HomeMy WebLinkAbout13 - Response to OC Grand Jury — "The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care AgencyQ ��W PpRT
CITY OF
s NEWPORT BEACH
cIt,FORCity Council Staff Report
November 10, 2015
Agenda Item No. 13
TO: HONORABLE MAYOR AND MEMBERS OF THE CITY COUNCIL
FROM: Police Department
Jay R. Johnson, Chief of Police
949-644-3701, JJohnson@nbpd.org
PREPARED BY: Steve Rasmussen, Acting Deputy Chief
949-644-3617, SRasmussen@nbpd.org
TITLE: Response to Orange County Grand Jury — "The Mental Illness
Revolving Door: A Problem for Police, Hospitals, and the Health
Care Agency"
ABSTRACT:
The City of Newport Beach is obligated to respond to a recent Orange County Grand
Jury Report on "crisis intervention and stabilization of the severely mentally ill" no later
than September 28, 2015 (with a current extension granted to November 26, 2015).
RECOMMENDATION:
Authorize the Mayor to send the attached response to the Presiding Judge of the
Superior Court.
FUNDING REQUIREMENTS:
There is no fiscal impact related to this item.
nIRM ISSION.
Please see the attached proposed draft response for details regarding the study and the
City's response to the study's findings and recommendations.
13-1
Response to Orange County Grand Jury
November 10, 2015
Page 2
ENVIRONMENTAL REVIEW:
Staff recommends the City Council find this action is not subject to the California
Environmental Quality Act ("CEQA") pursuant to Sections 15060(c)(2) (the activity will
not result in a direct or reasonably foreseeable indirect physical change in the
environment) and 15060(c)(3) (the activity is not a project as defined in Section 15378)
of the CEQA Guidelines, California Code of Regulations, Title 14, Chapter 3, because it
has no potential for resulting in physical change to the environment, directly or
indirectly.
NOTICING:
The agenda item has been noticed according to the Brown Act (72 hours in advance of
the meeting at which the City Council considers the item).
ATTACHMENTS:
Attachment A Proposed Draft Response to the Orange County Grand Jury
Attachment B Orange County Grand Jury Report — "The Mental Illness Revolving
Door: A Problem for Police, Hospitals, and the Health Care Agency"
13-2
[CITY LETTERHEAD]
November 10, 2015
The Honorable Judge Glenda Sanders
Presiding Judge of the Superior Court
700 Civic Center Drive West
Santa Ana, CA 92701
RE: Report of the 2014-2015 Orange County
Revolving Door: A Problem for Police,
Agency. "
Dear Presiding Judge Sanders:
The City of Newport Beach appreciates
development of their report, "The MentG
Hospitals, and the Health Care Agency. "
The City Council has reviewed the report %rid adihorized the attached response to the
findings and recommendationsoted in the report. The City values the opportunity to
respond to this report, share our perspective, and provide a response to each of the
issues requested by the Grand Jury iheir report.
If the City of Newport Bead can rovide additional information or clarification of our
response, please do not hesita contact me.
End: Reponse to Findings and Recommendations
cc: The Orange County Grand Jury (w/enclosure)
City of Newport Beach Council Members (w/enclosure)
Police Chief Jay R. Johnson (w/enclosure)
Deputy Chief David McGill (w/enclosure)
13-3
Response to Findings and Recommendations
November 10, 2015
Page: 4
RE: Report of the 2014-2015 Orange County Grand Jury — "The Mental Illness
Revolving Door: A Problem for Police, Hospitals, and the Health Care
Agency. "
FROM: City of Newport Beach, California
DATE: November 10, 2015
The Report obligates the City to respond no later than September 28, 2015 (with a
current extension granted to November 26, 2015) to:
• Findings: F1 and F2; and �N6,01
• Recommendations: R1 and R2. 4eql#�
The Newport Beach City Council and the Newport Beach Police Department have
reviewed the Orange County Grand Jury report, "The Mental Illness Revolving Door: A
Problem for Police, Hospitals, and the Health Care Agency." Under the authority of the
Chief of Police, Jay R. Johnson, Acting Deputy 60ef Steve Rasmussen has provided
the following response, in accordance withlifornia Penal Code Section 933.05 (a)
and (b).
FINDINGS:
F1: Deputy Sheriffs and potic fficers receive insufficient training on how to
evaluate and handle the mentally ill in the field.
The Newport Beach Police ent agrees with the finding.
F2: Deputy Sheriffs and police officers receive insufficient training regarding
Laura's Law
The NeortB ch Police Department agrees with the finding.
RECOMMENDATIONS:
R1: All law enforcement officers should receive at least 40 hours of
comprehensive Crisis Intervention Training on how to handle and evaluate the
mentally ill in the field with periodic refresher training. (F.1.)
The recommendation will not be implemented because it is not warranted or is not
reasonable.
The Newport Beach Police Department (NBPD) is committed to increasing training for
13-4
Response to Findings and Recommendations
November 10, 2015
Page: 5
its police officers as it relates to homelessness and mental illness. In the past four
years, the NBPD has cycled 32 police employees through the Commission on Peace
Officer Standards and Training (POST) approved Crisis Intervention Training (CIT) for
Law Enforcement two-day course (16 hours) offered through Golden West College.
The NBPD is well on its way to meeting its current mandate of having all of its police
officers attend this CIT two-day course (16 hours).
It is the position of NBPD that a CIT five-day course (40 hours) is excessive and
unnecessary and that the current POST -approved CIT two-day course (16 hours) is
sufficient to provide its police officers with the basic tools necessary to: identify signs
and symptoms of mental illness; recognize various developmental disabilities; increase
awareness and knowledge of community services and resources available; and develop
crisis intervention skills, communication techniques, and officer safety awareness to
effectively assist and address subjects suffering from mental illness that are
encountered in the field. Further, there is currently no POST -approved CIT five-day
course (40 hours) available.
Both SB 11 and SB 29 (as referenced in the Grand Jury's Report) were signed into law
by the Governor on October 3, 2015. However, the final versions of each law were
significantly amended since the release of the Grand Jury's Report and are no longer
accurately depicted. The changes to both bills were based in part on efforts made by
leaders of the California Peace Officers' Association (CPOA), California Police Chiefs
Association (CPCA), and the California State Sheriffs' Association (CSSA), who
collectively convinced the bill's author to reduce the mandated hours for mental health
training due to its significant and negative impact upon law enforcement in terms of
financial costs and deployment concerns. All law enforcement professionals believed
that more mental health training is certainly warranted, but mandating 40 hours is
unreasonable for the benefits received.
SB 11's final version signed by the Governor requires training on mental health for the
POST police academy basic course to be at least 15 hours, and that at least three
consecutive hours of mental health continuing education be mandated for all sworn
personnel with an active POST appointment assigned to patrol duties or supervising
those assigned to patrol duties. POST has until August 2016 to institute this change.
The NBPD's mandate of having all of its police officers obtain 16 hours of POST
approved CIT training via Golden West College far exceeds this bill's mandate.
SB 29's final version signed by the Governor requires all Field Training Officers (FTOs),
and not all police officers, to have at least eight hours of crisis intervention behavioral
health training, and that four hours of instruction in the FTO Course be dedicated to
addressing how to interact with persons with mental illness or intellectual disabilities.
Again, the NBPD's mandate of 16 hours of POST -approved CIT training for all of its
police officers will exceed this requirement.
13-5
Response to Findings and Recommendations
November 10, 2015
Page: 6
Finally, the NBPD believes the POST -approved CIT two-day course (16 hours) is
sufficient for its patrol officers due to our supplemental implementation of a Psychiatric
Evaluation and Response Team (PERT) team in May 2013. Our PERT team consists of
an NBPD patrol officer (designated mental liaison officer) and an embedded PERT
clinician from the Orange County Health Care Agency, Behavioral Health Services
(OCHCA-BHS). When patrol officers come across a subject who could benefit from the
assistance of our PERT team, they are requested to respond.
The NBPD PERT team makes weekly rounds to our homeless population andther
mentally ill residents to assess their physical and mental needs, build trust and raport,
and develop strategies for intervention and care. The patrol officer assigned to the
PERT team, Officer Tony Yim, has received extensive training well beyond the Grand
Jury's recommended 40 hours of CIT training, thus making him our resident expert on
homelessness and mental illness. Officer Tony Yim's OCHCA-BHS partner is PERT
clinician, Margaret "Peg" Peterson. We believe that maintaining a PERT team with
extensive and ongoing specialized training in addressing homelessness and mental
illness is much more effective than increasing the overall number of CIT training hours
for all police officers to 40 hours. �
The NBPD PERT team averages 10 mental 1144 h valuations and three California
Welfare and Institutions Code Section 5150olds a month. In addition to the mental
health evaluations and holds, the PERT teem nacious in their follow up with clients.
This encompasses hospital visits, home visits, phone follow-ups, linkages to appropriate
services, consultations with famil bers, and connections with ongoing mental
health resources.
By having an experienced mental alth worker in the patrol car and on scene during a
crisis intervention, the NBPD Neves the PERT team's onsite mental health
evaluations are more effectiv4 than those conducted by the Centralized Assessment
Team (CAT). This is of due to the embedded nature of the PERT clinician and her
familiarity with a e Ily'ill population, but rather the added value of not having to
wait for a mere alt professional to respond from another location when a mental
health evaluation is eeded. This immediacy of service is particularly useful in assisting
our homeless pculation as the PERT team is better able to assess all of the patient's
needs (e.WYNS'uccess
ental health, food, shelter, etc.) simultaneously during the contact.
Because o NBPD has had with our PERT partner, we implore the OCHCA
to increase the quantity of hours of PERT clinicians dedicated to OC law enforcement
agencies.
1132: All law enforcement officers should receive mandatory and specific
training regarding Laura's Law. (F.2.)
The recommendation will not be implemented because it is not warranted or is not
reasonable.
13-6
Response to Findings and Recommendations
November 10, 2015
Page: 7
An assisted outpatient treatment (AOT) referral under Laura's Law requires significant
documentation and background information on the patient before the petition can be
justified. Nine elements must be met under California Welfare and Institutions Code
Section 5346(a) for a successful petition. This necessitates knowledge of prior
treatment history and behavior of the patient along with subjective judgments that are
best left to an experienced mental health professional who either has knowledge of the
patient through previous encounters or has the training to establish a relationship of
trust and rapport with the patient that will allow them to conduct an in-depth, probing
interview that would reveal the necessary background information. %7)00*
Other than being informed about the benefits of an AOT under Laura's Law, the NBPD
believes it is unrealistic to expect a regular patrol officer to conduct a Laura's Law AOT
assessment. The NBPD believes such assessments are best left to a well-trained and
experienced PERT team as opposed to a police officer with basic CIT training.
13-7
THE MENTAL ILLNESS REVOLVING
DOOR: A PROBLEM FOR POLICE,
HOSPITALS, AND THE HEALTH
CARE AGENCY
GRAND JURY 2014-2015
13-8
The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
TABLE OF CONTENTS
EXECUTIVE SUMMARY................................................................................................4
BACKGROUND..............................................................................................................
4
Describing the Scope of the Problem......................................................................4
Mentally III and Homelessness..............................................................................5
Mentally III and the Jails.........................................................................................5
Dealingwith the Problem..........................................................................................
6
Voluntary Treatment of the Mentally III.................................................................
6
Involuntary Treatment of the Mentally III..............................................................
6
Mental Health Conservatorship.............................................................................7
Involuntary Assisted Outpatient Treatment (Laura's Law).................................8
Handling the Problem in the Field (Police and the Mentally III) ...........................13
Triagingthe Problem...............................................................................................14
Crisis Response Teams: CAT, PERT, and PET..................................................14
Evaluation and Treatment Services(ETS)..........................................................15
Hospital Emergency Rooms................................................................................15
REASON FOR THE STUDY.........................................................................................16
METHODOLOGY..........................................................................................................17
INVESTIGATION AND ANALYSIS...............................................................................18
Sufficiency of Police Training.................................................................................19
Sufficiency of Police Resources.............................................................................23
Dealing with Triage Decisions.............................................................................23
Experiences Dealing with CAT and PERT by Law Enforcement ......................
24
Dealingwith PERT................................................................................................27
Dealingwith ET:..................................................................................................27
Dealing with Transporting the Patient (to ETS or to a Hospital) ......................
29
Dealing with the Absence of In -Field Medical Clearance Authority .................
29
Dealing with Medical Clearance in Hospitals.....................................................30
Dealingwith the Transfer.....................................................................................31
Dealing with a Premature Release from ETS.....................................................31
ABroken System.....................................................................................................
31
Fixingthe System....................................................................................................33
Infrastructure Improvements...............................................................................33
Leadership Improvement.....................................................................................33
2014-2015 Orange County Grand Jury Page 2
13-9
The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Organizational Improvement...............................................................................
34
Psychiatric Emergency System: A Better Approach ............................................
34
Alternative Systems Nationwide.........................................................................
35
Alternative Systems in the State.........................................................................
35
TheAlameda Model..............................................................................................36
Helpis on the Way...................................................................................................
39
TheIdeal Solution....................................................................................................
40
Laura's Law..............................................................................................................
40
Defending Its Constitutionality............................................................................41
Locating its Candidates.......................................................................................
41
Measuring its Success.........................................................................................42
TimeMatters.............................................................................................................44
FINDINGS.....................................................................................................................
45
RECOMMENDATIONS.................................................................................................
46
REQUIRED RESPONSES............................................................................................47
COMMENDATIONS......................................................................................................
50
ENDNOTES.................................................................................................................
51
REFERENCES..............................................................................................................
54
APPENDIX: ACRONYM LIST......................................................................................
56
2014-2015 Orange County Grand Jury Page 3
13-10
The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
EXECUTIVE SUMMARY
Crisis intervention and stabilization of the severely mentally ill often begins with
the police officer on patrol. The triage conducted at that point—in the field—is critical,
and, as society has witnessed recently, can lead to violent and even deadly results. It is
crucial for officers to have the proper training, tools, and resources at their disposal to
help the mentally ill deal with their demons and, with respect to some suffering from
mental illness, control their homicidal or suicidal impulses.
Mental health agencies throughout the State and the nation are struggling to get
a grip on the seemingly intractable problem of how to deal with dangerous mentally ill as
they hopelessly cycle through the revolving door of crisis intervention, stabilization,
incarceration or hospitalization, and release. Unfortunately, Orange County relies on an
obsolete, inefficient triage system that handicaps the police officer and results in an
inordinate loss of time and resources. Moreover, the County jails and emergency rooms
are the worst places in which to treat the severely and dangerously mentally ill.
The Grand Jury has found that Orange County's failure to provide an adequate
emergency psychiatric stabilization system has resulted in emergency rooms that are
too full to handle medical emergencies. The presence of the severely mentally ill in
emergency rooms is also dangerous to staff, police, and other patients. The County's
shortcomings with regard to mobile response teams and in -the -field medical clearances
of the severely mentally ill, and have caused long delays in evaluating and treating the
mentally ill, many wasted hours of valuable police time spent in emergency rooms and
while driving the mentally ill to and from emergency treatment facilities. The County's
lack of vision and leadership have resulted in a disjointed, dysfunctional system that
contributes to the revolving door.
BACKGROUND
"More often than not, the only option for the mentally ill in crisis is to spin in the
emergency room's revolving door" (Simon, 2015.)
(An acronym list is included in the Appendix.)
Describing the Scope of the Problem
The most recent national and California data available demonstrate that mental
illness afflicts about 20% of the population (Newsweek, 2014). "The vast majority of
mental patients are not violent but this is [a television report] about the fraction who are:
a danger to themselves or others" (Pelley, 2014). Four to five percent of the adult
population in Orange County suffers from a "serious" mental illness that impairs their
ability to function, makes it difficult to carry out basic life activities, and sometimes leads
them to be a danger to themselves or others (Holt & Adams, 2013.). Examples of a
serious mental illness are mental disorders such as schizophrenia, bipolar disorder,
manic depressive, severe anxiety, and post-traumatic stress disorder (Bekiempis,
2014).
In Orange County, the annual suicide rate is about nine per 100,000 population
overall, but ranges from 16 to 18 per 100,000 population among people over 45 years of
2014-2015 Orange County Grand Jury Page 4
13-11
The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
age. About half of the mentally ill adults do not get treatment or medication of any kind.
