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HomeMy WebLinkAboutMINUTES - 02122008 - D.5 FHS #45 sE-L Contra TO: BOARD OF SUPERVISORS i Costa FROM: 2007 Family and Human Services Committee _ DATE: February 12, 2008 TA COUr� County SUBJECT: Elder Abuse and Conservatorship SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: CONSIDER 1) accepting the attached report from the Employment and Human Services Department (EHSD) regarding elder abuse and the County's conservatorship programs; 2) approving the transfer of the LPS Conservatorship Intake function from the Employment and Human Services Department (EHSD) to the Health Services Department (HSD) effective as soon as practical but no later than July 1, 2008; 3) approving the loan of staff from EHSD to HSD for an interim period to cover the on-going workload while HSD recruits and hires staff and to provide training and continuity to the services; and 4) directing Employment and Human Services, Health Services, and the County Administrator's Office to continue meeting and consider other options for improvements to the Public Guardian program including funding, organizational structure, process, and service provision, and return to FHS with recommendations for services improvement no later than March 2008. District Attorney, Public Defender and County Counsel staff will be consulted as needed. FISCAL IMPACT Undetermined at this time. There is sufficient 2007-08 fiscal year funding in the Health Services Department for the transfer of the LPS Conservatorship Intake function due to current year salary savings. Other possible programmatic changes will also impact funding and revenue in both the Health CONTINUED ON ATTACHMENT: X YES SI ATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION 6F BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): F deral Glover, Chair Susan Bonilla, Member ACTION OF BOARD ONoo— APPROVE AS RECOMMENDED OTHER AOA.00" VOTE OF SUPERVISORS (HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN. ABSENT: ABSTAIN7__ "lit: ATTESTED I � JOHN CULLEN,CLERK O BOARD OF UPERVISORS AND COUNTY ADMINISTRATOR Contact Person: Dorothy Sansoe 5-1009 CC: CAO HSD—Mental Health EHSD—Aging and Adult Services BY: DEPUTY ADDENDUM to D.5 February 12, 2008 On this day, the Board of Supervisors considered accepting a report from the Employment and Human Services Department regarding elder abuse and the County's conservatorship programs, approving the transfer of the Lanterman-Petris-Short Conservatorship (LPS) Intake function from the Employment and Human Services Department(EHSD)to the Health Services Department (HSD) effective no later than July 1, 2008, and approving other related actions, as recommended by the 2007 Family and Human Services Committee. Senior Deputy County Administrator, Dorothy Sansoe requested the Board approve the transfer of the (LPS) Conservatorship Intake function from the (EHSD)to the Conservatorship program within the Health Services Mental Health Division. She noted the proposal is not to transfer any positions but only the function. She went on to say (HSD) agreed to identify positions and funding necessary to assume the role. Ms. Sansoe said in addition, there could be other offsetting functions currently performed by the (HSD), which could be transferred to and may be handled more suitably by EHSD, and noted continuing meetings are taking place. Supervisor Uilkema noted constituents feel the public guardian, the public conservator and the estate unit should stay together, and said the estate unit is the section that allows direct provision of services for the customers, and reiterated the importance of keeping those three together. Ms. Sansoe said Probate and permanent Conservatorship functions are within the HSD but the Intake Services are with EHSD. She said she would return with a report on possible service improvements. The Chair invited the public to speak. The following individuals spoke: ■ Lois McKinney, representative, SEIU, Local 1021, told the Board the Union is opposed to moving only the Intake function. She said the Social Workers do the judicial process and it would be a disservice to the clients and their families if the transfer of the LPS Conservatorship Intake function from the EHSD to the HSD takes place without the Social Workers. She said the Union is not opposed to the transfer, but would like the 1021 members to go with the transfer, and said the Union is referring to only two members. She told the Board she was not apprised of this change and requested the Board to work out a plan. In conclusion, Ms. McKinney said the biggest need is for more full-time employees in the Conservatorship Intake Unit; ■ Suzanne H. Davis, Concord resident, said she agreed with Ms. Lois McKinney and said they have much work ahead and appreciates the Board's willingness to become educates about the Public Guardian. She said the Public Guardian is a 1 mandated program and their County needs help to work with LPS, and noted a new structure is needed. She said a Property Trust Officer's position is vacant for several months. She encouraged the Board to talk to Commissioner Don Green and Judge Flynn about the serious probate issues; and ■ Roland Katz, Business Agent, Local 1, said he agreed with Ms. Lois McKinney about the need for more full-time employees not only in Conservatorship but also in Mental Health and other departments. He said it sounds as though Management has not talked to the people who do the work in the S.E.I.U. and also with the employees who work in Mental Health. He requested the Board not to take any action today and to consider taking this back to staff to allow the Board and the Union to get a better idea of what the plan is. Supervisor Gioia said the system is not adequately funded, and new revenue should be created to make all our systems work, and said the issue here is how we can make the system work with the money the County