The SCAHRM SOURCE Newsletter

Summary of CSHRM & SCAHRM Behavioral Health Symposium January 12, 2024

March 2024

Submitted by Kathryn Biasotti, BSN, CPHRM, LNCC, MBA

Behavioral Health Legislative Update for 2024

Attorneys Alicia Macklin and Erin Sclar, of Hooper, Lundy & Bookman, presented a behavioral Health Legislative Update for 2024.

2023 State Law Changes included:

• SB 929 Data Collection: County Behavioral Health Directors submit quarterly data to DHCS.
• AB 2242 Care Coordination: Care coordination between the individual, county behavioral health department, health care payer, and facility.
• AB 2275 Changes to the Lanterman-Petris-Short Act (LPS): The 72-hour clock starts when the custodial hold is placed (5150). The 5150 form has a new section for the detainment start date and start time.
• SB 349 Bill of Rights: Creates a client bill of rights for substance abuse facilities and certified treatment programs.

2024 and beyond State Law Changes included:

• AB 1394 takes effect 1/1/25. General acute care hospitals must establish and adopt written policies and procedures to screen patients who are 12 years of age or older for purposes of detecting risk for suicide.
• SB 43 Gravely Disabled definition expands the eligibility of individuals to include personal safety, necessary medical care, or severe substance use disorder or co-occurring mental health disorder. Severe SUD as defined in the current version of DSM. Only two counties, San Francisco and San Luis Obispo, are moving forward with this now, and many are waiting until 2026.
• AB 1376 EMS Immunity: Provides civil and criminal immunity for private licensed ambulance providers and their employees for continued detainment of a person as requested by a police officer.
• AB 665, AB 816 Minor Consent Updates for Mental Health, and opioid use disorder Treatment. AB 665 updates and aligns Medi-Cal standards with billing minors 12 years and older for outpatient mental health treatment, counseling, and residential shelter service, effective 7/1/24. AB816 changes existing law to permit minors 16 years and older to consent to replacement narcotic abuse treatment that uses buprenorphine. Before this bill, the law allowed minors 12 or over to consent to SUD but specifically carved out OUD treatment for the use of buprenorphine in certain settings.
• AB 48 is a new requirement for nursing facilities administering psychotherapeutic medications. The bill expands the rights of residents to receive information material to the informed consent decision to accept or refuse psychotherapeutic drugs and adds the right of residents to be free from psychotherapeutic drugs for discipline, convenience, or chemical restraint except in an emergency that threatens to cause immediate injury to the resident or others.  The prescriber is responsible for disclosing material information and the facility must confirm that a written and signed consent form is on file. Residents must be informed every 6 months of any changes to the medication and of their right to revoke consent.  Prescribers may use remote technology to examine the resident and obtain consent. Willful or repeated violations constitute a misdemeanor.  DPH must develop and make available to facilities a standardized consent form.
• AB 1029 Psychiatric Advanced Directives: Adds Section 4679 to the Probate Code. Clarifies that an individual may execute a voluntary, standalone, psychiatric advanced directive, excluding committing the individual to a psychiatric facility. There is no form yet.
• SB 326 & AB 531 Behavioral Health Reforms: Both these Senate bills passed and will be a ballot initiative in March 2024. AB 326 Mental Services Act would change to the Behavioral Services Act, so SUD is covered under funding. AB 531 would provide new funding in capital projects bond measures of $6.38B to support construction of new behavioral health facilities.

Conflicts of the Emergency Psychiatrist

Dr. Aaron Meyer from UCSD gave a thought-provoking, and often times humorous,  presentation about balancing ethics as an emergency room psychiatrist. Dr. Meyer started off with an introduction to medical ethics, discussing autonomy, justice, beneficence, and non-maleficence. Next, he discussed the healthcare infrastructure not supporting psychiatric patients and the many layers that don’t meld together to support taking care of these patients. Dr. Meyer presented common scenarios with case studies of patients who are cycling through healthcare facilities.

Among the solutions discussed was placing patients into probate, in which case the city pays for their representation. Dr. Meyer discussed how the County of San Diego developed the Life Saving for Interventional Treatment (LIFT) program, which has representatives from the city attorney’s office, city fire and rescue, and healthcare professionals working together to advocate for people with severe Cognitive Disorders and severe SUD who are falling through the cracks.

Using a case study, he discussed the many disconnects within the criteria for Medical Necessity and Concurrent Authorization of Psychiatric Inpatient Hospital Services as set forth in Section 1820.205 of Title 22 of the California Code of Regulations.  He pointed out how cognitive disorders in the DSM are not reimbursed.  SB43 is regarding the gravely disabled definition, by expanding the eligibility of individuals to include personal safety, necessary medical care, or severe substance use disorder or co-occurring mental health disorder. (A county, by adoption of a resolution of its governing body, may elect to defer implementation of the changes made to by Senate Bill 43 regarding gravely disabled until January 1, 2026.)   Dr. Meyer feels SB43 will place hospitals in an untenable situation with a lack of resources. One solution is to expand the offerings for probate code to extend to board and care, SNFs, and memory care settings. Dr. Meyer finished with discussing the uncharted territory of “medical holds.”

