Laura’s Law Testimony
for the Orange County Ending Homelessness 2020 Commission
Nov. 17, 2011
Presented by
Carla Jacobs, Board Member, Treatment Advocacy Center
I am Carla Jacobs, Board Member of the Treatment Advocacy Center, a resident of Orange County, and one of the original sponsors who helped draft Laura’s Law.
(Note:Two parts: written and oral.-ed.)
Background of Laura’s Law
Laura’s Law (WIC 5345), California’s law for Assisted Outpatient Treatment (AOT) is the part of the Welfare and Institutions code known as the Lanterman, Petris, Short (LPS) Act. The LPS Act specifies how and under what circumstances a person with mental illness may receive court ordered treatment in California. Originally passed in 1967 and since amended, the Legislative intent of the LPS Act was to promote community care and end inappropriate institutionalization of people with mental illness. It sought to guarantee and protect public safety and protect mentally ill individuals from criminal acts.1
By 2002, the Legislature had found that “Some high-risk patients do not respond well to traditional community based mental health services. For various reasons, even when treatment is made available, high-risk patients do not avail themselves of the services.” They also found that the risk for poor outcomes for these individuals could be greatly avoided if they are provided intensive community services combined in consort with a court order. California’s Assisted Outpatient Treatment law, aka Laura’s Law, was written and passed to give counties a legal option to help high risk individuals with severe mental illness recover safely in the community and thus avoid the tragedy and expense of repeated involuntary hospitalizations, jailings or death.2
(How many homeless also have a severe mental illness?): Conservatively, approximately one-third of homeless individuals nationally,3 although the number is most likely considerably higher. Some can and do make use of community mental health treatment, various homeless services and shelters to keep them safe and help them off the streets. But others are just too psychiatrically disabled to do so. The quality of life for these individuals is abysmal. Many are victimized regularly. Women are raped.4 5 Food is handouts or foraged garbage. Some are very well known, hanging out at train stations and in front of grocery stores. Others hide from the eyes of most citizens. By day they shuffle quietly through our streets by day and at night hide under freeway over passes or in dark shopping center passageways.
Laura’s Law Promotes Community Care
Prior to Laura’s Laws, the only other civilly available option for court-ordered treatment was waiting until a person was imminently dangerous to themselves or others, gravely disabled and placing them in an acute care psychiatric hospital under WIC 5150. Or arresting them, usually for nuisance crimes, and putting them in the County jail.6 Laura’s Law provides a lifeline to people with severe mental illness who, because of the severity of their illness and deteriorating condition, have been unable to engage in Orange County’s community mental health system. Laura’s Law is not a panacea for Orange County’s homeless problems. It will prevent some of the most severely psychiatric disabled people in Orange County from being from being homeless, jailed, involuntarily hospitalized, victimized or too often dead.
Laura’s Law is for the most severely disabled
Schizophrenia and Bipolar Disorder are neurobiological brain disorders, as medical in nature as Alzheimer’s or Huntington’s Disease. Like these other medical conditions some individuals with severe mental illness have a neurological deficit known as anosognosia. Simply put, the brain can recognize when the leg is broken but the leg cannot take over for the brain-the computer of the body-when it is impaired. This impaired insight is associated with poorer treatment compliance, poorer psychosocial functioning, poorer prognosis, increased relapses, hospitalizations, arrests, and homelessness.7 8 9 10 11 12 With the current parole realignment to the county level, that recycling from jail to street will conceivably get even worse.
Evidence-based practices such as those contained within Orange County’s Behavioral Health Full Services Partnerships have been successful in providing care for many people with mental illness who are homeless without need for a court order. Yet, a significant number of the seriously ill remain difficult to engage and treat. Even with the best of outreach provided by the Orange County Department of Behavioral Health, the very severity of their illness precludes them from engaging in the treatment and services that can get them well and keep them safe in the community.