has. Supervisor Uilkema requested the estate unit to be linked to the services of either the public conservator or the public guardian. Supervisor Bonilla asked why the two employees are not being moved permanently to the HSD. Employment and Human Services Director, Jo Valentine said these two positions are funded by Adult Protective Service Funds. He emphasized in this proposal two positions would remain in the EHSD's department and they would be assigned what was originally intended for those positions. Supervisor Bonilla conceded that these two positions would continue to promote and help elderly people who become victims,which might not be the same as the intake role but they would continue to serve this vulnerable population. She clarified the action today would not fix the problem but a process would start to put pieces in place to continue with the commitment to address this issue. She said she supports the action today but clarified this is not to be seen as a solution but an issue of bringing clarification. She said she would appreciate seeing there has been broad input into the plans brought back to the Family and Human Services Committee that would include input from the employees who are actively working and said she would like this to be one of the components of any report back to the Board. She said she is looking for some leadership to come forward on this issue from staff. By an unanimous vote with all Supervisors present the Board took the following action: ACCEPTED Recommendation Nos. 1-4 (spelled out on Board Order). 2 Page 2 Services Department and the Employment and Human Services Department. Until program review has been completed, including expense and revenue projections, any savings and/or additional costs will not be known. Budgetary changes will be included in the 2008-2009 Proposed Budget. BACKGROUND/REASON(S) FOR RECOMMENDATION(S): The Omnibus Conservatorship and Guardianship Reform Act of 2006 (AB 1363, Chapter 493, Statutes of 2006), a landmark package of bills to overhaul California's troubled conservatorship system, was approved by the Governor on September 27, 2006. The legislative package, comprised of bills authored by Assemblyman Dave Jones (D-Sacramento), Senator Debra Bowen (D-Redondo Beach), Senator Liz Figueroa (D-Sunol), and Senator Jack Scott (D-Pasadena), is designed to remedy deficiencies in California's conservatorship system that led to abuses of California's elderly and most vulnerable. The Act requires more detailed and more frequent court review and oversight of conservators, along with uniform standards of conduct that conservators must follow, new training standards for all professionals involved in the system, and a new requirement that Public Guardians take the cases of all those at imminent risk of harm. This new requirement on the Public Guardian went into effect on July 2007. On December 17, 2007 the Family and Human Services Committee heard a report from the Employment and Human Services Department (EHSD) on the current conservatorship program in the County, including the Public Guardian. As the number of vulnerable individuals in Contra Costa County continues to grow, the current structure of the conservatorship program is prompting both financial and organizational questions. In Contra Costa County the conservatorship program and associated services are administered through three separate departments resulting in a system that does not maximize efficiency or effectiveness and where services are frequently fragmented. A lengthy discussion took place at the Committee meeting regarding the program, within which departments various portions of the program are housed, recent articles in the Contra Costa Times regarding financial abuse of the elderly and recent legislation which has impacted the program. EHSD reported on models in use by other counties. The attached report advocates for a continuing review and further development of an improved Program. As a result of the meeting on December 17, the 2007 Family and Human Services Committee is requesting that the Board of Supervisors consider restructuring the County's Conservatorship Program and associated services to implement a broad, holistic, integrated service delivery system. As a first step, it is recommended that the intake functions for Laterman-Petri s-Short (LPS) conservatorship now performed by EHSD staff be transferred to HSD. Currently there are two positions handling the workload in EHSD and funded by Adult Protective Services funds. The Health Services Department has agreed to assume responsibility for this workload within the Mental Health Division's Conservatorship Program. Due to restrictions on the use of revenue, funding and positions will not be transferred, but will be used to provide adult protective services. HSD has agreed to identify positions and funding necessary to assume the function. In addition, there may be other offsetting functions currently performed by the Health Services Department which could be transferred to and handled more appropriately by EHSD. On-going meetings are taking place. Currently under discussion and review is the probate function. It is currently anticipated that any programmatic changes recommended for this function will be presented to the 2008 Family and Human Services Committee for review and possible inclusion in the 2008-2009 Proposed Budget. The FHS Committee also requested that the functions performed by the District Attorney, Public Defender, County Counsel and the Court be reviewed to ensure that, under any new structure, services are not adversely impacted. Areas for service improvements will also be reviewed, including, but not limited to, inter-departmental communication, handling of urgent or emergency documents for the immediate protection of an elder, creation of a Financial Abuse Specialist Team to collaborate on 1 Page 2 financial abuse issues, and the possibility