Children’s Mental Health Crisis Services: Updates

Readers of this blog will remember that CMHACY published a series of blogs highlighting the current status of mental health crisis services designed specifically to meet the needs of children, youth and families.  In this edition of the blog, we will update readers on the status of several recent efforts undertaken to improve access to quality children’s mental health crisis care in California.

Assembly Bill 741 (Williams) and Assembly Bill 501 (Ridley-Thomas)

AB 741 was written by Assemblymember Das Williams to address a critical component missing from the Medi-Cal mandated continuum of specialty mental health services (SMHS) – mental health crisis residential services for children and youth in California.  (This would include having such option also available to children whose mental health needs are covered by commercial health care plans.) –. Provided in a less restrictive environment than acute inpatient hospitalization, and integrating the family into all components of the service, mental health crisis residential services would offer an alternative for children who in the short term cannot be safely treated in the community, but do not require an inpatient level of care. Crisis Residential Treatment Services comprise a Medi-Cal benefit (CCR Title 9, § 1810.208) that currently is available only to adult beneficiaries in California, including Transition Age Youth over the age of 18.

The details of this bill were provided in previous blogs.  What we did not report is that despite the breadth and depth of support, and the bill passing through both houses with unanimous “aye” votes, the governor vetoed the bill.  In his veto message, the Governor stated:

“I recognize that there is an acute shortage of residential programs that provide crisis mental health treatment to children and teens.  Therefore, I am directing the Departments of Social Services and Health Care Services to work with the county behavioral health directors and children’s advocates to develop a more viable licensing category.” 

Unfortunately, Assemblymember Das Williams termed out of the legislature before he could reintroduce the bill.  Fortunately, Assemblymember Sebastian Ridley-Thomas was eager to complete the important task of developing a licensing category and residential crisis care to meet the unique needs of children, youth, and those who provide them with physical and emotional support.

Assemblymember Ridley-Thomas’ current bill to address the lack of crisis residential services for children and youth is Assembly Bill (AB) 501.  At the time of this blog posting, it has already passed with unanimous “aye” votes in the Assembly Program Committees (Health and Human Services).  The fact sheet can be found here. This legislation would create the licensing category needed to ensure that county Mental Health Plans (MHP), as well as commercial health insurance companies, and their community-based providers can develop mental health crisis residential programs that can be accessed for children and youth experiencing mental health crises.

There is no question that a full continuum of crisis care for children and youth with urgent mental health needs is vital, and the lack of a licensing component for mental health crisis residential services is preventing the development of these much needed services.

How You Can Help

1. Despite the support for AB501, there is no guarantee that it will continue to progress through the legislative process, or that Governor Brown will sign this bill into law if and when it arrives on his desk.  Therefore, the author and sponsors of the bill are asking you to send a letter of support to the author of AB501 (Ridley-Thomas) care of Ryan Pessah: Ryan.Pessah@asm.ca.gov .  A support letter template that you can personalize is provided here.
2. Tell your local stakeholders involved with children’s crisis services (i.e.: hospitals, county mental health department, county board of supervisors, law enforcement, schools, etc.)  about the importance of adding their support to this bill.  Feel free to forward the above letter of support template to them and ask them to take 5-10 minutes to personalize and submit.  EVERY letter and call matters!

SB833

The Senate Budget Committee introduced a 2016-17 budget item designed to increase access to mental health services for children, youth, and families in crisis citing reports which called to attention a continuing problem of inappropriate and unnecessary utilization of hospital emergency rooms in California due to limited mental health services for individuals, children in particular, in psychological distress and acute psychiatric crisis. Due to the Senate Budget Committee’s efforts, $30 million was included in the state’s final 2016-17 budget for a grant program designed to develop capacity for children’s mental health crisis services. Section 20 of Senate Bill (SB) 833 (Statutes of 2016) (Jeremiah: include hyperlink to the senate bill here, which can be found at this web address:  https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB833 ) implements this proposal. Similar to the provisions of SB 82 (Chapter 34, Statutes of 2013) which was developed to expand the capacity for adult mental health crisis services, SB833 authorizes the California Health Facilities Financing Authority Act (CHFFA) to adopt emergency regulations to provide grant awards which can be used to expand local resources for an array of crisis services for children and youth 21 years of age under in the following areas:

(A) Crisis intervention

(B) Crisis stabilization

(C) Crisis residential treatment

(D) Mobile crisis support teams

(E) Family respite care

Unfortunately, the Governor’s Proposed Budget that was released this past  January (2017) includes the reversion (elimination) of $17 million General Fund from 201617 General Funds intended for grants to local governments to increase the number of facilities providing mental health crisis services for children and youth under the age of 21.

Both the Senate (sub-committee #1) and Assembly (sub-committee #1) Budget Committees questioned the governor’s proposed cuts to the funding for these important services.  The Assembly Budget Sub-1 Committee voted to reject this cut to the budget.  The Senate Sub-3 Committee expressed concerns but has not yet made a final decision about this funding.

