In-Home Outreach Team (IHOT) Assisted Outpatient Treatment (AOT) Pilot Program Community Conservatorship (CC) Pilot Program

Alameda County Behavioral Health Care Services Alameda County Social Services Agency

March 2016

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AB1421 planning process concluded in 2014

9 recommendations approved as alternatives to AB1421/ Assisted Outpatient Treatment (AOT)

5 of 9 recommendations completed. Remaining include the Peer Navigator, Family Groups, TAY Intensive Case Management and In-Home Outreach Team (IHOT) Programs

Board of Supervisors approved 5-person AOT Pilot and 12-person Community Conservatorship Pilot in November, 2015

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People Most in Need of Outpatient Treatment

669 adults (3%) out of 23,000 served

Age:

109 between 18 – 25 16%

560 between 26 – up 84%

422 have Medi-Cal 63%

Gender:

Male 57%

Female 43%

From what Part of County?

345 North 52%

242 Central 36%

43 South 7%

28 East 4%

Primary MH Diagnoses

Schizophrenia Disorders

Psychotic Disorders

Bi-Polar Disorders

Ethnicity:

264 African American 40%

204 Caucasian 31%

91 Latino 14%

75 API 11%

6 Native American < 1%

10 Other 2% 18 Unknown

122 did not have a Service

Team or Sub-Acute Episode

18%

Primary Language:

600 English 90%

23 Spanish 3%

7 Chinese 1%

2 Farsi < 1%

2 Vietnamese < 1%

35 Unknown 5%

Co-Occurring Substance or Alcohol Related Diagnosis

83 or (12% of 669) have a co-occurring diagnosis

45 African American 54%

20 Caucasian 24%

12 Latino 15%

4 API 5%

1 Native American 1%

1 Unknown 1%

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In-Home Outreach Team (IHOT): Outreach, engagement and linkage for people with severe mental illness who are not connected with services.

Assisted Outpatient Treatment (AOT): Full Service Partnership (FSP) level services for individuals who have a documented severe mental illness, who are not actively engaged in care, are in deteriorating condition, and have a history of failing to comply with treatment.

Community Conservatorship (CC): LPS conservatorship provided in the community rather than a locked facility.

Programmatic Comparisons

IHOT

60-80 slots

AOT

5 slots

LPS Conservatorship

(Current Program)

Community

Conservatorship

12 slots Voluntary

Governed by MHSA

principles

Referral: Flexible.

Family, law

enforcement, jail,

hospital, mental

health and

community programs,

advocacy agencies.

Meds: The client

retains the right to

consent to

medication

Placement:

Dependent upon

client choice. May be

utilized as the

“funnel” for AOT and

LPS process.

Involuntary

Governed by

Assembly Bill 1421

legislation

Referral can come

from any concerned

member of the

community including

a family member or

clinician

Meds: The client

retains the right to

consent to

medication

Placement: The client

resides in the

community with

intensive services

Involuntary

Governed by the

Welfare and

Institution Code

δ5000 et seq.

Referral comes from

qualified mental

health professional in

an acute psychiatric

setting

Meds: Client may not

retain the right to

consent to

medication

Placement: The client

remains in a locked

setting or supervised

community setting to

receive ongoing

involuntary treatment

Voluntary

Governed by WIC

5000 & MOU-SSA,

BHCS, acute

psychiatric hospitals,

Court, Counsel and

PD

Referral comes from

qualified mental

health professional in

an acute psychiatric

setting

Meds: Client will not

retain the right to

consent to

medication

Placement: The client

resides in the

community with

intensive services

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COUNTY 1421 IMPLEMENTATION DATE STATUS

Nevada April 2008 Fully implemented.

Yolo June 2013 – 5 person Pilot June 2014 - Full

Fully implemented following a successful pilot.

Los Angeles July 2014 Expanded to full program 11/14, 360 to 500 people.

Orange October 2014 Fully implemented.