of creating an elder court. Recommendations will be submitted to the Family and Human Services Committee for review and possible submission to the Board of Supervisors. Conservatorship Services in Contra Costa County 2007 Report to the Board of Supervisor's Family and Human Services Committee Background This year's report to the Family and Human Services Committee on Elder Abuse will focus on conservatorship programs which are experiencing an increasing demand for services from an aging county population. In Contra Costa County, the fastest growing segment of the population is the 85+age group. Over the next ten years, the 65+age group is expected to increase 37%; the 85+ segment is predicted to skyrocket by 55%. Due to fixed resources, the programs have had to triage clients and sometimes decline new cases, leading to an unmet need for services. There are actually three components of conservatorship and associated services that counties provide, formally delineated as: Public Conservator, Public Guardian, and Public Administrator. The Public Conservator handles Lanterman-Petris-Short (LPS) conservatorships. The Public Guardian(PG) handles probate conservatorships. The Public Administrator(PA) handles final disposition of deceased persons' estates when there is no identifiable living relative to do so. A conservatorship is the result of a legal proceeding which authorizes an individual (or public entity), the conservator, to protect the health and welfare of an individual when the Court determines that the individual is unable to manage his/her own affairs. Probate conservatorships can be of the person only, estate only, or person and estate. A Lanterman Petris Short Act(LPS) conservatorship is a legal procedure enabling a person, the conservator, to authorize psychiatric care and treatment to a person, the conservatee, found by the Court to be gravely disabled due to a mental disorder and unable to provide food, clothing, and shelter for him or herself. LPS conservatorships can be of the person, of the estate or both. In Contra Costa County an LPS conservatorship is used for involuntary placement in a secure or locked psychiatric facility. In practice, dementia is not considered a mental disorder and, thus, is carved out of LPS conservatorships, even though the behavioral presentation of a demented person may be identical to that of someone suffering from a mental disorder. The Public Guardian (PG), located in the Health Services Department(HSD), handles probate conservatorship. The HSD, Mental Health Division, oversees and provides services to the Conservatorship/Guardianship program. The program is divided into two sections: the LPS Section and Probate Section. These programs provide care, supervision and other mandated services to dependent adults. LPS conservatorship is for individuals who are considered gravely disabled (unable to provide themselves with food, shelter or clothing by reason of a mental disorder) and who are unwilling or unable to accept psychiatric treatment voluntarily. Frequently, LPS clients are also long term clients of the Mental Health Division. Page 1 1 The Probate Section of the PG Program maintains bank accounts and directly collects and disburses funds on behalf of the clients. It utilizes a dedicated electronic data processing system for case management and financial reporting. The Probate Section acts as the representative payee for almost all long-term conservatees and many temporary conservatees. Additionally, the Probate Section acts as the representative payee for many County mental health consumers who have not been conserved but have case managers within the HSD Mental Health Division. The Public Conservator provides involuntary psychiatric treatment to someone with a grave disability who is unable or unwilling to give consent. Such treatment is not possible beyond short-term holds of a few days (such as a 51501)unless the court appoints an LPS conservator to consent in the client's stead. The Lanterman Petris Short(LPS) Conservatorship Intake Unit is located in the Aging and Adult Services Division, and investigates all referrals for LPS conservatorship. During the course of the investigation, EHSD also serves as the Temporary LPS Conservator. The Conservatorship Investigator writes a report to the Superior Court if they intend to recommend that a long-term (often called"permanent") conservator be appointed. Permanent Conservatorship services are provided by the Health Services Department. The Public Administrator(PA)must, by law, be under an elected department head, although general law counties, such as Contra Costa County, may get a waiver from this requirement. The PA, housed in the District Attorney's Office, handles final disposition of a deceased persons' estate when there is no identifiable living relative to do so. When notified of a County resident's death, the Public Administrator determines assets. If there are no assets,the case is closed. If assets are located,the Public Administrator finds heirs and collects fees for settlement of the estate. If there are assets and no heirs the money is transferred to the State. History Before 1981 the Public Administrator(PA) and Public Guardian (PG) were located in the District Attorney's office. Only conservatorships of estate were handled by that office, not of person. In that year the County transferred the PG functions to the Health Services Department(HSD) in order to facilitate community placements after one patient lived on an acute care hospital ward for three years. The DA's office continues to serve as Public Administrator, settling decedents' estates when there is nobody else to do SO. Up until 1981 both intake and long-term conservatorship functions of LPS conservatorships were housed in the then Social Services Department. Social Services Page 2 I had twenty deputy conservators in two units of ten workers each. In 1981 when HSD assumed the