In preparation for the Assembly Budget Committee discussion on this topic, the committee documents argued,

 “It seems more than likely that … the purposes for which funding is being eliminated would result in long-term savings for the State. The children’s mental health crisis services are designed specifically for the purpose of reducing inappropriate and unnecessary emergency room use in favor of care that both costs less and is more effective….. Eliminating this funding will increase state costs by continuing to institutionalize very vulnerable people, rather than investing in prevention and appropriate health care.”

CMHACY strongly agrees with the Assembly Budget Committee analysis and have joined other mental health organizations in advocating for the restoration, if not expansion, of this funding.

How You Can Help

1. Contact the Governor’s office (916) 445-2841 to encourage Governor Brown to not only restore the funding to SB833, but to increase the funding to support the startup of children’s crisis programs throughout the state.  Remind them of the children “boarded” in hospital ER’s for days because local community alternatives are not in place.  This is not treatment and violates their right to access to care in the least restrictive environment…
2. Contact your local state elected official and encourage them to make funding for children’s crisis services a priority in this budget cycle. You can find your local state representative through this link: http://findyourrep.legislature.ca.gov/

MHSOAC Children’s Crisis Services Project:

As you may recall, the Mental Health Services Oversight & Accountability Commission (MHSOAC) initiated The Crisis Service Project in 2015 to understand the state of children’s mental health crisis services. The goals of the project were as follows:

• Identify issues

• Document challenges & barriers

• Research effective service delivery models

• Recommend and advance specific policy, funding, and regulatory changes to improve service quality and outcomes.

A subcommittee of the Commission was chaired by Commissioner John Boyd and advised by a workgroup comprised of subject matter experts.  The subcommittee was charged with defining crisis services specific to children and youth ; exploring the role of these services within a continuum of care that is prevention-focused and resiliency-oriented; identifying challenges, barriers, opportunities, and best practices. Based on the information gathered, the workgroup developed recommendations to improve access, service coordination, and outcomes.

The children’s mental health crisis workgroup began based on this identified problem:  The rate of children hospitalized for mental health conditions continues to rise across the state. According to the most recent data collected by the Office of Statewide Health Planning and Development (kidsdata.org), nearly 40,000 California children ages 5–19 were hospitalized for mental health issues in 2014. Since 2008, mental diseases and disorders accounted for the largest share of hospital admissions of children ages 0–17 in California. According to data collected by the California Department of Healthcare Services, during the 2013–2014 fiscal year, more than 23,000 involuntary 72-hour detentions for evaluation and treatment were placed for children (age 0–17) in California.

Key concerns identified by the workgroup:

• Too many children and youth do not have access to appropriate crisis services
• Crisis services are too often fragmented, not prevention or recovery focused
• Rural communities face particular challenges in responding to children and youth in crisis
• Accountability and quality improvement systems are incomplete

The subject matter experts involved in this project identified how crisis services for children should work:

1. Comprehensive assessment
2. Intensive care coordination
3. In-home services for the youth and their family
4. Safety planning
5. Therapeutic mentors
6. Family support and training
7. 24/7 electronic support (phone/text/social media)
8. 24/7 mobile crisis
9. Community based crisis stabilization
10. Facility based crisis stabilization
11. Family Respite
12. Crisis Residential
13. Inpatient care

Preliminary recommendations include:

• California must develop clear and compelling standards for care in response to mental health crises
• The State must create pathways to success in responding to mental health crises, within a system of care
• California must develop the tools and strategies to monitor crisis services and the effectiveness of those services

Fundamental Challenges to Address:

• Workforce development
• Data for Research, Evaluation, and Accountability
• Clear roles and partnerships between public and private systems
• Systems and strategies for technical assistance, training and learning
• Incentives for quality
• Clear and compelling systems for transparency and accountability

In an ideal world, all children suffering from severe emotional disturbance or serious mental illness would receive the support and care they needed and would not get to the point where the level of emotional and psychological distress overwhelms the capacity of their individual coping skills and natural supports. Also in an ideal world, which intensity of services need to be adjusted (up or down) to meet the ever changing needs and strengths of the child and family, the members of the support system (both formal and informal) would remain the same to ensure stable relationships and shared historical knowledge.

The Children’s Crisis Services Advisory Workgroup and the OAC Commission have yet to release their final report and recommendations but have committed to releasing this important document in the near future. A copy of the most recent draft of this report can be found here: http://mhsoac.ca.gov/sites/default/files/documents/2016-06/MHSOAC_Report_Draft_1d-1_Part1.pdf )

How You Can Help

1. Attend your local Mental Health Board and Mental Health Services Act Commission (each county has both) and encourage them to implement the draft recommendations from the MHSOAC workgroup.
2. Share the information from the crisis workgroup draft report with your networks, encouraging them to join your advocacy efforts.
3. Contact the MHSOAC at MHSOAC@mhsoac.ca.gov   or (916) 445-8696 and let them knoww you are interested in receiving a copy of the final report as soon as possible. Once received, share the information with others and encourage your state and local decision makers to implement the recommendations.