Placer January 2015 Fully implemented.

Kern October 2015 No details available yet.

San Francisco November 2015 Fully implemented as of 11/2/15.

Mendocino January 2016 4-person pilot.

San Diego April 2016 (anticipated) Referrals set to begin April 2016. 114 slots.

Alameda July 2016 Pilot program in planning, 5 slots for a one-year period

Ventura July 2016 20-25 person 18-month pilot program to launch.

San Mateo TBD RFP sent out 2/16.

Contra Costa TBD 3-year pilot started

San Luis Obispo TBD 10-12 people identified as potentially qualifying.

El Dorado TBD In development.

Shasta TBD 40-person program.

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Behavioral Health Care Services

Social Services Agency

Public Defender’s Office

County Counsel

***MOU finalized between all parties***

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1/26/16 African American Steering Committee Leadership 2 participants 2/3/16 ACCMHA Leadership Meeting 11 participants 2/3/16 Family Dialogue Meeting 11 participants 2/19/16 Adult System of Care Provider Meeting 35 participants March 2016 POCC Steering Committee 25 participants April 2016 Acute Care Meeting anticipated 25 participants April 2016 NAMI anticipated 20 participants TOTAL: 129 participants

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IHOT programs (Total = 60-80) will increase potential for program diversity in outreach and engagement of individuals across county. Will also require increased collaboration across agencies to increase system wide coordination throughout pilot implementation.

AOT Pilot size (N = 5) may limit inclusion of statistically significant data. Qualitative data and outcomes will principally be used to evaluate programming.

CC pilot (N = 12) to provide immediate access to intensive outpatient services within the community. Also likely to include utilization of additional housing placements, beyond sub-acute level supports.

IHOT, AOT Pilot, and CC Pilot to offer “rolling admissions.”

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Implementation Task IHOT AOT CC

BOS Approval X X X

Review of Statutes X X

Defined Program Process X

Researched Similar Programs in CA X X X

Developed Project Team X X X

Established Stakeholders and Agency Partners

X X X

Competitive Bidding Process X

Created FAQ Sheet X X

Educated Staff, Stakeholders and Community X X X

Developed Program Forms

Created Promotional Tools

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On track for July 1, 2016 implementation

• QUESTIONS?

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IHOT

PETITION

COURT

AOT

Alameda County Assisted Outpatient Treatment Referral Process (Updated March 22, 2016)

In Home Outreach Team (IHOT) or ACCESS accepts referral and screens for Assisted Outpatient Treatment (AOT). Referral sources include family members, behavioral health providers, psychiatric emergency services, jail, hospitals or other community sources.

Behavioral Health Director or designee conducts assessment/investigation to determine appropriateness in moving forward with petition.

Start

Person meets AOT eligibility criteria and petition filed. Petition includes affidavit from mental health provider stating examination (or an attempt to examine) has occurred.

Person does not meet AOT criteria. Petition process stops and person is referred back to IHOT and/or other community resources.

AOT/Court Process Begins • Court schedules a hearing date within 5 days after petition is filed

(hearing may be continued for good cause); • BHCS Director / designee serves court documents to person who is

subject of the petition, copying Patient’s Rights and IHOT; and • Court appoints public defender if requested by subject person.

AOT Hearing Results of examination are heard and findings determined. If person has not had face-to-face examination, court may order person to be held under Section 5150 for purposes of examination.

AOT Settlement Person may waive right to hearing and accept treatment plan.

Court Denies AOT Petition Person does not meet AOT criteria and is referred back to IHOT and/or other community resources.

Court Approves AOT Petition Court orders treatment for up to 180 days; may be extended upon application of AOT provider and order of the court.

Every 60 days, AOT provider files affidavit with court on continuing eligibility.

Provider may initiate a 72-hour hold if person meets existing 5150 criteria. Failure to comply with AOT alone may not be grounds for involuntary commitment or contempt of court.