PG functions from the DA's office, they also assumed responsibility for the long-term LPS conservatorship program. At that time it was believed that the same department that generates many LPS conservatorship referrals should not be the same department that screens them and thus, Social Services (EHSD) has retained the intake functions of LPS up to the present day. More recently,the County Administrator's Office issued a memorandum dated March 15, 2007 outlining some of the current program and funding opportunities which might be pursued in the future. Overall, some untapped opportunities exist for new revenue or low-cost program improvement. However, most options would require either additional County General Fund or time to develop, or would increase program complexity without benefit to the clients. As a result of the report, on April 23, 2007 there was a joint meeting between the Health Services and Employment and Human Services Departments to explore possible program improvements. Options discussed were: 1) Transfer LPS conservatorship intake from EHSD, Adult Protective Services,to HSD's Mental Health Division, and 2) Transfer the Public Guardian functions from HSD to EHSD's Aging and Adult Services Bureau. The HSD Public Guardian's office's had notified the EHSD Aging and Adult Services case management division that they would not be able to accept probate conservatorship referrals for an indefinite period of time due to staffing turnover and current caseloads. On October 31, 2007 representatives from the Health Services Department and the Employment and Human Services Department again met to consider options for improving program service delivery. As a result of these meetings, the Departments have agreed to recommend that the LPS Intake Unit be transferred to HSD and that they continue to meet to discuss other program improvement options. Vulnerable Residents' Needs For years Adult Protective Services has received reports of abuse on individuals who are evidencing signs of diminished or fluctuating mental capacity. Past reports to this committee have discussed the legal limitations of APS or other authorities to intervene because of the rights adults are assumed to have unless a court of law determines otherwise. This year we want to illustrate the nuances associated with providing services to this aging population given these challenges. Financial abuse is being called the crime of the 21St Century and elders may risk losing everything they've saved over a lifetime. The Protective Services Operations Committee of the California Welfare Directors Association in its Day in the Life of APS II report, issued in April 2006, focused on the financial abuse reports that had been received statewide on March 5, 2004. In the cases where a financial amount was able to Page 3 be determined out of the 98 financial abuse cases that were tracked, $20 million was determined to be at risk that day. This is a conservative estimate of the financial impact associated with financial abuse. In a county such as Contra Costa County, senior living communities are emerging designed to attract the retiring Baby Boomers. Rossmoor in Walnut Creek and Summerset in Brentwood may represent an attractive option for older people who want amenities, including the safety of a gated community. Retirement communities also represent a nicely congregated pool of available victims who may be susceptible to exploitation. Rossmoor, because it is an older community, has seen dramatic changes as its"young" active seniors have aged in place. As one example,the District Attorney's office successfully prosecuted a ring that had victimized 14 identifiable individuals from Rossmoor in an automobile damages scam. For years APS has seen instances where someone is living in their home for decades, but is having increasing difficulty in managing their affairs. Bills are unpaid; the house is not maintained as well as it had been inside and out. These more complex tasks of money and household management utilize cognition skills called executive functioning. Social service providers call these more complicated behaviors Instrumental Activities of Daily Living or IADLS. Scales and evaluation tools exist which measure the degree of impairment individuals may be experiencing in executive functioning, memory, and other brain functions. These tools are usually administered by neuropsychologists and can form an important basis for determining whether someone lacks capacity and should be conserved. APS has contracted with appropriate professionals to conduct these assessments and to complete capacity declarations for conservatorship petitions to the court. APS social workers are trained to try to meet a client's needs in the least restrictive, most independent fashion. APS believes many of these types of individuals could function safely at home, if they had a conservatorship of estate. Such a conservator would handle money management and arrange for housecleaning and other household tasks. This would be the most desirable solution to the protection issues from both the perspectives of the client and of APS. Individuals generally do not want to leave their homes and this solution might delay or prevent the imposition of more restrictive placements in nursing homes or residential care facilities for the elderly. If the individual developed a more significant dementia and became a wandering risk, for example, the conservator would then be in the right position to arrange for the most appropriate placement because the conservator would already have the legal authority to act in that capacity or to petition the court for expanded authority to arrange placement. APS is curtailed in its authority to act in those moments where placement is needed when there is not a conservatorship in place, because APS is a voluntary program. Clients do not have to work with APS and can refuse services. Earlier in 2007 