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(a) California Welfare and Institutions Code §§ 5345-5349.5, also known as "Laura's Law," authorizes counties to implement Assisted Outpatient Treatment ("AOT") to obtain court-ordered mental health treatment for individuals with mental illness for whom other methods of entering and maintaining treatment have been unsuccessful.
(b) AOT provides treatment through community-based, mobile, recovery-oriented, multidisciplinary, highly trained mental health teams with a staff-to-client ratio of no more than 10 clients per team member.
(c) Several independent studies of similar programs in other states cited in a background paper prepared by the Treatment Advocacy Center show that AOT promotes long-term treatment compliance, and reduces the incidence and duration of hospitalizations, homelessness, arrests, incarcerations, violent episodes, and the victimization of individuals with mental illness by others, while also relieving caregiver stress.
(d) These same studies show that states and municipalities that have successfully implemented AOT realized cost savings in their respective mental health, criminal justice, and emergency care systems.
(e) According to research cited in The Resident's Journal, a publication of The American Journal of Psychiatry, almost half of the individuals with a severe mental illness in the United States are untreated, and almost half of those individuals suffer from anosognosia (the inability to recognize one's own mental illness) and possess significant deficits in self-awareness.
(f) This same research also finds a clear link between lack of insight regarding one's own mental illness and the inability to adhere to treatment, which results in poorer clinical outcomes, illness relapse, hospitalization, and suicide attempts.
(g) For severely mentally ill individuals who are unable to maintain a consistent voluntary treatment regime, AOT provides a means to assist and support them through a structured treatment program.
(h) Before an AOT program may be implemented in a county under California Welfare and Institutions Code §§ 5345-5349.5, the county must authorize the application of the program in the county by appropriate legislation and make a finding that no voluntary mental health program serving adults, and no children's mental health program will be reduced as a result of implementing AOT.
(Added by Ord. 154-14, File No. 140557, App. 7/22/2014, Eff. 8/21/2014)
(a) The City and County of San Francisco ("City") authorizes the implementation of California Welfare and Institutions Code §§ 5345-5349.5 through court-ordered Assisted Outpatient Treatment ("AOT") within the City as provided in this Division II. The City finds that no voluntary mental health program serving adults, and no children's mental health program within the City will be reduced as a result of implementing AOT.
(b) As part of AOT, the City shall provide services that will conform to the requirements of California Welfare and Institutions Code § 5348, or any successor provisions. These services shall include, but are not limited to, community-based comprehensive individual service and delivery plans, which plans shall be gender, age, disability, linguistically and culturally appropriate. The plans shall provide access to housing, and be designed to allow the individual referred to AOT ("Referred Individual") to live in the most independent, least restrictive setting possible. The City shall provide AOT services in each case through a community-based multidisciplinary and highly trained mental health team ("AOT Team") with a staff-to-client ratio of no more than 10 clients per team member.
(c) The County Mental Health Director ("Director") shall create a Care Team. The Care Team shall work closely with the Referred Individual and the individual requesting the AOT petition to maximize all opportunities within AOT to engage individuals who meet AOT criteria into voluntary treatment.
(Added by Ord. 154-14, File No. 140557, App. 7/22/2014, Eff. 8/21/2014)
For the purposes of this Division II, the following words or phrases shall mean:
"Care Team" means a group of program staff charged with implementing AOT and shall consist of: 1) A forensic psychologist, who shall be the designated licensed mental health treatment provider responsible for clinical evaluation of the Referred Individual; 2) A peer specialist, who shall be a person who has lived experience with mental health recovery and has been trained to provide peer support to help the Referred Individual engage into treatment; and 3) A family liaison, who shall be a person who has had a family member with mental illness, and has been trained to provide lived experience to educate the referring source on the eligibility, benefits, limitations, and opportunities that AOT provides.
"City" means the City and County of San Francisco.
"Full Service Partnership ("FSP")" means the collaborative relationship between the City and the Referred Individual and, when appropriate, the Referred Individual's family, through which the City plans for, and provides, the full spectrum of community services so that the Referred Individual can achieve the identified goals. The City shall provide FSP services that conform to the requirements of California Code of Regulations Title 9, Section 3200.13c, defining FSP, or any successor provisions.
"Referred Individual" means the person on whose behalf an AOT petition is requested.