For the other half who do get treatment, inpatient care is decreasing, while outpatient
care and prescribed medication is increasing (Holt & Adams, 2013)
Untreated, the severely mentally ill can become violent, but treated, they can live
healthy, productive lives. Many lives have been lost when the dangerously mentally ill
are overwhelmed by severe psychiatric disorders—mired on the streets, fearful of all
authority figures, and spiraling out of control–in a decline usually stopped only by death,
prison, or a 5150 temporary hold. Many family members are at a loss when it comes to
coping with their loved one who poses a danger to himself/herself, his close relatives,
and society.
Mentally III and Homelessness
In 1985, the Bronzan-Mojonnier Act enacted provisions to identify the shortage of
services which results in the criminalization of the severely mentally ill and to provide
community support and vocational services for the severely mentally ill who are
homeless. In 1999, the Legislature authorized grants for pilot programs to provide
services for the severely mentally ill who are homeless, recently released from jail or
prison, or at risk of being homeless or incarcerated in the absence of services. This pilot
program was extended to all counties, including Orange County, the next year (Holt &
Adams, 2013) 0, )
"These persons wander the streets hungry, homeless, and without hope. They
cycle through our hospitals and are released with no assured after-care or plan to meet
their human needs – and, all too often, in my experience, wind up in our jails and
prisons, not because they are criminals, but because there simply is no place for them
in our society" (Judge Shabo, 2014).
Mentally III and the Jails
v
Research has shown that at least 20% of jail inmates and 15% of state prison
inmates have a serious mental illness. There are more mentally ill persons in jails than
in hospitals. The prevalence rates of serious mental illnesses in jails are three to six
times higher than for the general population. The county jail may very well be the
County's largest mental institution (Orange, 2015.)
The root problem is a patchwork mental-health safety net that long ago came
apart at the seams, resulting in the criminalization and stigmatization of people trying to
cope with severe mental illness. Mental health advocates take the issue back to the
1960s, when the doors of state psychiatric institutions were flung open and people who
could not afford mental health care were dumped out onto the streets. In Orange
County, the severely mentally ill cycle in and out of the County Jail, through the arrest -
incarcerate -release -repeat revolving door while painfully suffering the symptoms of their
illness.
The fact is that a jail is the last place where the mentally ill should be treated.
Jails simply were never created to be de facto mental health facilities. They are not
structurally appropriate for mental patients. Their dark, threatening, confining spaces
2014-2015 Orange County Grand Jury Page 5
13-12
The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
are even more constricting than the asylums and mental institutions of the past and are
not at all welcoming environments conducive to treatment or therapy. (Miller, 2013)
"The use of a jail as a mental health ward is inefficient, ineffective, and, in many
cases, inhumane" (Sewell, 2014). Without the appropriate treatment and services,
people with mental illnesses continue to cycle through the criminal justice system, often
resulting in tragic outcomes for these individuals and their families" (Orange, 2015).
Former Supervisor John Moorlach is reported to have stated, "We cannot allow our jails
to be the predominant location for housing mentally ill people" (Gerda, 2014).
Moreover, jails require two to three times more funds to house and treat the
mentally ill than to treat the non -mentally ill. The mentally ill stay longer, require more
staff, cause more management problems, are more likely to commit suicide, and are
more susceptible to abuse by other inmates and are at a higher risk of recidivism upon
release than other inmates. Furthermore, jails are ill suited to assuring that mentally ill
persons will receive the psychiatric aftercare that they will need upon their release.
(Orange, 2015)
Dealing with the Problem
Voluntary Treatment of the Mentally III
All counties in California are required to provide mental health programs. Under
previously existing law; however, a health care agency could only encourage the
severely mentally ill—no matter how psychotic, delusional, and dangerous—to
voluntarily seek and submit to treatment and medication. To this end, Orange County
(OC) Behavioral Health Services (BHS) offers many valuable, effective programs to
treat the mentally ill. The BHS has a program called Full Service Partnerships, which
offers an all-encompassing continuum of services, including carefully tailored treatment
plans, assistance with entitlements (Social Security, Medi -Cal), an integrated -person
focus—combining psychiatric, medical, and substance use issues—life skills training,
and community integration (Orange, n.d.)
Some of these programs and services are provided by the OC Health Care
Agency (HCA) BHS staff, and some are delivered by private providers under contract
with the County. In addition, HCA avails itself of a Mental Health Court —one of several
collaborative courts—to assist the mentally ill who merit diversion from the criminal
justice system into programs that can treat their illness. Of the 239 Mental Health Court
graduates in 2014, only 34% have been re -arrested (Superior, 2014).
Involuntary Treatment of the Mentally III
If a mentally ill person refuses to submit to treatment or medication, the law
provides for involuntary treatment. However, this is only temporary and only where, as a
result of his mental condition, the person is a danger to himself or others or is gravely
disabled. Moreover, the short-term involuntary treatment is given only to stabilize the
individual, after which he must be released immediately.
2014-2015 Orange County Grand Jury Page 6
13-13
The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
In 1967, the Lanterman-Petris-Short Act (LPS Act) was signed into law and was
codified in Welfare and Institutions Code sections 5150 et seq. A 5150 is a term
commonly used to describe a person who, due to a mental condition, is a danger to
himself, a danger to others, or is in so gravely disabled a state that he is unable to
provide for his own food, clothing, or shelter. The term "5150" is used throughout this
report, but the Grand Jury means in no way to demean the people who are experiencing
a psychiatric crisis. Under the LPS Act, a County health care clinician, a police officer,
or a psychiatrist can place a 72 -hour hold on a 5150 for involuntary evaluation,
stabilization, and treatment (California Welfare and Institution Code section 5150).
A 5150 hold can last only 72 hours. It may be extended by a psychiatrist, for an
additional 14 -day hold if the patient remains unstable (California Welfare and Institution
Code, section 5250). Within four days of the 5250 hold, the 5250 is entitled to a
certification review and probable cause hearing before a judge or hearing officer
(California Welfare and Institution Code, section 5256). This 5250 hold may also be
extended another 14 days.
If the patient is still unstable after two consecutive 14 -day 5250 holds, the
attending psychiatrist may extend the hold for an additional 30 days (California Welfare
and Institution Code, sections 5270, 5300). If at any time the patient refuses to take his
medication, a capacity hearing is conducted (also known as a"Riese" hearing), at the
conclusion of which the patient can be forced to take his medication (California Welfare
and Institution Code section 5332). 'N
Mental Health Conservatorship , A�
Involuntary hospitalization beyond 61 days requires a mental health
conservatorship (LPS conservatorship) hearing in the superior court. An LPS
conservatorship is used only for the mentally ill whose psychiatric disorder is so severe
that it renders them gravely disabled, in that, it prevents them from providing for their
basic needs of food, clothing, and shelter. An LPS conservatorship serves to provide
individualized treatment, supervision, and living arrangements for the gravely disabled
and can involve confinement in a locked psychiatric facility.
Only the professional treatment staff at the hospital where the 5250 is being
treated can start the process. After an investigation, the OC Public Guardian petitions
the Probate Court to establish a temporary, 30 -day mental health conservatorship and
eventually a general, six-month conservatorship. Appointed counsel represents the
conservatee from the Public Defender's Office. If the Court grants the petition, it must
ensure that the placement is in the least restrictive, appropriate setting, must maintain
ongoing supervision over the conservatorship, and must terminate the conservatorship
if it determines that the person no longer meets the criteria. (See Figure 1)
2014-2015 Orange County Grand Jury Page 7
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Figure 1: Involuntary Hold Process
"515D i
(Dangerto Self)
(14 Days)
"525D i
(14 Days) i Days)
ProbableCause Temporary Hold"
Hearing Conservatorship Hearing F . _
rto Others)
(Day 7) (Day 12) Days)
Certification� writ Full
Review Hearing Conservatorship
Hearing Hearing
(Darr 21) (Day 26) (Day 47)
Involuntary Assisted Outpatient Treatment (Laura's Law)
On January 10, 2001, Laura Wilcox was at work at California's Nevada County
Behavioral Health Clinic. A client appeared for a scheduled appointment. Without
warning or provocation, he drew a handgun and shot Laura four times. When the
rampage at the clinic and at a nearby restaurant ended, Laura and two others lay dead,
and two were injured. California passed Laura's Law to help make sure the same thing
does not happen to another family. Laura was at the clinic that day to help (About
Laura's Law, n.d.).
The Reason for Laura's Law
Because the 1967 LPS Act requires that the person be released as soon as his
condition has been stabilized, it actually impedes those in need of extended care from
receiving it. It fails to take into account new discoveries about mental illness, the vastly
different present framework of mental services, and the hugely improved medications
that are now available. Thus, the present process has proven to be dysfunctional,
2014-2015 Orange County Grand Jury Page 8
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
resulting in a shameful, revolving -door pattern that neither shows care for the gravely
disabled nor protects the public from the clear, ever -returning danger posed by a 5150
to himself or to others.
As reported to have been stated by Chairman Todd Spitzer at the meeting of the
Board of Supervisors when Laura's Law was adopted, "We have an obligation to do
whatever we can to assist those who really have no remedy. They don't know how to
help themselves." At the meeting, Chairman Spitzer is reported to have noted that one
of his relatives had schizophrenia and had revolved in and out of the criminal justice
system. "I watched it just grind away at my uncle. We have to deal with the guilt and the
frustration and the obstacles that the families are dealing with, because they're watching
their loved ones deteriorate" (Gerda, 2014)).
It is the paranoid, schizophrenic nature of severe mental illness that prevents
those in desperate need of help from having insight into their need to take their
prescribed medication or from availing themselves of traditional community-based
mental health services. The best evidence shows that high-risk, dangerous 5150s are
routed into the temporary, involuntary treatment system, not because they are not able
to access voluntary outpatient services, but because their mental impairment renders
them unable to recognize their illness and deprives them of the self-awareness
sufficient to engage in voluntary, community-based outpatient treatment programs. At
the same time, studies demonstrate that high-risk 5150s with psychotic disorders can
greatly benefit from intensive, sustained outpatient treatment provided in concert with an
outpatient court order (Holt & Adams, 2013).
In fact, extensive assisted outpatient treatment (AOT) under Laura's Law can
actually lead to significant reductions in police contacts, emergency room visits,
hospitalizations, incarcerations, suicides, violence, and homelessness. Published
studies have shown that court-ordered AOT not only results in improved clinical
outcomes for the participants, but also in overall cost savings. It is estimated that if AOT
were adopted statewide, the projected savings over the following two -and -one-half
years would be $189,491,479 (Quanbeck, n.d.).
Description of Laura's Law
Laura's Law (California Welfare and Institution Code section 5345 — 5349.5; AB
1421), adopted in 2002, created as an optional program for counties to provide
multidisciplinary, intensive, court-ordered, involuntary outpatient treatment in renewable
six-month periods for the high-risk, substantially deteriorating 5150 who is unlikely to
survive in the community and who has neither the capacity to understand his need for
treatment nor the competence to make rational decisions. Thus, Laura's Law offers
court -supervised, extensive, sustained, early -intervention outpatient treatment of the
severely mentally ill in programs called Full Service Partnerships (FSPs). In contrast to
court-ordered, temporary, involuntary 72 -hours commitments, which operate to stabilize
temporarily a 5150 who has reached a crisis point in which he poses a danger to
himself or to others, Laura's Law allows health professionals to provide medication and
treatment on an ongoing, sustained basis.
2014-2015 Orange County Grand Jury Page 9
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Referrals to Laura's Law may be made by a police officer or probation officer,
immediate family members, adults residing with the individual, the director of a treating
facility or hospital, or a treating licensed mental health professional. Laura's Law applies
to the severely mentally ill person whose illness is severe and persistent.
To qualify for AOT, the person must be an adult with a history of noncompliance
with prior attempts to treat him, as shown be at least two placements in a hospital or the
mental health unit of a correctional facility in the last three years, or at least one incident
(an act, threat, or attempt) involving serious and violent behavior toward himself or
others in the last four years. In addition, the mental condition must be substantially
deteriorating, the person must be in need of AOT to prevent a relapse that would be
likely to result in grave disability or serious harm to himself or others, and there must be
a clinical determination that the person is unlikely to survive safely in the community
without supervision (California Welfare and Institution Code, section 5346).
Before filing an AOT petition, the Outreach and Engagement Team must offer the
candidate an opportunity to participate voluntarily in the development of a treatment
plan for services. If the candidate fails to engage and refuses to settle, the superior
court may order that the candidate submit to a clinical assessment of his present
condition. If he refuses, the court may order that the candidate be taken to a hospital for
the assessment for up to 72 hours.
The candidate has the right to counsel at the hearing. After the Superior Court
hears the testimony, it must determine whether the candidate meets the criteria and, if
so, whether there exists any appropriate or feasible less restrictive alternative. It may
then order AOT under a treatment plan to be implemented by the FSP, which may not
exceed six months. HCA/BHS assigns a personal service coordinator.
The FSP Program Director must file an affidavit every 60 days stating the
candidate continues to meet AOT criteria. The candidate is entitled to a hearing every
60 days to challenge the need for an AOT order. The candidate also has the right to file
a petition for writ of habeas corpus.
Success of Laura's Law
Forty-four states have implemented AOT programs. Nevada County, the first
county in California to implement the AOT program under Laura's Law, opted into the
program in 2008. The success of Nevada County's experiment is shown by dramatic
decreases in homelessness, police contacts, arrests, incarcerations, 5150 holds,
emergency room visits, and hospitalizations (Assisted Outpatient Treatment, 2014). In
addition, Nevada County realized significant cost saving as a result of its
implementation of Laura's Law (Cost Savings, 2012). See Figure 2 for a summary of
these successes.
Moreover, New York's Kendra's Law — after which Laura's Law was patterned —
has similarly resulted in quantifiable, striking decreases in police contacts,
homelessness, incarcerations, and hospitalizations, when compared with the old,
revolving -door system. See Figure 3 for details.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
70
60
50
40
30
20
10
Figure 2: Success of Laura's Law in Nevada County
rcent Reduction over first 2.5 years of implementation
0 4--� 1 ---1
Homeless Days Emergency Jail Days Hospital Days Net Cost
Contacts Savings
(Police) (Hospital & Jail)
(Assisted Outpatient Treatment, 2014)
Figure 3: Success of Kendra'staw in New York State
Percent Reduction Between 2000 -2005
100
90
80
70
60
50
40
30
20
10
0
Homeless Days Emergency
Contacts
(Police)
(Carpinello, 2005; Swartz, 2009).
Jail Days
Hospital Days Net Cost
Savings
(Hospital & Jail)
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Some critics of Laura's Law point to the absence of any real "teeth" in the law
that can force an unwilling outpatient to take his medications or impose sanctions for
walking away from the outpatient treatment program whenever he wishes. However,
Laura's Law works because it depends on the "black robe effect," to which the severely
mentally ill are particularly sensitive. The "black robe effect" is the intimidating factor that
leads a mentally ill person to accept treatment. In other words, "someone who is
reluctant to accept treatment is given the alternative of a treatment plan he is involved
with, or turning it over to a judge to decide, and there is no telling what the outcome will
be" (Sforza, 2015).
The law's success, as demonstrated by the above statistics, cannot be denied.
Laura's Law may very well be the missing piece of the mental -illness -treatment puzzle.
Laura's Law was needed to fill the treatment gap between a 5150's release and his/her
relapse. If used properly, AOT may be the solution to the seemingly endless, revolving -
door predicament faced by the mentally ill. (See Figure 4)
Voluntary
Outpatient
Treatment
Assist
Outpatie
Treatment
Figure 4: The Revolving Door of Mental Illness
Mental Crisis
(In the Field)
Release 115150 Holc
(Police)
Psychiatric
Emergency
System
Hold"
Hold"
"6300
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
AOT is aimed at getting the severely mentally ill the treatment he/she needs in
the long term. Its objective is to assist the severely mentally ill to be treated and
eventually end the seemingly endless cycle of 5150 episode, medication, stabilization,
release, and repeat.