the District Attorney's office successfully prosecuted a perpetrator who had victimized an APS client in East County. This case amply demonstrates the vulnerability of these demented people who are living at home without legal protection. Page 4 The perpetrator, J.G., represented himself to APS as this client's caregiver, yet there was no fresh food in the house, the house was filthy, and his medications had expired. He eased into this victim's life by befriending him, offering to mow his lawn, and do things around the house. It was immediately apparent on the first APS visit that this client had significant cognitive impairment. By the time the case was prosecuted, the victim had lost over$320,000 to this criminal. The perpetrator received a 10-year jail sentence. There was extensive print and broadcast media coverage about this case. APS is very concerned about people such as the victim in the above case because they are unable to resist undue influence and become victims without knowing it. The incidence of financial abuse will only increase and APS is limited in its response capabilities. APS would like to strengthen the response to financial abuse through increased cooperation of the necessary public sector responders, through its Financial Abuse Specialist Team (FAST). APS is very interested in being able to call upon the Public Guardian's office to invoke Probate Code § 2900, 2950, and 2952 which permit the freezing of assets, when it looks like a crime is occurring and transactions may be taking place that are not in the best interest of the client. Challenges With the Current Conservatorship Structure in Contra Costa County The areas of operational difficulties that have been identified for improvement include: 1. arranging transportation for clients to appear in court, 2. getting treating physicians or mental health providers to appear in court to testify about their clients' condition, and 3. communication and cooperation between all the providers. For example LPS intake rely on a mental health staff aide located within the PG office for transportation to bring clients to court. EHSD has been in the position more than once of being threatened with contempt of court for failing to produce the client in court due to problems transporting the individual. EHSD has hired a retiree with limited time to fill in the gap in transporting clients again at APS expense. This retiree is also used by the PG/PC. In addition these clients may represent a flight risk once they are out of the locked psychiatric facility and some have a known history of violence. As another example, expert witnesses at hearings or trials where a conservatorship is being challenged must be hired and paid. Without such testimony the conservatorship would be dropped and the individual/client would be released to the community and such release could present a risk to this individual as well as to the community. The HSD crisis stabilization unit psychiatrists and psychiatrists at locked treatment facilities do not get paid for time taken to testify because there is not funding source for these services. Communication across conservatorship programs is key to effective service provision. County Counsel must represent EHSD in court trials where conservatorships are contested; the Public Defender's office represents the client in contested cases; CCRMC provides acute psychiatric services; the Mental Health program is responsible Page 5 for authorizing placement in psychiatric facilities; and the Deputy Conservator gives legal consent to provide care and treatment. Without consolidation and unity of purpose there is potential for duplicative services,wasted efforts and inefficient use of funds, including General Fund. Some of the challenges with the Public Guardian's office surrounding probate conservatorships have been previously mentioned. Due to staffing and caseload challenges, they have been closed to new referrals since April 2007. They do not have resources to accept individuals residing in their own home and concentrate their efforts on those in institutional settings with 24-7 supervision. The PG office does not have the capacity to conserve people in the community because of the enhanced case management time and cost that would necessitate. However, because of the Omnibus Act(AB 1363, Statutes of 2005 —Jones), individuals will first be presumed to be most appropriate to remain in their homes. This law places increased pressure on PG to prove that 24-hr supervised settings are better than an individual's home in a given situation. Staffing (Note—This section updated 1/17/08 and reflects authorized staffing as of 12/31/07) There is a variety of staffing and differing levels of compensation between County departments for the provision of conservatorship services. A total of 21.5 full time equivalent staff positions are devoted to conservatorship and associated services in some way. The table below displays the distribution of staffing of compensation levels by department. Number of DISTRICT ATTORNEY(Public Administrator) FTE Chief Deputy Public Administrator 1.0 Public Administrator Program Assistant 1_0 TOTAL DISTRICT ATTORNEY 2.0 EMPLOYMENT AND HUMAN SERVICES(LPS Intake) Social Casework Specialist H 2.0 Social Work Supervisor II* 0_5 TOTAL EMPLOYMENT AND HUMAN SERVICES 2.5 HEALTH SERVICES (Probate and Permanent Conservatorship) Conservatorship/Guardianship Program,Manager 1.0 Mental Health Clinical Specialist 4.0 Mental Health Specialist II 4.0 Properties Trust Officer 1.0 Accounting Technician 2.0 Clerk—Senior Level 2.0 Patient Financial Services Specialist 1.0 Conservatorship Program Supervisor 1.0 Conservatorship Program Aide 1_0 TOTAL HEALTH SERVICES 17.0 TOTAL STAFFING FOR CONSERVATORSHIP 21.5 Page 6 Other Models Alameda County Earlier this year, Eric Cho, EHSD Social Work Supervisor II, through a BASSC internship program prepared a report from his research with