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San Diego County Analyzes Programs For The Severely Mentally Ill

July 10, 2013 1:20 p.m.


Alfredo Aguirre, San Diego County Mental Health Director

Theresa Bish, former San Diego County Mental Health Board member. She has a family member who suffered from severe mental illness.

Related Story: San Diego County Analyzes Programs For The Severely Mentally Ill


This is a rush transcript created by a contractor for KPBS to improve accessibility for the deaf and hard-of-hearing. Please refer to the media file as the formal record of this interview. Opinions expressed by guests during interviews reflect the guest’s individual views and do not necessarily represent those of KPBS staff, members or its sponsors.

ST. JOHN: There are 40,000 adults in San Diego's mental health system. In March, San Diego County's Board of Supervisors asked for a review of programs to care for the most severely mentally ill. This week, the report was made public and compared the current voluntarily treatment programs with a program called Laura's Law. Here with us to talk about the findings of the report, Alfredo Aguirre, the behavioral health director for San Diego County.

AGUIRRE: Good afternoon.

ST. JOHN: And we also have Theresa Bish, former San Diego County Mental Health Board member, and she has a family member who suffered from mental illness.

BISH: Thank you, Alison.

ST. JOHN: So why did the county Board of Supervisors want a review of the mental health programs?

AGUIRRE: Well, certainly the issue of serving people who do not accept treatment has been an ongoing issue, a policy concern really across the country. And this county has had a particular interest in addressing the needs of this population. We have developed a pretty rich array of services over the past few years to service people with serious and persistent mental illness. We do recognize that some people do not accept care, and the Board of Supervisors recognizes that. So they were requesting the county to do a report, to do a study, to really look at this population, how is the alternative to Laura's Law that we implemented, how is that fairing, what are we learning from that, and comparing that approach with the approach. Laura's Law which in essence requires a court order for treatment.

ST. JOHN: What is the alternative that the county has been using?

AGUIRRE: We have had this program implemented for a little over a year, it's about a year and a half, it's the in-home outreach team, IHOT, and it's a pilot program that serves three regions. It consists of a team, a counselor, a basically peer support specialist, and a family specialist that really gets the referrals from all kinds of sources, including family, and does outreach to the home and really to try and build a relationship, to make a connection with the family and ultimately certainly with the client in question who has been resisting care.

ST. JOHN: So treesa, you actually have a family member who suffered from mental illness. Why did you feel like the county needed to review its programs?

BISH: Well, as chairing 2010 and 2011 of the county mental advisory board, I looked at the services for the severely mentally ill, in addition to conservatorship utilization for housing and so forth. We actually took all those numbers into account of the number of adults that would meet the criteria, whereas the current report that's out takes a 1-year look back. Consequently, as a result of the 2-year in-depth investigation, we found that Laura's Law met a need here for the severely mentally ill, because we'd been in this chronic historical reactive treatment utilizing the most expensive and most restrictive services. And this report confirms that again with the IHOT program. Jail, hospitalizations, ER, etc. And so consequently, we recommended to the Board of Supervisors that Laura's Law be implemented county-wide.

ST. JOHN: And can I ask you, do you have some personal experience that suggests the IHOT program is not adequate in all cases?

BISH: Lcertainly. Unfortunately my brother's -- he was schizophrenic for 20 years, and his outcome was tragic. He killed himself in 2003.

ST. JOHN: I'm so sorry.

BISH: Although his outcome, you know, was heartbreaking, it doesn't have to be that way for so many others in our community, our loved ones. Laura's Law, what it does, Alfredo touched on IHOT, IHOT is directing the majority of its engaged consumers over to the most expensive services. You can read it here. Per EPU, jail, etc, conservatorship. Laura's Law says wait a minute, we'll preempt that, do a paradigm shift, be proactive, put public safety No. 1, taxpayer savings on a par with that, and preempt the need to transition people into these costly services that again are reactive. So Laura's Law follows civil code. So there isn't the need for an arrest because we're intervening prior to an incident. And prior to somebody really degrading in their condition.

ST. JOHN: Okay. Alfredo, your team had 90 days to compile this report comparing the two programs. What kinds of things did you look at to understand how well the system of care works as well as options like Laura's Law?