The adoption of Laura's Law is optional for each county. Counties must "opt in,"
i.e., the board of supervisors must pass a resolution authorizing implementation of the
AOT program. Each county must evaluate the AOT program's effectiveness in reducing
homelessness and hospitalizations by persons in the program and in reducing their
involvement with local law enforcement.
Orange County's Adoption of Laura's Law
Orange County is only the second county in California—and the first large county
in California—to opt -in to Laura's Law. Thus, Orange County will serve as a laboratory
for the rest of the state to see what works and what does not work. Many other counties,
including San Francisco, Los Angeles, Ventura, and San Diego are studying and
considering full implementation of this law (Personal interview, June 12, 2015).
At the urging of Supervisor John Moorlach, SB 585 (2013) was introduced and
passed to authorize the use of Mental Health Services Act (MHSA) (Proposition 63)
funds for any county that implements Laura's Law. (Sforza, 2015) On May 13, 2014, the
Board of Supervisors unanimously voted to opt in, ordered that it commence on October
1, 2014, and allocated $4.4 million of its Proposition 63 funds to treat an estimated 120
severely mentally ill persons during the 2014-15 fiscal year. These funds can be used to
cover the expenses for voluntary enrollments as well as for involuntary AOT.
At the time of the County's adoption of the program, the Board of Supervisors
requested that OC HCA/Behavioral Health Services (HCA/BHS) set up systems to
collect data and that data be reviewed and analyzed for performance outcome, the
program's cost effectiveness, and quality improvement. It also directed HCA/BHS to
obtain the services of an outside evaluator to produce a complete report on the use and
access into the program (who was referred, how many actually met the criteria, how
many entered into a negotiated settlement, and how many were court ordered). It
ordered measurement of the benefits achieved by the AOT patients, benefits derived by
the community and the legal system, such as LPS reduction in conservatorship
numbers, and benefits received by law enforcement, such as reduction in calls for
service by police and reductions in 5150s.
Handling the Problem in the Field (Police and the Mentally III)
Persons desiring to become a sworn police officer in Orange County must
graduate from a police academy. POST (Peace Officers Standards and Training)
requires that all persons attending police academies receive some training on how to
deal with the mentally ill. This POST -certified training on mental illness is concentrated
into four hours, which includes crisis intervention training (CIT).
The number of police encounters with the mentally ill in the field is on the rise
(Bernard, 2014). For a dangerous and severely mentally ill person, contact with a police
officer in the field can be an entry point to the criminal justice system, to a psychiatric
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
treatment facility, or to the morgue. The difficulty posed in defusing a potentially
explosive situation results from three considerations that the officer faces: (1) how to
protect him or herself from this dangerous and possibly violent individual, (2) how to
protect the public from this person, and (3) how to assist this mentally ill person in
receiving the treatment he or she needs.
As first responders to a 911 call involving a dangerous and mentally deranged
individual, police officers often act as "street -corner psychiatrists." They hold the power
to prescribe a jail cell or a hospital bed for people living with mental illness. Thus, a
police officer must be able to recognize the symptoms of a mentally deranged
individual, deescalate the situation, allay the individual's fears, gain the person's trust,
convince the individual that it is in his or her best interest to cooperate with the officer
who merely wants to help, persuade the individual to seek assistance, and prepare to
assess and refer the individual to the appropriate agency.
Those decisions require proper training. Police officers need to be trained to
defuse mental health crises with the least force possible and connect people to
treatment. An encounter with a CIT -trained police officer can help people receive
treatment, potentially stopping the arrest -to -court -to -jail cycle from continuing.
Traditional police and SWAT tactics with the severely mentally ill can quickly
spiral out of control, backfire, and lead to deadly results. Fully 50% of Americans killed
by police officers are mentally ill. Many officers may find it hard to override their prior,
ingrained training to contain situations quickly, which sometimes stresses the
"command-and-control—do as I say or else" mindset in which some police agencies are
steeped. (King, 2015)
CIT -trained officers, on the other hand, are injured 80% less frequently than
untrained officers in interactions with the mentally ill, are better at linking people to
services, and are less likely to use force. CIT training, based on the "Memphis model"
created in 1988, teaches officers how to recognize mental illness, how to interact with
people in crisis, and how to de-escalate situations involving a person who needs a
psychiatric evaluation'. Police and the public are at risk if officers do not have CIT
training, which includes role-playing exercises with method actors, based on real-life
situations. (National, n.d.: Dupont, 2007)
The "TACT" method was developed to assist CIT trained officers in approaching
and communicating with the potentially dangerous mentally ill person in a calm, safe,
reassuring, and peaceful manner. The acronym stands for four non -threatening
techniques that officers can employ to retain control in a non-volatile situation: time,
atmosphere, communication, and tone. These concepts are not meant to replace officer
judgment when facing changing dynamics in the field.
Triaging the Problem
Crisis Response Teams: CAT, PERT, and PET
Orange County utilizes a Centralized Assessment Team (CAT) and a Psychiatric
Evaluation and Response Team (PERT) to provide 24/7 mobile response services to
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
assess the mentally ill in the field. The teams assist the police and paramedics by
initiating a 5150 hold. Whereas members of CAT are on call and respond to the scene
when called by the police, PERT members are already embedded with a city's police
agency and accompany designated mental liaison officers into the field.
A police officer or a member of CAT or PERT can prepare and "write" the 5150
hold. The 5150 is then transported to the County -operated Evaluation and Treatment
Services (ETS), or to the emergency room of a designated hospital for diagnosis,
treatment, and stabilization. "Designated" means that the hospital emergency room has
been approved by HCA/BHS to receive 5150 patients.
Psychiatric Evaluation Team (PET) members are stationed 24/7 in two hospitals:
College Hospital in Costa Mesa (also called College Hospital Crisis Response Team
(CRT) and Mission Hospital in Laguna Beach. When potential 5150s arrive at any
hospital in Orange County or at a police station, a PET clinician can be dispatched to
make a 5150 evaluation if a police officer or a CAT or PERT clinician has not already
done so. If the 5150 patient is not insured, the PET clinician will call ETS, fax the results
from the medical screening, and inquire into bed availability at ETS or at a contract
hospital if the patient has not already been stabilized.
Evaluation and Treatment Services (ETS)
Established in 1970, ETS is a ten -bed psychiatric crisis stabilization unit that
provides crisis intervention and stabilization to 5150s. ETS is an outpatient facility and
therefore can hold the 5150 no longer than 24 hours. If ETS cannot stabilize the patient
within that time, it must have the patient transferred to a contract hospital that has
inpatient psychiatric beds.
Other than a psychiatrist, ETS does not have trained medical doctors,
pharmacists, or lab technicians. It is not a medical facility, is not a designated
emergency facility, cannot conduct medical screening or lab work, and is not certified to
perform medical emergency procedures.
Consequently, ETS cannot accept patients who are experiencing a medical
problem in addition to their acute psychological disorder, even if the medical issue is no
more serious than high blood pressure. ETS also rejects admission to any 5150 who is
or may be under the influence of alcohol or drugs. ETS can receive only people who are
on Medi -Cal or are indigent.
Hospital Emergency Rooms
In 2014, 15,000 mental health patients were taken to emergency rooms in
Orange County. Of these, 2429 were 5150s.
We have been slammed in our Emergency with both psychiatric patient and flu
patients. Last night the Medical Director called me and said that we have 17
psychiatric patients in our emergency room—four of them in restraints, with none
to spare. Our unit was full. I called ETS at about 8:00 p.m. and was told that they
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
hadn't even started placing patients from the day as they were still working on
the list from two days ago.
Not being able to transfer patients who have been medically cleared and who
have been in our emergency room for more than 24 hours is not acceptable. If
ETS can handle only 23 patients in a 24-hour period that is simply not adequate
for the volumes of patients we are seeing in our emergency room. Anyone going
to the John George PES will see the huge contrast between the volume of
patients they are triaging and the volume that ETS is capable of triaging, with its
limited space and staff.
(Hospital Administrator in Orange County, Personal communication, January 28,
2015.)
Emergency rooms do not offer an appropriate setting for persons experiencing a
psychiatric emergency and are not conducive to stabilize a 5150. They are cold,
confining, and cluttered with strange and confusing sights and sounds. They are usually
crowded and anything but private.
Emergency rooms are often forced to hold mental patients who are acutely
dangerous to themselves or others for long periods until an inpatient bed can be found.
Psychiatric patients awaiting treatment in hospital emergency rooms for hours and even
days—a process known as boarding—has become a major issue across the United
States, with exposes appearing in publications such as The Washington Post and the
Los Angeles Times. Comparable California averages show psychiatric patients boarding
in emergency rooms for 11 hours (Zeller, 2013).
The presence of a 5150 poses a danger to staff and to the other patients and
their families. Moreover, 5150s can be noisy and disruptive, which adds to the tension
normally found in emergency rooms. Many times, the 5150 must remain in the hospital
emergency room for hours or even days until an inpatient bed can be found.
REASON FOR THE STUDY
The Orange County Board of Supervisors voted to implement Laura's Law and
ordered that it take effect on October 1, 2014. Since Laura's Law will sunset on January
1, 2017 (AB 1569), the Grand Jury chose to investigate how the County intended to
implement Laura's Law and how it intended to measure its cost effectiveness and
performance outcomes in order to provide data regarding the advisability of extending
Laura's Law The Grand Jury also wanted to find out how the County intended to
disseminate information about Laura's Law to various departments within the County's
HCA, the Sheriff's Department, city police agencies, and the public.
As the investigation progressed, however, the Grand Jury discovered that the
County's entire crisis -intervention system for handling 5150s was seriously flawed.
During its investigation, the Grand Jury encountered complaints about the County's lack
of leadership, vision, and ownership of the problem. It became clear that the County's
bean -counter approach to addressing the problem was narrow and that the County
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
appeared unwilling to develop systems to relieve the police and the hospital emergency
rooms from the undue burdens placed on them and to make their jobs easier.
The Grand Jury decided to change the focus of the investigation to crisis triage,
intervention, and stabilization systems and services. The Grand Jury also wanted to see
how Laura's Law fit into the continuum of treatment available to 5150s. The overall
purpose of this study, then, is to seek a solution to the presently dysfunctional,
revolving -door pattern of endless cycles of homelessness, arrests, incarcerations, crisis
interventions, and serial hospitalizations.
The focus of this study, then, is to highlight the presently dysfunctional, revolving -
door pattern of endless cycles of homelessness, incarcerations, and serial
hospitalizations under court-ordered, temporary involuntary 72 -hour commitments. The
Grand Jury chose to investigate this topic in order to determine if the County's system
was "broken" and, if so, offer recommendations on how to fix it. As a sidelight, the
Grand Jury wanted to examine the effectiveness of Laura's Law and to see how it
factored into the equation by reducing the need for so much crisis intervention.
METHODOLOGY
As the Orange County HCA is responsible for caring for the County's indigent
mentally ill persons, several HCA personnel were questioned. The Grand Jury
interviewed members of BHSs upper management several times. Additionally, individual
interviews were held with several field clinicians working as CAT or PERT responders.
Since hospitals play an important part in the triage/evaluation/care system, a
number of hospital -related personnel were interviewed. Among these were hospital
administrators, emergency room staff, and Southern California Hospital Association
members.
Police officers and administrators had a great deal of input in this report. Two
separate questionnaires were sent out and responded to by all police departments in
Orange County as well as the County Sheriff's Department. The first asked questions
about CIT training, comments about the triage process in the field, and knowledge
about laws relating to the mentally ill. The second asked for opinions about the
adequacy of the County's triaging process and suggestions for improvement of the
County's crisis stabilization system. The responses helped identify specific problems
and possible solutions from the law-enforcement point of view.
It was important to see the facilities where mentally ill people were evaluated,
stabilized, and treated. Members of the Grand Jury visited the following: ETS in Santa
Ana, a county -contracted hospital emergency room in central Orange County, and a
county -contracted in-patient mental health facility in South Orange County. Two Grand
Jurors visited the John George Psychiatric Hospital in San Leandro, California.
Two other county systems relate to the seriously mentally ill: the courts and the
Public Guardian. The Grand Jury learned a great deal by visiting the Veteran's Mental
Health Court, by attending conservatorship proceedings in the superior court, and by
interviewing several high-ranking officials in the Public Guardian's office.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
To get a sense of the big picture relating to the police and the mentally ill,
members of the Grand Jury attended all of the monthly meetings of the OC Criminal
Justice Coordinating Council, where various members provide updates and information
concerning the criminal justice system in the County.
Regarding the training of police officers, the Grand Jury visited and reviewed the
course outlines of both Golden West College's Police Training Academy and the O.C.
Sheriff's Office Training Center. Members of the Grand Jury also viewed five training
DVDs relating to police encounters with mentally ill persons, provided by the Orange
Police Department.
Lastly, reports (online, media, and hard copy) relating to all aspects of identifying,
referring, evaluating, triaging, and treating the seriously mentally ill—in Orange County
and elsewhere—were read and considered for this report.
INVESTIGATION AND ANALYSIS
Initially, the OC Grand Jury set out to evaluate how Laura's Law was going to be
applied and how its performance metrics would be measured. The Grand Jury also
wanted to examine how the County intended to coordinate the involuntary assisted
outpatient program with its many successful voluntary outpatient psychiatric Full
Partnership programs. It soon became apparent during the investigation, however, that
there was a serious problem with the manner in which the HCA/BHS was administering
its stewardship over the 5150 process.
Numerous complaints were registered with the Grand Jury concerning the
County's alleged lack of vision, initiative, and leadership regarding the 5150 process
and psychiatric crisis intervention in general. Many police agencies stated their
perception that, the County Health Care Agency's attitude regarding 5150s was to keep
the numbers down artificially, and its posture was merely to manage the problem like a
traffic cop doing traffic control rather than to embrace it, solve it, and own it. Police
agencies expressed the feeling that the County was acting as if the problem of having
dangerous and severely mentally ill persons on the streets was the police agencies'
problem rather than the Health Care Agency's problem.
As a result of these revelations, the Grand Jury decided to redirect its efforts and
to shift the focus of its inquiry. The correctness of this decision was validated when a
high-ranking County official conceded that the County was extremely deficient in terms
of dealing with the mentally ill. That official went on to state that, while the County
tended to compartmentalize its tasks, all departments in the County needed to
coordinate better with each other and with outside agencies in order to have a broader,
more comprehensive view of the problem.
The main task of the police is to protect and serve the public in the city where
they are deployed. It appears to the Grand Jury, therefore, that the time spent waiting
for County clinicians to arrive at the scene, the time spent driving the mentally ill to ETS
or to a series of hospital emergency rooms, and the time spent waiting hours or days in
an emergency room with the mentally ill until a bed becomes available at ETS or in a
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
contracted hospital, is wasted. All this wasted time is precious time that needlessly
takes the police away from carrying out their primary duty of patrol
Moreover, the primary task of the doctors and nurses in hospital emergency
rooms is to provide emergency medical treatment and care to arriving patients.
Emergency rooms are not designed to be repositories for 5150s or to provide
psychiatric care or treatment, other than medication to stabilize a 5150. The time spent
by doctors and nurses on dealing with 5150s is precious time that is taking them away
from their principal duties.
Sufficiency of Police Training
Training on crisis intervention and treatment (CIT) is of paramount importance,
as illustrated by the following example.
Ms. Jones had a history of schizophrenia and bipolar disorder. Her parents called
for an ambulance to take her to the hospital. When she was disoriented and went
outside, her family called the police, and the cops agreed that Ms. Jones needed
to go to the hospital, but when the police quickly moved to put her into the squad
car, she panicked. She was holding on to the car doors. The police tried to get
her into the car. The big cop slammed her to the ground. She kicked and
resisted. One officer put his knee into her back as he handcuffed her. She died.
She was 37. It was ruled a homicide. The Anderson family is suing Cleveland
and has demanded that all officers be trained to deal with the mentally ill (Simon,
2015).
r,.
The Grand Jury sent questionnaires to the Orange County Sheriff and to all 21
police chiefs in Orange County concerning the quantity and quality of training that is
given on how to approach and deal with the mentally ill in the field, how to conduct 5150
evaluations, and how to triage an individual displaying signs of mental instability.
Questions also were asked regarding the amount of crisis intervention training (CIT) that
is required of all sworn officers. The Grand Jury received responses from the OC
Sheriff's Department and from all 21 police agencies in Orange County.
