Supervisors vote to opt in to Assisted Outpatient Treatment (Laura’s Law)

SAN JOSE – In a 5-0 vote today, the Santa Clara County Board of Supervisors moved to opt in to Assisted Outpatient Treatment (AOT), also known as Laura’s Law, a program that would allow the County to provide court-ordered outpatient mental health treatment to residents with severe mental illness.

While the Board’s final decision on this issue was uncertain until this afternoon, County Supervisors Joe Simitian and Otto Lee had already expressed their support several weeks prior.

In their capacity as Chair and Vice Chair, respectively, of the Board’s Health and Hospital Committee (HHC), Simitian and Lee recommended that the full Board move to opt in to the program on March 24, 2021, following a special HHC session dedicated exclusively to discussing AOT/Laura’s Law.

The special meeting lasted over 3 hours and featured public comment from over 20 speakers, as well as presentations from the County’s Behavioral Health Services Department and two nonprofit agencies, Caminar and Telecare, that manage AOT/Laura’s Law programs in neighboring San Mateo and Alameda counties.

The program is targeted specifically to individuals whose illnesses are so severe that they don’t recognize the need for treatment, have a history of refusing or abandoning treatment services, and are unlikely to survive safely in the community without supervision.

“These are folks who continue to suffer from untreated illness,” said Simitian. “They’re folks whose families have been told again and again that there is nothing we can do to help them if their loved ones don’t agree to accept care. They have a right to mental health care, and now, we have the chance to finally get them some help.”

The County’s Behavioral Health Services Department initially recommended opting out of the program, citing concerns about cost, capacity, and the need for the Department’s existing services to expand. Simitian, however, said he found the presentations from Caminar and Telecare “compelling” in making the case that AOT could be a useful tool for Santa Clara County’s most vulnerable residents.

 Simitian also said there were three developments over time that influenced his decision:

• “I’ve had concerns in the past about civil liberties and due process issues with AOT,” said Simitian. “But I am now convinced that the law is crafted narrowly enough, and has enough protections built into it, that these concerns have been alleviated.”
• Simitian also noted that a significant number of large urban counties have already adopted the AOT/Laura’s Law approach, “so we now have the benefit of their experience. It’s getting harder and harder to justify opting out when 20 different counties across the state have already implemented this program and can show, as Caminar and Telecare did, that they are having real positive effects on reducing psychiatric emergency services, crisis episodes, and hospitalizations among these populations.”
• Lastly, Simitian acknowledged that the County’s Behavioral Health Services Department already provides a number of services for residents struggling with severe mental illness, but said, “It’s clear these services have not been enough to help those who refuse treatment. AOT provides a right to service for individual patients and their families, friends, supporters and colleagues who frankly are not getting the help they not only need, but deserve.”

The County’s Behavioral Health Services Department estimates that between 39 and 236 County residents would meet the AOT/Laura’s Law criteria each year, out of a County population of approximately 1.9 million. Of those, only 20 to 50 may require mandated treatment through the AOT/Laura’s Law process.

The Department estimates an annual cost of about $4 million to assemble a behavioral health team to implement the program, in addition to other costs. Simitian said he believes the cost is warranted. “For a program like this to work, you need the resources to do it right.”

“I understand it’s not a panacea,” Simitian continued. “I understand it’s not a cure-all. I understand that it’s not right in every instance. But it is, in my judgment, one more tool that we can and should use, that we can and should put to work for helping people in the community.”

Simitian said the need for AOT was captured perfectly in a letter submitted to the HHC by the Santa Clara County affiliate of the National Alliance on Mental Illness (NAMI) in support of an “opt-in” position: “Often, the brain is too ill to understand that it is ill.”

"In these instances,” NAMI’s letter continues, “the persons see no reason to accept treatment. Under our current system, they remain ill with much suffering for themselves, their families, and often the community at large when, as is often the case, they exhibit unacceptable behavior. With AOT in place, we have an opportunity to help these individuals start along the road to recovery and to a more fulfilling life.”

“In a perfect world, all of the people mental health agencies are trying to reach would come to us willingly, asking for help,” said David K. Mineta, President and CEO of Momentum for Health. “But in reality, many of those who need help the most are not interested in receiving services. Their families are often made to endure the grueling pain of watching their loved ones suffer through addictions, mental health crises, legal problems, and homelessness, while refusing to accept treatment.”

“For such individuals and their families, the current situation in Santa Clara County offers few options outside of the “revolving door” of repeated hospitalizations and incarcerations,” Mineta said. “More resources are gravely needed to engage those with severe mental illness into existing outpatient treatment programs, to give them a fair chance at recovery. Assisted Outpatient Treatment (AOT) could offer families and providers another tool to reach those individuals and connect them to care.”

San Jose City Councilmember Matt Mahan and 40 other residents and local mental health, business, and environmental leaders also submitted a letter advocating for adopting AOT/Laura’s Law at the March 24^th HHC meeting.

“AOT would serve to benefit the most vulnerable members of our society: severely mentally ill individuals who refuse to receive the care that they need,” they wrote. “It is not compassionate, equitable, nor fiscally responsible to allow the revolving door between emergency rooms, jails, and streets to continue.”

The State of California authorized counties to implement AOT programs almost two decades ago with the passage of the AOT Demonstration Project Act of 2002 (“Laura’s Law”). But counties had to actively “opt in” to the program to start providing these services, and Santa Clara County had not chosen to do so before today.

Following the passage of new state legislation in 2020 (AB 1976), however, all counties are now required to implement an AOT process unless their Board of Supervisors takes steps to specifically opt out. Counties that opt out must also now publicly explain the reasoning behind their decision.

With AOT/Laura’s Law in place, concerned family members, caregivers and providers could ask the County Behavioral Health Services Department to file a petition with a civil judge to mandate treatment services for individuals with severe mental illness.

Clients may be placed in AOT only if, after a hearing, a court finds that the client meets several very specific criteria. There is a right to counsel at every stage of the process, paid for by the County if the patient cannot afford an attorney.

The AOT/Laura’s Law process is temporary, until the clients are well enough to maintain their own treatment, and exclusively involves outpatient treatment services provided by community-based mental health teams. AOT cannot mandate inpatient treatment or medication.

To be eligible for AOT, clients must meet all of the following criteria:

1. Be 18 years of age or older

2. Be suffering from a mental illness;

3. Be unlikely to survive safely in the community without supervision, based on a clinical determination;

4. Have a history of non-compliance with treatment that has either;

• ​Been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months; or
• Resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last forty-eight months;

5. Have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health department but continue to fail to engage in treatment;

6. Be substantially deteriorating;

7. Be, in view of treatment history and current behavior, in need of assisted outpatient treatment in order to prevent a relapse or deterioration that would likely result in the client meeting California’s inpatient commitment standard, which is being;

• ​A serious risk of harm to himself or herself or others; or
• Gravely disabled (in immediate physical danger because unable to meet basic needs for food, clothing, or shelter);

8. Be likely to benefit from assisted outpatient treatment; and​

9. Have their participation in the assisted outpatient program be in the least restrictive placement necessary to ensure the client’s recovery and stability.