Thank you to Kendra Ramada, SCAHRM Membership Chair for bringing forward Dr. Meyer.

Managing Behavioral Healthcare Challenges after Patients Leave the ER Setting

Meredith Mead, Senior Director of Gateways Hospital and Mental Health Center, spoke about managing behavioral healthcare challenges after patients leave the Emergency Department.Gateways Hospital and Mental Health Center is a nonprofit organization funded by the CA Department of State Hospitals and the Los Angeles County Department of Mental Health. Located in Echo Park it has been serving the greater Los Angeles area since 1953. It includes Adult and Adolescent locked units.   Gateway accepts uninsured, indigent patients and they receive a flat rate each day from the county of Los Angeles. The facility receives many patients referred to them from the jail. The flow is the inmate is discharged from the jail to an ER and then to Gateway to be conserved. Meredith reviewed the flow of patients once they start in the mental health system.  If in an inpatient bed, they next may be sent to a CRS-crisis residential treatment program; originally, it was an intermediate step, and LOS was a couple of days; now, it is about 30 days, then the individual may be sent to sober living. They can go to Enriched Residential Services (ERS), which is a step-down, like a board and care, with in and out privileges. Conserved patients ideally go back into the community.  Private conservators often block placement into a private Institute for Mental Disease (IMD) for convenience of location.  If a dispute and an investigation is opened, it usually takes 13-14 months.

Gateway works closely with the HOME team, consisting of the street psychiatric team that goes to Skid Row, the streets, and works with homeless with psychiatric conditions.  The team can put a hold on an individual while out on the street and bring the individual into the ER.

There are challenges with getting sent a Jane or John Doe, and when identification becomes known, the patient may have Medi-Cal or some other type of insurance disqualifying them from staying at Gateway. Another challenge Gateway faces is a lack of resources and collateral information sharing because of restrictions on releasing information. In addition, Gateway is not connected with EPIC like many hospitals.

Meredith listed the following services of Gateway:

• Child and adolescent outpatient programs that DCFS, schools, and the community can refer children and adolescents to.
• Provide an integrated, comprehensive continuum of non-traditional services to mentally ill adults who are homeless
• Assist mentally ill clients who are in the final stages of the recovery process by building links in the community to support physical and mental health.

Meredith reviewed The Community Assistance Recovery and Empowerment Act (CARE) instituted in October 2023 which created a new pathway to deliver mental health and substance use disorders for the most severely impaired Californians who often suffer in homelessness or incarceration without treatment. As this act evolves, she pointed out there are many questions about the parameters and funding.

Meredith gave an overview of SB 1152, which became effective on 7/1/19 and requires hospitals to create a written plan of care coordination for discharge. Meredith discussed the following challenges:

• Discharges: Homelessness, dumping, SB 1152, CARES act, conserved-public guardian vs. private, DCFS, and the medically psychiatric- probably the most challenging of all.
• Staffing: lack of psychiatrists; Stigma; Pay; Injuries
• Substance Abuse: Drug and Alcohol use alone is not considered a mental illness, Stigma, and substance-induced psychosis.

Michelle Gross, CEO of Evolve adolescent treatment centers across CA, gave an overview of Evolve, which provides residential treatment for 12–17-year-olds. Evolve will often receive patients from hospitals, which is challenging to collaborate with ERs and Hospitals to use the same tools so that the insured will cover the treatment. Evolve offers three levels of care:

• The residential treatment is a home-like environment. Typically, six beds maximum, adolescents usually stay 35-60 days, 24/7 care, staffing one to three, line of sight rule, basically one-to-one, intensive therapy, mandatory family therapy, and involvement. Psychiatry visits with stabilization on Medications.
• Lower level of care- is the Partial Hospitalization Program (PHP), a day program, a step below a residential program. The teen will have finished the residential treatment program and live at home, they have not gone back to school, and it entails an eight-hour day
• Intensive Outpatient Program (IOP). Flexible treatment option, 3-4 hours after school, with psychiatry once a month. Can last 3-6 months. They do offer virtual IOP services for those adolescents who are in a treatment desert. The challenge is getting interventions and connecting resources for the parents.

Evolve has a community outreach team to screen and provide resources if adolescents don’t come to Evolve. Evolve tries to work with schools and teachers and educate parents at PTA meetings, but a barrier is that some school districts can’t refer them because the district has to pay for IOP.  Some districts now employ psychiatrists to get around this barrier. Lastly, Michelle expressed the large shortage of adolescent psychiatrists with a retiring population.