Orange County Grand Jury
• 2014-2015
The Mental Illness Revolving Door: a Problem for Police, Hospitals, and the Health Care Agency*
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⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings 14 findings
F1
Deputy Sheriffs and police officers receive insufficient training on how to evaluate and handle the mentally ill in the field.
F2
Deputy Sheriffs and police officers receive insufficient training regarding Laura's Law.
F3
Orange County's Centralized Assessment Team is inadequate in that it takes too long for them to respond to the scene to assist police officers in their evaluations of the mentally ill.
F4
Orange County's mental illness triage system is inadequate in that there are no field screening protocols that would allow medical clearance in the field by law enforcement personnel or paramedics.
F5
Orange County's mental illness triage system is inadequate in that the police agencies either do not have a triage desk to advise and assist officers in the field or do not have psychiatric crisis mobile response teams at their disposal.
F6
Orange County's Psychiatric Evaluation and Response Team clinicians are insufficient in number to meet the needs of police agencies in Orange County.
F7
Orange County's Evaluation and Treatment Services facility is inadequate in that its capacity is insufficient to permit police officers to take all the mentally ill to it and drop them off at the facility, instead of transporting the patient to a hospital emergency room.
F8
Orange County's Evaluation and Treatment Service facility is inadequate in that the County does not permit medical triage or medical clearance in the field, and therefore directs police officers to obtain medical screening for even minor health conditions that could easily be treated at the facility.
F9
Orange County's Evaluation and Treatment Service facility is inadequate in that it directs police officers to take the mentally ill who may be under the influence of alcohol or drugs to a hospital emergency room rather than to a psychiatric emergency facility.
F10
Orange County's crisis intervention system is inadequate in that there is only one Evaluation and Treatment Service facility for the entire County. The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
F11
The County's crisis intervention system is inadequate in that it does not provide strategically located, stand-alone, drop-off psychiatric emergency stabilization facilities with medical treatment capability at convenient locations throughout the County.
F12
The County's crisis intervention system is inadequate in that there is no real-time, empty-bed registry to enable officers and clinicians in the field to determine bed- availability at the Evaluation and Treatment Service facility and at designated hospitals.
F13
The County's crisis intervention system is inadequate in that there is no 5150, case management, and conservatorship database in place to assist officers and clinicians in the field to triage the mentally ill who do not qualify for a 5150 hold.
F14
The Health Care Agency has not established benchmarks and a complete performance-measurement system with which to track the success and cost effectiveness of Laura's law, as directed by the Board of Supervisors in May 2014. RECOMMENDATIONS In accordance with California Penal Code sections 933 and 933.05, the 2014- 2015 Grand Jury requires (or, as noted, requests) responses from each agency affected by the recommendations presented in this section. The responses are to be submitted to the Presiding Judge of the Superior Court. Based on its investigation titled "The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency," the 2014-2015 Orange County Grand Jury makes the following 14 recommendations:
Recommendations 15
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R1All law enforcement officers should receive at least 40 hours of comprehensive Crisis Intervention Training on how to handle and evaluate the mentally ill in the field with periodic refresher training. (F.1.)
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R2All law enforcement officers should receive mandatory and specific training regarding Laura's Law. (F.2.)
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R3Orange County's Centralized Assessment Team's response time should be improved significantly with a goal of eventually reducing its maximum response time to less than 20 minutes. (F.3.)
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R4The Orange County Health Care Agency should adopt field screening protocols to allow (a) medical clearance in the field by law enforcement personnel and/or paramedics; and (b) transport by paramedics rather than police officers. (F.4.)
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R5All law enforcement agencies should either have a psychiatric triage desk to advise and assist officers in the field or a psychiatric crisis mobile response team. (F.5.) The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
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R6The Orange County Psychiatric Evaluation and Response Team staff should be increased significantly so that an embedded clinician can be placed with each law enforcement agency and can provide service 24/7 if requested. (F.6.) Orange County's Evaluation and Treatment Services facilities should be
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R7expanded to easily accommodate all 5150 walk-ins and all 5150s dropped off by police, paramedic, or ambulance. (F.7.)
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R8Orange County Evaluation and Treatment Services should acquire the capability of conducting limited medical screening for minor health problems and cease from directing police officers to obtain medical screening for 5150s with minor health conditions that could easily be treated at Evaluation and Treatment Services facilities. (F.8.)
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R9Orange County's Evaluation and Treatment Services facilities should acquire the capability of handling 5150s who may have ingested alcohol or drugs, but who are not under the influence to such an extent that it inhibits stabilization or requires medical clearance at a hospital. (F.9.)
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R10The Orange County Health Care Agency's crisis intervention system should be expanded so as to provide a minimum of four Psychiatric Emergency Service facilities—one in South County, one in Central County, one in West County, and one in North County. (F.10.)
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R11The County's Health Care Agency should provide strategically located, stand- alone, drop-off psychiatric emergency stabilization facilities with medical treatment capability at convenient locations throughout the County. (F.11.)