Alameda County's LPS conservatorship (Public Conservator)program. His BASSC paper outlines both how Alameda County's Public Conservator(LPS)program functions with its necessary partners and offers recommendations for improving Contra Costa's system. This report highlights some of Mr. Cho's findings. For example, in Alameda County LPS conservatorships rarely go to trial. They may average one trial annually where the conservatorship is contested. The Public Defender generally works with the Public Conservator to keep their client on a conservatorship if a longer period of treatment and stabilization is indicated. Alameda's Social Services Agency, which houses APS, the PG and the PC, pays for one seasoned attorney's time out of the county counsel's office to represent them in court. In addition, Alameda also has Public Defender attorneys specifically dedicated to LPS cases. As an aside, San Francisco also has Public Defenders and County Counsel attorneys specifically dedicated to LPS conservatorship and the working relationships in San Francisco, as in Alameda, are such that conservatorship trials are rare. In contrast, CCC's county counsel and Public Defenders offices rotate the duties among newer staff attorneys. In addition, CCC Public Defender's office generally uses new attorneys eager to gain trial experience and in the first eight months of 2007, 29 trials were set contesting LPS conservatorships in CCC. Alameda locates APS, the PG(probate conservatorships) and PC (LPS conservatorships within the Department of Adult and Aging Services, Division of Adult Protection. It has been structured this way for some time. It has two APS units, an LPS unit and a probate unit. Each unit has 8 deputy conservators. They use one classification, "assistant public guardian conservator" for both PG and PC units and may also draw interchangeably for the APS worker classification because the pay scale is the same with the top step at around $74,000. Both the PG and PC units carry caseloads of around 40- 45 cases per deputy conservator. Their Public Administrator is located in the Sheriff's Department. They also have an accounting unit for performing estate functions for both PG and PC. It is unknown what the PA staffing levels are for their estate duties. Both Alameda's PG and PC units share the services of a property manager who prepares houses for sale, handles evictions, and deals with estate issues. This unit has three administrative assistants who conduct searches for relatives, wills, and other property and documentation. Out of 423 open LPS cases, 65 of them have conservatorship of estate or about 15%. Out of around 400 probate cases, 95% of them are required to have conservatorship of estate as well. They also charge fees for estates of a certain size. They have a vertical model, where conservatorship referrals are handled by the same people from intake through permanent conservatorship. Alameda's PC is funded from both Page 7 mental health($1 million) and APS funding. The unit supervisor states that mental health stays "hands off'with this money. The division of adult protection operates closely together. The Division Manager meets biweekly with the APS, PG and PC unit supervisors. The PG serves on APS' FAST team and APS understands the criteria for accepting probate referrals. Since the passage of SB 1018, which has added employees of financial institutions as mandated reporters of elder financial abuse, the numbers of financial abuse reports has increased 400% in Alameda County. Therefore, one of the most important benefits of having the PG participate in the FAST meetings is the ability to respond quickly in abuse situations. The PG unit supervisor, Emily Galimba, indicated that they do invoke Probate Code § 2900 to freeze assets. She also indicated that it is"invaluable" for the PG to be co- located with APS because of the ability to share case information and files. In addition the most significant legal ramification since the passage of the Omnibus Act(AB 1363) is that the law now presumes that remaining at home is the most appropriate placement. Lawyers must now overcome this presumption to have the court agree to placement in 24-hr supervised settings, such as nursing homes or board and care homes. Sonoma County Four years ago Sonoma County reorganized its PG/PA/PC program under its Human Services Department. It requested and received a waiver from the requirement that the PA to be under an elected official. In the 1990s the PG was in the DA's office; the PC was in Mental Health; and the PA was under the coroner's office. During the 1990s APS had actually funded one deputy conservator position in the PG's office, which then was cut because of budgetary restrictions. Sonoma's Mental Health Department had taken an $8 million cut, which hurt the PC program. This budget reality created the need for a variety of stakeholder meetings and conservatorship task force meetings. Out of these task forces meetings they decided to co-locate and cross-train all their conservatorship programs. They were sensitive to the conflict of interest that the PC had being located in Mental Health. The PG staff began to time study to APS and the CAO's office was willing to show an overmatch of APS funding because PG was then able to claim around $200,000 annually in federal money. The county General Fund allocation to the PG program remained virtually unchanged. In May 2007 the programs were actually moved together in the same building and on the same floor. Since then both the APS section manager and the Chief Deputy of the PG/PA/PC have found the change to be beneficial. Initially, the PG staff members were concerned about clear role expectations. There had been historical differences of opinion. They did not want to become social workers and thought that APS expectations did not match their actual duties. They also were concerned about losing the autonomy to decide