(Added by Ord. 154-14, File No. 140557, App. 7/22/2014, Eff. 8/21/2014)
(a) Referral to AOT provides two key opportunities for voluntary engagement of individuals meeting AOT criteria prior to a court hearing:
(1) Immediately after the request for petition and before the filing of a petition with the court; and
(2) After the filing of a petition and before the conclusion of the court hearing on the petition.
(b) At each of the two opportunity points listed in Subsection 4114(a), the Care Team shall make every attempt to engage the Referred Individual into voluntary treatment.
(c) The Referred Individual shall at all times have the opportunity to voluntarily participate in a FSP. The Care Team shall work closely with the Referred Individual and the individual initiating the petition in an effort to engage the Referred Individual into a FSP as a preferred alternative to court-ordered treatment.
(d) All evaluations of the Referred Individual shall be conducted in the least restrictive setting.
(e) The Referred Individual may not be transported for evaluation by a peace, probation or parole officer, unless there is probable cause to believe that the individual meets the criteria required by California Welfare and Institutions Code § 5150, or there is no other means to safely transport the Referred Individual.
(f) The AOT Team shall also ensure that individuals referred for AOT who do not meet AOT criteria are evaluated for, and connected to, the appropriate level of mental health treatment.
(Added by Ord. 154-14, File No. 140557, App. 7/22/2014, Eff. 8/21/2014)
(a) The following persons may request the Director, or the Director's designee, to file a petition with the Superior Court for AOT:
(1) Any person 18 years or older with whom the Referred Individual resides;
(2) Any person who is the parent, spouse, adult sibling, or adult child of the Referred Individual;
(3) The director of a facility providing mental health services where the Referred Individual resides, the director of a hospital where the Referred Individual is hospitalized or a licensed mental health treatment provider who treats the Referred Individual or supervises the treatment of the Referred Individual; or
(4) A peace, probation or parole officer assigned to supervise the Referred Individual.
(b) If the Director or designee finds that good cause supports the request, he or she may file a verified petition with the Superior Court that sets forth all of the following elements:
(1) That the Referred Individual is at least 18 years old and is present in the City;
(2) That the Referred Individual is suffering from a mental illness as defined in California Welfare and Institutions Code §§ 5600.3(b)(2) and (3), or any successor provisions;
(3) That there has been a clinical determination that the Referred Individual is unlikely to survive safely in the community without supervision;
(4) That there is a history of the Referred Individual's lack of compliance with treatment, based on at least one of the following:
(A) twice within the last 36 months, mental illness was a substantial factor in the Referred Individual's hospitalization or receipt of mental health services in jail, not including any period during which the Referred Individual was hospitalized or incarcerated immediately preceding the filing of the petition, or
(B) within the last 48 months, the Referred Individual's mental illness resulted in one or more acts of serious violent behavior toward himself or herself or others, or the Referred Individual threatened or attempted to cause serious physical harm to himself or herself or others, not including any period in which the Referred Individual was hospitalized or incarcerated immediately preceding the filing of the petition;
(5) That the Referred Individual has been offered the opportunity to participate in a treatment plan that includes all of the services set forth in Section 4112, but continues to fail to engage in treatment;
(6) That the Referred Individual's condition is substantially deteriorating;
(7) That participation in AOT would be the least restrictive placement necessary to ensure the Referred Individual's recovery and stability;
(8) That the Referred Individual's treatment history and current behavior indicate that the Referred Individual needs AOT to prevent relapse or deterioration that would likely result in grave disability or serious harm to himself or herself or in a civil commitment under California Welfare and Institutions Code §§ 5150, et seq.; and,
(9) That it is likely that the Referred Individual would benefit from AOT.
(c) The Director or designee shall submit with the petition the supporting affidavit of a licensed mental health treatment provider, or providers, testifying as to all of the elements identified in subsection (b). The provider must be willing and able to testify at the hearing and must base the affidavit on his or her personal examination of the Referred Individual occurring no more than 10 days prior to the filing of the petition, unless the provider attempted to examine the Referred Individual during that time, but the Referred Individual refused to be examined, in which case the affidavit shall so state.