At the OC Sheriff's Training Center, each officer candidate receives only a basic,
five-hour introductory course on dealing with the mentally ill in the field (known as
Learning Domain 37). The curriculum includes such topics as recognition of the
behaviors associated with mental illness, indicators of potential for dangerous behavior,
factors that show suicidal tendencies, and tactics to de-escalate crisis situations. It also
includes an explanation of the LPS Act and strategies for resolving conflicts involving
the mentally ill.
This course is certified by Peace Officer Standards and Training (POST). Only
three of the 21 police agencies require re -certification of this course—one yearly, one
every two years, and one every three years. The Orange County Sheriff's Department
(OCSD) requires no re -certification of this coursework.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Regarding crisis intervention training (CIT), only nine of the 21 municipal police
agencies in Orange County and the OCSD offer POST -certified CIT courses taught by
Golden West College at the Sheriff's Academy. Five police agencies contract with
another college, local consultants, or the American Psychiatric Nurses' Association in
conjunction with St. Joseph Hospital to offer CIT training. Five police agencies use their
own supervisory staff offer CIT training to their officers. The other two offer no
specialized CIT training at all.
Because almost all CIT training is certified by POST, these hours count toward
an officer's re -certification. The respondents indicated that the number of CIT -training
hours varies between agencies. Ten agencies offer only four or less hours, eight
agencies (including the Sheriff's Department) offer 16 to 18 hours, four agencies offer
24 hours, and only one city—Santa Ana—offers 40 hours. It can range from zero to 40
hours, but the majority of police departments offer only 16 or 24 hours.
The CIT course taught by Golden West College at the Sheriff's Academy is a 16 -
hour course, offered in cooperation with the National Alliance on Mental Illness (NAMI)
and College Hospital. This course goes well beyond the academy instruction and is
modeled after the Memphis program. It contains chapters on understanding stress,
5150 legal issues, suicide by cop, post-traumatic stress disorder, other cognitive
disorders such as dementia and developmental disabilities, tactical communication,
operational and procedural protocol, designated mental health facilities, community
resources, and psychiatric medications. r 1%
The Grand Jury has learned that this CIT course has been approved by
HCA/BHS and will soon be expanded to a 24-hour course. The additional eight hours
will include role-playing responses to mental illness crisis situations using a simulator.
However, this course is only optional, not mandatory.
The number of CIT training hours required by police agencies is another matter.
Only 11 of the 21 police agencies require any CIT training. The cities of Orange and
Westminster require 24 hours and Fullerton requires 18 hours The Sheriff's Department
offers, but does not require, 16 hours of CIT training.
Still another issue is the number of law enforcement agencies that require that all
of their deputies or officers receive post -academy mental illness training. Of the 11
agencies that require post -academy CIT training, only four police agencies require CIT
training for all their sworn officers. (See Figure 5)
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
r
Anaheim
Brea
Buena Park
Costa Mesa
Cypress
Fountain Valley
Fullerton
Garden Grove
Huntington Bch
Irvine
La Habra
La Palma
Laguna Beach
Los Alamitos
Newport Beach
Orange
Placentia
Santa Ana
Seal Beach
Sheriff Dept
Tustin
Westminster
Figure 5: Police Agencies Intervention Training
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0
Hours
In the Grand Jury's estimation, CIT training in Orange County is inadequate in
three respects, in that: (a) the amount of CIT hours is insufficient; (b) for most of the
agencies, CIT training is not mandatory; and (c) at almost all of the agencies, CIT
training is not required of all sworn officers. A Senate bill that is presently pending in the
California Legislature, SB 11, would require at least 20 additional hours of CIT training
in the academy relating to police interaction with the mentally ill. Another Senate bill, SB
29, would require 40 hours of post -academy CIT training to help officers recognize, de-
escalate, and refer persons with mental illness who are in crisis.
This proposed legislation reflects a growing trend in many California counties and
cities and throughout the United States, which is to place more emphasis on training
police officers on methods to use in dealing with the mentally ill. Many police agencies
in California presently offer and require much more CIT training than is offered or
required in Orange County, but this may change. Pursuant to a national Community
Oriented Policing Services (COPS) grant awarded to the Major County Sheriffs'
Association, The OC Sheriff was recently appointed to a select nationwide sheriffs'
committee of the Major County Sheriffs' Association to study and make
recommendations regarding training protocols and crisis intervention models of the best
practices for diverting the mentally ill from the jails. In addition, on May 19, 2015, the OC
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Board of Supervisors adopted a resolution in support of a nationwide initiative to reduce
the number of people with mental illnesses in our County jails (Orange, 2015).
Other counties, including Ventura, Los Angeles, and San Diego, already expect
and require more of law enforcement. In Alameda County, each police agency has a
CIT coordinator and liaison. CIT training consists of a 40 -hour course, it is mandatory,
and it is required of all police officers. Of course, taking all officers out of service for one
week, even if done on a rotational basis, can pose logistical and financial challenges
(with overtime costs), but 90% of all officers have received the CIT training to this date.
In Orange County, the City of Orange Police Department and the Westminster
Police Departments are shining examples of this more enlightened approach. These
two cities require that 100%of its officers receive 24 hours of post -academy, CIT
training. In addition, the City of Fullerton has excellent CIT training materials and
courses ranging from one to four days that are conducted by a private firm.
The Orange and Santa Ana Police Departments, in conjunction with the Mental
Health Association of Orange County and St. Joseph Hospital, have taken the initiative
to produce a series of excellent, 30 -minute DVDs on how to deal with the mentally ill.
These DVDs address real mental health issues faced by officers in the field, feature
dramatized, yet realistic reenactments of field encounters based on actual incidents and
interviews with experts, police officers, and the mentally ill and their relatives. The titles
of these DVDs are as follows: "Close Encounters: Managing Field Encounters with
Persons with Mental Illness," "Schizophrenia: Listen to my Voice," "Autism: A Different
Way of Viewing the World," "Hoarding: Understanding Their Possessions," and "Bipolar
Disorders: Managing the Highs and Lows."
More DVDs, including one on Alzheimer's, are in production and may be
released in 2016. These videos have been offered free of charge to all police
departments in Orange County at the monthly meetings of the Association of Orange
County Sheriff and Police Chiefs and to any other agency that requests them. Many
police agencies, mental health facilities, and health care providers in Orange County as
well as from all over the nation have availed themselves of this outstanding opportunity
to help their personnel gain exceptional insight into these mental disorders on how to
recognize and deal with those who display the various symptoms of these mental
disturbances.
With regard to training on Laura's Law, responses to the Grand Jury's
questionnaire revealed that this training has been rather sporadic and superficial. It has
been given to police departments, but only "on demand." In addition, information about
Laura's Law has been disseminated through field advisories, protocols, or bulletins.
These advisories, protocols, and bulletins may have been distributed to the officers and
front line deputies, but there is no assurance that they were read or that any questions
concerning the application and implementation of Laura's Law were ever answered.
It would appear that accurate knowledge about the parameters of, and
requirements for, Laura's Law is lacking, as demonstrated by the fact that the OC
HCA/BHS has received only 23 Laura's Law referrals from police officers in the last 9
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
months. Further proof is shown by the fact that the majority of respondents stated that
they wanted to receive more training on Laura's Law.
Based on responses received from all law enforcement agencies in Orange
County, the Grand Jury concluded that police officers and deputy sheriffs have received
insufficient training regarding how to deal with and interact with the mentally ill in the
field. Moreover, it appears that neither the OCSD nor the 21 police agencies in Orange
County are even approaching the prevailing standard among many jurisdictions, which
is that 100% of all sworn officers receive mandatory post -academy CIT training.
Furthermore, it is apparent that the training received by law enforcement on
Laura's Law has been lacking. All but two police agencies remarked that the training on
Laura's Law had been insufficient, that they could use more training, and that they
would welcome more training. A majority of the police agencies stated that Laura's Law
was a valuable new tool in their arsenal for dealing with the mentally ill.
Sufficiency of Police Resources
Dealing with Triage Decisions
Triage decisions after encountering an apparently mentally ill person in the field
are difficult. However, the police officer must first decide whether a person fits the 5150
criteria. Police officers call CAT or PET members to assist in the evaluation.
Jr
However, even if the person does not presently meet the criteria, he/she may
have previously been under a 5150 hold and may be in need of additional treatment.
He/she may already have a BHS case manager who has been assisting him to enroll
and receive treatment in one of several County mental health programs or who has
been monitoring his court -directed involuntary AOT. He/she may be on probation, be
under a mental illness conservatorship, or may have recently "eloped" or escaped from
the hospital where he was being treated.
The following incident demonstrates this point:
Jason, 28, had been hospitalized at least 15 times since being diagnosed with
bipolar disorder in 2009.Police were called after he got into a heated argument
with someone, and the police were advised of Jason's prior hospitalizations.
When a CIT -trained police officer showed up and asked him nicely to come with
him to a hospital, Jason readily complied.
Not long after arriving at the hospital, however, Jason slipped out of the hospital.
In a manic state, he walked the streets until he saw a man who he thought had
tried to rob him a few years earlier. He attacked the man, who flagged police for
help.
Rather than arrest Jason, the two police officers ran a background check on him
and discovered that he was missing from the hospital. "Then they took him to the
hospital, took off his handcuffs, and just told him to walk into the hospital.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
The two officers were CIT trained. They realized the best tactic was not to use
physical force." After so many encounters with non -CIT -trained police officers,
Jason considered himself lucky. "[1] [c]ould have a bullet hole," he said, "or I
could have a felony arrest."
(Emmanuel, 2015)
Consequently, of tremendous assistance to the officer facing this type of triage
decision would be an on-line, easily accessible database containing the names of all
prior 5150s, 5250s, 5270s, conservatees, persons who have been hospitalized for
mental illness, and persons on probation or parole. The County has no such database.
The County has neither a "dashboard data" tracking system, such as the one used in
San Diego, nor a database such as the one used in Los Angeles.
The Grand Jury is aware of the privacy laws regarding the safeguarding of
medical information, such as the Health Insurance Portability and Accountability Act of
1996 (HIPAA) (See also California Welfare and Institution Code section 5328).However,
this proposal would not violate any privacy because it would not reveal sensitive
medical or mental health information about the 5150. The proposed database would
only list the name and prior legal status of the individual, not mental health information
such as diagnoses, treatment plans, medications, etc. In any event, HIPAA itself permits
the sharing of information when necessary to lessen a serious threat to a person or the
public. W, )
Of additional assistance would be a voluntarily created registry to which family or
household members have entered the names of the mentally ill person so that the
police will know whom to contact. Such a registry would also give advance warning to a
police officer who has been dispatched to the home of a mentally ill person. The County
has no such database.
The law requires that guns be confiscated from 5150s and prevents guns from
being sold to 5150s (California Welfare and Institution Code section 8100-8103; AB
1014). The lesson learned from massacres, rampages, and suicides in Aurora,
Colorado; UC Santa Barbara; Tucson, Arizona; Newtown School, Connecticut; Virginia
Tech, and Sandy Hook Elementary School is that guns must be kept away from the
5150s. Thus, a database of prior 5150s would be useful to the police in deciding
whether to pat down or search the person in the field and in enforcing all laws regarding
confiscation of weapons possessed by a mentally ill person. Again, the County has no
such database.
Experiences Dealing with CAT and PERT by Law Enforcement
The clinicians on the County's CAT and PERT teams are supposed to assist
police officers in determining whether a person meets 5150 criteria. The Grand Jury
discovered, however, that some of these clinicians have not received uniform training
regarding the 5150 criteria. As a result, the clinicians cannot be expected to apply
uniform 5150 standards or to render uniform assessments in making the 5150
determination, and at least one police agency said that CAT was inconsistent in its
application of the criteria.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
The following incidents were reported by police agencies to the Grand Jury as
examples of perceived inconsistencies in the CAT program. Police report that on one
occasion, police units received a call of a mentally unstable son. Upon determining that
he met the criteria for a 5150 hold, they notified the PET team and waited for the PET
evaluator's arrival. As the investigation continued, it became apparent that the father
also clearly met the criteria for a hold. A second call was made to PET. This was
approximately 30 minutes after the initial call. Officers were advised that a separate
evaluator for the father would be sent.
About 30 minutes later (one hour after the initial call), the evaluator for the father
arrived at the scene. The evaluator for the son did not arrive for another 30 minutes—
well over one and one-half hours after the initial call. The evaluator for the son was
inefficient and tentative, and took an excessive amount of time to handle the evaluation.
The officers asked their watch commander to call HCA. When he called HCA to
complain, the excuse was given that the evaluator was new and was still learning.
Several months later, the same evaluator responded to another call and handled it in a
similar, unacceptable fashion in that she left the officers with the 5150 without providing
any updates or information while she disappeared into her vehicle for 20 minutes, acting
in an extremely tentative manner, and nearly refusing to issue a 5150 hold on a man
who the police officers believed clearly met the criteria.
As another example, one police agency described a scenario wherein a transient
who had run out into the lanes of traffic was extremely distraught and agitated. He
began yelling at the police, who were doing their best to prevent him from going back
into traffic. They requested CAT to evaluate him. When the CAT clinician arrived, she
spent only one minute with the transient and told the officer she could not evaluate him
because she believed the transient was under the influence of drugs. The officer
explained that he was a drug recognition expert and that the transient showed no signs
of narcotics use. The clinician then told the officer that she could not evaluate him
because he was not "obviously" a 5150, and she was not prepared to deal with the
unobvious. The officer informed her that he could handle an "obvious case myself, but
that he was asking for her professional expertise. She refused to talk further to the
officer, so he called her supervisor, who ultimately convinced her to place the subject on
a 5150 hold.
What is more, seven police agencies stated their officers have had differences of
opinion with regard to the 5150 evaluation criteria applied by CAT and PERT clinicians.
In other words, on one occasion, the police officer would opine, based on his or her
prior knowledge of the individual's history and behavior, and based on what he
observed before the clinician arrived, that the person fit the 5150 criteria, but the
clinician would render a contrary opinion. The clinician would leave after telling the
police officer that the officer could go ahead and write the 5150 hold and handle the
matter based on his own assessment.
On another occasion, a police agency stated that the CAT clinician chose not to
place a hold on an individual who was found lying in the middle of an intersection. The
individual had told the police that he wanted to die in what appeared to be suicide.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
However, no action was taken by the CAT team, requiring the officer to make the 5150
hold.
On still another occasion, police officers were called about a Ione female that had
been living in her car for an extended time. Many people were in fear that she would die
in her car. Officers discovered rotting food throughout the car and determined she was a
danger to herself and was not able to care for herself. The officers contacted OC Adult
Protective Services (APS), who believed that the appropriate action would be to call
CAT. The initial request to have CAT respond was denied. Only after the officers had
called their supervisors did CAT respond. Once CAT arrived, the clinician denied the
hold and disagreed with the officers' assessments then left. The APS forensic team
responded, agreed with the officers, and accepted the 5150 hold.
Another source of confusion is the wording of section 5150 itself. To meet the
criteria, the person must be a danger to himself or to others as a result of a mental
disorder. There is no requirement, however, that the danger be "imminent."
Correct interpretation of the 5150 criteria is not merely an academic exercise. On
one occasion, a mentally ill man held a ten -inch knife to his chest. His family wrested
the knife away while he was threatening them. Officers called CAT. When the clinician
arrived, two and one-half hours later, he decided that no 5150 hold was necessary.
Officers reported believing that the clinician made this determination because the man
knew who the president was and said he was not going to hurt himself. Only after the
officer threatened to write a detailed report on the clinician's refusal to hold the patient
did the clinician write the hold.
k
In sum, police agencies had problems with CAT because of time between call
and arrival, ETS availability, or evaluation criteria. One police agency called CAT
"uncooperative," and another agency claimed that CAT actively "discourages" 5150
holds. One police agency went so far as to state that CAT is "a joke."
Another example is illustrative of the problems reported by the police in respect
to dealing with CAT. Officers reported that they were called about a female who was
attempting to cut her wrists inside a doctor's office. The officers detained the person and
believed she qualified for a 5150 hold. They contacted CAT, but CAT declined putting
her on a 5150 hold. The officers then transported the female to a mental health clinic in
Santa Ana for further treatment. Only four hours later, other officers responded to a call
of a woman attempting to hang herself in the area of the clinic. This same woman had
earlier tried to cut her wrists. The officers placed a 5150 hold on her and transported her
to a hospital.