which cases to take and which to refuse. They did not want to be forced to take every APS referral. While APS still Page 8 experiences frustration when the PG will not take a case, there is mutual appreciation for the improved relationships they are experiencing. APS and PG staffs talk to each other informally as well as through case consultation meetings; the ability to walk over to someone's cubicle has eased the tensions tremendously. The APS section manager, Gary Fontenot, anecdotally reports he has seen some greater flexibility on the part of the PG to accept cases, including cases where conservatees are living out in the community. When asked directly,the Chief Deputy of the PG/PA/PC, Sally Liedholm, could not think of a single disadvantage of the reorganization and of the co-location together now that the move has happened and people have had a chance to settle down. She appreciated being able to talk to the Medi-Cal eligibility staff, which becomes important for nursing home payment, the veterans service office and to APS. She even appreciated access to county cars, which they did not have as easily before. The only drawback for them was not programmatic: they are now further away from the county hospital, county counsel and courts. They now set up regular meetings with county counsel to discuss cases in order to conduct their business together. Although Sonoma County's population base is smaller than Contra Costa's, their APS staffing levels are quite similar to Contra Costa County's levels. They have 10.5 FTE APS social workers; Contra Costa County has eleven. Both counties have 2 social work supervisors. Sonoma has one public health nurse, for whom Human Services Department contracts with Health Services; Contra Costa has two PHNs, both contract with Health Services Department. Sonoma has one .75 FTE mental health liaison and Contra Costa has 1 FTE mental health clinical specialist, for whom EHSD pays HSD. In Sonoma's PG/PA/PC office there are eight total staff members: the Chief Deputy, one account clerk, one senior office assistant, one supervisor over all three components, and four deputy conservators. They used to have two supervisors, each supervising 1.5 deputy conservators for the PG and PC programs, respectively. San Mateo County Lastly,this report will comment on another county that has decided to integrate its services, but to do so under its Health Department rather than under its social service department. San Mateo's Aging and Adult Services Department is located under the Health Department Director. It includes APS, MSSP, Linkages, AIDS case management, the Public Guardian, a representative payee program, a case management program for patients who frequently use the hospital's emergency room, family caregiver services (respite program), a clinical 24-hr response program(it covers after hours for APS, nursing home complaints, and for other consumers of Aging and Adult Services), Information and Referral, IHSS, and the IHSS Public Authority. They have a centralized intake unit which is comprised of all of APS, Information and Referral, the 24-hour clinical response program and three deputy Public Guardians, who are separate from the Deputy Public Guardians who are in the PG program. There are two supervisors in centralized intake. One person(an MSW) supervises 8 APS Page 9 investigators, which includes one public health nurse. The other supervisor is over the Deputy PGs, who comprise phone workers, three investigating Deputy Public Guardians and one representative payee. The three phone workers may go out on immediate APS reports, where a response is needed anywhere from immediately up to three days. They also conduct investigations not requiring an initial face-to-face investigation (NIFFI). Because APS and the PG are located together within the centralized intake unit the manager has the authority to send out workers under Probate Code §2901 to freeze someone's assets, if it appears that a conservatorship is necessary. They are certain to differentiate between someone who lacks judgment but has mental capacity from someone who lacks capacity. They will lose the petition for conservatorship in the former situation. The worker who goes to the bank in these instances of financial abuse may either be an APS worker or a Deputy Public Guardian. The Health Services manager over Aging and Adult Services also commented on Contra Costa County's query about conflict of interest issues. The flow of accepting conservatorship referrals is exactly the same for every referring entity. If the county hospital, which is literally across the street from Aging and Adult Services offices,wants to conserve someone immediately in order to place them out of an acute care bed or if an MSSP or APS worker wants to conserve someone,they must complete the PG application, including the capacity declaration, and submit it to centralized intake, who then will investigate the referral. If the investigation yields the conclusion that a conservatorship is in order, centralized intake submits the referral to the court. The court has its own investigators who then gather their own information for the judge. If the court grants either a probate or an LPS conservatorship and the PG's office in Aging and Adult Services is appointed as conservator, then the PG accepts the case. Outside of their centralized intake is the Public Guardian office, which includes probate and LPS conservatorships. While their centralized intake conducts initial probate investigations, initial LPS investigations are conducted by their Mental Health division, which is in their behavioral health department, which include Senior Mental Health Services and alcohol/drug services. The unit supervisors in and out of centralized intake comprise the leadership team of Aging and Adult Services and so all decisions about cases are decided internally. There is no fragmentation about whether PG