Title
Receive a presentation on the Community Assistance, Recovery, and Empowerment (CARE) Act program in the County of Monterey.
Report
RECOMMENDATION:
It is recommended that the County of Monterey Board of Supervisors:
Receive a presentation on the Community Assistance, Recovery, and Empowerment (CARE) Act program in the County of Monterey.
SUMMARY/DISCUSSION:
At the request of Supervisor Alejo, the County of Monterey Health Department, Behavioral Health Bureau (BHB) will provide an overview of the CARE Act and summarize the collaborative planning efforts that led up to the December 1, 2024, program launch in the County of Monterey.
Background
On September 14, 2022, Governor Newsom approved Senate Bill (SB) 1338 establishing the Community Assistance, Recovery, and Empowerment (CARE) Act, to provide community-based behavioral health services and supports to Californians living with schizophrenia spectrum or other psychotic disorders who meet certain eligibility criteria. The CARE Act creates a new pathway via a civil court process to deliver mental health treatment and support services to eligible individuals (adults aged 18+) who have untreated schizophrenia spectrum or other psychotic disorders and are not currently stabilized in treatment. An individual enters this pathway when a petitioner requests court-ordered treatment, services, supports, and housing resources under the CARE Act, for an eligible individual (or “respondent”). Certain people including family members, first responders, and providers (healthcare, mental healthcare, and social services), may file a petition with the court. In situations where someone other than County Behavioral Health files the petition, Behavioral Health is substituted in as the petitioner at the initial court appearance. Individuals may exit out of the CARE process in several forms, including early voluntary engagement in county treatment services up to and including graduation from a CARE agreement or CARE plan. A CARE agreement or CARE plan may include treatment, housing resources, and other services. The CARE Act is intended to serve as an upstream intervention for individuals experiencing severe impairment to prevent avoidable psychiatric hospitalizations, incarcerations, and Lanterman-Petris-Short (LPS) Mental Health Conservatorships.
The CARE Act was implemented statewide in two cohorts. Cohort I began on October 1, 2023, and included seven counties: Glenn, Orange, Riverside, San Diego, Stanislaus, Tuolumne, and the City and County of San Francisco. All remaining counties are part of Cohort II which went live on December 1, 2024; however, three counties elected to implement early. Los Angeles County went live December 1, 2023, San Mateo County in July 2024, and Kern County in October 2024.
The County of Monterey received $328,604 from the State for CARE Act startup and implementation costs. As the Court received separate funding for their start-up costs, this funding supports the efforts of Behavioral Health, County Counsel and Public Defender for allowable activities including: Planning, Preparation, Hiring, Development of Policies & Procedures, Information Technology and Case Tracking.
Local Implementation
Our local CARE Court Planning Committee, under the leadership of Monterey County Superior Court Judge Julie R. Culver, convened regular monthly meetings starting in January 2024 as well as ad hoc workgroups and a mock trial in November 2024 all leading up to the CARE program launch on December 1, 2024. The Planning Committee includes several key partners from the Court, the Court Self-Help Center, County Counsel, Behavioral Health, Public Defender, District Attorney, and Public Administrator/Guardian/Conservator. Health Management Associates (HMA) Consultants, the Department of Health Care Services (DHCS) contracted provider for training and technical assistance (TTA) and data collection and reporting support, has been a key resource for the committee. The committee has and continues to engage a variety of stakeholders to provide information and presentations including but not limited to Hospitals, Monterey County Chief Law Enforcement Officers, Social Services, Public Administrator/Guardian/Conservator, District Attorney’s Multi-Cultural Community Council, Monterey County Bar Association, Behavioral Health Commission, Behavioral Health staff/providers and the National Alliance on Mental Illness (NAMI).
CARE Act Process
The parties involved in CARE Court include the Petitioner, Respondent, Court/Judge, County Behavioral Health Agency, Public Defender, Supporter, and County Counsel. The CARE process is quite involved and includes 18 hearings for each case from start to finish (assuming there are no continuances), and 4 evidentiary hearings (witnesses are sworn in and testify) throughout the process. Behavioral Health is required to prepare and serve a written report before almost every hearing. The respondent must be personally served all notices and reports prior to each hearing. Behavioral Health is responsible for locating, serving, and getting respondents to court. Each case can last almost 3 years from the date of filing the petition. Hearings are held every 30-60 days for the entire case lifespan. Behavioral Health must provide wrap-around services to all persons with a CARE Agreement/CARE Plan, including housing.
