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New law allows more involuntary mental health holds. Should San Diego County delay its implementation?

San Diego Union-Tribune - 11/30/2023

A new law that significantly expands the rules for involuntary mental health holds takes effect Jan. 1, but San Diego County will consider delaying the change for one year, though it appears that idea will not sail through without significant debate.

The matter is set to come before the county Board of Supervisors for a vote at their regular meeting Tuesday.

Existing state law allows for the involuntary detention — often called a 5150 hold — and treatment of citizens if they may be a danger to themselves or others or if they are thought to be "gravely disabled." Today, the definition of that phrase means that a person can't "provide for their basic personal needs for food, clothing or shelter or has been found mentally incompetent."

But a new law, Senate Bill 43, signed into law on Oct. 10, broadens that definition to include conditions where, due to "a severe substance use disorder, or a co-occurring mental health disorder," a person is "unable to provide for their personal safety or necessary medical care." The law allows counties to delay implementation for up to two years.

Nora Vargas, chair of the county board, said Wednesday that there are concerns that expanding the meaning of gravely disabled at the first of the year could result in a significant increase in the number of "5150" holds that occur, especially among unhoused residents, potentially putting too much additional pressure on emergency medical resources that are already overtaxed.

The concern, she said, is that these holds won't do much but widen the current revolving door between the streets and local emergency departments if there isn't a better-laid path for how to make sure that holds turn into long-term treatment rather than a short hospital stay and a discharge back to the streets.

"We need to make sure that, if they end up in a hospital room, in an emergency room, that we know how we're going to make sure they get what they need," Vargas said. "You can't do that just by saying, 'let's just open it up, and let's figure it out as we go.' I think that's irresponsible."

But it would appear that the chair's stance is not universally held.

Fellow supervisor Terra Lawson-Remer issued a statement late Wednesday afternoon that said she will not vote to delay. Doing so, she said, would amount to slow rolling change that needs to happen now.

"We have to act with urgency in addressing the mental health crisis that is occurring on our streets and in households across San Diego County," Lawson-Remer said. "Our county should not be delaying the implementation of Senate Bill 43."

San Diego Mayor Todd Gloria took a similar stance, asserting that city firefighters and police officers spent "over 130,000 hours responding to over 53,000 behavioral health related emergency calls in the past year.

"This equates to 38 first responders spending their entire 10 hour shifts every day responding to behavioral health emergencies in my city alone," Gloria said. "Many of these individuals are frequent high utilizers of emergency services, cycling from the streets, emergency rooms and jails.

"It is inhumane to allow this to continue and this issue demands action, not delay."

Though Lawson-Remer said she will offer a "friendly amendment" Tuesday to implement the statute on Jan. 1, but to also "evaluate the early stages based on initial data to assess where systemic improvements are needed to ensure people are genuinely getting the help that they need through long-term treatment."

Local hospitals, though, clearly have significant influence on the implementation schedule because state law requires 5150 holds to be transported to certified medical facilities for evaluation by trained health care professionals.

The idea of delaying implementation for a year has the support of the Hospital Association of San Diego & Imperial Counties, which sent a letter to Vargas on Oct. 27 requesting that the new law not take effect on Jan. 1, 2024.

"SB 43 is anticipated to significantly increase the number of people placed on involuntary holds brought to emergency departments who continue to be impacted by record level patient volumes without adding the capacity or other critical resources to make sure we are equipped to serve these individuals," the letter states.

Chris Van Gorder, chief executive officer of Scripps Health, applauded Vargas for proposing the delay.

"Implementing before we are ready as a community and as hospitals who would be the receiving sites for many if not most of those individuals who would now be considered gravely disabled would be a disaster for the hospitals as we don't have the capacity to board even more patients than we do now," Van Gorder said in an email. "We have been telling the community for years that we have half of the behavioral health and stepdown beds and resources needed in San Diego County, and that is before we add this new population."

Neither Lawson-Remer nor Mayor Gloria's statements pushing back against deferral directly address assertions that moving forward now would put devastating pressure on ERs. Asked whether the mayor was saying that he believes those assertions are false, a spokesperson said in an email "yes, he is." Lawson-Remer did not respond to the same question.

It remains to be seen how the change will impact the county's law enforcement agencies, which already respond to tens of thousands of mental health calls a year. In 2021, the most recent year of data available, local police agencies handled more than 38,000 crisis calls.

Police leaders have previously noted how time-consuming these calls can be for officers. It can take several hours to get an individual evaluated at a mental health facility or hospital — hours that could be spent investigating or deterring crime.

And while officers receive some mental health crisis training, it's not their area of expertise. It's why some agencies were quick to welcome the county's Mobile Crisis Response Teams, which are made up of behavioral health clinicians, case managers and peer support specialists, and can respond to some mental health emergencies.

It would appear that other counties are considering similar delays. Luke Bergmann, director of behavioral health for the county, said Wednesday that the County Behavioral Health Directors Association of California, of which he is a member, has been receiving similar information from other counties considering delays.

"It seems that virtually every county is seeking that opportunity," Bergmann said, adding that most appear to be exploring delays until 2026 rather than 2025 as is the case in San Diego.

But Gloria noted that one big city, San Francisco, has already said it will implement the new law on Jan. 1, 2024.

"San Diego County should follow suit," Gloria said.

Bergmann said that taking an additional year to prepare for implementation of SB 43 will give more time for organizations affected by the change to work together on a solid set of procedures for how an influx of additional 5150 holds would be handled.

A key topic of discussion and collaboration, he added, will be finding ways to bridge between hospitals and the outpatient substance abuse treatment centers that provide long-term treatment.

"One area of focus, certainly, will be coordinating what happens in emergency departments with what happens in community-based addiction treatment," Bergmann said. "There have been long-standing challenges there."

He added that additional work is also needed on helping patients manage withdrawal from drugs and alcohol, especially in cases, now the majority, who are using multiple substances simultaneously.

San Diego also is one of a handful of counties participating in a pilot project for CARE Court, a new government law that allows loved ones, service providers and others to petition the court for intervention with residents diagnosed with severe mental illnesses. Bergman noted that while the court has so far received only 40 petitions, the process has only been up and running for two months. Time is needed, he said, to make sure that there is enough training and procedure to make sure CARE Court and SB 43 procedures mesh.

Lyndsay Winkley contributed to this report.

Updates:

6:37 p.m. Nov. 29, 2023: This story has been updated to include comments from San Diego Mayor Todd Gloria and Supervisor Terra Lawson-Remer

This story originally appeared in San Diego Union-Tribune.

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