $ 2,850,000.00 $ 48,072.00 Assumes $37,500 per individualHousing76 $ 803,472.00 Assumes 100% need housing @ ~$880/month (Average of studio/1 bedroom FMR‐30% SSI contribution)Total$ 3,653,472.00 Assisted Outpatient Treatment FSP Services10 $ 375,000.00 $ 102,176.30 Assumes $37,500 per individualHousing10 $ 105,720.00 Assumes 100% need housing @ ~$880/monthCourt10 $ 282,042.99 No existing capacity, requires new calendar, 12 hours per weekCounty Counsel10 $ 124,000.00 Assumes .5 FTE attorneyPublic Defender10 $ 135,000.00 Assumes .5 FTE attorney, .5 FTE paralegalTotal$ 1,021,762.99 GRAND TOTAL $ 5,931,026.94
Phased in 10 person AOT Program Budget(16 court hours/week)22Program Service Capacity Annual Cost Cost per Person NotesIn Home Outreach TeamIHOT Services 1 team$ 735,395.10 N/AStaffing: Clinical, Case Manager, Peer, FamilyPES/Hospital Transition TeamTransition Services1 team$ 520,396.85 N/A Staffing: Clinical, Peer, Family Full Service PartnershipFSP Services76 $ 2,850,000.00 $ 48,072.00 Assumes $37,500 per individualHousing76 $ 803,472.00 Assumes 100% need housing @ ~$880/month (Average of studio/1 bedroom FMR‐30% SSI contribution)Total$ 3,653,472.00 Assisted Outpatient Treatment FSP Services10 $ 375,000.00 $ 111,577.73 Assumes $37,500 per individualHousing10 $ 105,720.00 Assumes 100% need housing @ ~$880/monthCourt10 $ 376,057.32 No existing capacity, requires new calendar, 16 hours per weekCounty Counsel10 $ 124,000.00 Assumes .5 FTE attorneyPublic Defender10 $ 135,000.00 Assumes .5 FTE attorney, .5 FTE paralegalTotal$ 1,115,777.32 GRAND TOTAL $ 6,025,041.27
AOT Implementation Considerations23If the Board adopts AB1421, the workgroup makes the following recommendations to include an in AOT program:Consider the amendments passed by the SF Board of Supervisors.Limit AOT participation to only those consumers who absolutely need it the most.Maximize and support opportunities for consumer choice, wherever appropriate and allowable.Create an interdisciplinary team that includes clinical as well as peer counselor and family liaison staff.Adopt the collaborative court model for an AOT program. Select a judge and other AOT involved professionals who are willing to embrace the collaborative court model and work together in service of the consumer and their wellness and recovery.Transport referred individuals by law enforcement for a mental health evaluation only if the individual meets 5150 criteria. Use an external evaluator to conduct required program evaluation.
Next Steps (4-9 months)24If the board chooses to move forward with any of the recommendations, the following steps would be necessary:Identify funding sources.Develop a workgroup to plan, design, and implement new services.Hire and train new and selected staff.If the board chooses to move forward with an AOT program, the following steps would be necessary:Pass a board resolution adopting the 1421 legislation and issue a finding that no voluntary mental health program serving children or adults would be reduced as a result of the implementation.Develop a workgroup to plan, design, and implement a collaborative process with CCBHS, the Courts, County Counsel, and the Public Defender. Engage in outreach efforts, as set forth in the AB1421 legislation, to educate people likely to come into contact with the AB1421 population including family members, primary care physicians and other service providers, law enforcement, homeless service providers, and other relevant parties.If the board would like to consider the use of MHSA funding for any of the recommendations, engage in a Community Program Planning (CPP) process, as described in the MHSA legislation and Welfare and Institutions code, to develop an amendment to the three year program and expenditure plan.
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