It appears to the Grand Jury that there are insufficient CAT members to meet the
demands of police officers in the field. At least seven different police agencies stated
that they had encountered delays in reaching CAT, and had experienced significant
delays in waiting for a CAT member to arrive out in the field after the initial call, all of
which resulted in officers being delayed from returning to service for several hours. At
least one police agency stated that CAT would sometimes merely provide advice over
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
the telephone rather than send a clinician into the field to assist the officer in evaluating
the 5150.
Dealing with PERT
Most police agencies that had an embedded PERT clinician, including the
Sheriff's Department, were generally satisfied with the assistance they were receiving.
They noted, however, that their assigned PERT clinician only worked Monday through
Friday and only from 9:00 AM to 5:00 PM. They indicated that it would be highly
preferable to have assigned PERT clinicians 24/7.
Some police agencies and the Sheriff's Department indicated that they need
embedded clinicians who are available 24/7, who can interact with the officers and
investigators at all levels, and who have their own desk and their own telephone at the
police department. The Grand Jury has concluded that there are insufficient PERT
clinicians to fulfill various police agencies' requests for an embedded clinician.
HCA/BHS has declared that it will assign a PERT member to any city that requests one,
but several agencies told the Grand Jury that their requests have not been granted.
In a triage grant application, HCA/BHS has expressed the desire to increase the
number of PERT teams from four to nine and to expand the number of CAT staff to
meet the needs of the police agencies and of the OC Sheriff's Department. The
responses from the police agencies, however, demonstrate that these needs are far
from being met.
Dealing with ETS 4 � A
The ETS Center has remained the same for 30 years. It has only ten beds—the
same number of beds that it had 30 years ago. Almost all of the police agencies
complained that ETS had too few beds, which, in turn, caused long delays while holding
a 5150 in the field or in an emergency room just waiting for an ETS bed to become
available. C
ETS staff informed the Grand Jury that the BHS would soon be modifying the
interior spaces at ETS to increase the capacity to 18 by adding some loungers. Other
than that, however, the OC HCA has no plans to expand or improve ETS.
Upon visiting and inspecting ETS on two different occasions, the Grand Jury was
told by staff that it was never full or beyond capacity. ETS staff assured the Grand Jury
that it never experienced any overcrowding or delays and that it managed to keep
everything under control, no matter how high the demand. They denied that they had
ever had to turn anyone away for lack of beds or chairs.
The responses to the questionnaire paint a different picture, however. Police
agencies responding to the questionnaires overwhelmingly indicated that ETS is too
small and inadequate to handle all the 5150s who need to be dropped off at the facility.
According to the police, they were very frequently told to transport a 5150 to an
emergency room rather than to drop the "client" off at ETS, and if they brought the 5150
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
directly to ETS, the officers perceived that during the intake process ETS was looking
for reasons not to admit.
Respondents accused ETS and its supervisors of artificially keeping the number
of 5150 admissions low to manage costs and capacity, almost invariably by telling the
police to drive the 5150 to a hospital emergency room for medical clearance even if
such clearance was unwarranted; i.e., when there was no apparent medical emergency.
Moreover, police agencies complained about ETS' refusal to allow officers to drop off
5150s that may have been under the influence of alcohol or drugs, no matter how
insignificant that influence might have been. Thus, police agencies stated that ETS
rarely accepted patients and discouraged officers from taking patients to ETS, by
requiring medical clearance for minor medical issues common among people with
mental health issues, such as high blood pressure or diabetes.
Such medical clearances can take six to 20 hours, especially if drugs or alcohol
is involved. Keeping a patrol officer out of the field for that length of time greatly affects
staffing levels and interferes with the police agency's ability to provide efficient police
services not related to mental health issues. Police agencies believe it is OC HCA's
responsibility to assist the police in dealing with the mentally ill, not the other way
around.
What is more, according to some police agencies, ETS virtually shuts down and
refuses to accept additional 5150s when a single patient has become violent and
combative. Furthermore, numerous police agencies found a lack of consistency
regarding ETS admittance policies and practices, calling them "marginal" and
"inconsistent." In addition, police agencies stated that ETS staff at times is non-
responsive and even resistant to admissions; it discourages admissions and fails to
cooperate with police officers by telling them that there are no available beds at ETS.
The OC HCA does not have a real-time, on-line, empty -bed registry for police
officers or CAT/PERT members to see ETS bed availability at a glance. Consequently,
police officers and CAT/PERT must resort to calling ETS on the telephone.
According to several of the respondents, ETS was always trying to keep a very
"low profile," to "carefully couch" their responses to the police officers' requests, and to
"do the least amount possible." Numerous respondents went so far as to characterize
ETS' attitude with regard to 5150s as being "someone else's problem" or "the police
officer's problem," as if ETS' only responsibility was to "just sit there and direct traffic."
Respondents voiced their concern that ETS considered the police to be the "catch-all,"
whose duty it is to be the repository of the mentally ill.
Another unflattering image of ETS is portrayed by the County itself. In a grant
application, the County Health Care Agency asserted that the average wait time for
access to a bed at ETS or an inpatient hospital is more than ten hours. The grant
application further states that during peak demand periods, the wait time is even higher
and can last from two to three days. (Orange County, 2013) This confirms what the
Grand Jury learned from the police departments' responses.
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Dealing with Transporting the Patient (to ETS or to a Hospital)
The law clearly states that the officer must not be required to stay with the 5150
any longer than the time necessary to complete documentation of the factual basis of
the 5150 hold, and to transfer the 5150 in a safe and orderly manner (California Welfare
and Institution Code, section 5150.2). While a police officer may accompany a
combative patient during transport, the law does not require him to do so, provided he
makes the proper arrangements with the paramedics to transport the 5150 to ETS or
the hospital in a secure manner. The law requires that designated hospitals have
appropriate security plans and security officers to maintain a safe environment (Health
and Safety Code, section 1257.7, 1257.8).
Therefore, under the law, once a police officer has made proper arrangements
for the transport, he may resume his normal duties in the city where he works. This is
not the case in Orange County; however. In a majority of the cases, the police officer
transports the 5150.
For example, on one occasion, a man was laying on the railroad tracks in an
effort to commit suicide. The officer contacted the CAT team. A clinician responded and
contacted the suicidal man. The officer then observed the clinician making several
phone calls in an unsuccessful attempt to place the suicidal man in a secure facility. The
officer finally decided to complete the hold himself and transport the man to a hospital.
The officer was forced to remain with the suicidal man inside the crowded emergency
room until he could be triaged and transferred to a bed.
To make matters worse, the police officer may have to transport the 5150 a long
distance, or in heavy traffic, or both. ETS is located in Santa Ana, so officers driving
from the outlying areas of the County must drive long distances. And if the officer is told
to transport the 5150 to a hospital to obtain medical clearance—which happens more
often than not—he might try the nearest hospital, but usually would travel farther to a
hospital that would be more receptive.
Dealing with the Absence of In -Field Medical Clearance Authority
Thus, after an officer or a CAT/PERT clinician has made a 5150 hold in the field,
the officer or clinician must either transport the patient to the nearest designated
hospital (for medical clearance) or call ETS to inquire if it will accept the hold, even if the
hold has no apparent need of being medically cleared in an emergency room. The
industry standard in other counties, however, is for the police officer or paramedic to
conduct the medical clearance in the field, in accordance with field screening protocols
adopted by a county's Emergency Medical Services (EMS). If the patient meets the
criteria under the medical clearance protocols, the industry standard permits
transporting the patient directly to the crisis stabilization center, and dictates that once
the patient arrives at that facility the field medical assessment must be confirmed.
HCA/BHS has not written or instituted an in -the -field medical clearance protocol
for the County. To date, there is no HCA/BHS policy that would permit medical triage or
medical clearance in the field. In addition, because OC ETS does not even have a
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
limited emergency room designation, there are no medical personnel at ETS who can
confirm an in -the -field medical clearance.
Therefore, in the vast majority of cases, the police officer must transport the
patient to the nearest hospital emergency room. Respondents to the questionnaire
overwhelmingly stated that it was a waste of the police officer's time to transport the
patient to a hospital and to wait with the patient in the emergency room for lengthy
periods. The transport could just as easily be conducted by paramedics or by
ambulance, thereby allowing the police officer to return to his regular duties.
Dealing with Medical Clearance in Hospitals
A majority of the responding police agencies complained of the long delays at
hospital emergency rooms. Respondents to the questionnaires claimed that their
officers regularly had to waste from two to 28 hours with a 5150 client in an emergency
room, either awaiting stabilization and medical clearance or awaiting confirmation from
ETS that ETS had a bed available for the patient after medical clearance was obtained.
For example, when one officer took a 5150 patient to a hospital, he was told he could be
waiting up to 26 hours for a bed to open.
Even after the patient has been medically cleared, which could take many hours,
the police officer must wait many more hours to transport the patient to ETS or to a
contract hospital if ETS does not have a bed available.
When a hospital's emergency room is completely full or overloaded by medical
patients and 5150 patients, 911 dispatchers are informed and are told to divert all
paramedics and ambulances to other hospitals, for the next two hours. Diversion rates
show that each emergency room in Orange County must divert new patients an average
of once a day. Diversion rate statistics also show that during these periods when
emergency rooms have reached full capacity and cannot absorb additional patients for
the next two hours; about one-half of the patients in the emergency room that caused
the diversion of new patients were 5150 patients.
Thus, the presence of 5150 patients in emergency rooms for medical clearance
purposes is causing a series of problems. First, it places the medical staff and the other
patients in danger. Second, it is diverting staff's attention away from handling medical
emergencies. Third, it is causing the new medical emergencies to be redirected to other
hospitals when the emergency room reaches a capacity level.
In a grant application, HCA/BHS disclosed the following facts concerning its
present system. The average wait time for a 5150 to see a mobile crisis evaluation team
member (CAT or PET) in the emergency room is consistently over four hours; at night
and peak times, it exceeds eight hours. Increasingly, hospitals are complaining that their
emergency room personnel are at risk of physical injury and are becoming injured as a
result of delays in treatment for psychiatric patients. The scarcity of capacity and the
volume of 5150s being taken to emergency rooms consistently leads to extended
delays for 5150s to be treated in the most restrictive and expensive level of care.
(Orange County, 2013)
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Clearly, the greatest concern to a police officer in dealing with a mentally ill
person in the field is where to take the patient for evaluation and treatment. The time
that is required for the officer to stand by with the patient in the emergency room waiting
area can be problematic and unsafe for the officer, hospital staff, and other citizens. The
admitting procedures, coupled with the frequent shortage of beds, turn the police officer
into a caregiver for upwards of three or more hours at a time, or much longer.
Dealing with the Transfer
Once the 5150 has been medically cleared in the hospital emergency room, he
must then be transported to ETS or to a contract hospital. Therefore, the police officer,
the clinician, or someone at the hospital has to call ETS to see if a bed is available. If
someone has arrived from PET, however, the person can take the 5150 directly to a
contract hospital.
Dealing with a Premature Release from ETS
As noted above, the 5150 must be released as soon as he has been stabilized. A
problem arises, however, when ETS staff incorrectly assesses the 5150's condition and
prematurely discharges him. Premature or ill-advised releases of a 5150 can place
extensive burdens on police agencies and have deadly consequences.
For example, on one occasion, a man was discharged from a 5150 hold after
less than 12 hours. Shortly thereafter, he walked into a flood control channel and killed
a transient by striking him in the head with a rock. When questioned by the police, the
man stated that he believed the transient was the devil.
Numerous police agencies have encountered a disturbing lack of consistency
regarding ETS discharge policies and practices. Indeed, many police agencies stated
that ETS prematurely releases some 5150s before they are completely stabilized and
while they are still posing a danger to self or a threat to others.
Another example serves to illustrate the point. Responding officers found a man
who had armed himself with a machete and was swinging it in a threatening manner.
They determined that he was a danger, disarmed him, and transported him to ETS on a
5150 hold. Only five hours later, officers responded to a call where the same man was
destroying the interior of his mother's house. The officers attempted to contact ETS but
did not receive a return call. Officers were forced to arrest him for felony vandalism and
transported him to jail for booking.
A Broken System
As noted, a high-ranking County official has declared that the County is "very
deficient" in terms of dealing with the mentally ill. This assessment is echoed
resoundingly by the two stakeholder groups that interface with the County Health Care
Agency on a daily basis to triage and treat the mentally ill: the police agencies and the
hospitals. All seem to agree that the County's crisis intervention system is fragmented
and disjointed in that the County is not working cooperatively with police and hospitals
to obtain the optimal system of triage and treatment of the mentally ill.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Many of the questionnaire respondents from the various police agencies in
Orange County characterized the County's crisis intervention system as itself being in a
state of crisis. The agencies adamantly asserted that the Health Care Agency's current
system was "extremely inefficient and ineffective," "not responsive," "very poor,"
"marginal and inconsistent," "unacceptable," "totally inadequate," "broken," and a "failed"
system meriting "an F." Numerous respondents were at a loss to explain why the
County has not seen fit to overhaul its crisis intervention and triage system and replace
it with a system that is modeled after the new systems that are being installed in other
counties across the state.
One police agency provided the following assessment, which reflects how many
of the other agencies evaluated the County's crisis intervention system:
The present system is neither efficient nor effective with regard to the immediate
medical and psychiatric needs of the patients, and it has little regard for the time
expended by first responders who are tasked with stabilizing and obtaining
treatment for those clients in crisis. There is lack of treatment capacity in the
system, which pushes clients (along with our police officers) to busy emergency
rooms, where they sometimes languish for hours. This is not only inefficient, but
also unsafe, as patients with severe mental illness can present a danger to
themselves and others when they are not promptly stabilized. This also causes a
drain on police resources, because it takes one or more officers out of service for
hours when they could be on the streets responding to other emergencies (Police
agency respondent, personal communication, April 27, 2015).
An expert in the field of crisis intervention has noted that Orange County lags far
behind other counties in the state and across the nation, who have opted to follow an
acute -psychiatric -and -stabilization model, called a Psychiatric Emergency System
(PES) that was proposed and established several years ago in Memphis, Tennessee.
The nationally known Memphis model, which includes a template for specialized first -
responder Crisis Intervention Teams (CIT) that accompany law enforcement into the
field, has been replicated throughout the California with great success, including
Alameda County, Santa Clara County, Marin County, and Ventura County.
The Memphis Crisis Intervention Team is an innovative police -based first
responder program that provides crisis intervention training. CIT works in partnership
with those in the county health care agency to provide very efficient crisis response
times and to increase pre -arrest jail diversion. Performance -outcome research has
shown CIT to be effective in developing positive perceptions and increased confidence
among police officers and in decreasing police -officer injury rates.
The Hospital Association of Southern California (HASC) issued a press release
on January 8, 2014, in which it declared, "There exists an urgent need to expand and
improve response times for mental health patients experiencing psychiatric
emergencies in Orange County." HASC went on to claim, "There is a great need to
expedite treatment for mental health patients in the most appropriate, least restrictive
care setting, avoiding hospitalization whenever possible" (Press release, Jan. 8, 2014).
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Fixing the System
Infrastructure Improvements
HCA/BHS has seemingly begun to recognize that its present system is
inadequate and that its care system needs improvements that will expedite crisis
intervention, stabilization, and treatment for patients in psychiatric crisis in the most
appropriate care setting, bypassing hospital emergency rooms when not truly needed.
The County has taken a major step in that direction by applying for two grants this year
to improve its crisis intervention system. In the grant applications, OC HCA/BHS admits
that ETS is too small, and that another ETS is badly needed in South Orange County.
Moreover, in the grant proposals, HCA/BHS admits that the wait time for a 5150 to be
evaluated is too long and requests grant funds to increase the size and quality of its
triage staff and to improve its mobile response system.