AGUIRRE: One of the things we took a close look at is what is Laura's Law. What are the shortcomes of Laura's Law, what are the requirements of it, and comparing that to the population at that the in-home outreach team served. We looked at the fact that IHOT actually served individuals that would not be eligible for Laura's Law. These were people that were resisting to care or not accepting care for various reasons. And we were able to build relationships with most of them, and actually we -- it's a concerted effort to do the outreach and engage and connect them to services. So partly it was really understanding what Laura's Law is. One of the things we recognized under Laura's Law is the enforcement mechanism is pretty weak. Ultimately an individual can reject the court order. The only way to effectively get them into treatment is to basically use what's current law, which is the law that governs inpatient detention and hospitalization. So we do revert to that. That's the only option you have when someone denies the court order. The other thing I want to mention just to comment on Theresa's point about IHOT leading to these more expensive outcomes, that is not accurate. Actually the individuals that we serve under IHOT, we're building a relationship, it's not a treatment program. It's a way to connect them. These are people that are not accepting treatment.

ST. JOHN: Right.

AGUIRRE: The goal is to connect them to the resources they need. And because of the nature of their illness, the fact they're not being treated, they're already at risk for contacts with PERT, with jail, with the hospitals. It's a very high-risk population. So when we did the comparison, certainly the ones that would meet Laura's Law criteria --

ST. JOHN: Are going to be more expensive.

AGUIRRE: Well, they're going to have more contacts. But to suggest that IHOT leads to these more expensive contacts is not accurate.

ST. JOHN: Do you have a response to that?

BISH: I sure do. I'm looking at the report, and I'm looking at the numbers here of those that have been engaged, and by entering he's including PERT, EPU, jail, etc, hospital admissions and conservatorship. Psychiatric emergency response team is PERT.

ST. JOHN: And when you compare the type of person who might fall within the purview of Laura's Law, it might be appropriate for these more expensive solutions.

BISH: But that's just it. Laura's Law creates that framework that says we're going to preempt the need for these traditionally expensive and less effective means of treatment and they're the most highly restrictive. Laura's Law isn't supposed to fall under LPS or the more --

ST. JOHN: That being?

BISH: Lender man petric act. And also the 5150.

ST. JOHN: I'm sorry, these technical terms are beyond us!

BISH: Okay, well, these are --

ST. JOHN: The more serious.

BISH: These are involuntary services. So what Laura's Law says is look, you have the ability now, the opportunity to access these very same programs that are already funded on a voluntary basis, and there is a hammer, called a directive, that would direct that client if they chose to go through a due process of their civil right. And if the judge deemed it appropriate, then a more restrictive treatment plan would be implemented. However, I'm just going off their own data here. So I understand this is probably -- it's a pilot program that's a year and a half in as far as IHOT goes. It's not a three year program. If you remember, YOLO county has voted to implement Laura's Law as a pilot study. Nobody yet in the state is saying we're going to adopt IHOT. So we have continued legislature that's pending up in Sacramento to strengthen Laura's Law.

ST. JOHN: So that's just get a little context here. San Diego is not the only county that does not use Laura's Law. Tonight, there's only one county I believe --

BISH: Nevada.

ST. JOHN: That does use it. Is there some change in the legislation which might make it easier to use and easier for the county to fund?

BISH: Well, we know that Nevada is using mental health services act moneys to fund their Laura's Law program. I'm holding the stellar statistics that have been published out of Nevada county as to the cost savings, and the result of people going through their assisted outpatient treatment program, showing the levels of improvement, and the cost savings is now going for every dollar saved, it's approaching $2.52. Also Los Angeles has partially implemented Laura's Law. So you're going to have three counties.

ST. JOHN: So let's just look at the costs here. That's always a big question. Is that one of the reasons that the county did not adopt Laura's Law?

AGUIRRE: That was certainly a factor, and now we're taking a closer look at the cost of implementing Laura's Law. Our estimate based on the cost including public safety cost is about $34,000 per individual that's basically enrolled into Laura's Law as compared to what we project as a blended cost for our in-home outreach team, which is a little over $10,000. I also want to mention something about outcomes. It's an important point that Theresa made. Our outcomes are very similar for the program that really looks like assisted outpatient treatment. That's our full-service partnerships. The real difference between full-service partnerships, and Nevada county's program, that program is like a full-service partnership program on a mild dosage of steroids. In other words, they have the court order without -- and with limited enforcement. You also have to note that San Diego County is the second largest county in the state, and I think it's problematic when you start comparing us to one of the smallest counties in the state.

ST. JOHN: I want to stick with this issue of the cost. And I believe that one of the issues is whether in fact, although it might cost more, it might save more as well, and there were a number of people at the meeting of the county health board last night who were advocating for Laura's Law. And here's what Michael Plopper, the chief medical officer at Sharp had to say.