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R12The County's Health Care Agency should provide a real-time, empty-bed registry to enable officers and clinicians in the field to determine immediately and accurately the current bed availability at Evaluation and Treatment Services facilities and at designated hospitals. (F.12.)
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R13The County's Health Care Agency should create and maintain a 5150, case management, and conservatorship database in place to assist officers and clinicians in the field to triage the mentally ill in the field who do not qualify for a 5150 hold, but who may qualify for Laura's Law. (F.13.)
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R14The Health Care Agency should establish benchmarks and a complete performance-measurement system with which to track the success and cost effectiveness of Laura's law, as directed by the Board of Supervisors in May 2014.
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R20Tustin Westminster The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency
Commendations 3
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CM1The Memphis Model The first CIT was established in Memphis in 1988 after the tragic shooting by a police officer of a man with a serious mental illness. This tragedy stimulated a collaboration between the police, the Memphis chapter of the National Alliance on Mental Illness, the University of Tennessee Medical School, and the University of Memphis to improve police training and procedures in response to mental illness. The so-called Memphis model has achieved remarkable success, having been adopted by more than 2000 communities in more than 40 states and having been implemented statewide in several states. The Memphis Model of CIT has several key components: A community collaboration between mental health providers, law
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CM2Defense of Laura's Law On January 3, 1999, Kendra Webdale was pushed to her death before an oncoming subway train beneath the streets of Manhattan by a man diagnosed with paranoid schizophrenia and with a history of mental illness and hospitalizations who had neglected to take his prescribed medication. Responding to this tragedy, the Legislature enacted Mental Hygiene Law § 9.60 (Kendra's Law) (L. 1999, ch. 408), thereby joining nearly 40 other states in adopting a system of assisted outpatient treatment (AOT) pursuant to which psychiatric patients unlikely to survive safely in the community without supervision may avoid hospitalization by complying with court-ordered mental health treatment. In enacting the law, the Legislature found that there are mentally ill persons The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency who are capable of living in the community with the help of family, friends, and mental health professionals, but who, without routine care and treatment, may relapse and become violent or suicidal, or require hospitalization. (L 1999, ch. 408, § 2.) In addition, in mandating that certain patients comply with essential treatment pursuant to a court- ordered written treatment plan, the Legislature further found that some mentally ill persons, because of their illness, have great difficulty taking responsibility for their own care and often reject the outpatient treatment offered to them on a voluntary basis. (Id.) It did not take long for the law's constitutionality to be challenged. The question was whether the law achieved its goal of creating a mechanism to ensure that individuals who met the criteria remained treatment-compliant while in the community, in a way that was consistent with the Constitutional rights of those individuals. In the Matter of K.L., 500748/00 (Sp. Ct., Queens County, 2000), the Mental Hygiene Legal Service (MHLS) moved for dismissal of a petition, arguing that the statute was unconstitutional on two grounds: that it unconstitutionally deprived patients of the fundamental right to determine their own course of treatment, and that the statutory provisions concerning removal for observation following non-compliance with the AOT order are facially unconstitutional. The Attorney General of the State of New York intervened to support the constitutionality of the statute. The Supreme Court rejected each of the arguments advanced by the MHLS, upheld the constitutionality of Kendra's Law, and found that it comported with due process, noting that Kendra's Law does not permit forced medication or treatment . The Court reasoned that the restriction on a patient's freedom affected by a court order authorizing AOT is minimal, inasmuch as the coercive force of the order lies solely in the compulsion generally felt by law-abiding citizens to comply with court directives. The Court observed that although the existence of such an order and its attendant supervision increases the likelihood of voluntary compliance with necessary treatment, a violation of the order, standing alone, ultimately carries no sanction.
