Senate Bill 43: Expanding Involuntary Behavioral Health Treatment

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• Who will be impacted by SB 43?

  People with a severe substance use disorder who may have trouble caring for themselves could be detained by peace officers and placed on a 5150 detention. This may result in people with a severe substance use disorder being more likely to receive involuntary treatment or be placed on a conservatorship.

  Peace officers will need to make a decision on whether a person meets the expanded criteria for grave disability which is defined as a condition in which a person as a result of a mental health disorder, a severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder, is unable to provide for their basic needs for food or clothing or shelter or access to necessary medical care or personal safety.

  Local hospitals and emergency rooms will likely see more people on 5150s brought in for evaluation and treatment. Because emergency rooms are best suited to manage the medical aspects of care associated with substance use disorders (versus the management of behavioral health and social needs), it is anticipated that peace officers will collaborate with Emergency Medical Services in the field to determine who specifically requires emergency medical services, and who can be safely transferred to alternative behavioral health settings such as crisis stabilization units, the County’s Emergency Psychiatric Unit (EPU) and other sites. A clinical decision will need to make as to whether continued detention is appropriate. Collaborative work will need to be done to mitigate concerns of additional behavioral health “boarding” in the emergency room setting.

  Community-based substance use providers will likely have increased requests and contacts from crisis stabilization units, emergency departments, and hospitals for care transitions of clients.

• How does SB 43 intersect with the CARE Act Program?

  The Community Assistance, Recovery, and Empowerment (CARE) Act program creates a new pathway to deliver mental health and substance use services to people who are diagnosed with schizophrenia or other psychotic disorders and are not engaged in treatment. The intention of the CARE Act Program is to connect people to voluntary treatment through a civil court process.

  With SB 43, the CARE Act program will be considered as a less restrictive path to treatment for people who are referred for LPS conservatorship through the Office of the Public Conservator.

• How is SB 43 funded? Is there State or federal funding that comes with these changes?

  At this time, there is no designated State or federal funding to support implementation of SB 43. The County of San Diego is pursuing pathways to allow for services to be eligible for federal and State reimbursement.

• Does SB 43 mandate or coerce people into treatment?

  Yes it could, if the person meets criteria and does not go into treatment voluntarily. SB 43 broadens who is eligible to be detained for involuntary treatment.  

• How does SB 43 impact youth under 18?

  For minors, SB 43 does not change the definition for the first 72 hours of detention pursuant to grave disability, but it does apply to minors if any other detention beyond 72 hours is used. Refer to WIC § 5585.20 and WIC § 5585.25.

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• What is considered "severe" substance use disorder under this new law?

  Clinically, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) allows clinicians to specify how severe or how much of a problem a substance use disorder is. Out of eleven criteria outlined in the DSM-5-TR, a person would need to have six or more symptoms to indicate a “severe” substance use disorder. 

  In practice under SB 43, a peace officer will need to determine in the field whether a person appears to have a severe substance use disorder and would qualify for an initial 5150 hold under the new expanded criteria. 

• If a person is brought in intoxicated, does the clearance of their intoxication mean that they'll be released?

  Severe substance use disorder is a diagnosis made independent of intoxication. Someone brought in on a 5150 detainment suspected of severe substance use disorder may continue to be detained even after intoxication clears.

• What if my loved one needs substance use treatment now?

  An array of substance use and mental health treatment options are always available by calling the County’s Access and Crisis Line at 1-888-724-7240. 

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• What is the LPS Act?

  The LPS Act is a California law signed in 1967 related to involuntary detention and conservatorship of people with behavioral health conditions. The LPS Act established a system of short-term holds as well as a path to temporary and “permanent” conservatorships.

• What is conservatorship?

  LPS Conservatorship is for the most severely impaired individuals and involves a court-appointed conservator who can make decisions related to treatment and placement for individuals when they are unable to care for themselves.

  • People on a conservatorship receive case management and often reside in congregate care settings such as mental health rehabilitation centers, skilled nursing facilities, and board and care facilities.
  • Conservatorship may last for up to one year and is evaluated for renewal annually.
• What happens if someone is placed on an LPS detention due to severe substance use disorder?

  The person would be transported to an LPS Designated facility – likely an emergency room or hospital (or an alternative site designated as LPS by the County) – for evaluation and treatment for up to 72 hours. After the 72 hours expires, a few different things could happen: 

  • The person could be released if the person does not continue with treatment; (e.g., they are no longer considered “gravely disabled");
  • The person is relased from the hold and enters voluntary treatment; or
  • The person continues to receive involuntary treatment by being placed on a 5250 hold for up to 14 days.
• What is an LPS Designated facility?

  County LPS Designated facilities are mental health treatment facilities that are designated by the county for evaluation and treatment, approved by the State Department of Health Care Services (DHCS), and licensed as a health facility or is certified by the State DHCS to provide mental health treatment. San Diego County LPS Designated facilities include, but are not limited to, licensed psychiatric hospitals, licensed psychiatric health facilities (including some hospitals), and crisis stabilization units.

  The full list of LPS Designated Facilities in San Diego County can be found on the DHCS Website.

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• Can a client with a serious medical issue that is also on a hold be transported to an emergency department without a behavioral health unit with LPS designation?

  Yes, clients with urgent medical needs should be transported to the closest emergency department regardless of hold status.

• How is transportation arranged for clients from a crisis stabilization unit to an emergency department?

  For clients on behavioral health holds, the crisis stabilization unit will arrange transportation with contracted ambulance companies. The Managed Care Plan pays for the transport. If the crisis stabilization unit is unable to bill or the ambulance company does not cover the full amount, the crisis stabilization unit covers the cost.

• Where can an individual, detained for involuntary treatment assessment, be transported?

  According to the County 5150 Handbook, an individual can be transported to any LPS Designated facility. If the individual has a medical or psychiatric need that is beyond what the crisis stabilization unit can provide, law enforcement is trained to take them to a hospital. Law enforcement may call the crisis stabilization unit prior to help determine if the crisis stabilization unit is the appropriate destination.

• Is the peace officer regulation? Or something that County determines as the LPS authority?

  Law enforcement and the County follow WIC 5150.

• What are the regulations and reimbursement related to transporting a client from an emergency department to a community-based crisis stabilization unit without an attached behavioral health unit?

  If the client is on an involuntary hold, this is allowable under the Emergency Medical Treatment & Labor Act (EMTALA). The hospital will coordinate with the crisis stabilization unit and determine that the referral is appropriate, and that the mental health needs or medical needs are not too acute for the crisis stabilization unit.

  Generally transportation services are covered by Medi-Cal Managed Care Plans though procedures may differ from plan to plan.

  A client is not required to be put on a hold before being transported, per WIC 5150, WIC 508, Section 1799.115 to the Health and Safety Code. 

  The regulations related to transportation are outlined in the WIC 5150, WIC 508, Section 1799.115 to the Health and Safety Code, and EMTALA.

  Refer to the EMTALA Quick Sheet for more information.