Furthermore, the County has recently taken another major step forward by
partnering with HASC to hire an independent, outside consultant to do the following:
• assess the County's present psychiatric emergency/crisis response
system
• evaluate successful models of PES care that are already in place in
California for their applicability in Orange County;
• determine the optimal number and capacity of the PES facilities that would
be required in Orange County to meet the needs, based upon known and
projected volumes and residence of persons facing psychiatric
emergencies; k f
• delineate the field triage functions of the police, EMS, clinicians, and other
protocols and policies needed to support the most effective
implementation of a new response model and a new PES model;
• list the functions to be performed by the PES facilities, including medical
screening, crisis intervention, case management, and referral to post-
discharge services;
• describe the pros and cons of hospital affiliation;
• make recommendations regarding business model, i.e., County owned
and operated, County owned, with operations contracted out; privately
owned and operated, or a combination of County and private funding; and
• conduct an assessment of the presently available post -discharge services
and provide recommendations for additional services to support the
recommended changes to the ETS facility and to any new PES facilities.
Leadership Improvement
HCA/BHS does not appear to have a cooperative relationship with the other
agencies and licensed service providers with whom it must interface to triage and treat
the 5150s. It does not appear to value the other members of the Mental Health Services
Act Local Oversight Committee (Steering Committee) as collaborative partners, active
participants, and important stakeholders in a joint enterprise of crisis intervention. The
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
HCA/BHS has failed to (a) provide proactive, aggressive leadership, (b) construct or
lease new crisis intervention facilities throughout the county, and (c) develop a more
cooperative relationship with police agencies and hospitals. The HCA/BHS has missed
an opportunity to demonstrate to the police and hospitals that it understands the
problems they are facing and wants to alleviate those problems.
Organizational Improvement
Moreover, a mechanism that would foster and encourage positive, constructive
criticism of the present system is lacking. The Grand Jury has studied other models that
include a multi -disciplinary forensic team and stakeholder working group, consisting of
all the chiefs, directors, and coordinators of all agencies, including police agencies,
hospitals, ambulance services, 911 dispatchers, the district attorney, the public
defender, the probation department, the jail liaison, mental health providers, NAMI
representatives, actual consumers, and the courts. The most important aspect of such a
collaborative task force is that all participants have equal standing and feel free to
provide input, suggestions, and comments.
The County's HCA/BHS already has the Steering Committee, which includes
representatives from law enforcement, the District Attorney's Office, the Public
Defender's Office, HASC, the Juvenile Court, and the Probation Department. Although
HASC is a member of the Steering Committee, there is no direct representation from
individual hospitals on this committee. `
Psychiatric Emergency System: A Better Approach
The new, cutting-edge model that is recognized by experts interviewed during
this investigation as the ideal system to triage the dangerously mentally ill is the
Psychiatric Emergency System (PES). PES programs are designed to provide
accessible, professional, and cost-effective psychiatric and medical evaluations to
individuals in psychiatric crisis, to stabilize the clients on site, and to avoid psychiatric
hospitalization whenever possible. A PES team provides 24/7 emergency services to all
walk-ins, police -initiated evaluations, and crisis phone services. The reason a PES
facility can conduct medical screening and provide basic primary medical care is that it
has medical staff and laboratory testing services (Zeller, 2013).
Thus, a PES team provides both medical and psychiatric evaluation and
treatment. This obviates the need to transport the 5150 to a hospital emergency room,
where the 5150 could languish for hours and even days before receiving the psychiatric
evaluation that he needs. The PES program calls for treating the patient in the least
restrictive setting possible and then, when he is completely stabilized, releasing him/her
with a solid aftercare plan, including follow-up appointments, medication information and
prescriptions, and strategies to help the person avoid crises in the future (Zeller, 2013).
The outdated concept that most acute psychiatric care requires inpatient
hospitalization has been replaced by the more modern concept of confronting the
problem head on by treating patients at a specialized psychiatric emergency center. The
fundamental concept is that most psychiatric emergencies can be treated to the point of
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
stability and discharge in less than 24 hours. Thus, considering inpatient hospitalization
as the only option is a tremendous waste of resources (Zeller, 2013).
What people in crisis need is immediate help, not sitting for hours untreated in an
emergency room while already overwhelmed staff members call around to arrange a
multiple -day hospital stay. Thus, using a PES decreases emergency room boarding
times by over 80% and reduces the need for psychiatric hospitalizations by up to 75%.
What is more, the costs of all the care in the PES is less per patient than the cost of the
typical boarding time in an emergency room alone—not to mention the thousands of
dollars more saved from avoiding a psychiatric hospitalization (Zeller, 2013).
Alternative Systems Nationwide
The Grand Jury has learned that many cities and counties throughout the nation
are developing or revamping their crisis intervention systems to deal with the
increasingly problem of how to assist the police in dealing with the mentally ill in the
field. Some of the more progressive or cutting edge psychiatric evaluation and
stabilization systems are now found in Portland, Oregon; Ithaca, New York; Boston,
Massachusetts; Seattle, Washington; Denver, Colorado; Grand Rapids, Michigan;
Tucson, Arizona; San Antonio, Texas; and Albuquerque, New Mexico.
Alternative Systems in the State )
Los Angeles County has already taken aggressive steps to deploy a highly
regarded mobile crisis co -response system with a System -Wide Mental Assessment
Response Teams (SMART) that are similar to OC MHS's CAT and PET teams, but
which pair many more teams of CIT -trained police officers with embedded mental health
clinicians to enable 24/7 coverage. In addition, Los Angeles County has installed a
Sequential Intercept Model and Mapping System to triage, track, and divert the mentally
ill from the criminal justice systema. Moreover, Los Angeles County and San Diego
County have crisis intervention and stabilization PES centers which are run by Exodus
Recovery, Inc. Sacramento, California (Exodus 2015).
Los Angeles County recently approved a major expansion of its PES crisis
center. The Board of Supervisors voted to use $40.9 million in state funding to open
three new PES drop-off facilities, "where police can bring people undergoing mental
health crises instead of taking them to overcrowded emergency rooms or jail" (Sewell,
November 12, 2014). A consultant report commissioned by the Los Angeles District
Attorney's task force had called for more crisis response teams and more drop-off
centers because, "sadly, it's often more time -efficient for law enforcement to book an
individual into jail on a minor charge ... rather than spend many hours waiting in an
emergency room for the individual to be seen" (Sewell, November 12, 2014).
Sacramento County recently approved an increase in spending for mental health
care. The county's health care agency stated that it wanted to reduce the spiraling cost
of treating the mentally ill in hospitals. The Sacramento County Board of Supervisors
voted to spend $13.4 million to expand the county's existing crisis stabilization center
and to construct three new 15 -bed crisis intervention centers.
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The Alameda Model
Although other counties in the California have established noteworthy county -run
PES systems and facilities, the best one in the estimation of the Grand Jury is Alameda
County Health Systems Medical Center's John George Psychiatric Hospital in San
Leandro, California, also known as the "Alameda" facility. The Grand Jury considers the
Alameda model to be the "gold standard" among PES crisis intervention systems in the
State. It provides psychiatric emergency and acute care services to adults experiencing
severe and disabling mental illnesses and treats all who seek care regardless of their
economic or social status.
Opened in 1992, the Alameda facility was authorized by Alameda County's
Behavioral Health Care Services as a designated facility for 5150s. Its qualified,
multidisciplinary team of mental health professionals provides patient -centered care for
nearly 100% of all acute psychiatric emergencies in Alameda County. It also provides
psychiatric evaluation and treatment to patients arriving voluntarily.
Members of the Grand Jury visited and inspected the Alameda facility and were
impressed with the multi -disciplinary staff's skill in the diagnosis and evaluation of
patients with acute psychiatric illnesses. The facility is housed in an attractive, wide-
open, and beautifully landscaped setting with many windows looking out to the hillside
or the spacious patio.
A local health care professional told the Grand Jury that representatives from
HCA had visited the Alameda PES and reported they could not support such a model
because it appeared that patients were lying around everywhere looking like they were
in a drugged stupor, instead of receiving clinically appropriate care (Personal
communication, June 3, 2015).
These comments prompted an onsite visit to Alameda County by the Grand Jury.
What the Grand Jury members saw was a very large, brightly lit wide-open area, where
44 people were lying or sitting in "sleeper chairs" (chairs that can be opened up for full
recline). Everyone seemed relaxed -- from doctors and nurses in street clothes— to the
patients waiting for their medications to take effect. In addition, there were three rooms
where people who wanted or needed isolation could stay, but no one was isolated
during the time the Grand Jury members were there. The PES, unlike Orange County's
ETS, did not look like a hospital—with patients in beds behind closed doors, but who is to
say that the more hospital -like environment is more appropriate for the stabilization of
the mentally ill than a less restrictive, more home -like atmosphere?.
The Grand Jury observed four things that seemed clinically appropriate. First,
two patients were brought in on gurneys by ambulances, immediately triaged at the
door, then taken into private consulting rooms for assessment by the psychiatric staff.
Secondly, there was a medical doctor's examining room office set up within the PES
with the necessary equipment to provide medical screening exams. Third, there was a
psychiatric evaluation area (in clear sight of the staff) where patients could be evaluated
by the on -staff psychiatrist before discharge. Lastly, nurses were not dressed in scrubs
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
or uniforms. There was one nurse assigned to no more than six patients, and every
patient knew who his nurse was at all times.
The Alameda PES (a part of John George Psychiatric Hospital) is a Dedicated
Emergency Department (DED) that follows the clinical requirements set up by Federal
Emergency Medical Treatment and Labor Act (also known as EMTALA) and has a
relationship with a licensed hospital. The OC ETS, not being designated as a DED or
licensed to a hospital, has no such requirements. Therefore, the Alameda PES, unlike
the OC ETS, can handle limited medical screening without a need to first transport the
patient to a hospital emergency room.
The Alameda system is noteworthy and remarkable because of the following
characteristics that distinguish it from Orange County's outdated model:
• It provides for initial medical clearance to be conducted in the field by CIT -
trained EMS personnel, rather than in a hospital emergency room.
• It provides for CIT -trained EMS personnel (special mental health
transport) to conduct all transports of 5150s via ambulance to the PES
facility or hospital.
• It enables the police officer to remain in the field after the 5150 has been
placed in the ambulance, rather than having to drive to a hospital.
• The average wait time for the 5150 to begin receiving treatment after his
arrival at the PES facility is 19 minutes, rather than ten hours.
• It has 80 licensed beds/sleeper chairs, rather than 10 beds and 5
recliners.
• It serves up to 1,500 patients per month, rather than only 315.
• It has a lab and can handle limited medical clearances.
The Alameda facility is a leader in the use of evidence -based practice and data
analytics to inform and formulate effective care decisions and strategies. It has what the
HCA/BHS does not have and offers what the HCA/BHS cannot offer. Table 1
graphically illustrates the differences between Orange County ETS and Alameda
County PES.
Table 1: Comparison of County Crisis Intervention Systems
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Orange County
Alameda County
Population
3,147,655
1,594,569
Facility Type
Evaluation and Treatment
Psychiatric Emergency
Services (ETS)
Services (PES)
-Established in 1970's
-Established 1992
Crisis Beds
10 beds, 5 recliners,
80 licensed beds/sleeper
chairs
2 seclusion rooms
3 seclusion rooms
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Orange County
Alameda County
Staffing
1 Psychiatrist 24/7
1-5 Psychiatrists 24/7
1 Registered Nurse
Several Registered Nurses
1-2 Mental Health Specialists
Psychologist
1 Social Work Intern
Licensed Social Workers
No Security Guards
2-3 Security Guards 24/7
Pharmacist
1-2 Medical Doctors
Chaplain On Request
P/T Occupational Therapist
Patients seen
310-315
1,200-1,500
per month
Patient Source:
Ambulance
70%
80%
Police
15%
0%—
Walk-in
5%
20%
Other (CAT,
10%
0%
clinics, jail, etc.)
Size of Facility
4600 sq. ft.
6115 sq. ft.
Wait room seats
6
14
Average time
10 minutes at ETS, but 70% go to
Varies per triage designation
between police
hospital ER first;
at PES: Immediate, 15
contact and
Could be 10 hours or 2-3 days
minutes, or 30 minutes
treatment
until mental treatment
30% go to hospital first. These
(per HCA/BHS Grant application)
return to PES within average
of 4 hours.
Acceptance
Anyone over 18 years
Anyone over 18 years
Criteria
Indigent or Medi -Cal only
Assessed by EMT onsite
Medically cleared by designated
Brought by ambulance
hospital
PES does screening onsite
No alcohol or drugs
Low-level drugs or alcohol ok
Facility
Hard to find with locked entrance
Easy to find
Appearance
Patients assigned to hospital -like
Open, welcoming lobby
rooms
Patients relax in common area
No windows or common area
on sleeper chairs
Staff sees clients in their rooms
Airy, community atmosphere
Institutional atmosphere
Staff and patients mingle.
Admittance stats
July `13—Jul `14
3,630
13,249
July `14—Mar `15
2,735
12,910
Medical
No medical clearance in field
Dedicated Emergency
Clearance
Department
Requires ER evaluation at
Does own medical screening
designated hospitals.
exams
Only transports to hospital if
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
(Grand Jury, 2015)
Help is on the Way
In December 2014, HASC and OC applied for two grants: a PES triage planning
and staffing grant, and a PES facility construction grant. The grant submissions
culminated weeks of strategic, collaborative discussions that were facilitated by HASC
for hospitals and the County. The Emergency Medical Care Advisory Committee of the
County sent a letter to the OC Board of Supervisors in support of the PES initiative.
Only the triage planning and staffing application was granted. The PES facility
construction grant application was denied for failure to provide sufficient details about
the proposed facility. To cure this—in anticipation of an opportunity to apply again for a
PES facility construction grant—HASC decided to send out requests for proposals for a
PES study that would evaluate the need for, and feasibility of establishing, one or more
PES facilities in OC. OC HCA and the County Medical Association have agreed to help
fund the independent performance audit and study.
Finally, Laura's Law will be the impetus for OC HCA/BHS to concentrate on how
best to assist the severely mentally ill after their release from jail, ETS, or a hospital. If
upon discharge, they fail to seek voluntary treatment or to self -medicate, they will
relapse or recidivate, once again spinning in the same revolving door that will lead to
another crisis in the streets. Prompt follow-up with an outpatient mental health provider
after discharge is important to maintain continuity of care and to prevent relapse or re-
hospitalization. This can be accomplished through AOT.
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Orange County
Alameda County
no ability to treat at PES
Funding
Orange County Health Care
Alameda County Behavioral
Agency/Behavioral Health
Health Care Service
Services
Police 5150
Police calls CAT;
Police calls county -contracted
procedure
Police or CAT writes 5150;
Emergency Medical Service;
Police takes to ETS or hospital ER
Emergency Medical Tech
and stays till client is admitted;
assesses and transports to
Officer can be off patrol for many
licensed hospital or PES;
hours
Officer free to continue patrol
Criteria for
No written criteria
Health Metrics:
transport to
All patients evaluated individually
BP over 190/110
acute hospital
Need to be medically screened
Pulse over 120
Alcohol or drugs possibly in
Glucose under 60 mg/dl
system
Unable to treat at PES
(Grand Jury, 2015)
Help is on the Way
In December 2014, HASC and OC applied for two grants: a PES triage planning
and staffing grant, and a PES facility construction grant. The grant submissions
culminated weeks of strategic, collaborative discussions that were facilitated by HASC
for hospitals and the County. The Emergency Medical Care Advisory Committee of the
County sent a letter to the OC Board of Supervisors in support of the PES initiative.
Only the triage planning and staffing application was granted. The PES facility
construction grant application was denied for failure to provide sufficient details about
the proposed facility. To cure this—in anticipation of an opportunity to apply again for a
PES facility construction grant—HASC decided to send out requests for proposals for a
PES study that would evaluate the need for, and feasibility of establishing, one or more
PES facilities in OC. OC HCA and the County Medical Association have agreed to help
fund the independent performance audit and study.
Finally, Laura's Law will be the impetus for OC HCA/BHS to concentrate on how
best to assist the severely mentally ill after their release from jail, ETS, or a hospital. If
upon discharge, they fail to seek voluntary treatment or to self -medicate, they will
relapse or recidivate, once again spinning in the same revolving door that will lead to
another crisis in the streets. Prompt follow-up with an outpatient mental health provider
after discharge is important to maintain continuity of care and to prevent relapse or re-
hospitalization. This can be accomplished through AOT.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
The Ideal Solution
Almost all of the police agencies have insisted that there should be "multiple"
PES facilities in Orange County. They maintained that they should have "plenty of beds"
and should be placed in "several locations." The police agencies stated that there
should be multiple PES facilities to improve capacity and ease of transportation.
