The LPS Act Governs Only One Part of Counties’ Broader Mental Health Systems
Figure 1 depicts the voluntary and involuntary components of counties’ mental health systems. One side of the figure represents the voluntary component with a picture of an individual in a community setting. Text call-outs from the picture identify food and clothing, wellness centers, housing programs, voluntary residential care, educational programs, and outpatient services as types of voluntary treatment and services located in the community setting. The other side of the figure uses a picture of a treatment facility to represent the involuntary treatment and services provided under the LPS Act. Text under the voluntary and involuntary components of the figure details the different characteristics of voluntary treatment and services, which are located at various places within a county and serve generally people with serious mental illnesses, and involuntary treatment, which is located in a range of treatment facilities and serves those who are experiencing mental health crises and meet LPS Act criteria.
California’s Approach to Mental Health Treatment Has Changed Over Time
Figure 2 presents the passage of the LPS Act in 1967 and other key moments in the history of the State’s approach to mental health treatment from the 1950’s through the present. Generally, it shows that during this time the California Legislature passed various pieces of legislation that established and provided funding for county-based mental health treatment services.
The LPS Act Outlines a Process That Generally Involves Three Stages of Involuntary Treatment for Mental Illness
Figure 3 is a chart showing the process for the three stages of involuntary treatment that the LPS Act generally involves. The chart presents three columns identifying these three stages: a short-term hold, extended hold, and conservatorship. Under the column headings identifying these three stages, the chart includes three rows of information detailing who can apply the involuntary treatment, the criteria a person must meet in order to be treated involuntarily, and the period of time during which the involuntary treatment can occur at each stage. The chart illustrates that the LPS Act imposes more constraints on the application of involuntary treatment as the period of treatment becomes longer. Specifically, designated professionals can place someone who meets the criteria of danger to self, danger to others, or grave disability on a short-term hold of up to 72 hours. However, designated professionals are subject to secondary review when they place a person who meets those criteria on an extended hold of up to 14 days. For the longest stage of involuntary treatment, a year-long conservatorship with the possibility of annual renewal, a county public guardian must petition the court to apply conservatorship, and a person subject to involuntary treatment at this stage must be gravely disabled.
Counties Receive Billions in State and Federal Funds That They Can Use to Support Their Mental Health Systems
Figure 4 identifies that in 2018-19 counties had $7.7 billion in mental health funding from major funding sources. The $7.7 billion was comprised of $2.0 billion in MHSA funding, $1.5 billion in 2011 realignment funding, $1.3 billion in 1991 realignment funding, and $2.9 billion in federal Medi-Cal reimbursements for specialty mental health services.
Individuals Placed on Holds or Conservatorships in Each of the Three Counties Exhibited Similar Indications That They Had Met the LPS Act Criteria
Figure 5 shows that people who were placed on involuntary holds or conservatorships in Los Angeles, San Francisco, and Shasta exhibited similar behaviors indicating they were dangerous to themselves, dangerous to others, or gravely disabled. In chart form, the figure shows that in each county people exhibiting symptoms of mental illness such as delusions or hallucinations and suicidal or homicidal behavior were held based on the criteria of danger to self or danger to others. Also in each county, people exhibiting a broader range of symptoms and behaviors were held or conserved based on the criteria of grave disability. This broader range included symptoms such as delusions and a lack of awareness of mental illness and behaviors such as the inability to maintain sufficient nutrition or to voluntarily take medication that would enable an individual to provide for their basic needs.
A Shortage of State Hospital Facility Beds Has Delayed Critical Treatment for Individuals Placed on LPS Act Conservatorships
Figure 6 is a graphic showing that individuals receiving treatment under the LPS Act made up a smaller portion of the population at state hospital facilities and waited longer on average for admission than individuals involved with the criminal justice system. The figure uses color-coding to show that individuals receiving involuntary treatment under the LPS Act, color-coded blue, made up 12 percent of the population admitted to state hospital facilities as of November 2019. Individuals involved with the criminal justice system, color-coded orange, made up 88 percent of that population. Overall, the figure shows that state hospital facilities had insufficient capacity for the population in need, as over 650 individuals from the criminal justice population and over 200 individuals from the LPS Act population were waitlisted for admission as of August 2019. The figure further details that the 200 individuals from the LPS Act population were waiting an average of 345 days for admission. In contrast, individuals involved with the criminal justice system must be admitted within 60 days of commitment.
