PACA MH/DS and AOT

1. PACA MH/DS and AOT PACA MH/DS Spring conference April 11, 2019 Daniel Eisenhauer, Administrator Dauphin County Department of Mental Health/Autism/Developmental Programs

2. Topics Climate of Commitment Law changes PACA MH/DS White Paper on Commitments HB 1233 - PACA MH/DS Position SB 599 - PACA MH/DS Position Brief Overview of AOT Criteria

3. Climate of Commitment Changes PACA MH/DS had been tracking and opposing several pieces of legislation, including but not limited to: Senator Greenleaf bill (modeled on NY Kendra’s Law) Federal Legislation- Rep Tim Murphy bill incentives for; or mandating AOT Legislation blending MH commitment laws and Drug and Alcohol commitment concepts in response to opioid crisis OMHSAS was under pressure to train and support Counties on use of outpatient commitment in existing MHPA of 1976 In 2013, The County Commissioners Association of Pennsylvania adopted a new plank to its platform to support a comprehensive legislative review and evaluation of the Commonwealth’s Mental Health Procedures Act, and accompanying policy and procedure for voluntary and involuntary mental health commitments, in close collaboration with counties. But PACA MH/DS was consistently in the position of opposing changes to commitment laws, but never being “for” anything…. So, we drafted a white paper saying what we can support.

4. PACA MH/DS Commitment White Paper Highlights Approved by the PACA MH/DS Board in November of 2016 Consistent with the DHS Secretary’s goals of “serving people in the community” and enhancing “value and efficient/effective use” of the Department’s resources. Outpatient civil commitment/assisted outpatient treatment is recognized by the federal agencies and federal law as an evidenced based treatment option for individuals with Serious Mental Illness. PACA MH/DS supports the overarching goals of the MHPA and recommends an amendment, to add an alternative pathway to the traditional involuntary commitment process. We recommend that the standards in the MHPA be clarified to explicitly differentiate the criteria applied to inpatient and outpatient involuntary commitment similar to what was done in Ohio. While the current MHPA permits outpatient commitment, the current “clear and present danger” criteria limit its effective use.

5. PACA MH/DS Commitment White Paper Highlights II Funding for community mental health services has not risen to meet demand over time. In addition to training, the funding for county programs not only needs to be maintained and preserved, new investments are needed to create a vital array of services to meet the needs of individuals with mental illness. In summary, people who are seriously mentally ill, face a mental health “Catch 22”, since on the one hand the law prohibits intervening early enough to help prevent them from becoming a danger to themselves or others; and… [s]ometimes people become incarcerated which results in even more narrow services available which is the ultimate restriction on their civil liberties. We hope to promote a new pathway … where assisted outpatient treatment helps to prevent people who are seriously mentally ill, from experiencing a tragic cycle of hospitalization, incarceration, homelessness, substance abuse, violence, or suicide.

6. HB 1233 Introduced by Rep. Murt At around the same time our White Paper was approved and distributed, Rep. Murt was drafting HB 1233. PACA MH/DS was neutral on the bill. There was no consensus on simple support or oppose, mostly because of the complexity of the language, the lack of funding, concerns about provider capacity, and the uncertainty over the impact on consumers and County programs. PACA MH/DS role was to comment on the bill so that in the event it were passed the bill would be able to be implemented from an operations point of view and to also comment consistent with our white paper. PACA MH/DS representatives met with Rep Murt, provided specific feedback on many elements of 1233 including description of services, “lookback periods”, commitment criteria, definitions of professionals, consistency with existing MHPA of 1976. PACA MH/DS representatives had numerous exchanges with the people drafting the bill and several language improvements suggested by PACA MH/DS were incorporated to the HB 1233 that eventually passed the House 189 - 0 in June of 2017.

7. HB 1233 - SB 599 • PACA MH/DS met with Mike Cortez, Chief of staff for Senator Lisa Baker; then Chair of the Senate Health and Human Services Committee, re: HB1233/SB599 in June of 2017 when HB 1233 was referred to the Senate. • PACA MH/DS attended a stakeholder meeting convened by Mike Cortez re: HB 1233 / SB 599 and provided written feedback in March of 2018 addressing: • Section 103.1 Definitions and Section 107; • 103.1 Qualified Professional; • Section 117 County Implementation - Option to Opt Out of AOT, • Section 301 Determination of Need for AOT (re: look back periods) • PACA MH/DS collaborated with PA College of Emergency Physicians to jointly propose alternative language regarding qualified professional who can conduct an exam under AOT which was incorporated into the final bill. • 1233 as amended, passed in the Senate 49-0, and the house concurrence vote on 1233 as amended by the Senate, was 181-0. • Act 106 was signed into law by Governor Wolf on October 24, 2018.

8. AOT: Overview of Criteria (i) To be considered for AOT the person has to meet all four criteria (i), (ii) (ii) and (iv) with section (ii) having an A or B option Determination of Need for Assisted Outpatient Treatment. The need for assisted outpatient treatment shall be shown by establishing by clear and convincing evidence that the person would benefit from assisted outpatient treatment as manifested by evidence of behavior that indicates all of the following: (i) The person is unlikely to survive safely in the community without supervision, based on a clinical determination.

9. AOT brief overview of Criteria (ii) (ii) The person has a history of lack of voluntary adherence to treatment for mental illness and one of the following applies: (A) At least twice within the 12 months prior to the filing of a petition seeking assisted outpatient treatment, the person's failure to adhere to treatment has been a significant factor in necessitating involuntary inpatient hospitalization or receipt of services in a forensic or other mental health unit of a correctional facility, provided that the 12 -month period shall be extended by the length of any hospitalization or incarceration of the person in a correctional institution that occurred within the 12 month period. [OR] B) Within the 48 months prior to the filing of a petition seeking court-ordered assisted outpatient treatment, the person's failure to adhere to treatment resulted in one or more acts of serious violent behavior toward others or himself or threats of, or attempts at, serious physical harm to others or himself, provided that the 48-month period shall be extended by the length of any hospitalization or incarceration of the person in a correctional institution that occurred within the 48-month period.

10. AOT brief overview of Criteria (iii) & (iv) (iii) The person, as a result of the person's mental illness, is unlikely to voluntarily participate in necessary treatment and the person previously has been offered voluntary treatment services but has not accepted or has refused to participate on a sustained basis in voluntary treatment, provided that voluntary agreement to enter into services by a person during the pendency of a petition for assisted outpatient treatment shall not preclude the court from ordering assisted outpatient treatment for that person if reasonable evidence exists to believe that the person is unlikely to make a voluntary sustained commitment to and remain in a treatment program. (iv) Based on the person's treatment history and current behavior, the person is in need of treatment in order to prevent a relapse or deterioration that would be likely to result in substantial risk of serious harm to the others or himself.

11. PACA MH/DS continuing concerns No additional funding has been provided in support of the bill. Lack of sufficient training for Counties, providers, MHRO’s, or attorneys on Act 106. Act 106 AOT draft commitment forms language and content proposed by OMHSAS not always compared to the language in the law, or the MHPA of 1976. Potential issues including civil rights protections for the “opt out” provisions whether a County opts out or implements the law. Operationalizing the mechanics of the law and the specific criteria of the law.

12. Questions/Comments Daniel Eisenhauer, Administrator Dauphin County Mental Health/Autism/Developmental Programs 100 Chestnut Street, 1st Floor Harrisburg, PA 17101 deisenhauer@dauphinc.org 717.780.7049