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CM3The Sequential Intercept Model The Sequential Intercept Model provides a conceptual framework for communities to use when considering the interface between the criminal justice and mental health systems as they address concerns about criminalization of people with mental illness. The model envisions a series of points of interception at which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system. The concept is that most people will be intercepted at early points, with decreasing numbers at each subsequent point. The interception points are law enforcement and emergency services; initial detention and initial hearings; jail, courts, forensic evaluations, and forensic commitments; reentry from jails, state prisons, and forensic hospitalization; and community corrections and community support. The model provides an organizing tool for a discussion of diversion and linkage alternatives and for systematically addressing criminalization. Using the model, a community can develop targeted strategies that evolve over time to increase diversion of people with mental illness from the criminal justice system and to link them with community mental health treatment. (Munetz & Griffin, 2006) The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency Although many communities are interested in addressing the overrepresentation of people with mental illness in local courts and jails, the task can seem daunting and the various program options confusing. The Sequential Intercept Model provides a workable framework for collaboration between criminal justice and treatment systems to systematically address and reduce the criminalization of people with mental illness in their community The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency REFERENCES About Laura's Law. (n.d.). In Ten years after murders: law meant to prevent tragedies remains overlooked and unused. Retrieved from http://www.lauraslawoc.org./about.html Assisted Outpatient Treatment (2014, June 13). The Nevada County Experience. Retrieved from: http://www.mynevadacounty.com/nc/hhsa/bh/Pages/Assisted- Outpatient-Treatment.aspx Bekiempis, V. (2014, February 28). New study on mental illness. Newsweek. Carpinello, S. (2005, March) Kendra's Law: Report on the Status of Assisted Outpatient Treatment. New York State, Office of Mental Health. Albany, New York. Cost Savings for AOT (2012, June 12). Mental Illness Policy Organization, found at http://lauras-law.org. Dupont, R. Cochran, S, & Pillsbury, S. (2007, September). Crisis Intervention Team Core Elements. University of Memphis. Memphis TN. Emmanuel, A. & McBride, S. (2015, April 30). Police face choice of handcuffs or helping hand for mentally ill. Chicago Reporter. Chicago, Ill. Exodus Recovery, Inc. (2015). Mental Health Urgent Care Center at MLK Medical Center by Exodus, found at www.exodusrecoveryinc.com/MLK_UCC.html. Gerda, N. (2014, May 14). Orange County adopts Laura's Law. Voice of OC. Retrieved from http:// voiceofoc.org. Holt, W., & Adams, A. (2013). Mental health in California: Painting a picture. California Healthcare Foundation. Oakland, CA. Retrieved from http://www.chcf.org/publicaations/2013/07/mental-health-california. King, S. (2015, April 5) American tragedy: A staggering percentage of police shooting victims struggled with mental illness Daily KOS. Retrieved from: http://www.dailykos.com/story/2015/04/05/1375335 Miller, J. (2013, March 5) Patients as prisoners, jails new mental health institutions, CBS News.. Retrieved from: http://www.cbsnews.com/news/patients-as- prisoners-jails-new-mental-health-institutions/. Munetz, M. & Griffin, P. (2006, April). Use of the sequential intercept model as an approach to decriminalization of people with serious mental illness. Psychiatric Services. Retrieved from http://www.dbhds.virginia.gov/library/document- library/ofo%20%20sim%20article%20munetz%20%20griffin%202006.pdf. National Alliance on Mental Illness (n.d.). CIT toolkit; CIT facts. Retrieved from http://www2.nami.org/Content/ContentGroups/Policy/CIT/CIT Facts 4.11.12.pdf The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency Orange County Board of Supervisors. (2015, May 19). Adoption of stepping up initiative resolution (Agenda Staff Report). Santa Ana, CA. Orange County Health Care Agency and Hospital Association of Southern California. . (2013, December 17). Triage grant application, Vol XII (27). Santa Ana, Ca. Orange County Health Info. (n.d.). Full Service Partnership Homepage. Retrieved from http://www.ocgov.com/gov/health/bhs. Santa Ana, CA. Pelley, S. (2014, September 14). The shortcomings of mental health care. CBS 60 Minutes (Television news program). New York, NY. Quanbeck, T, Tsai, G, & Szabo K. (n.d.) Cost-effectiveness analysis of assisted outpatient treatment implementation in California's civil sector. Retrieved from: http://dhmh.maryland.gov/bhd/Documents/ Sewell, A. (2014, July 15,). D.A. Jackie Lacey calls jailing of mentally ill a moral question. Los Angeles Times. Los Angeles, CA. Sewell, A. (2014, November 12). In push to keep mentally ill out of jail, county to expand crisis centers, Los Angeles Times. Los Angeles, CA. Shabo, H. (2014, August 20). Governor Davis signs Laura's Law: AB1421 will help those with severe mental illnesses who are too sick to help themselves. Retrieved from: http://oceanpark.com/notes/ab1421_background.html. Simon, R. (2015, January 25). Crisis Stabilization of the Mentally III. CBS 60 Minutes (Television news program). New York, NY. Superior Court of Orange County (2014). Annual Report, Collaborative Courts, p. 23, Santa Ana, CA. Swartz, M., Steadman, H. & Monahan, J (June 30, 2009). Program Evaluation: New York State Assisted Outpatient Treatment Program Evaluation, Duke University School of Medicine, Durham, NC. Wolfson, B. J. (2014, October 25,). Psychiatric treatment in Orange County. Orange County Register. Santa Ana, CA. Zeller, S. (2013, September 16). Psychiatric boarding: Averting long waits in emergency rooms. Psychiatric Times. Retrieved from: http://www.psychiatrictimes.com. The Mental Illness Revolving Door: A Problem for Police, Hospitals, and the Health Care Agency APPENDIX: ACRONYM LIST AAOAPOD Adult and Older Adult Performance Outcome Department AOT Assisted Outpatient Treatment BHS Behavioral Health Services CAT Centralized Assessment Team CIT Crisis Intervention Training COPS Community Oriented Policing Services CRT Crisis Response Team EPU Emergency Psychiatric Unit ETS Evaluation and Treatment Services FSP Full Service Partnership HCA Health Care Agency LPS Lanterman-Petris-Short Act NAMI National Alliance on Mental Illness PERT Psychiatric Evaluation and Response Team PES Psychiatric Emergency Services PET Psychiatric Evaluation Team POST Peace Officers Standards and Training TACT Time, Atmosphere, Communication, and Tone: A method of talking to the mentally ill
Agency Responses 18
Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.
* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.