Further, police agencies and hospital administrators that the Grand Jury
interviewed stated that the County needs stand-alone, emergency stabilization drop-off
centers, with medical and psychiatric staff, to relieve the burdens placed on these two
principal stakeholders: the police and the emergency rooms. Each PES would ideally be
adjacent to, or in very close proximity to, a hospital with a large emergency room linked
under a licensed relationship (Personal communication, June 12, 2015).
An ideal solution, as stated by Alameda County law enforcement executives,
includes having ambulance personnel transport all of the 5150s to the nearest PES. The
911 dispatchers receive CIT training so they will know whether to send the special
mobile evaluation or mental response team to the scene and whether to send the CIT -
trained ambulance company to the scene. The ambulance personnel receive CIT
training in how to handle and triage the mentally ill and how to safely transport them,
with appropriate use of restraints. This allows police officers to remain in the field and
return to service immediately upon the ambulance's departure.
Laura's Law
In addition, the importance of Laura's Law as the last piece of the puzzle cannot
be overemphasized.
What is really needed is long-term care for months or years. We need to be able
to set up a system where we follow the mentally ill back into the community, we
follow their families, we make sure they have a safety net and that somebody's
watching them and monitoring them. If they're not hooked into the [assisted
outpatient treatment] system that's watching them, taking care of them, then we
will have problems on our hands. There's really no place to go afterthe hospital,
so the mentally ill end up coming back home, or going back to the streets, right
where the situation started. And you know, the police officers on the street and
psychiatrists in the hospital will say, `You're right. The system is broken.'
(Pelley, 2014)
As noted above, the County "went live" with Laura's Law (AOT) on October 1,
2014. The County's recent implementation of AOT has gotten off to a good start. It has
led to a surprising number of voluntary enrollments.
As of June 8, 2015, the total number of patients linked to voluntary mental health
programs was 45. In other words, while the Outreach and Engagement Team was
screening these individuals for AOT, they decided to accept voluntary services. Thirty-
two cases are still open, and five filed petitions have resulted in negotiated settlements
approved by the superior court. Only a single AOT petition has been set for a hearing.
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
The success of Laura's Law will depend on three things. First, it must be properly
implemented and well -defended in the courts. Second, aggressive action must be taken
to find and identify those individuals who meet the criteria of Laura's Law. Third, its
performance metrics and cost effectiveness must be accurately measured and
compared with meaningful benchmarks.
Defending Its Constitutionality
Although a Sacramento -based civil rights advocacy group—Disability Rights
California—has threatened to file a lawsuit attacking the constitutionality of Laura's Law,
no such action has been filed in Orange County to date. Moreover, legal experts opine
that it will withstand such an attack because (a) the candidate may not be forced to sign
a release of his medical records; (b) the patient can be ordered to take his medication,
but cannot be forced to do so; and (c) the patient can walk away from the AOT, in which
case the only sanction is the bringing of a new petition. Furthermore, New York's
Kendra's Law, which was patterned after Laura's Law, has already passed
constitutional muster in the courts.
The Grand Jury found that the County does not meticulously track all the
negotiated settlements with AOT petitions and all the voluntary linkages following AOT
referrals. This failure to track all settlements and voluntary linkages may adversely
impact the ability to defend the constitutionality of Laura's law as applied.
Locating its Candidates Jr
The County HCA/BHS has established a Laura's Law Outreach and Engagement
Team, consisting of social workers, marriage and family counselors, and psychologists,
to conduct investigations when referrals are made. If the referral meets the criteria
regarding prior hospitalizations and prior acts of violence, and if he refuses voluntary
treatment, a psychological assessment is conducted to ascertain whether he has a
mental disorder and whether he is deteriorating. However, this "outreach" program does
not really reach out; it merely investigates referrals from family members, hospitals,
jails, police officers, and law probation officers. HCA/BHS is merely waiting for referrals.
The County has failed to find and identify all possible candidates who may qualify
for AOT under Laura's Law. After all, the County set aside $4.4 million to treat about
120 severely mentally ill persons during the 2014-15 fiscal year, but of the 317 Laura's
Law referrals received by HCA/BHS, it has been able to link only 75 persons to
voluntary services and to enroll only five into AOT through negotiated settlements
approved by the superior court.
HCA/BHS found that 112 referrals did not qualify under the criteria of Laura's
Law. It has 45 open cases that are under investigation. The remainder of the 317
referrals-80—are severely mentally ill people who could not be helped by HCA/BHS
not because they did not qualify—but because they could not be located (Personal
communication, May 14, 2015).
This again demonstrates the efficacy of a 5150 tracking system and database for
use by the police agencies, members of CAT, clinicians at ETS/PES, staff at the County
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Jail, probation officers, and hospitals. In the alternative, County HCA could comb
through the 5150 files that it and the hospitals have compiled over the last few years to
make an alphabetical list that could be used to compare with lists of arrestees, jail
inmates, and probationers. Orange County does not have relevant data about 5150s
that are migrating from an adjoining county.
Another major issue is the degree to which the mentally ill are left to fend for
themselves upon their release from jail, ETS/PES, or a hospital. Without an appropriate
aftercare plan and a secure safety net, they are left to their own devices and may
immediately deteriorate, relapse, and become dangerous if they do not take their
medication. It is at this juncture that they need to be linked immediately and seamlessly
with the County's mental health services, including assisted outpatient treatment
(Laura's Law), either through the probation officer, the mental health courts, the
HCA/BHS case worker, or the conservator.
Measuring its Success
Establishment of benchmarks is important in order to evaluate accurately the
effectiveness and efficiency of Laura's Law. To assess performance outcomes, the law
requires that all key performance indicators be measured precisely and scrupulously
against these benchmarks. It appears, however, that the County has failed to establish
countywide benchmarks for all severely mentally ill who may benefit from the
implementation of Laura's Law. Jr `
Because Laura's Law is funded by the state, the law itself mandates that
counties measure and report to the State Department of Health Care Services certain
markers and indicators by May 31 of each year (California Welfare and Institution Code,
section 5348) However, since the County does not yet have a single, court-ordered
AOT in the system, it was able to obtain a one-time exemption from the report -filing
requirement. %�& IF AF )
Next year (2016), when the County prepares its report for filing, the law requires
that HCA/BHS include the following data markers with regard to all persons in court-
ordered AOT:
• Reductions in homelessness and in hospitalizations
• Reductions in police involvement and police contacts
• Number of persons served by AOT, and, of those, the number who
maintain housing and maintain contact with the treatment system
• Reductions in arrests and incarcerations
• Number of AOT persons participating in employment services programs
• Reductions in days of hospitalization
• Adherence to prescribed treatment
• Other indicators of successful engagement
• Victimization of persons in the AOT program
• Violent behavior by persons in the AOT program
• Substance abuse by persons in the AOT program
• Type, intensity, and frequency of treatment of persons in the program
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
• Extent to which enforcement mechanisms are used by the AOG program
• Social functioning of person in the AOT program
• Skills in independent living of persons in the program
• Satisfaction with program services both by those receiving them and by
their families
(California Welfare and Institution Code, section 5348)
Those indicia not specifically included are the following: (1) emergency calls; (2)
diversion referrals; (3) threats; (4) crisis interventions (apart from police contact); (5)
suicides; (6) homicides; and (7) conservatorships. Moreover, the BHS Adult and Older
Adult Performance Outcome Department has indicated that it has not established
benchmarks for comparison between pre -Laura's Law and post -Laura's Law statistics.
Furthermore, BHS has not standardized the program data for easy comparison.
It is hard to understand how the HCA/BHS plans to track the effectiveness of
Laura's Law in its Adult and Older Adult Performance Outcome Department
(AAOAPOD). HCA/BHS has a database system that provides electronic health record of
all its clients, but it does not have an integrated, centralized, standardized database that
would provide "snapshot" information at a glance regarding reductions in police
contacts, arrests, or incarcerations. The same holds true for homelessness,
hospitalizations, and unemployment data. In addition, HCA/BHS does not have a web -
based data system or dashboard to track outpatient volumes, ETS volumes, high
utilizers, community of origin, frequency of outpatient treatment, length of successful
engagement, number of psychiatric visits, enrollment in voluntary programs, court
appearances, and dispositions.
To prepare to provide performance measurements regarding its implementation
of Laura's Law, HCA has issued a Request for Proposals (RFP) for the provision of
technical assistance and development of a plan to evaluate the AOT program. The
RFP's scope of work calls for an independent evaluator to measure the performance
indicators and conduct a statistical analysis of the impact of Laura's Law. In addition,
the scope of work includes a calculation of the cost-effectiveness of Laura's Law.
However, the scope of work fails to include vital categories and domains that
would track single events and separate them from the multiple events by the same
individuals. For instance, a valuable statistic to track would be to compare the recidivism
rate (1) to the frequency of contacts by the case manager or personal service
coordinator, (2) to the caseload size of the case manager, (3) to the frequency and
consistency of medication, and (4) to the frequency of psychiatric visits.
In addition, it remains to be seen how the County will accurately measure the
cost effectiveness of Laura's Law. The county has indicated that it has no intention to
first establish a pre -AOT baseline and then track the cost of AOT versus the costs of
emergency responses, arrests, incarcerations, ETS handling, emergency room
handling, 5150 evaluations, 5150 holds, 5250 holds, 5270 holds, hospitalizations, and
conservatorships. It does not plan to measure the impact of AOT on the District
Attorney's Office, the Public Defender's Officer, the Probation Department, and the
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Superior Court. The Grand Jury found that the Board of Supervisors expects this type of
information.
Furthermore, Orange County has prided itself in data -driven decision-making and
in measuring performance outcomes that not only reflect bare statistics, but also
meaningful trends and cross analysis of data. However, it is not clear that HCA/BHS is
prepared to establish a vigorous, robust program to establish metrics and benchmarks,
collect data, compare statistics, measure trends, and track the performance outcomes
of the implementation of Laura's Law. As reportedly stated by former Supervisor Pat
Bates, "We need to have strong performance metrics in this program so we know we'll
have outcomes." (Gerda, 2014)
There is yet another important reason to track the success of Laura's Law,
including the high number of voluntary enrollments and negotiated settlements. As
alluded to above, a few police agencies have expressed their doubts that Laura's Law
will have a positive impact in Orange County because it has "no teeth," i.e., no forced
medication and no sanctions for non-compliance. As noted, however, Laura's Law and
Kendra's Law have met with singular success, based on the "black robe effect," leading
to an extremely high number of voluntary enrollments.
Nevertheless, this police agency attitude toward a perceived ineffectiveness of
Laura's Law might have a deleterious effect on whether the police agencies seek further
training on how to implement Laura's Law and on whether they make referrals of all
potential candidates. A reduction in training and referrals, in turn, would tend to lower
the effectiveness and success of Laura's Law. This would inevitably result in a self-
fulfilling prophecy.
Therefore, the HCA has not publicized Laura's Law sufficiently throughout the
County and has not provided adequate training to all deputy sheriffs and police officers
regarding its implementation. The HCA has not instructed all police agencies regarding
the qualifying criteria for AOT. Laura's Law is the missing component that was created
to fill the gap in the treatment continuum between a previously violent 5150's release
and his relapse, and it will not work unless all stakeholders work together to ensure and
measure its success.
Time Matters
It may appear trivial, but the time taken to detain, evaluate, transport, medically
clear, and stabilize an individual suffering from a mental disorder that is causing him to
have suicidal thoughts or to want to hurt someone else is crucial. When a person hears
voices that tell him to kill himself or to kill another, time is of the essence. It may be only
a matter of time before this County sees another tragic occurrence, and, as aptly stated
by one police chief, "We are beyond lucky that we have not had another Kelly Thomas."
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FINDINGS
In accordance with California Penal Code sections 933 and 933.05, the 2014-
2015 Grand Jury requires (or, as noted, requests) responses from each agency affected
by the findings presented in this section. The responses are to be submitted to the
Presiding Judge of the Superior Court.
Based on its investigation titled "The Mental Illness Revolving Door: A Problem
for Police, Hospitals, and the Health Care Agency," the 2014-2015 Orange County
Grand Jury has arrived at 14 principal findings, as follows:
F.1. Deputy Sheriffs and police officers receive insufficient training on how to evaluate
and handle the mentally ill in the field.
F.2. Deputy Sheriffs and police officers receive insufficient training regarding Laura's
Law.
F.3. Orange County's Centralized Assessment Team is inadequate in that it takes too
long for them to respond to the scene to assist police officers in their evaluations
of the mentally ill.
F.4. Orange County's mental illness triage system is inadequate in that there are no
field screening protocols that would allow medical clearance in the field by law
enforcement personnel or paramedics.
F.S. Orange County's mental illness triage system is inadequate in that the police
agencies either do not have a triage desk to advise and assist officers in the field
or do not have psychiatric crisis mobile response teams at their disposal.
F.6. Orange County's Psychiatric Evaluation and Response Team clinicians are
insufficient in number to meet the needs of police agencies in Orange County.
F.7. Orange County's Evaluation and Treatment Services facility is inadequate in that
its capacity is insufficient to permit police officers to take all the mentally ill to it
and drop them off at the facility, instead of transporting the patient to a hospital
emergency room.
F.B. Orange County's Evaluation and Treatment Service facility is inadequate in that
the County does not permit medical triage or medical clearance in the field, and
therefore directs police officers to obtain medical screening for even minor health
conditions that could easily be treated at the facility.
F.9. Orange County's Evaluation and Treatment Service facility is inadequate in that it
directs police officers to take the mentally ill who may be under the influence of
alcohol or drugs to a hospital emergency room rather than to a psychiatric
emergency facility.
F.10. Orange County's crisis intervention system is inadequate in that there is only one
Evaluation and Treatment Service facility for the entire County.
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F.11. The County's crisis intervention system is inadequate in that it does not provide
strategically located, stand-alone, drop-off psychiatric emergency stabilization
facilities with medical treatment capability at convenient locations throughout the
Cou nty.
F.12. The County's crisis intervention system is inadequate in that there is no real-time,
empty -bed registry to enable officers and clinicians in the field to determine bed -
availability at the Evaluation and Treatment Service facility and at designated
hospitals.
F.13 The County's crisis intervention system is inadequate in that there is no 5150,
case management, and conservatorship database in place to assist officers and
clinicians in the field to triage the mentally ill who do not qualify for a 5150 hold.
F.14. The Health Care Agency has not established benchmarks and a complete
performance -measurement system with which to track the success and cost
effectiveness of Laura's law, as directed by the Board of Supervisors in May
2014.
RECOMMENDATIONS
In accordance with California Penal Code sections 933 and 933.05, the 2014-
2015 Grand Jury requires (or, as noted, requests) responses from each agency affected
by the recommendations presented in this section. The responses are to be submitted
to the Presiding Judge of the Superior Court.
Based on its investigation titled "The Mental Illness Revolving Door: A Problem
for Police, Hospitals, and the Health Care Agency," the 2014-2015 Orange County
Grand Jury makes the following 14 recommendations:
R.1. All law enforcement officers should receive at least 40 hours of comprehensive
Crisis Intervention Training on how to handle and evaluate the mentally ill in the
field with periodic refresher training. (F.1.)
R.2. All law enforcement officers should receive mandatory and specific training
regarding Laura's Law. (F.2.)
R.3. Orange County's Centralized Assessment Team's response time should be
improved significantly with a goal of eventually reducing its maximum response
time to less than 20 minutes. (F.3.)
R.4. The Orange County Health Care Agency should adopt field screening protocols
to allow (a) medical clearance in the field by law enforcement personnel and/or
paramedics; and (b) transport by paramedics rather than police officers. (F.4.)
R.S. All law enforcement agencies should either have a psychiatric triage desk to
advise and assist officers in the field or a psychiatric crisis mobile response team.
(F.5.)