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Referral is given to AOT Coordinator to ensure timely assessment of eligibility by Behavioral Health Director or designee.

Person declines AOT Person accepts AOT

Court may order person to meet with AOT Team

Person declines AOT

DECLINES AOT

SUMMARY

Assisted Outpatient Treatment, also referred to as “AOT or” “Laura’s Law,” was enacted in 2002 by California Assembly Bill 1421 and refers to court-ordered outpatient treatment for individuals who have a severe mental illness. In counties that choose to adopt the program, AOT allows for adults who meet certain requirements to request that the county mental health director petition the court to mandate treatment for individuals who have previously refused care and meet strict eligibility requirements.

ELIGIBILITY

Who is Eligible for AOT?

Per W&I Code 5345-5349.5 an individual must meet all of the following

criteria to qualify for AOT:

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. 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: • 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.

• 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.

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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.

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.

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Per W&I Code 5345-5349.5, the following may request a Petition for AOT:

1. Any person 18 years of age or older with whom the person who is the subject of the petition resides.

2. 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.

3. 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.

4. The director of a hospital in which the person who is the subject of the petition is hospitalized.

5. 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.

6. A peace officer, parole officer, or probation officer assigned to supervise the person who is the subject of the petition.

FAQs

1. Who is AOT designed to help?

AOT is designed to assist individuals who have a documented severe mental illness, who are not actively engaged in care, are in deteriorating condition, and have a history of

failing to comply with treatment. AOT requires that individuals meet strict eligibility guidelines, as outlined above.

2. How many people are expected to be eligible for AOT in Alameda County?

In a 2015 report, BHCS identified 669 of the highest utilizers of acute services in Alameda County. It was determined that 122 of the 670 are unserved in Alameda County. Our

hope is that AOT will help connect this group to much needed support and services.

3. Does AOT help provide care for people with mental illness who are homeless?

In some cases, homeless people will be eligible for AOT; in other cases they will not. AOT has strict eligibility criteria that apply regardless of whether an individual is housed.

These criteria include the requirement that AOT be initiated by someone who knows the individual, either personally (family member or co-habitant) or professionally (mental

health provider or peace, parole or probation officer assigned to supervise the individual), and that the individual not be actively engaged in mental health treatment.

4. What are the individual’s rights in the process?

AOT strictly defines patient eligibility criteria in an effort to ensure appropriate application of the law and to protect individual rights. AOT provides at least two opportunities to

engage patients in voluntary treatment prior to a court hearing. Additionally, AOT specifically defines the rights of the individual with mental illness who is subject to AOT,

including adequate notice of hearings, to receive a copy of the court-ordered evaluation, to a court appointed public defender in the absence of private counsel, to be present at

the hearing, to present evidence and call and/or cross-examine witnesses, to appeal decisions, and regular review of appropriateness of AOT.

5. What is the difference between AOT and a 5150?

A “5150” refers to Section 5150 of the California Welfare & Institutions Code and is an emergency hold in response to a psychiatric crisis, allowing for up to 72 hours of involuntary

psychiatric evaluation and treatment of persons believed to be a danger to self, a danger to others, or gravely disabled by mental illness. AOT is a non-crisis process that allows for

an adult that meets AOT criteria and declines voluntary treatment to be compelled by a civil court process to receive mental health care in the community. The goal of AOT is to

support individuals with mental illness in the community in an effort to prevent future crisis.

6. If someone does not comply with court-ordered AOT are they automatically subject to a 5150?

No. Failure to comply with AOT alone may not be grounds for a 5150 involuntary hold or for a contempt of court finding. The criteria for a 5150 involuntary hold are already

prescribed in state law and are no different for AOT participants than for any other individual. In order to meet the criteria for a 5150 an individual must be at imminent risk for

danger to self, at imminent risk for danger to others, or be gravely disabled (unable to care for basic needs such as food, shelter, and clothing) due to a mental illness.

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7. What are consequences of noncompliance with court-ordered AOT?

