latest news California counties scramble ahead of CARE Court launch

In four months, the hammer will fall and the state’s first CARE courts will be in session.

Seven counties have opted for an Oct. 1 rollout of the law that directs each county to create special courts, whose judges have the power to order voluntary treatment plans for people with untreated schizophrenia and related disorders. .

The CARE Act, signed into law by Governor Gavin Newsom last September, requires counties to put in place the bureaucratic mechanisms that will support the goal of mitigating an epidemic of serious mental illness on the streets and in communities.

“We’re in the weeds, thinking about what everyday life will be like for people who engage in this work,” said Luke Bergmann, director of behavioral health for San Diego County.

Among the many challenges of the CARE Act is developing a manageable workflow for disparate groups.

For each individual appearing in court, there will be the clerks who handled the motions who initiated the proceedings, the outreach teams who found the individual and served the documents, the psychiatrists who prepared a treatment plan, the defense attorneys who will represent the individual, behavioral health clinicians who will present the plan, and judges who will negotiate its implementation.

Additionally, there will be insurance companies who pay for the plan, administrators who handle the paperwork associated with the plan, and health care providers who execute the plan.

The first group – San Diego, Orange, Riverside, San Francisco, Stanislaus, Tuolumne and Glenn – reflects California’s geographic and demographic diversity. Their courts will serve as a model for Los Angeles and the other 50 counties. (LA County will open its court on Dec. 1; the rest of the state has until Oct. 1, 2024.)

Many counties will catch up with a crisis that has gone unchecked for decades. County supervisors and behavioral health directors describe a neglected system with an unknown number of people who may be eligible for a CARE tribunal.

The state has estimated that 7,000 to 12,000 people will be eligible for a treatment plan. The range is so wide, officials say, in part because the law allows roommates or family members to initiate an evaluation of a family member suspected of having a serious mental illness.

Some counties fear being overwhelmed by families who have been unable to seek help caring for people with mental illness through laws that protect their rights and privacy.

They are also prepared for the frustration of families whose applications are denied because they do not meet the criteria specified by law. People brought to a CARE tribunal must be at least 18 years old, diagnosed with “schizophrenia spectrum and other psychotic disorders” and not currently being treated.

“We just don’t know who this law will bring to the door,” said Veronica Kelley, director of behavioral health for Orange County.

Orange County estimates it will receive petitions for about 1,500 people in the first year, including about 1,000 who meet the court’s criteria. Of these, authorities estimate that nearly 300 should agree to a treatment plan without having to be brought before the CARE tribunal, leaving 700 for the tribunal to monitor for at least a year.

One of the smaller counties, Stanislaus, has identified 150 people who will be eligible based on frequent emergency room visits. “Beyond that,” county supervisor Terry Withrow said, “anyone’s guess.”

Such estimates are critical for counties that need to hire staff at a time when the state is experiencing a shortage of behavioral health workers. Meeting this need will be more difficult for rural counties, which have fewer providers able to work with people with acute mental illness.

“In a small county, it’s not like staff numbers are growing to meet capacity, especially when it comes to administration and management,” said Joe Hallett, director of behavioral health for Glenn County, 60 miles north of Sacramento. “Instead, we’re just adding these new responsibilities to the existing workload.”

Health executives like Hallett look to Sacramento lawmakers for continued advocacy and support. Glenn County will receive nearly $1.4 million in advance allocations.

Seed funding for the CARE Act was $57 million. The state has budgeted $26 million to distribute among the first group of counties as they resolve implementation issues. Another distribution of $31 million will be shared among all counties before full implementation in 2024.

While Orange County received one of the highest allocations — $7.1 million — Kelley worries about lawmakers’ determination to keep the CARE Act fully funded.

“It’s fine for a year,” she said, “but for the next year, we don’t know.”

Funding for behavioral health services was one of the reasons Riverside County signed up early, said county chief executive Jeff Van Wagenen, who says he hasn’t received support from the county. State proportional to its population growth. The first allocation of $6.6 million will help, but what comes after the first year is unknown.

“One of CARE Court’s concerns is that this could be the state’s last unfunded term,” he said.

Reflected in the Sacramento budget for CARE Court is the presumption that the initial counties will fix the issues in legislation so that other counties can start their courts cheaply. This means answering a number of trivial but critical questions left unanswered by the law itself.

For example, who should serve the petition and transport individuals to court?

While behavioral health departments may seem like the logical choice, Bergmann fears it could create a conflict of interest when the agency bringing the person to court represents the interests of the party that went to court. Calling on law enforcement for this task is equally problematic for encounters on the street which will likely require more trust than authority, he said.

Building that trust is one of the reasons Orange County arranges for its staff to help family members complete the motions the court needs to initiate the response.

“We imagine a loved one at their wits end — restless, frustrated and tired — for everything they’ve been through to get to this moment,” Kelley said. “So court staff have to be ready for that. We are also trying to get the $433 filing fee waived. That’s a lot of money.”

To help families understand the process, Riverside County is developing an app that will track individual progress through the CARE system. The county could also hold civil hearings remotely, so someone living in Blythe, for example, wouldn’t have to travel to court in Riverside, 170 miles away.

“All we need is a table, a chair and a laptop,” Van Wagenen said. “So we could buy a van and turn it into a mobile courtroom. This would avoid the problem of having to store goods or keep pets for those who are homeless.

Homelessness creates a unique dilemma for counties required to hold a case management hearing within two weeks of determining the validity of the claimant’s claim.

“We will need more than 14 days to find the person and try to get them to accept treatment,” Kelley said. “What if a person has moved to another county? We cannot deploy all of our resources trying to find them. We are not investigators.

“We’re in the weeds, thinking about what everyday life will be like for people who engage in this work,” said Luke Bergmann, director of behavioral health for San Diego County.

(Kristian Carreon / For San Diego Union-Tribune)

Hallett, along with Glenn County, has similar concerns. The two-week window is “really, really quick to find someone, do outreach and process a report,” he said. “A month would be more reasonable.”

Still, lawmakers crafted the law in an effort to pressure counties to act quickly, letting counties meet that deadline or pay the price.

“The CARE plan is like a settlement agreement between the county and the defendant,” said Jacqueline Wong-Hernandez, policy officer for the California State Assn. counties. “Once a plan is in place, the petitioner falls through and an agreement to comply with it must be made between the county behavioral health department and the court participants.”

The stakes for not meeting the 14-day deadline are high. If the court finds the county non-compliant, a penalty of $1,000 per day per case may be imposed.

Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, calls the counties’ efforts so far “very promising.”

Not only does the legislation hope to change “the arc of life for some of the most vulnerable among us”, but it also represents “a culture shift in how we collectively do business as a system, which will take time and repetitions.

“Frankly,” he said, “it’s our responsibility to do better.”

As much as behavioral health directors welcome the CARE Act, they emphasize that more work is needed to address broader and deeper issues in the state’s behavioral health system.

“We’re moving too fast,” Kelley said. “Give us five years, that’s the time the county needs to build anything. Without the infrastructure, these programs will not be as successful as the Legislative Assembly wishes, and we could lose people we could serve in the process.

Newsom hopes to address this shortcoming by creating new revenue streams for housing and services, but his proposals are up to voters and will take years to implement.

“We’re standing at the front door,” Bergmann said. “We paint it, we put windows in, we line it with mother-of-pearl, and yet when we enter, we find a building without a roof.”