A Small Proportion of Individuals Who Were Held Multiple Times for Involuntary Treatment Were Then Enrolled in Intensive Outpatient Services in Los Angeles and San Francisco
Figure 7 presents bar graphs showing that a small proportion of those people who were subject to multiple involuntary holds were enrolled in intensive outpatient services in Los Angeles and San Francisco. The figure identifies the population of individuals subject to five or more holds from fiscal years 2015-16 through 2017-18 and shows the portion of the population enrolled in intensive outpatient services in fiscal year 2018-19. For Los Angeles, the population was about 7,400 individuals and only about 2 in 20 were enrolled in intensive outpatient services. For San Francisco, the population was about 200 individuals and only about 1 in 20 were enrolled in intensive outpatient services.
Many Individuals Have Been Subject to Multiple Short‑Term Holds
Figure 8 uses three pie charts to show that in each county we reviewed many people who were placed on short-term holds between fiscal years 2014-15 and 2018-19 had been subject to multiple short-term holds during their lifetimes. In Los Angeles, 43 percent of the 166,000 individuals placed on a short-term holds during those five fiscal years had been subject to multiple short-term holds over their lifetimes, and nearly 10,000 people had been subject to 10 or more such holds. In San Francisco, 31 percent of the 14,000 individuals had been subject to multiple short-term holds and nearly 300 had been subject to 10 or more. In Shasta, 23 percent of 2,000 individuals had been subject to multiple short-term holds but none had been subject to 10 or more such holds.
Many People Cycled Back to Conservatorships After They Stopped Taking Their Medications
Figure 9 depicts that medication was a key factor for some people who recovered during conservatorship, deteriorated in their communities, and became conserved again. It shows that when people recover their abilities to provide for their basic needs they transition from conservatorship, which can involve restrictive settings and court-ordered medication, to community settings, which are independent and do not involve court-ordered medication. The chart shows that one in four of the people whose conservatorships we reviewed made this transition but then cycled back to conservatorship again after they stopped taking their medications.
Assisted Outpatient Treatment Helps Some Individuals Receive Critical Treatment in Their Communities, But Its Criteria Limit Access for Those Who Recently Were Gravely Disabled
Figure 10 shows that successful recovery during conservatorship can effectively limit people who have been gravely disabled from accessing intensive ongoing services in their communities through assisted outpatient treatment. The top of the figure shows the contrast between two individuals. One is leaving conservatorship, providing for basic needs, accessing mental health services voluntarily, and taking prescribed medication. The other is substantially deteriorating, historically noncompliant with treatment, failing to voluntarily engage in treatment, and behaving in ways that result in hospitalization or violent acts or threats. The individual who is leaving conservatorship does not meet the criteria for assisted outpatient treatment, but the other individual does. The bottom of the figure shows that, as a result, the individual leaving conservatorship cannot benefit from assisted outpatient treatment—namely, having a highly trained mental health team manage wraparound services for them, including coordination and access to medications, psychiatric and psychological services, substance abuse services, supportive housing assistance, vocational rehabilitation, or veterans’ services.
A Unified Framework for Reporting Spending and Outcomes Could Help Policymakers and Others Better Understand the State’s Mental Health System
Figure 11 is an infographic showing that critical information which is currently missing from the State’s public reporting about the mental health system could be captured through an improved reporting framework. The figure focuses on three components of reporting: whether it includes all relevant funds, details the services counties provide with those funds, and details broader outcomes that would help stakeholders assess how well the mental health system is working. The top of the figure demonstrates that the current reporting is deficient on all three components. The figure then presents an improved reporting framework that would successfully address all three components. First, it shows that the framework would include all funds that counties have for mental health. Second, it shows that county reports would detail programs and services and their outcomes, and it depicts that county reports would feed into aggregate county and statewide data showing the amount of money spent on various types of programs and services, such as: emergency services, inpatient care, intensive outpatient services, basic social supports, general outpatient services, community wellness supports, and outreach and education. Third, the figure shows that reporting would encompass broader statewide outcomes which would show the extent to which the mental health system was working to reduce negative impacts of mental illnesses. The figure shows examples of areas in which broader outcomes could be measured, such as suicide, incarceration, homelessness, unemployment, school failure or dropout, repeated LPS Act holds, and quality of life.