If the treating mental health treatment provider believes that the individual is a danger to self, a danger to others, or gravely disabled and in need of involuntary treatment, the provider

may initiate the 5150 process. There are no additional enforcement mechanisms for individuals who do not meet 5150 criteria. However, some jurisdictions that have implemented

AOT have noted that court involvement itself can prompt some patients to choose treatment, including medication. This has been called the “Black Robe Effect.”

8. Would AOT reduce the number of 5150s?

The impact of AOT on 5150 involuntary holds is unknown. Once implemented, the data collection, reporting, and evaluation requirements under AOT would likely answer this question.

9. How does AOT differ from Community Conservatorship?

Program Comparison at a glance:

10. Can AOT mandate medication?

No. State statute specifies that involuntary medication shall not be allowed absent a separate court order available only for individuals who are conserved due to their grave disability.

11. How much will AOT cost?

Other communities that have implemented AOT (Orange County, Nevada County) estimate the mental health treatment costs at $35,000-$40,000 per person per year. This does not

include costs associated with the judicial system. Per State statute, no voluntary mental health programs may be reduced as a result of the implementation of AOT.

12. How will the effectiveness of AOT be evaluated?

Counties that implement AOT are required to collect and report key data to the State Department of Health Care Services for evaluation. At minimum the evaluation is required to

include data that relates to number of individuals that receive services through AOT, engagement of AOT participants in services, and key data points to measure the effectiveness of

AOT as an intervention and engagement tool (e.g., hospitalization, contact with law enforcement, social functioning, employment).

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AOT COMMUNITY CONSERVATORSHIP

Voluntary. Court can order treatment, but if client refuses, involuntary 72 hour hold ONLY if client meets 5150 criteria. Client resides in community with intensive outpatient services.

Voluntary. Client chooses between LPS and Community Conservatorship. Client resides in the community with family engagement (not in locked setting) and receives intensive community, wrap around services.

Referral can come from any concerned member of the community including a family member or clinician.

Referral can come from qualified mental health professional in an acute psychiatric setting.

Meds: Client retains the right to consent. However, if adjucated, Judge can order treatment which can include medications on an involuntary basis.

Meds: Client may not retain the right to consent to meds, if clinically indicated.

Initial referral process Vetting process

COMMUNITY CONSERVATORSHIP REFERRAL AND VETTING PROCESS Updated March 22, 2016

Follows standard initial T-CON process - no later then day 11 of the 5250 (5250 certification period is 14 days)

Initial Referral Process

Acute hospital staff will identify potential participant during the 5250 process and send referral packet with the vetting form to

PG-C office via fax

Conservator’s office receives full referral packet and assigns staff following standard practice

Conservator sends packet to BHCS staff member

Conservator’s office forwards packet to SSA county counsel for filing a petition for temporary conservatorship

All above stakeholders must sign vetting form indicating approval to participate

Public defender interviews client

Conservator’s office interviews client following standard protocol

Client is 5150’d to an acute hospital

County counsel alerted that potential participant identified

Vetting process

Conservator sends form to the public defender after PG & BHCS agree

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COURT PROCESS BHCS ACTIONS

COMMUNITY CONSERVATORSHIP REFERRAL AND VETTING PROCESS

Updated March 22, 2016

Conservator interviews clients before the hearing date and prepares court report requesting community conservatorship

and, together with BHCS partners and FSP identifies the treatment plan.

COURT PROCESS

Physician at acute hospital completes specialized declaration in lieu of testimony form (DLT)

During the 30 day temp-conservatorship period certification and prior to Community Conservatorship conversion hearing

date, BHCS staff will identify appropriate wrap around services:

Housing/food justice Assigns to FSP level of service, which includes community medication monitoring and appointment coordination Additional services

Conservator’s office sets community conservatorship conversion hearing

Testimony not required; DLT sufficient. Judge makes final decision.

BHCS ACTIONS

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