San Mateo Board of Supervisors
Housing Health and Human Services Committee
Laura’s Law Hearing
October 18, 2011 Meeting

(This document contains the position of San Mateo Health Care Officials on Laura’s Law and the position of San Mateo NAMI.  Note that Laura’s Law not only compels certain individuals to accept treatment it also compels the mental health department to stop sending the least ill to the head of the line for services and offloading the others to shelters, jails, prisons, and morgues. That accounts for why most mental health officials oppose it. NAMI’s position is unfortunately and understandably based on false information spread by mental health officials: that there is no money to fund Laura’s Law. MHSA funds may be used to fund Laura’s Law in spite of Mental Health Authority statements to contrary. Both LA County and Nevada County fund it with MHSA funds (supplemented by Medicaid, Medi-Cal, private insurance and patient fees. Read funding Laura’s Law)

Supervisor Rose Jacobs-Gibson (RJG): Good afternoon everyone.  Our Housing, Health and Human Services Committee meeting for October 18 is now called to order and we are now at a point where we canTranscript ask for oral communications meaning anyone who wishes to speak on an item that is not listed on the agenda may do so at this point.

I think that we have two people.  It looks like, oh, everybody wants to speak on Laura’s Law and we are going to talk about that one on the agenda so I guess that means they will wait until then.  So there is no one wishing to speak on any other item.

The next item on the agenda is approval of the minutes for August 16.

Supervisor Groom (CG): They are OK with me.

RJG: Alright, they are OK with me so they are now approved and we move now to Realignment Updates.  OK.

Unknown male voice: Can we take this out of order?

RJG: I could do that, I could easily do that, so we will just move on now to Laura’s Law and then we will come back to the Realignment Updates a little bit later.  (1:47)

(San Mateo Mental Health Officials on Laura’s Law-ed.)

Jean Fraser (JF): Good afternoon.  Thank you for giving us this opportunity to present to you on AB1421, which is often referred to as Laura’s Law.  This is a law that is often believed to be a law that can help us with getting services to people with mental illness who are somewhat recalcitrant to enter treatment.  As I think you will hear in the presentation, unfortunately as it ended up coming through the legislative process, it doesn’t quite meet everyone’s expectations.

What I am going to ask is that Steve Kaplan, who is the head of our Behavioral Health and Recovery Services, and Dr. Bob Cabaj who is our medical director for Behavioral Health and Recovery Services, who is board certified in psychiatry as well as addiction medicine, actually do the presentation.  Bob in particular has had a lot of experience with the history of the movement towards Laura’s Law and then if you wouldn’t mind I may reserve the opportunity to come up afterwards.  Thank you.

RJG: That is perfectly OK. (2:52)

Bob Cabaj (BC): Yes, thank you.  I would like to introduce myself.  My name is Dr. Bob Cabaj.  I am the medical director for Behavioral Health and Recover Services located at 225 37th Avenue in San Mateo.  I appreciate the chance to present this.  The slides in front of you are a summary of what we have looked at, in terms of beginning with the clinical issues you might have to consider when you look at something like Laura’s Law and then I will hand this over to Mr. Kaplan.

What we have seen over the years is that we have made tremendous advances and we are able to treat almost everybody who is mentally ill.  We have found that medications are one of the principal tools.  They have helped tremendously, as well as our other treatment interventions.

Behavior Health and Recovery Services, which does all the mental health and substance abuse services for the County, has over 9,700 clients regularly in services, for adults and older adults, so you can see from the statistics, over ninety-seven percent (97%) are never hospitalized, and are never in need of the types of services we are looking at.

Over the years there has been an evolution of treatment, including programs called Full Service Partnerships.  These are programs that are funded by the Mental Health Services Act.  If you remember, the Prop. 63 money that came to the counties.  And Full Service Partnerships are based on an evidence based model of what is called Assertive Community Treatment or ACT programs in which it works as a wraparound, you provide housing and all kinds of other services and interventions, including intensive case management and medications and it helps people stabilize in the community and never need to go into the hospitals or institutional care.