NEW SPEAKER: One of the requests by the Board of Supervisors was to look at all the other types of costs which might be saved associated with utilizing Laura's Law. And I don't see that here in terms of reduced incarcerations, reduced hospitalization, reduced police contacts, etc. There are many different associated savings which aren't referenced here.

ST. JOHN: So Alfredo, why did the report not include cost savings for Laura's Law?

AGUIRRE: Well, if you look at the directive by the board, it did not ask to do a comparison of the evaluation and outcomes. But we actually do that as part of our study. And if you look at the actual evaluation comparison, in Nevada county in terms of homeless status, in terms of the program it is 62% reduction. For the full-service partnerships, it's 94%. Hospital days, 47%.

ST. JOHN: And is this for Laura's Law or IHOT?

AGUIRRE: We're talking about comparing Nevada county's statistics to our full-service partnership.

ST. JOHN: I see. Okay.

AGUIRRE: Very similar programs. The difference is we do not have a court order. Full-service partnerships were started in 2006 serving a population that had many that historically that had not accepted treatment. So some of the advocates will say it's not enough. But I will say the full-service partnership has provided services that are close to 1,000 people who historically were not accepting or not responsive to treatment.

ST. JOHN: So based on the report, what is the recommendation you're going to make to the county Board of Supervisors?

AGUIRRE: I think it's an important recommendation. We are the second largest county. We are basically stating we want to expand IHOT to six regions. We're asking them to accept the report. But the third recommendation is that we move toward implementing Laura's Law contingent on identifying revenues and seeking legislative remedies that will make the enforcement part of Laura's Law more effective. So I think this is a profound statement. A large county stating that they're willing -- taking steps toward implementing. And we do see the value of outpatient commitment. We just think it needs to be strengthened.

ST. JOHN: What is your reaction to that?

BISH: I'm encouraged by that. Alfredo has made a sea change in his position. When I moderated a public forum in the fall of 2010, his closing statement was that he was opposed to implementation even though he was opposing something that he hadn't studied here in our county for appropriateness. So I'm encouraged now that there's a move toward accountability. As to appropriateness of Laura's Law. The cost savings problematic right now as well as the figures he's coming up with, the $34,000, Laura's Law right now is a 6-month program, they're quoting an annual. These are things that have to be vetted.

ST. JOHN: Is there any possibility for changing or adding to some of the results of this report before it goes to the supervisors in a couple of weeks?

AGUIRRE: No. The report has been completed.

ST. JOHN: This is the report the supervisors will be considering. And do you have some questions, Theresa?

BISH: Well, when you look at a report, you typically see footnotes and an appendix that shares where the data was derived from. Where did they get this information so that we can do our own due diligence that it's accurate and reflective of the true situation here in our county?

ST. JOHN: Just before we wrap up, I want you to sum up why you think it is important for the county to be considering Laura's Law.

BISH: Sure. I think it's fundamentally important because we know from our mental health board study that we are looking at high numbers of individuals in our system accessing mental health services, a large number. We have a public safety issue for those that are not engaged --

ST. JOHN: In treatment. . They can commit an act of violence. We need to support our law enforcement, save taxpayer money, and utilize the least extensive all right existent programs through outpatient treatment. We have a staggering number, a high population here, and we cannot sustain the model that says we're going to continuously treat people through the least effective and costliest means.

ST. JOHN: Okay, thank you. And Alfredo what would have to happen for health and human services to implement Laura's Law fully? &%F0

AGUIRRE: Well, first of all as the board letter refers to, we want to make sure that we've identified the appropriate revenues. Certainly that's one aspect. The other of course is really strengthening the law. We do see flaws in the law itself. And overall I think what this effort reflects is that this is a real commitment to improving our system, to improving and broadening the strength in our community.

ST. JOHN: And quickly, the changes in the law would have to happen in Sacramento?

AGUIRRE: Absolutely.

ST. JOHN: And might they happen this year?

AGUIRRE: Well, I know our county will be reviewing what our legislative agenda will be in the Fall. And certainly some of these recommendations to strengthen the law will be part of that.

ST. JOHN: Great. Thank you for joining us to help us understand it. Alfredo Aguirre is San Diego health director for the county.

AGUIRRE: You're welcome.

ST. JOHN: And Theresa Bish, former San Diego County Mental Health Board member. Thank you.

BISH: Thank you, Alison.