In 2002, the California Legislature passed AB1421, which authorized counties to implement Assisted Outpatient Therapy (AOT), also known as Laura’s Law. San Francisco launched its program in November 2015. The law mandates early intervention by mental health professionals and wraparound services, such as intensive case management, housing, job training and regular contact with a mental health professional to provide long-term stability to those who have a serious mental illness.
“So far, Laura’s Law has been a false promise, for all the same reasons we have a crisis in mental illness on the streets in the first place,” said POC Administrative Assistant Virginia Spiegel, LCSW who also sits on San Francisco’s Mental Health Board. She criticized the SF Department of Public Health’s latest failure to provide the range of services and support for the severely mentally ill mandated through AOT under State Welfare and Institutions Code 5348. “Like many other programs, the failure to put adequate money into the required treatment facilities made it just another ‘good idea’ gone awry in the face of what it would really take, not only to provide services to the severely mental ill, but to address the underlying problems that manifest in mental illness or exacerbate it,” said Spiegel.
Angelica Almeida, director of San Francisco’s AOT program, stated in a March 2016 interview with POC that since eligibility criteria for the law are strict, only 49 people have been referred for AOT since the county launched the program in November 2015. Of those, only 26 were eligible to receive AOT’s wrap-around services, including housing. Twelve of those voluntarily accepted services.
If the person meets criteria, but refuses voluntary participation, the San Francisco Department of Public Health personnel who first evaluate the case can either petition the court for a hearing or the DPH can continue to reach out to the person to get them to voluntarily accept treatment. If the case goes to court, a special AOT judge can mandate a full range of treatments including intensive case management, housing, job training and regular contact with a mental health professional or deny the petition. However, no petitions were ever filed for the remaining fourteen, despite their having been hospitalized or incarcerated because of their mental illness twice in the past three years or involved in one or more acts of serious and violent behavior toward themselves or others within the last 48 months.
Barbara Garcia, M.P.A., SF’s Director of Public Health, posted in July 2014 on the agency’s website that “based on national data, it is expected that fewer than 100 individuals in San Francisco will meet criteria for the [AOT] program.”
However, based on figures from the 2015 Homeless Point-in-Time Count and Survey compiled by the nonprofit social-research firm Applied Survey Research, approximately 1,700 out of 6,700 homeless people on the streets of San Francisco are suffering from a severe mental illness. If individuals are ordered into treatment through the court system established as part of the AOT legislation, the treatment plans are mandated to provide access to housing, one of San Francisco’s most sought after and fought over commodities. “This creates a disincentive to enroll people, because there is such a dearth of available housing,” noted psychiatrist Gil Viella, M.D., formerly with San Francisco’s Citywide Services, an agency tasked with finding housing to stabilize patients after release from psychiatric emergency holds or locking wards.
Almeida claimed, “Even without a court order, AOT helps voluntary participants use money received from other programs to access housing and find housing they can afford.”
San Francisco rents rose 12.3 percent in 2014 – four times the national average, such that the median rental rate for a two-bedroom apartment is now $3,350. Building developers cater to employees who work for companies like Google, Apple, Genentech, Twitter, Firefox, and Salesforce.com who can better afford inflated housing prices.
Since 2010, SF has lost over 7,000 housing units available to low-income individuals and those with severe mental health conditions. On the one hand institutions like the Academy of Art University have been buying rent-controlled units to use as dorms for their 15,000+ students, while foreign language schools and other educational institutions such as the Make School, have been taking up affordable housing units by contracting with the city’s single-room occupancy hotels for dorm space.
Developers are required to contribute only 12 percent of their project’s cost to affordable housing, according to the City’s charter. Jane Kim, Aaron Peskin, and other San Francisco supervisors have placed a charter amendment on the June ballot to increase this requirement.
The U.S. Department of Housing and Urban Development’s HOME Investment Partnerships Program cut San Francisco’s funding allocation for affordable housing construction and down-payment assistance from $15.7 million in 2008 to $4.2 million in 2015.
After Governor Brown shut down California’s multibillion-dollar redevelopment initiative in 2011, San Francisco, which had been spending most of its redevelopment money on affordable housing, was hit hard. Around $50 million per year disappeared, resulting in severe cuts in SF’s affordable housing market.
No Beds, Either
“Our entire city is awash with people needing mental health services. The services and the facilities needed to provide for them are insufficient all the way down the line – from decent affordable housing, board-and-care homes, sub-acute treatment, adult diversion units to intervene before a psychiatric crisis and locking wards for the severely mentally ill in crisis. We’re getting reports from psychiatrists and case managers who are quitting their practices due to the hopelessness of accessing appropriate services for their clients.”
Meanwhile the City and County of San Francisco gives away $37.9 million a year in tax breaks and direct subsidies to the non tax-paying, non-profit hospitals like Kaiser and Sutter Health’s four-hospital California Pacific Medical Center (CPMC) division, which provide scant mental health services. Sutter/CPMC has not replaced any of the 52 acute inpatient psych beds they cut from their St. Luke’s and Davies facilities and Kaiser maintains no acute inpatient beds in San Francisco.
These corporate giveaways are in addition to the $34 million “Twitter Tax Break” the county gave in the form of payroll tax exemptions to tech firms to keep them from moving elsewhere.
Based on the most urgent unmet psychiatric needs, Physician’s Advocacy and Information Task Force (PAITF) is pursuing the demands it submitted to the County Board of Supervisors in March of 2013 that Sutter/CPMC create a 38-bed unit to replace the beds they closed to include 10 acute and 12 sub acute psychiatric beds, 8 medical detox beds and 8 non medical detox/stabilization beds and that Kaiser fund the construction of a 100-unit supportive housing complex.