We’ve learned also that people who do best, do services, and get their services on a voluntary basis and we’ve have always been seeking to engage people in voluntary efforts.  We know that from history and from clinical experience that people do best when they are engaged as part of the service rather than have it forced upon them.  And we’ve developed new strategies to help people because we focus on their basic needs, including housing and food, as I mentioned.  (5:17)

And we are really excited about a new program we are developing for early identification of younger adults, but it actually could be any age group, but it’s mostly going to be younger adults, who are at risk of having a psychotic episode or severe mental illness onset.  And our hope is that we could intervene early enough with these people and they would be prevented from having to ever enter a system of intensive treatment that Laura’s Law would have addressed so we hope people would never have to even be there. (5:47)

With the current services that we provide in our Full Service Partnerships we’ve seen tremendously exciting results, a ninety-six percent (96%) reduction in incarceration, an eighty-eight (88) reduction in homelessness, an eighty-two percent (82%) reduction in hospitalization.  These goals and achievements are far better than most counties in California so we are really excited about these results.  (6:10)

The individuals that we see currently could get treatment on a required basis.  We have some California laws in place that allow people with mental illness, especially severe mental illnesses to be required to get treatment.  This is over and above any proposals with Laura’s Law.  And the law was developed in the context of abuses of patients in the past.  So a very high standard was set before somebody was to be forced into treatment.  In the old days, parents, who were disgruntled with their youth, sometimes could just have a child committed and they could stay and they could stay in hospitals or institutions for years and that is long gone with consumer rights protections.  (6:55)

And in many counties they have these laws, the laws are available in all counties of course in California, but some interpret them very narrowly, so many people go through the cycles of deterioration, hospitalization, stabilization, release and deterioration but in San Mateo we are much more comfortable in using the laws, such as conservatorship, and so allow mental health people to be engaged in services and work with us on a voluntary basis.  (7:24)

The Laura’s Law was created with the intent to make it easier to force treatment on those people who did not want to enter the system.  It was really created after an unfortunate incident in Nevada County where a young woman was killed by a delusional, mentally ill client years ago.  It was a person who was not taking medications.  The original intent was to set up a court process that would require people to take their medicines even when not in a hospital.  The judge would order such a treatment, and they would not only take meds, but engage in treatment services; but the services they were going to require are exactly the same ones that we currently have in our Full Service Partnership.  They’re identical in terms of what they were based on.  And the original Laura’s Law was actually passed, created even before the Mental Health Services Act.  So Prop. 63 came in after this.  So the money and the funding for that.  So we have created those Full Service Partnerships and we have other great programs, such as Pathways that work with our clients who are eligible, as alternatives to jail, in our system right now.  (8:33)

The law had great intentions but unfortunately as the law was created, as you know the political process, they describe it like making sausages, you know don’t want to know what goes into it, but unfortunately I was there watching this process for the last ten (10) years and they unfortunately had to gut most of the powerful forces in the law, so that happens.  And what happened is the ability to force medicines was taken out of the law and, in fact, the ability to even force treatment was taken out of the law.  So if a person doesn’t want to go, they just don’t go.  The judge can order them, and they talk about the Black Robe Effect, but, in fact, the judge has no moral power to say to somebody go back to talk to your therapist and if they don’t want to, that’s it.  (9:16)

There’s also been studies, and certainly the study, even before the law came out, a famous study called the Rand Study of 2001, showed that there was no proof that involuntary services were effective and it was inconclusive if they were any better at all than voluntary services, in fact, they seemed to be worse, and that court ordered services did not necessarily work to really engage people.  (9:44)

Now I’d like to turn the presentation over to Mr. Steve Kaplan who is our Director of Behavioral Health and Recovery Services.  (9:50)

Steve Kaplan (SK): Good afternoon.  So I’m going to talk a little bit about some of the non-clinical parts of the law because they are very important and, hopefully, I’ll get this right.

So there are some revisions in the law, related to how things can or cannot be funded if Laura’s Law was to be implemented and I think its important first to note there is no money for Laura’s Law that’s been allocated and you cannot take funding away from a program for persons who are in the program voluntarily to pay for Laura’s Law.  So, in other words, we couldn’t, Bob’s talked about the Full Service Partnerships, people for the most part are in Full Service Partnerships voluntarily, you can’t money from that program or any other to fund this program.  So the only way to actually fund this, absent state funding, would be to provide more county dollars to this program or take money out of programs that are for people who are in there involuntarily, which we’ve been cutting, due to budget cuts anyway.  So the funding issue is really, really important.  (11:10)

The other issue is that if Laura’s Law is implemented you basically have to offer that same level of service to all clients.  So we’ve estimated that to do that would cost the County, and again these would be County funds, up to seven and one-half million ($7,500,000) because we anticipate that could be an additional four hundred (400) clients that would have that level of care.  So those are important budgetary considerations, obviously, around implementing Laura’s Law.  So now I have to hit this thing, this arrow.  (11:50)