A CARE agreement and a CARE plan are documents that specify services to support the respondent’s recovery and stability. A CARE agreement is a voluntary agreement between the respondent and the county behavioral health agency after a court has determined that the respondent is eligible for the CARE process. If a CARE agreement is not reached, the court may order the creation of a CARE plan. A CARE plan includes a range of community-based services and supports ordered by the court. There will be status review hearings to review progress and challenges. Services and supports in the CARE plan can be changed to support the respondent’s success. If included in the CARE plan or agreement, stabilizing medications are prescribed by the treating licensed behavioral health care provider. The CARE team will work with the respondent to address medication concerns and make changes to the treatment plan as needed.
CARE eligibility criteria require all of the following:
(1) An individual must be 18 years of age or older,
(2) Experiencing a severe mental illness and have a diagnosis of schizophrenia spectrum or other,
(3) Have severe and persistent symptoms interfering with daily functioning,
(4) Not stabilized with ongoing voluntary outpatient treatment,
(5) Participation in the CARE Act is the least restrictive alternative,
(6) Will benefit from participating in a CARE plan or CARE agreement.
And at least one of the following:
(1) Unlikely to survive safely and is deteriorating,
(2) Intervention is needed to prevent relapse or deterioration.
Evidence is required in support of the petition in the form of an affidavit from a licensed behavioral health professional supporting that the person meets the criteria for CARE (CARE 101 Form) OR evidence that the respondent was detained for a minimum of two intensive treatments (Wel. and Inst. §5250 holds at a hospital) with the most recent one within the previous 60 days.
Issues, Repercussions, and Reporting Requirements
Some possible issues are anticipated to arise due to limited housing and supportive programs, and competing priorities. The CARE process requires to prioritize connecting respondents to treatment, support services and housing, giving them priority over others including conserved clients, yet the County can be liable for failing to house LPS conservatees. The County can be fined up to $1,000 per day, not to exceed $25,000, for each individual violation for failing to provide services to CARE respondents. There is also the potential for Behavioral Health, Public Guardian, and Hospitals to have different opinions about where on the continuum of care (voluntary outpatient treatment, CARE Court, or LPS Conservatorship) the person should be served therefore cross-system coordination and collaboration will be essential.
Both County Behavioral Health Agencies and the Judicial Council of California are required to begin data collection at the time of CARE Act implementation and provide submissions to DHCS quarterly, with the data organized into monthly increments. The data reporting requirements for CARE are extensive and have required significant Behavioral Health resources and IT system development to be able to capture and ultimately extract the necessary data points to be able to meet this mandate.
Data collected from Cohort 1 counties (for 3 quarters) reveals families are the leading source of petitions. A total of 557 petitions have been filed and 217 (39%) of those have been dismissed. There have also been 362 persons voluntarily engaged in services and diverted from CARE before a petition filing. 100 (18%) of petitions filed resulted in CARE Agreements or CARE Plans.
In December 2024, our first month of CARE Court in the County of Monterey, Behavioral Health did not receive any CARE referrals or petitions.
This work supports the County of Monterey Health Department 2025-2028 Strategic Plan Goal(s): 1. Build Community Power and Partners’ Capacity to Increase Equity and Improve Health, 2. Provide Exceptional Person-Centered Care through Accessible, Community-Focused Health Services.
OTHER AGENCY INVOLVEMENT:
Health Department, Behavioral Health Bureau, Monterey County Superior Court, Office of County Counsel, Office of the Public Defender, Office of the District Attorney, Public Administrator / Guardian / Conservator.
FINANCING:
Receiving this report will have no impact on the Health Department Behavioral Health Bureau’s FY 2024-2025 Adopted Budget nor to the General Fund.
BOARD OF SUPERVISORS STRATEGIC INITIATIVES:
Check the related Board of Supervisors Strategic Initiatives:
☐ Economic Development:
• Through collaboration, strengthen economic development to ensure a diversified and healthy economy.
☐ Administration:
• Promote an organization that practices efficient and effective resource management and is recognized for responsiveness, strong customer orientation, accountability and transparency.
☒ Health & Human Services:
• Improve health and quality of life through County supported policies, programs, and services, promoting access to equitable opportunities for healthy choices and healthy environments in collaboration with communities.
☐ Infrastructure:
• Plan and develop a sustainable, physical infrastructure that improves the quality of life for County residents and supports economic development results.
☒ Public Safety:
• Create a safe environment for people to achieve their potential, leading businesses, and communities to thrive and grow by reducing violent crimes as well as crimes in general.
Prepared by:
Melanie Rhodes, LMFT, LPCC, Interim Behavioral Health Bureau Chief, 796-1742
Fabricio Chombo, Interim Assistant Behavioral Health Bureau Chief, 755-4580
Approved by: Elsa Mendoza Jimenez, Director of Health Services, 755-4526
Attachment(s):
Board Report
Presentation