On behalf of the Tulare County Board of Supervisors, we respectfully request your consideration of the County's concerns with SB 1338 (Umberg & Eggman) to ensure that the paradigm shift contemplated in CARE Court can be successful.
CARE Court would establish a new court process to engage individuals with schizophrenia and psychotic disorders into treatment via county behavioral health and to ensure these individuals can access local housing resources. CARE Court appears to build out a behavioral healthcare for all approach, by opening this court process and access to county behavioral health and other public services, regardless of payer status. The proposal as outlined in SB 1338 (Umberg & Eggman) has some challenges, however, that we believe must be addressed in order to make CARE Court effective and successful in moving our state beyond the status quo:
1. Funding: The CARE Court program includes new responsibilities and obligations imposed on counties that require additional resources. Adequate and sustainable funding will be needed across multiple departments, including county behavioral health, public defender, county counsel, public guardians and conservators, and county social services. However, to date, no new county funding has been proposed for the significant expansion of county behavioral health services contemplated under CARE Court. CARE Court will not succeed without new, earmarked funding for this significant expansion of county behavioral health's responsibilities. We respectfully request that any county behavioral health services not covered under Medi-Cal or private insurance be fully funded to ensure CARE Court does not divert county behavioral health funding and services from children and youth in the midst of the children's mental health crisis. The Public Defender and Public Guardian have similar concerns about adding workload to their respective systems which have already saturated their available resources, and the consequent impact it might have to their vulnerable clients if such an increased workload were to be absorbed without sustained funding to hire and retain sufficient staff.
2. Sanctions: The proposal to impose sanctions and even receivership on counties for any instance of alleged "noncompliance" with CARE requirements raises significant concerns.
a. Any proposal which does not provide additional funding for expanded county behavioral health responsibilities for CARE Court participation and activities should not include any threat of sanctions. Medi-Cal already has broad sanction authority to hold county behavioral health plans accountable for entitlement services.
b. If county behavioral health is funded for implementation, sanctions should be reserved for deliberate and chronic deficiencies and should be imposed only after meaningful engagement with the responsible state agencies and existing procedural safeguards.
3. Housing: Ensuring housing is included in CARE Court is foundational for addressing homelessness and a critical component in the successful treatment of those with severe mental illness. We are appreciative of recent amendments which strengthen the court's ability to leverage the billions in new housing resources already invested by the state via CARE Court. Without the real opportunity for clients to access available housing options through CARE Courts, very little will change through this court process for our clients experiencing homelessness and housing instability. Furthermore, the Public Defender asserts that existing programs in Tulare County, such as AOT, Mental Health Diversion and Mental Health Court, lack sufficient resources to house clients in a timely manner. Without sufficient additional housing to meet the needs of the CARE Court, it is likely that it will encounter the same obstacles as these already existing programs.
4. Ramp-Up Period: Given the significance of this paradigm shift and the far-reaching consequence of the CARE Court proposal, we believe the path to success for implementers and more importantly - for those who stand to benefit from CARE Court services -- must allow for an initial ramp-up period prior to expanding CARE Court on a statewide basis. Regions of the state with severe workforce, provider and housing shortages in particular should be afforded additional time to implement some of the state's recent infrastructure investments.
5. Undefined Terms: The plan includes provisions for "evaluators", "supporters", petitions, and referrals, among others. These terms are being created and described in the upcoming detailed proposal, but at this time remain undefined. In current conservatorship law, referrals of patients come from a physician/psychiatrist who have examined an individual and refer them to the public conservator. A petition is created and filed with the courts to formalize the conservator relationship. As these terms have specific and legal meaning in the current system, those terms must be consistent to avoid confusion and to remain in compliance with the law.
6. Improved Screening for Referrals: To ensure that the initial court hearing in CARE proceedings is well-informed and productive, we believe a preliminary investigation by qualified county behavioral health agencies is needed when petitions are filed to ensure the courts and county behavioral health clinicians are not overwhelmed by inappropriate referrals of individuals not likely to meet CARE Court criteria.
7. Eligibility Criteria: As amended on May 19th, SB 1338 significantly expands eligibility to include individuals with schizophrenia spectrum and psychotic disorders who are not already engaged into treatment and where their impaired insight or judgment presents a risk to their health or safety. This overly broad criteria would significantly expand CARE Court beyond the 7,000-12,000 individual target population put forward by the Administration in developing this framework. Counties request that eligibility be limited to those for whom CARE Court engagement could prevent conservatorship in order to balance the need for engagement into available treatment with the need to protect the individual's rights to self-determination.
8. Close Behavioral Health Parity Loophole: While SB 1338 does include a provision to compel some private health plans to reimburse for a limited number of services, these provisions need to be strengthened to ensure that private health plans are not incentivized to side-step their payer responsibility to county behavioral health by making referrals to CARE Court.
Thank you for your consideration of the above outlined concerns. Counties recognize the vital role we play in offering a unique set of safety net services for those individuals with the most acute psychiatric conditions and believe that these amendments are essential to ensuring the success of CARE Courts.
Sincerely,
Eddie Valero
Chair, Tulare County Board of Supervisors
Cc: Assembly Member Stone; Honorable Members of the Assembly Judiciary Committee; Leora Gershenzon, Deputy Chief Counsel, Assembly Judiciary Committee; Agnes Lee, Office of Speaker Rendon; Ana Matosantos, Cabinet Secretary, Office of Governor Newsom; Jason Elliott, Senior Counselor, Office of Governor Newsom; Kim McCoy Wade, Senior Advisor, Office of Governor Newsom; Jessica Devencenszi, Deputy Legislative Secretary, Office of Governor Newsom; Tulare County State Delegation; Shaw Yoder Antwih Schmelzer & Lange; Dr. Mark Ghaly, Secretary, CalHHS; Marko Mijic, Undersecretary, CalHHS; Stephanie Welch, Deputy Secretary, CalHHS; Corrin Buchannan, Deputy Secretary for Policy and Strategic Planning, CalHHS; Michelle Baass, Director, DHCS; Jacey Cooper, Medicaid Director, DHCS; Susan DeMarois, Director, Department of Aging; Mary Watanabe, Director, DMHC; Martin Hoshino, Administrative Director, Judicial Council; Joshua Lin, Legislative Analyst's Office; Mark Newton, Legislative Analyst's Office