Laura’s Law is Missing component in Orange County’s Adult System of Care
Laura’s Law—Assisted Outpatient Treatment— is a missing component to Orange County’s adult system of care. It combines the intensive case management of a Full Service Partnership, including medication management, support, and supervision, with the needed court order that will help these individuals get off the streets, stay off the streets and recover while safely living in the community.
Laura’s Law-Assisted Outpatient Treatment–works
The combination of the therapeutic jurisprudence of the court order and the intensive treatment support for this severely ill populations works. Decades of experience in other vicinities show this.
A Duke University study of New York State’s similar statute concluded that assisted outpatient treatment reduced their psychiatric hospitalizations by 77%, dramatically reducing the most expensive and restrictive form of psychiatric treatment. Homelessness plummeted by 74%. There was an 83 percent reduction in arrest and an 87 percent decline in incarcerations. Moreover, the individuals found a positive effect on their lives. Seventy-five percent of recipients reported that AOT helped them gain control over their lives; 81 percent said that AOT helped them to get well and stay well; and 90 percent said AOT made them more likely to keep appointments and take medication. New York is far from the only state where AOT has proven effective. Findings elsewhere include steep declines in the number of hospital admissions and length of hospital stays in Washington, DC, Ohio, Iowa and North Carolina. In California both Nevada County and Los Angeles County’s experience with AOT confirm these findings.13 14 15 16 17
Laura’s Law will save Orange County money.
Untreated severe mental illness is costing Orange County dearly. Given the fact that this population requires costly acute psychiatric services, homeless services and law enforcement interaction at disproportionately higher rates than those who are able to accept treatment, any effort to increase engagement with them in stable, consistent community based treatment will save Orange County’s general fund and other revenues.
It costs approximately $1200 per day to treat an individual in a California psychiatric hospital. Housing an individual in a California prison or jail costs on average $51,000 per year. The cost of providing mental health treatment to a jailed mentally ill inmate in California sometimes can easily exceed $100,000 per year. By contrast, a comprehensive package of the most intensive community services for an AOT recipient in Orange County will cost on average $65 per day.18 19 20
Based upon results from other AOT programs, Laura’s Law will reduce costs associated with this population by approximately 85%. It will also AOT will reduce the burden on courts, police departments, fire departments, ambulance services and other health care.
Resources are available to pay for Laura’s Law.
Resources are available to provide for AOT under Laura’s Law. One such source is California’s Mental Health Services Act (MHSA, or Prop. 63). MHSA services are the very same ones required under AOT, and — as is already happening in Nevada County and Los Angeles County – this funding may be used to implement Laura’s Law. In fact, MHSA regulations require that they be provided in such a manner that they do not discriminate against a person’s receipt based on their mental health legal status and encourage fully inclusion of such individuals in the County’s community mental health system of care. 21 22 23
Moreover, the many AOT-eligible outpatients who are indigent and will qualify for some combination of Medicaid matching funds, Medicare, Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). The case management for the AOT recipient will help those individuals who have not yet applied for such benefits to do so. And, for those who are already receiving SSI or SSDI, money management services can help assure that these benefits are used as intended — to provide food, shelter, and clothing — rather than to finance the consequences of untreated mental illness on Orange County streets.
Nevada County which has fully integrated Laura’s Law into its mental health system of care has found that for every $1 they invested in MHSA services for Laura’s Law recipients they have saved $1.81 that can then be re-invested into their mental health program to serve even more people with severe mental illness. They used no county general funds to implement their program.24 25 26
Laura’s Law will reduce the victimization of people with mental illness.
Some people in Orange County who are severely ill with mental illness are on the streets, victimized and dying, solely because the severity of their illness is such that they cannot engage in treatment on their own.
When a person with Alzheimer’s or Huntington’s Disorder goes missing we as a society do everything we can to find that person and get them back to safety. The fact that we don’t provide that same level of protection for someone with other severe illness such as schizophrenia & bipolar disorder is discrimination, plain and simple.
- Laura’s Law will save money.
- Laura’s Law will prevent some homelessness
- Laura’s Law will save lives.
- Laura’s Law will help people get well and recover safely in the community.
You can’t end homelessness without addressing untreated mental illness. Laura’s Law is an important piece of the solution.