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R.6. The Orange County Psychiatric Evaluation and Response Team staff should be
increased significantly so that an embedded clinician can be placed with each
law enforcement agency and can provide service 24/7 if requested. (F.6.)
R.7. Orange County's Evaluation and Treatment Services facilities should be
expanded to easily accommodate all 5150 walk-ins and all 5150s dropped off by
police, paramedic, or ambulance. (F.7.)
R.B. Orange County Evaluation and Treatment Services should acquire the capability
of conducting limited medical screening for minor health problems and cease
from directing police officers to obtain medical screening for 5150s with minor
health conditions that could easily be treated at Evaluation and Treatment
Services facilities. (F.8.)
R.9. Orange County's Evaluation and Treatment Services facilities should acquire the
capability of handling 5150s who may have ingested alcohol or drugs, but who
are not under the influence to such an extent that it inhibits stabilization or
requires medical clearance at a hospital. (F.9.)
R.10. The Orange County Health Care Agency's crisis intervention system should be
expanded so as to provide a minimum of four Psychiatric Emergency Service
facilities—one in South County, one in Central County, one in West County, and
one in North County. (F.10.)
R.11. The County's Health Care Agency should provide strategically located, stand-
alone, drop-off psychiatric emergency stabilization facilities with medical
treatment capability at convenient locations throughout the County. (F.11.)
R.12. The County's Health Care Agency should provide a real-time, empty -bed registry
to enable officers and clinicians in the field to determine immediately and
accurately the current bed availability at Evaluation and Treatment Services
facilities and at designated hospitals. (F.12.)
R.13. The County's Health Care Agency should create and maintain a 5150, case
management, and conservatorship database in place to assist officers and
clinicians in the field to triage the mentally ill in the field who do not qualify for a
5150 hold, but who may qualify for Laura's Law. (F.13.)
R.14. The Health Care Agency should establish benchmarks and a complete
performance -measurement system with which to track the success and cost
effectiveness of Laura's law, as directed by the Board of Supervisors in May
2014.
REQUIRED RESPONSES
The California Penal Code section 933 requires the governing body of any public
agency which the Grand Jury has reviewed, and about which it has issued a final report,
to comment to the Presiding Judge of the Superior Court on the findings and
recommendations pertaining to matters under the control of the governing body. Such
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
comment shall be made no later than 90 days after the Grand Jury publishes its report
(filed with the Clerk of the Court). Additionally, in the case of a report containing findings
and recommendations pertaining to a department or agency headed by an elected
County official (e.g. District Attorney, Sheriff, etc.), such elected official shall comment
on the findings and recommendations pertaining to the matters under that elected
official's control within 60 days to the Presiding Judge with an information copy sent to
the Board of Supervisors.
Furthermore, California Penal Code section 933.05, subdivisions (a), (b), and (c),
provides as follows, the manner in which such comment(s) are to be made:
(a) As to each Grand Jury finding, the responding person or entity shall indicate one of
the following:
(1) The respondent agrees with the finding
(2) The respondent disagrees wholly or partially with the finding, in which case
the response shall specify the portion of the finding that is disputed and shall include an
explanation of the reasons therefore.
(b) As to each Grand Jury recommendation, the responding person or entity shall report
one of the following actions:
}
(1) The recommendation has been implemented, with a summary regarding the
implemented action.
(2) The recommendation has not yet been implemented, but will be implemented
in the future, with a time frame for implementation.
(3) The recommendation requires further analysis, with an explanation and the
scope and parameters of an analysis or study, and a time frame for the matter to be
prepared for discussion by the officer or head of the agency or department being
investigated or reviewed, including the governing body of the public agency when
applicable. This time frame shall not exceed six months from the date of publication of
the Grand Jury report.
(4) The recommendation will not be implemented because it is not warranted or
is not reasonable, with an explanation therefore.
(c) If a finding or recommendation of the Grand Jury addresses budgetary or personnel
matters of a county agency or department headed by an elected officer, both the
agency or department head and the Board of Supervisors shall respond if requested by
the Grand Jury, but the response of the Board of Supervisors shall address only those
budgetary /or personnel matters over which it has some decision making authority. The
response of the elected agency or department head shall address all aspects of the
findings or recommendations affecting his or her agency or department.
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Comments to the Presiding Judge of the Superior Court in compliance with Penal Code
section 933.05 are required from:
Responses are required for Findings F.3 through F.14. and for
Recommendations R.3 through R.14. from the Orange County Board of
Supervisors.
Responses are required for Findings F.1 and F.2. and for Recommendations R.1.
and R.2.from the Orange County Sheriff -Coroner.
Comments to the Presiding Judge of the Superior Court in compliance with Penal Code
section 933.05 are requested from:
Responses are requested for Findings F.3 through F.14. and for
Recommendations R.3. through R.14.from the OC Health Care Agency.
Responses are requested for Findings F.1 and F.2. and for Recommendations
R.1. and R.2.from the Police Chiefs of the following cities:
1. Anaheim
2. Brea
3. Buena Park
4. Costa Mesa
5. Cypress
6. Fountain Valley
7. Fullerton
8. Garden Grove
9. Huntington Bch �►
10. Irvine
11. La Habra
12. La Palma '
13. Laguna Beach
14. Los Alamitos
15. Newport Beach
16. Orange
17. Placentia
18. Santa Ana
19. Seal Beach
20. Tustin
21. Westminster
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COMMENDATIONS
The Grand Jury commends the Police Department of the City of Orange, the
Santa Ana Police Department, the Hospital Association of Southern California, and St.
Joseph Hospital for collaborating on and producing a set of training videos for use by
police officers and deputy sheriffs in CIT training. The Grand Jury commends the
Director of the John George Psychiatric Hospital in San Leandro, California and the
Director of Behavioral Health for Alameda County for their valuable assistance. The
Grand Jury also commends Golden West College for developing and expanding its CIT
course to 24 hours.
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END NOTES
1. The Memphis Model
The first CIT was established in Memphis in 1988 after the tragic shooting by a
police officer of a man with a serious mental illness. This tragedy stimulated a
collaboration between the police, the Memphis chapter of the National Alliance on
Mental Illness, the University of Tennessee Medical School, and the University of
Memphis to improve police training and procedures in response to mental illness. The
so-called Memphis model has achieved remarkable success, having been adopted by
more than 2000 communities in more than 40 states and having been implemented
statewide in several states.
The Memphis Model of CIT has several key components:
• A community collaboration between mental health providers, law
enforcement, and family/consumer advocates, which determines the best
way to transfer the mentally ill into the mental health system
• A community coalition to ensure that there are adequate facilities for
mental health triage
• A curriculum of specialized training to teach police officers how to interact
with persons experiencing a psychiatric crisis
• Special training to respond safely and quickly to people with serious
mental illness in crisis
• Focused training on how to recognize the signs of psychiatric distress and
how to de-escalate a crisis
• Materials on how to link people with appropriate treatment, which has a
positive impact on fostering recovery and reducing recidivism
The benefits of the Memphis Model of CIT are as follows:
• Helps keep the severely mentally ill out of jail and gets them into treatment
• Reduces stigma and prejudice toward the severely mentally ill
• Reduces officer injuries and SWAT team emergencies
• Reduces the amount of time officers spend on the disposition of mental
disturbance calls
2. Defense of Laura's Law
On January 3, 1999, Kendra Webdale was pushed to her death before an
oncoming subway train beneath the streets of Manhattan by a man diagnosed with
paranoid schizophrenia and with a history of mental illness and hospitalizations who had
neglected to take his prescribed medication. Responding to this tragedy, the Legislature
enacted Mental Hygiene Law § 9.60 (Kendra's Law) (L. 1999, ch. 408), thereby joining
nearly 40 other states in adopting a system of assisted outpatient treatment (AOT)
pursuant to which psychiatric patients unlikely to survive safely in the community without
supervision may avoid hospitalization by complying with court-ordered mental health
treatment. In enacting the law, the Legislature found that there are mentally ill persons
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
who are capable of living in the community with the help of family, friends, and mental
health professionals, but who, without routine care and treatment, may relapse and
become violent or suicidal, or require hospitalization. (L 1999, ch. 408, § 2.) In addition,
in mandating that certain patients comply with essential treatment pursuant to a court-
ordered written treatment plan, the Legislature further found that some mentally ill
persons, because of their illness, have great difficulty taking responsibility for their own
care and often reject the outpatient treatment offered to them on a voluntary basis. (Id.)
It did not take long for the law's constitutionality to be challenged. The question
was whether the law achieved its goal of creating a mechanism to ensure that
individuals who met the criteria remained treatment -compliant while in the community, in
a way that was consistent with the Constitutional rights of those individuals. In the
Matter of K.L., 500748/00 (Sp. Ct., Queens County, 2000), the Mental Hygiene Legal
Service (MHLS) moved for dismissal of a petition, arguing that the statute was
unconstitutional on two grounds: that it unconstitutionally deprived patients of the
fundamental right to determine their own course of treatment, and that the statutory
provisions concerning removal for observation following non-compliance with the AOT
order are facially unconstitutional. The Attorney General of the State of New York
intervened to support the constitutionality of the statute.
The Supreme Court rejected each of the arguments advanced by the MHLS,
upheld the constitutionality of Kendra's Law, and found that it comported with due
process, noting that Kendra's Law does not permit forced medication or treatment . The
Court reasoned that the restriction on a patient's freedom affected by a court order
authorizing AOT is minimal, inasmuch as the coercive force of the order lies solely in
the compulsion generally felt by law-abiding citizens to comply with court directives. The
Court observed that although the existence of such an order and its attendant
supervision increases the likelihood of voluntary compliance with necessary treatment,
a violation of the order, standing alone, ultimately carries no sanction.
3. The Sequential Intercept Model
The Sequential Intercept Model provides a conceptual framework for
communities to use when considering the interface between the criminal justice and
mental health systems as they address concerns about criminalization of people with
mental illness. The model envisions a series of points of interception at which an
intervention can be made to prevent individuals from entering or penetrating deeper into
the criminal justice system. The concept is that most people will be intercepted at early
points, with decreasing numbers at each subsequent point. The interception points are
law enforcement and emergency services; initial detention and initial hearings; jail,
courts, forensic evaluations, and forensic commitments; reentry from jails, state prisons,
and forensic hospitalization; and community corrections and community support. The
model provides an organizing tool for a discussion of diversion and linkage alternatives
and for systematically addressing criminalization. Using the model, a community can
develop targeted strategies that evolve over time to increase diversion of people with
mental illness from the criminal justice system and to link them with community mental
health treatment. (Munetz & Griffin, 2006)
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Although many communities are interested in addressing the overrepresentation of
people with mental illness in local courts and jails, the task can seem daunting and the
various program options confusing. The Sequential Intercept Model provides a workable
framework for collaboration between criminal justice and treatment systems to
systematically address and reduce the criminalization of people with mental illness in
their community
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REFERENCES
About Laura's Law. (n.d.). In Ten years after murders: law meant to prevent tragedies
remains overlooked and unused. Retrieved from
http://www.lauraslawoc.org./about.html
Assisted Outpatient Treatment (2014, June 13). The Nevada County Experience.
Retrieved from: http://www.mynevadacounty.com/nc/hhsa/bh/Pages/Assisted-
Outpatient-Treatment.aspx
Bekiempis, V. (2014, February 28). New study on mental illness. Newsweek.
Carpinello, S. (2005, March) Kendra's Law: Report on the Status of Assisted
Outpatient Treatment. New York State, Office of Mental Health. Albany, New
York.
Cost Savings for AOT (2012, June 12). Mental Illness Policy Organization, found at
http://lauras-law.org.
Dupont, R. Cochran, S, & Pillsbury, S. (2007, September). Crisis Intervention Team
Core Elements. University of Memphis. Memphis TN.
Emmanuel, A. & McBride, S. (2015, April 30). Police face choice of handcuffs or
helping hand for mentally ill. Chicago Reporter. Chicago, III.
Exodus Recovery, Inc. (2015). Mental Health Urgent Care Center at MLK Medical
Center by Exodus, found at www.exodusrecoveryinc.com/MLK—UCC.html.
Gerda, N. (2014, May 14). Orange County adopts Laura's Law. Voice of OC. Retrieved
from http:H voiceofoc.org.
Holt, W., & Adams, A. (2013). Mental health in California: Painting a picture. California
Healthcare Foundation. Oakland, CA. Retrieved from
http://www.chcf.org/publicaations/2013/07/mental-health-california.
King, S. (2015, April 5) American tragedy: A staggering percentage of police shooting
victims struggled with mental illness Daily KOS. Retrieved from:
http://www.dailykos.com/story/2015/04/05/1375335
Miller, J. (2013, March 5) Patients as prisoners, jails new mental health institutions,
CBS News.. Retrieved from: http://www.cbsnews.com/news/patients-as-
prisoners-jails-new-mental-health-institutions/.
Munetz, M. & Griffin, P. (2006, April). Use of the sequential intercept model as an
approach to decriminalization of people with serious mental illness. Psychiatric
Services. Retrieved from http://www.dbads.virginia.gov/library/document-
library/ofo%20%20sim%20article%20munetz%20%20griffin%202006.pdf.
National Alliance on Mental Illness (n.d.). CIT toolkit; CIT facts. Retrieved from
http://www2.nami.org/Content/ContentGroups/Policy/CIT/CIT Facts 4.11.12.pdf
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The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Orange County Board of Supervisors. (2015, May 19). Adoption of stepping up
initiative resolution (Agenda Staff Report). Santa Ana, CA.
Orange County Health Care Agency and Hospital Association of Southern California. .
(2013, December 17). Triage grant application, Vol XI I (27).Santa Ana, Ca.
Orange County Health Info. (n.d.). Full Service Partnership Homepage. Retrieved from
http//www.ocgov.com/gov/health/bhs. Santa Ana, CA.
Pelley, S. (2014, September 14). The shortcomings of mental health care. CBS 60
Minutes (Television news program). New York, NY.
Quanbeck, T, Tsai, G, & Szabo K. (n.d.) Cost-effectiveness analysis of assisted
outpatient treatment implementation in California's civil sector. Retrieved from:
http://dhmh.maryland.gov/bad/Documents/
Sewell, A. (2014, July 15,). D.A. Jackie Lacey calls jailing of mentally ill a moral
question. Los Angeles Times. Los Angeles, CA.
Sewell, A. (2014, November 12). In push to keep mentally ill out of jail, county to
expand crisis centers, Los Angeles Times. Los Angeles, CA.
Shabo, H. (2014, August 20). Governor Davis signs Laura's Law. AB1421 will help
those with severe mental illnesses who are too sick to help themselves.
Retrieved from: http://oceanpark.com/notes/abl421 background.html.
Simon, R. (2015, January 25). Crisis Stabilization of the Mentally III. CBS 60 Minutes
(Television news program). New York, NY.
Superior Court of Orange County (2014). Annual Report, Collaborative Courts, p. 23,
Santa Ana, CA.
Swartz, M., Steadman, H. & Monahan, J (June 30, 2009). Program Evaluation: New
York State Assisted Outpatient Treatment Program Evaluation, Duke University
School of Medicine, Durham, NC.
Wolfson, B. J. (2014, October 25,). Psychiatric treatment in Orange County. Orange
County Register. Santa Ana, CA.
Zeller, S. (2013, September 16). Psychiatric boarding: Averting long waits in
emergency rooms. Psychiatric Times. Retrieved from:
http://www.psychiatrictimes.com.
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APPENDIX: ACRONYM LIST
AAOAPOD
Adult and Older Adult Performance Outcome Department
AOT
Assisted Outpatient Treatment
BHS
Behavioral Health Services
CAT
Centralized Assessment Team
CIT
Crisis Intervention Training
COPS
Community Oriented Policing Services
CRT
Crisis Response Team
EPU
Emergency Psychiatric Unit 11Z)
ETS
Evaluation and Treatment Services
FSP
Full Service Partnership
HCA
Health Care Agency
LPS
Lanterman-Petris-Short Act 100�
NAMI
National Alliance on Mental Illness
PERT
Psychiatric Evaluation and Response Team
PES
Psychiatric Emergency Services
PET
Psychiatric Evaluation Team
POST
Peace Officers Standards and Training
TACT
Time, Atmosphere, Communication, and Tone: A method of talking
to the mentally ill
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