(d) After the Director or designee files the petition, but before the conclusion of the court hearing on the petition, the Referred Individual or with the Referred Individual's consent, the Referred Individual's legal counsel, may waive the Referred Individual's right to the hearing, and agree to obtain treatment under a written settlement agreement, provided an examining licensed mental health treatment provider states that the Referred Individual could survive safely in the community. The term of the settlement agreement may not exceed 180 days, and the agreement shall be subject to the provisions of California Welfare and Institutions Code § 5347.
(e) The Superior Court may order AOT for the Referred Individual if the court finds that all of the elements of the petition, as required in subsection (b), have been established by clear and convincing evidence.
(a) The Referred Individual shall have the following rights:
(1) To receive personal service of all notices of hearings, as well as notice to parties designated by the Referred Individual;
(2) To receive a copy of the court ordered evaluation;
(3) To be represented by counsel, and if the Referred Individual cannot afford counsel, to be represented by the Public Defender;
(4) To be present at all hearings, unless the Referred Individual knowingly waives such right;
(5) To be informed of the right to judicial review by habeas corpus;
(6) To present evidence, call and examine witnesses, and cross-examine witnesses, at the AOT hearing; and
(7) To be informed of the right to appeal the court's decisions.
(b) If Referred Individual is not present at the AOT hearing, and the court orders AOT for the Referred Individual, the Referred Individual may file a habeas corpus petition challenging the court's imposition of AOT on the Referred Individual, and AOT may not commence until that petition is resolved.
(c) During each 60-day period of AOT, the Referred Individual may file a habeas corpus petition to require the Director, or the Director’s designee, to prove that the Referred Individual still meets all the criteria for AOT, as set forth in Section 4115(b).
(d) If the Referred Individual refuses to participate in AOT, the court may order the Referred Individual to meet with the AOT Team designated by the Director. The AOT Team shall attempt to gain the Referred Individual cooperation with the treatment plan ordered by the court. If the Referred Individual is still not cooperative, he or she may be subject to a 72-hour hold pursuant to the requirements of California Welfare and Institutions Code § 5346(f).
(e) Except as stated in subsection (d), failure by the Referred Individual to comply with AOT is not a basis for involuntary civil commitment, or contempt of court.
(f) Involuntary medication is not authorized under AOT without a separate and specific court order.
(g) The court may order no more than six months of AOT. If the Director, or Director's designee, determines that further AOT for the Referred Individual is appropriate, the Director must, prior to the expiration of the initial period, apply to the court for authorization to extend the time for a period not to exceed an additional 180 days.
(h) Every 60 days, the Director, or Director’s designee must file an affidavit with the court affirming that the Referred Individual continues to meet the criteria for AOT, as set forth in Section 4115(b). If the Referred Individual disagrees with this affidavit, he or she shall have the right to a hearing, at which the Director shall have the burden of proving that the Referred Individual continues to meet the criteria for AOT.
(a) The Director of Public Health shall, in consultation with the State Department of Health Care Services, client and family advocacy organizations, and other stakeholders, develop a training and education program for purposes of improving the delivery of services to individuals with mental illness who are, or who are at risk of being, involuntarily committed to AOT. This training shall be provided to mental health treatment providers and to other individuals, including, but not limited to, mental health professionals, law enforcement officials, and certification hearing officers involved in making treatment and involuntary commitment decisions.
(b) The training shall include both of the following:
(1) Information relative to legal requirements for detaining a person for involuntary inpatient and outpatient treatment, including criteria to be considered with respect to determining if a person is considered to be gravely disabled.
(2) Methods for ensuring that decisions regarding involuntary treatment as provided for in this part direct patients toward the most effective treatment. Training shall include an emphasis on each patient's right to provide informed consent to assistance.
(c) The Director of Public Health is authorized to promulgate regulations to implement this Division II.
(a) The Department of Public Health shall comply with the reporting requirements as set forth in California Welfare and Institutions Code § 5348(d).
(b) The Department of Public Health shall provide an annual report to the Board of Supervisors on the number of participants in AOT, the length of their treatment, the outcome of their treatment, and other matters the Department deems relevant.
(c) The Department of Public Health shall retain an external consultant to evaluate the efficacy of the AOT program, including but not limited to collecting and analyzing information regarding the demographics of Referred Individuals and the cost of the program. By no later than three years after the effective date of this Section 4118, the Department of Public Health shall provide a copy of this external evaluation to the Board of Supervisors.
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