Please pass a recommendation that the Board of Supervisors to pass a resolution allowing Laura’s Law to be implement in Orange County.
NOTES
1 http://leginfo.ca.gov/cgi-bin/waisgate?WAISdocID=5579757244+0+0+0&WAISaction=retrieve
2 http://leginfo.ca.gov/pub/01-02/bill/asm/ab_1401-1450/ab_1421_bill_20020928_chaptered.html
3 Ohlemacher S. Study: 744,000 in U.S. Associated Press archives, January 10, 2007
4 Padget DK, Struening EL. Victimization and traumatic injuries among the homeless; associations with alcohol, drug and mental problems. American Journal of Orthopsychiatry 1992;62:525-534
5 Breakey WR, Fisher PJ, Kramer M et al. Health and mental health problems of homeless men and women in Baltimore, Journal of American Medical Association 1989;262:1352-1357
6 LPS Reform Task Force, http://www.desertpacific.mirecc.va.gov/news/lps-reform.shtml, 1998
7 Ho, A. K., Robbins, A. O. and Barker, R. A. (2006), Huntington’s disease patients have selective problems with insight. Movement Disorders, 21: 385-389. doi: 10.1002/mds.20739
8 15) Shad MU, Keshavan MS, Tamminga CA, et al. Neurobiological underpinnings of insight deficits in schizophrenia. International Review of Psychiatry 19 (4): 437-46, 2007.
9 16) Cooke MA, Fannon D, Kuipers E, et al. Neurological basis of poor insight in psychosis: a voxel-based MRI study. Schizophrenia Research 103 (1-3): 40-51, 2008.
10 17) Young DA, Davila R, & Scher H. Unawareness of illness and neuropsychological performance in chronic schizophrenia. Schizophrenia Research 10 (2): 117-24, 1993.
11 18) Kasapis C, Amador XF, & Yale SA. Neuropsychological and defensive aspects of poor insight and depression in schizophrenia. Schizophrenia Research 18 (2): 117-8, 1996.
12 19) Gonzalez-Pinto A, Reed C, Novick D, et al. Assessment of medication adherence in a cohort of patients with bipolar disorder. Pharmacopsychiatry 43 (7): 263-70, 2010.
13 Appelbaum, PS. Assessing Kendra’s Law: Five Years of Outpatient Commitment in New York. Psychiatric Services 56 (7): 791-2, 2005.
14 Fernandez GA & Nygard S. Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital & Community Psychiatry 41 (9): 1001-4.
15 Swanson JW, Swartz MS, Borum R, et al. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry 176: 324-31.
16 Steadman HJ, Gounis K, Dennis D, et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52 (3): 330-6, 2001.
17 Phelan JC, Sinkewicz M, Castille DM, et al. Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State. Psychiatric Services 61 (2): 137-43, 2010.
18 California Office of the Legislative Analyst. (March 18, 2010). (The average cost to incarcerate an inmate in CDCR in 2008-2009 was roughly $51,000. Of that amount, roughly $16,000 was spent on Health Care, including about $2,280 for mental health care. Costs for services for inmates needing intensive case management, enhanced outpatient treatment, crisis or acute care services can easily double the costs of incarceration)
19 19 See http://mimh200.mimh.edu/mimhweb/pie/reports/ACT%20Issue%20Brief.pdf, citing Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe mental illness. New York: W.W. Norton & Company, Inc.
20 http://taxdollars.ocregister.com/files/2011/10/HCA-report-on-Lauras-Law.pdf
21 Nevada County MHSA plan approval letter, State Dept. of Mental Health, May 22, 2007
22 County of Los Angeles, Enriched Services Assisted Outpatient Treatment, program description, brochure
23 http://www.dmh.ca.gov/Laws_and_Regulations/CompletedRegulations.asp
24 https://mentalillnesspolicy.org/states/california/nami_ctac_hca_response.html
25 Email from Michael Heggerty, Director of Mental Health, 11/12/2011
26 Tsai, G, Stanchfeild, C., 2011, Bridging the Gap in Care for the Severely Mentally Ill in Nevada County, California
Orange County Ending Homelessness 2020 Commission
Nov. 17, 2011
Oral Testimony
Carla Jacobs, Board Member, Treatment Advocacy Center
We know them. The mental health system sees them. Jails & hospitals know them. Ambulance drivers, emergency rooms, paramedics know them. Some do use county shelters, accept mental health services, and are trying to get off the streets. The rest are just plain too ill. Women raped, men victimized, food foraged from garbage cans. They sleep in dark, isolated shopping center doorways and they die on the streets.
