Grading the States 2006: California - Narrative
California stands at the threshold of a unique opportunity to improve services for people with serious mental illnesses. Enactment of Proposition 63, a "millionaire's tax," will provide a stable source of significant new revenue for mental health services. How much difference this will make over time remains to be seen.
Enactment of Proposition 63 (also known as the Mental Health Services Act) by referendum in 2004 stands nationally as one of the most dramatic innovations in financing mental health services, as both states and counties search for stable sources of dedicated revenue. On a county-by-county basis, planning for use of the $750 million in projected new money to be raised by the tax is currently underway, with emphasis on directing these new resources for services to unserved and underserved individuals. Clearly, it is needed - within the state, significant gaps exist in the availability and quality of treatment and services at the community level, since each county is responsible for administering its own mental health services.
California is the most populous state, with more than 35 million residents. Non-white residents comprise a significant percentage of the population; Latinos constitute the majority among residents younger than 17. Since 1991, responsibility for mental health services has been vested in the state's 58 counties and two city agencies (Berkeley and Tri-City). Simultaneously, a federal waiver resulted in the creation of California's Medi-Cal (Medicaid) program, a statewide managed mental healthcare system. In each county, a single managed behavioral health plan administers the program.
In 2003, the California Mental Health Planning Council estimated that approximately 300,000 adults with serious mental illnesses did not have access to needed services. State budget cuts haven't helped. Many indigent individuals in the state go without desperately needed mental health services simply because they don't exist.
California is increasing its emphasis on evidence-based practices (EBPs). Proposition 63 provides an opportunity to develop these programs statewide. The state is currently piloting the federal Assertive Community Treatment (ACT) model in four counties (Ventura, Los Angeles, Stanislaus, and Alameda). A number of other California counties have implemented ACT teams; however, these programs are not being monitored for adherence to the federal standard.
California's state hospitals are a major problem. Disturbing patterns of abuse and neglect recently surfaced in these hospitals, particularly at Napa State Hospital, serving the northern part of the state, and Metropolitan State, serving the Los Angeles area. The U.S. Department of Justice (DOJ) has investigated all four due to alleged civil rights violations. A preliminary letter of findings by the DOJ on June 27, 2005 asserted that the state had refused to cooperate with the investigation of Napa State, including refusal to give DOJ access to the facility until sometime in 2006. The state Department of Mental Health denies this allegation, explaining that they had simply sought to delay the DOJ inspection until an accreditation visit from the Joint Commission on Accreditation of Health Organizations (JCAHO) had been completed.
Allegations in the Napa investigation include:
- Repeated patient-on-patient assaults, resulting in at least one death and serious injuries, with failure by Napa staff to take steps to intervene or protect vulnerable individuals.
- Inadequate suicide prevention procedures, even when patients are known to be potentially suicidal, resulting in at least six successful suicides since 1999.
- Significant availability and heavy use of illegal drugs by patients, including testimony under oath by a Napa physician that Napa staff bring drugs into the facility in exchange for cash. In fall 2004, three Napa patients overdosed on amphetamines and/or cocaine. One died.
- Excessive misuse of seclusion and restraint, resulting in an investigation by the Federal Center for Medicaid and Medicare Services (CMS) that documented numerous cases of patients in physical restraints for excessive periods - sometimes for days at a time.
In 2004, California passed a law designed to reduce the use of seclusion and restraints. DMH reports that it is making progress in this area. For example, it states on its website that use of seclusion and restraints is down by 79% at Napa. However, according to the DOJ, Napa continues to employ seclusion and restraints in excess.
The proposed FY 2006/2007 budget for the Department of Mental Health includes nearly $38 million in general funds to "implement a new recovery treatment model in the state hospitals." Hopefully, these funds will be used to address the horrendous problems detailed in the investigations being conducted by the Justice Department.
In California, like other states, jails and prisons have become de facto psychiatric treatment facilities. County sheriffs and local police chiefs, such as Bernard Melekian of Pasadena, have called for alternatives to incarceration for non-violent offenders with serious mental illnesses - who, as they recognize, need treatment, not incarceration.
The DMH's response to NAMI's question about jail diversion programs stated: "California's jail diversion programs are administered locally," which is literally true. Thirteen local mental health courts have been established, including several serving juvenile offenders. The Court Transition Project, operated by the Los Angeles County Department of Mental Health, has received national attention as an exemplary program. The DMH must take a more active leadership role in promoting jail diversion as an integral component of a recovery-oriented public mental health system.
On the positive side, DMH is working to make sure that the most vulnerable individuals don't fall through the cracks - such as by increasing supportive housing options for people who are either homeless or at risk of homelessness. These efforts are critically important, as homelessness has reached epidemic proportions in some of California's major cities.
Under the leadership of DMH, county mental health agencies in many parts of the state have adopted cultural competence as an integral part of their work. The DMH has established an office of Multicultural Services which has worked hard to promote cultural competence in mental health services and provide technical assistance to counties in adopting culturally competent practices.
The state also can be applauded for increasing investment in supported employment. Programs exist in at least 22 counties. DMH believes such services also are available through the State Department of Vocational Rehabilitation in many additional counties, but could not document them.
California also supports statewide involvement of consumers and families in the planning and implementation of evidence-based practices, as well as consumer and family education. DMH's Web site also includes links to 24-hour crisis hotlines throughout the state.
California is a big state and providing it with necessary mental heath services is inevitably a big challenge. Transforming or adapting its system doesn't come easy, but for those same reasons, more is expected. We know it can do better. Proposition 63 provides an unprecedented opportunity to do so.
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