should take a case or who should handle which aspects of a case because they all work it out together. APS and the other case management programs understand they have to submit complete documentation, including getting doctors to complete capacity declarations, for the application for a conservatorship. Best Practices for Contra Costa County Significant questions remain about what is in the best interest of the most vulnerable clients and how our County can best respond to those needs. The first issue thwarting cases needing conservatorship is the issue of carving out dementia from eligible criteria for beginning a psychiatric hold' on clients who are presenting as gravely disabled Page 10 and may need an initial period of evaluation and treatment. Current law does not consider dementia a mental illness. A second issue pertaining to long-term LPS conservatees is the increasing need for medical and estate management services as these conservatees age. Some counties have concurrent probate and LPS conservatorships to handle both psychiatric care and medical treatment or placement issues. Approximately, 20%of the adult population has defined mental health problems and this bifurcation of services along physical and mental health care becomes arbitrary and fragmented at a certain point because of the funding streams for providing these services. Elderly people experience multi-system health conditions in higher proportion than the younger population. Examples include diabetes, hypertension, and cardiovascular conditions. An aging schizophrenic with diabetes who develops a dementia will need some of the same types of assistance as other diabetic and dementia patients. There may be a conflict of interest if the PG is placed under the health department. In fact the law requires a separation where a conflict of interest has been demonstrated.2 A conservator should consider what is in the best interest of the conservatee, despite the fact that a chosen course of action may cost more. It may be true that differences of opinion about proper courses of action will always exist between providers. Caution must be exercised when the person with the legal authority to give consent is under the same umbrella as the treating providers. In any organizational structure, a range of probate referral sources must continue to be serviced, including acute care hospitals, including CCRMC, skilled nursing facilities, board and care homes, courts, community organizations, APS, banks, and occasionally the District Attorney's office. The key to servicing referral sources, has to do with adequate staffing and good communication between providers more than where the receiving entity is located. However, in the research done for this presentation, counties with fewer silos of discreet divisions and with more unification experience more comprehensive services, friendlier collaborations, easier flow of services, and greater levels of service. Conclusion This report described areas for potential improvement in Contra Costa County's Conservatorship Service programs, as viewed by APS. The primary challenge for the County's Conservatorship and Adult Protective Services programs is an increasing demand for services from an aging county population. The fastest growing segment of the population in Contra Costa County is the 85+ age group. Over the next ten years, the 85+ segment is predicted to skyrocket by 55% and the 65+ age group is expected to increase 37%. Due to fixed resources,the programs have triaged clients and sometimes decline new cases, leading to an unmet need for services. The recommended consolidation of services could yield greater efficiencies in services and more efficient use of public funds. Contra Costa County is committed to providing the best services to some of the most vulnerable residents of Contra Costa County. Page 11 r Acknowledgements Many people have contributed to make this report possible. I would like to thank the following people for their input and wisdom: Eric Cho, EHSD Social Work Supervisor Il; Al Flanagan, CCC Deputy Conservator/Guardian Conservatorship Program Supervisor; Ednah Friedman, retired CCC Conservatorship/Guardianship Manager; Diane Kaljian, Sonoma County Human Services Department Division Manager; Gary Fontenot, Sonoma County Section Manager, which includes APS; Sally Liedholm, Sonoma County Chief Deputy of the PA/PG/PC program, Harry Gin, Alameda County PC unit supervisor; Emily Galimba, Alameda County PG unit supervisor, and Chris Rodriguez, San Mateo Health Services Manager. Footnotes 1This psychiatric hold is commonly referred to by the Welfare and Institutions Code section that creates it, or a"5150". A"5150"is a 3-day period in which the patient is held involuntarily for evaluation. A"5150" is the usual first step towards an LPS conservatorship. Often it is difficult to ascertain the cause for some of the behaviors that are presenting and field workers or law enforcement personnel are not necessarily aware of preexisting mental disorders that would otherwise"qualify"someone for a 5150-hold. 2 WIC §5371. ... Conservatorship investigation and administration shall be conducted independently from any person or agency which provides mental health treatment for conservatees,if it has been demonstrated that the existing arrangement creates a conflict of interest between the treatment needs of the conservatee and the investigation or administration of the conservatorship. The person or agency responsible for the mental health treatment of conservatees shall execute a written agreement or protocol with the conservatorship investigator and administrator for the provision of services to conservatees. The agreement or protocol shall specify the responsibilities of each person or agency who is a party to the agreement or protocol,and shall specify a procedure to resolve disputes or conflicts of interest between agencies or persons. Page 12