I am the sister of a man with schizophrenia who has been missing for 15 yrs. Last I heard about him was from a Santa Ana police detective: Frank had been assaulted on a skid row street. My sister-in-law spent 2 years on Orange County streets until she killed her mother. She is now spending the rest of her life, locked up, because of her untreated delusions. She wishes she hadn’t.
I am also Carla Jacobs, , a resident of Orange County, and helped draft Laura’s Law.
The intent of the Lanterman, Petris Short Act back in 1967 wasn’t that people died on the streets: it wanted to end lifelong institutionalization, protect public safety and mentally ill people from criminal acts. Laura’s Law, Assisted Outpatient Treatment, was amended into that act in 2002 and now its up to Orange County to use.
Laura’s Law is for the most severely disabled
Schizophrenia and Bipolar Disorder are neurobiological brain disorders, as medical in nature as Alzheimer’s or Huntington’s Disease. Think the college professor with Huntingtons Disease who recently went missing from Orange County. She also suffered a neurological deficit known as anosognosia. Simply put, sometimes the brain can’t recognize when it is broken. She got quick help.
Neither my brother nor my sister-in-law. They also didn’t recognize they were ill. They did not get help.
Not all people with severe mental illness suffer anosognosia. Only about 50% and then in fluctuating degrees.
Missing component in Orange County’s Adult System of Care
Mark Revowitz at the Aug. 9 meeting said LL was the missing component to Orange County’s adult system of care. He was right.
Laura’s Law—Assisted Outpatient Treatment–works
The combination of the therapeutic jurisprudence and the intensive treatment support helps the most severely ill.. Decades of experience in other vicinities show this for the people whom we are addressing.
77% reduced hospitalizations.
Homelessness plummeted 74%.
83% and 87% decline in incarcerations.
Throughout the United states these findings have been confirmed. Ohio, North Carolina, Iowa. Where and when AOT is being used involuntary hospitalizations, jailings and homelessness are reduced.
.
Both Nevada County and Los Angeles County’s experience with AOT confirm these findings
Laura’s Law will save Orange County money.
Not using AOT is expensive. Hospitals, jails, homeless services, death cost more.
Resources are available to pay for Laura’s Law.
MHSA funds can pay for them. Nevada County and Los Angeles County use them. To do less is discriminating against the most severely ill.
OC can maximize federal funds like Medicaid and medicare. People with mental illness and who are now on the county dime can use SSI/SSDI for what it is intended: shelter, and clothing rather than to finance the consequences of untreated mental illness on Orange County streets.
Nevada County found that for every $1 they invested in MHSA services for Laura’s Law recipients they have saved $1.81. They used no county general funds to implement their program.
Laura’s Law will reduce the victimization of people with mental illness.
People in Orange County on the streets are being victimized and dying, solely because the severity of their illness is such that they cannot engage in treatment on their own.
When a person with Alzheimer’s or Huntington’s Disorder goes missing we as a society do everything we can to find that person and get them back to safety. The fact that we don’t provide that same level of protection for someone with other severe illness such as schizophrenia & bipolar disorder is discrimination, plain and simple.
Laura’s Law SAVES MONEY, prevents homelessness, saves lives. People get better and recover safely in the community.
You can’t end homelessness without addressing untreated mental illness. Laura’s Law is an important piece of the solution.
Please pass a recommendation that the Board of Supervisors to pass a resolution allowing Laura’s Law to be implement in Orange County.
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