Bob talked a little bit about how in San Mateo we are using existing laws differently than many other counties and the most significant example is that, is that we have two hundred twenty-seven (227) people, who are currently on conservatorships, who are living in the community and they are receiving outpatient services under a conservatorship and therefore that allows us to medicate them, keep them into treatment et cetera.  So that’s very unusual and I think we are the county with the highest number of people, out in the community in conservatorships.  (12:30)

The other thing is, as the Mental Health Services Act has been implemented, the work that has gone on to make sure that there is as much connection for people between levels of service is something we are constantly looking at and this last bullet on this page is just an example that persons that are hospitalized, psychiatric hospitalization, do receive a fairly quick follow-up to their inpatient services.  There isn’t long waits.  As I said, we follow-up very quickly to make sure they are engaged in treatment.  So there is no discontinuation of service.  (13:09)

So we are not perfect.  We still have gaps in our system.  We still have people that could benefit from a higher level Full Service Partnership model of care that we are not able to provide at this point.  So, certainly, more Full Service Partnership slots are definitely something that is a feasible option.  The cost for a Full Service Partnership, and remember this is a twenty-four seven (24/7) team response to people, including providing housing and other supports, medication et cetera; the gross cost for that is about twenty-five thousand dollars ($25,000) a year.  We draw federal dollars to pay for essentially half of that, so the net to the County is twelve thousand five hundred dollars ($12,500) a year for every person that is in our Full Service Partnership.  (14:05)

The other thing just as a note as well.  We have ongoing conversations with our key partners including NAMI, the Sheriff’s Office, the police departments, the District Attorney and others, where we are currently in a pretty engaged process to look at all of our front end alternatives that can help direct people to care, instead of hospital and to incarceration.  You are familiar with most of those, SMART and Pathways and First Chance, those kinds of responses in the community, CIT, those things.  We’re working on to see if there are ways to bolster those services.  Thank you.  (14:55)

Jean Fraser I think it’s important to understand the impetus behind, what was the original intent behind Laura’ Law, what is it that is motivating people, motivated people to try to get it passed originally and now to ask counties around the state to implement it.

And I actually started my career, as you may know, as a deputy City Attorney in San Francisco and I represented the Public Health Department.  And if there was one thing that I found extraordinarily frustrating in that work it was precisely this vicious cycle for people who are mentally ill.  San Francisco courts were, one could call it quite conservative (15:35), odd to call a San Francisco institution conservative, but they were very conservative in how they applied the existing mental health law and so, in San Francisco, people really could only receive medications for their mental illness on a forced basis when they were in an institution, when they stabilized, then they were determined to be competent, they would be released from the institution and there really was this terrible, vicious cycle.  And so, even many years ago when I was a deputy City Attorney, I was one of the greatest advocates for the idea of giving courts the authority to require individuals with serious mental illness to continue medication, even in an outpatient setting.

As it turns out, that is actually something that can be done and San Mateo County really leads, I think, the state in the way that we use conservatorships, which is the existing mechanism where a court determines that a person is not competent and does need to have continued mental health treatment.  As you saw from the statistics, we use it more than most counties.  There remains, however, way too many people who get to us, to the mental health system, after bad things have happened, bad things have happened to their families, bad things have happened to the individuals, bad things have happened to other people and they are involved in the criminal justice system.  So I think it’s very important to understand and to deeply empathize with the pain that the families and individuals impacted by people with untreated mental illness; but we also have to recognize that, unfortunately Laura’s Law with great promise, doesn’t actually accomplish what we all hoped it would.  (17:25)

And so while we understand and, as I said, really empathize with those who would like us to implement it, we, one (1), believe it does not accomplish even what those advocates hope it does.  Two (2), as you can see it brings with it some very difficult funding issues, but three (3), perhaps more importantly, it distracts us from what is the most important work, which is to continue to refine our systems, continue to engage with our criminal justice partners, continue to engage with families to find better ways to get people engaged in treatment.  And so, while I cannot today recommend that we implement Laura’s Law, I very strongly urge the County to continue, all parts of the County, to continue to search for better ways to engage our residents with serious mental illness who are, at this point, not getting the treatment that they need.  With that, I am happy to answer any questions.  (18:23)

RJG: I don’t have any right now.