Currently, the county is allowing Sutter to build two new hospitals without a single psych bed in either one and doesn’t charge Kaiser for the emergency psych visits of Kaiser patients to the county’s Psychiatric Emergency Services PES unit.
San Francisco County closed 66 of 87 acute psych beds from 2008 to 2011. John Rouse, M.D., veteran psychiatrist at SF General Hospital (SFGH) currently working in the remaining adult inpatient psychiatric wards, noted that only 10 of the 37 patients in his unit have been designated as “acute” by the in-house utilization review staff who report to the California Department of Public Health “Some of those deemed by the auditors as not being sick enough to satisfy the Medi-Cal criteria are, however, rejected by the community based locked sub-acute treatment (LSAT) facilities as being ‘too acute,’” noted Rouse.
One of Dr. Rouse’s patients has been in SFGH’s acute psych ward for 205 days waiting for an LSAT bed, while the county gets zero reimbursement from the state.
The majority of the other 27 of the 37 patients in the hospital’s locking wards are waiting for a bed in an LSAT, of which the City has cut 150 in the last four years, leaving the county with just 203 out-of-county contracted beds and 20 to 30 at the county’s Behavioral Health Center.
“As a result of the state refusing to pay for patients being treated in the county’s acute locking wards – many with suicidal, homicidal, or other psychotic ideation or actions – SFGH has had to absorb millions of dollars in uncompensated care,” noted POC membership coordinator Brian Tseng.
In addition the demands to the Board of Supervisors, the Task Force will also submit Dr. Rouse’s proposal to convert one of the county’s shuttered acute psych units into an LSAT, to the County Department of Health. “It makes no sense to have a completely functional unit sit empty when there is such a tremendous need,” noted Rouse.
Supportive housing units like the Richardson Apartments on Gough and Fulton Streets and the Rene Cazenave Apartments at 25 Essex Street in San Francisco demonstrate what can be done. Although insignificant compared to the overall need, these 120-bed purpose-built apartments have stoves that turn off when you walk away from them, and walls made with diatomaceous earth to kill fleas and bed bugs. The apartment complexes each have case managers and an on-site clinic to help residents maintain stable lives. They are projected to save the county $2.4 million per year in ambulance, emergency room, jail and psychiatric treatment each year.
The total cost for these two facilities was approximately $87 million, but there are funds available for more. California’s Mental Health Services Act (MHSA) generates approximately $1 billion per year, $75 million of which is mandated to go towards the capital costs of permanent supportive housing people with serious mental illness and their families that are homeless or at risk of homelessness and $40 million for operating subsidies in these developments Despite the mandate, MHSA claims to have allocated only $255 million for total housing dollars since the program began in 2004, and the California Housing Finance Agency can account for only $41.8 million of MHSA money having been spent on supportive housing during the same time period.
According to MentalHealthIllnessPolicy.Org, “$1-2 billion was intentionally diverted to social service programs masquerading as mental illness programs, while $2.5 billion of the Full Service Partnership funds were spent without oversight and $23 million went to organizations directly associated with oversight commissioners.” The site lists over $7 million that went to organizations like Disability Right California, California Network of Mental Health Clients and Mental Health America’s California and San Francisco chapters who used the money to lobby against the adaptation of AOT programs, in effect “working to prevent the seriously mentally ill from receiving treatment until after they become violent.”
Nonprofit hospitals and HMOs not helpful
Despite federal mandates for insurance companies to provide mental health services on a par with medical and surgical treatments, only 2 of 26 insurance companies in California were even close to compliance according to a recent finding by the state insurance commissioner.
Without access to proper care, the severely mentally ill often end up trapped in a cycle of living on the street, getting arrested and going to jail or PES. They then get released to programs that fail to treat their mental health problems and they end up back on the streets or in jail. The number of mentally ill people in Californian prisons has doubled since 2000. According to a recent report from the National Sheriff’s Association and the Treatment Advocacy Center, ten times as many mentally ill people are in prison and jail in the United States than are in mental health treatment facilities.
Kaiser Permanente was fined $4 million in 2013 by the Department of Managed Health Care for “serious” and “systemic” violations of California law: falsifying patients’ appointment records, forcing patients to endure illegally long waits for care, and failing to provide psychiatric services that are on par with primary care health services. Nearly 1400 Kaiser mental health workers voted to strike in October 2014 as staffing levels were still deemed severely inadequate by those clinicians.
Take back public resources from corporate pockets
“Even if fully implemented, AOT will not diminish the population of mentally ill people living on the street unless we stem the tide of shell-shocked vets returning from foreign wars and shell-shocked workers losing their pensions, homes and healthcare in this worker-hostile collapsing economy,” noted Nick Munoz, POC staff member.
According to Samuel Patterson, Commander of American Legion Post 198, “Returning vets from Iraq, Afghanistan and other US military operations are coming back with PTSD and other psychological damage to the point that 22 veterans are committing suicide per day with tens of thousands of others suffering from serious mental illness, some self-medicating with drugs and ending up homeless on the streets.”
“We need a complete reversal in the priorities for housing, access to care, case management and other needs of the mentally-ill that would only be possible if we end the private theft of public resources,” said Munoz. Psychiatrists and other mental health professionals interested in participating on POC’s Physicians Advocacy and Information and Task Force and fighting to reverse those policies should contact POC and ask for David at (415) 434-9335.