RESEARCH WEEKLY: People with Serious Mental Illness May Not Receive Adequate Care in California Under Current Laws
By Kelli South
According to a report released last week by the California State Auditor’s office, California should increase its hospital bed capacity and access to assisted outpatient treatment (AOT) for those suffering from severe mental illness, while also overhauling its data collection practices.
The audit reviewed practices from the Lanterman-Petris Short Act (LPS) for three counties: Los Angeles County, San Francisco County and Shasta County. The LPS Act, originally passed in California in 1967, “permits involuntary mental health treatment when, because of mental illness, individuals pose a risk of harm to themselves or others or cannot provide for their basic needs.”
Individuals lack appropriate care
One major finding of the audit is that the state and local governments in California do not currently have enough psychiatric hospital bed capacity to treat all those who are in need. State hospitals are required to treat individuals involved in the criminal justice system, which leaves less beds available for other individuals in need of treatment. At the time of the audit, California’s number of state hospital beds was just under 6,300 and only 11% of these beds were occupied by individuals receiving treatment under the LPS Act, while 84% of the beds were occupied by criminal justice-involved individuals.
Additionally, wait times for the existing beds has increased by nearly 500% since 2014, the audit shows. In 2014, there was an average of 31 individuals waiting for a bed in a state hospital, but by 2019, there was an average of 197. State Hospital officials estimated that they would need an additional 330 beds in order to adequately meet the treatment needs of all individuals at any given time.
County ability to provide assisted outpatient treatment is limited
The audit reinforced the importance of assisted outpatient treatment (AOT) as a treatment option for people with severe mental illness in the community. The auditors found that many counties in the state were restricted from forming AOT programs due to the current state law.
A number of individuals in the three counties studied were found to have been placed under multiple short-term holds or conservatorships. Between 2014-2019, over 500 individuals in Los Angeles were placed on 72-hour holds each of whom had already been placed on at least 50 prior holds in their lifetime. The costs associated with just one 72-hour hold were estimated to be between $2,800 and $8,400, according to the report.
In total, between 2014-2019, Los Angeles placed 166,447 people on short-term holds under the LPS Act. Using the midpoint estimated cost associated with a 72-hour hold, the cost of this was over $932 million.
The report finds that AOT would be an efficient, cost-effective alternative to the repeated short-term holds and conservatorships that are currently happening. However, only 19 of 58 counties currently have an AOT program in place. And, even in counties that currently have AOT programs, many individuals who could benefit from AOT were not enrolled. From 2015 to 2018, “Los Angeles had nearly 7,400 individuals with five or more short‑term holds… and only 9 percent of those individuals were enrolled in full‑service partnerships or assisted outpatient treatment,” and in San Francisco only about one in 20 individuals were enrolled in these programs.
The audit recommends that AOT become a transitional program for individuals between a conservatorship and less intensive community treatment. This would reduce the number of individuals who, while stable at the end of their conservatorship, experience a regression in their illness due to lack of treatment, often leading the individual to be placed on more short-term holds.
State needs data management overhaul
The last major finding of the audit focuses on the need for improved data management across California in order to better understand where money for mental health services is being spent and how effective it has been.
The auditors recommend “a statewide framework for determining spending and outcome information across all funding sources” and say that until this system is in place, California “will remain unable to fully and efficiently understand the effects of its investments in mental health services and, if necessary, make changes to better serve those who need critical services.”
Last year, counties received $3 billion in funding for mental health but are unable to measure how successful their goals were after the funding was used. As stated in a previous Research Weekly regarding the importance of good data, implementing a new state-wide data collection and reporting framework will hold counties accountable for funding received while increasing cost-effectiveness and program effectiveness.
Broader implications
Building on the research presented in the report, the audit also provides a number of policy recommendations to fix the issues discovered. A few of the major policy recommendations for the California State Legislature include:
- Requiring all counties to implement assisted outpatient treatment and changing certain regulations associated with AOT programs, like allowing courts to require medications as part of treatment and changing eligibility requirements to allow individuals leaving conservatorships to be enrolled.
- Developing a framework for mental health services reporting procedures, which would include data from all funding sources and outcomes data for county and state mental health programs.
- Allowing counties to spend Mental Health Services Act funds to connect individuals to “community-based services” like AOT after they leave an involuntary hold or conservatorship.
If these recommendations are followed, California could see major improvements to its mental health care system. Furthermore, other states could use this report to examine their own mental health practices and highlight areas for improvement.
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