HOUSE OF REPRESENTATIVES STAFF ANALYSIS BILL #: CS/HB 915 Outpatient Mental Health Services SPONSOR(S): Children, Families & Seniors Subcommittee, Daley and others TIED BILLS: IDEN./SIM. BILLS: SB 960 REFERENCE ACTION ANALYST STAFF DIRECTOR or BUDGET/POLICY CHIEF 1) Children, Families & Seniors Subcommittee 15 Y, 0 N, As CS Curry Brazzell 2) Appropriations Committee 3) Health & Human Services Committee SUMMARY ANALYSIS Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community. In Florida, the Baker Act provides a legal procedure for voluntary and involuntary mental health examination and treatment. The Department of Children and Families (DCF) is responsible for the operation and administration of the Baker Act. CS/HB 915 modifies the Baker Act and makes changes to the statutory process for mental health examinations and treatment. The bill combines the process for courts to order individuals to involuntary outpatient services and involuntary inpatient placement in the Baker Act to streamline the process for obtaining involuntary services. This provides more flexibility for courts to meet the individuals’ treatment needs. The bill grants law enforcement officers discretion on initiating involuntary examinations. The bill also allows a psychiatric nurse to release a patient from a receiving facility if certain criteria are met. The bill prohibits a receiving facility from releasing a patient from involuntary examination outside of the facility’s ordinary business hours if the examination period ends on a weekend or holiday and specifies that the 72 hour examination period begins when a patient arrives at the facility. The bill allows witnesses to appear and testify remotely under oath at a hearing for involuntary services. The bill requires DCF to publish certain specified reports on its website. The bill makes technical and conforming changes and updates cross references. The bill will have a significant negative fiscal impact on state government. The bill provides an effective date of July 1, 2024. This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives . STORAGE NAME: h0915.CFS DATE: 1/30/2024 FULL ANALYSIS I. SUBSTANTIVE ANALYSIS A. EFFECT OF PROPOSED CHANGES: Background Mental Health and Mental Illness Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community.1 The primary indicators used to evaluate an individual’s mental health are: 2 Emotional well-being- Perceived life satisfaction, happiness, cheerfulness, peacefulness; Psychological well-being- Self-acceptance, personal growth including openness to new experiences, optimism, hopefulness, purpose in life, control of one’s environment, spirituality, self-direction, and positive relationships; and Social well-being- Social acceptance, beliefs in the potential of people and society as a whole, personal self-worth and usefulness to society, sense of community. Mental illness is collectively all diagnosable mental disorders or health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress or impaired functioning.3 Thus, mental health refers to an individual’s mental state of well-being whereas mental illness signifies an alteration of that well-being. Mental illness affects millions of people in the United States each year. Nearly one in five adults lives with a mental illness. 4 During their childhood and adolescence, almost half of children will experience a mental disorder, though the proportion experiencing severe impairment during childhood and adolescence is much lower, at about 22%. 5 Mental Health Safety Net Services The Department of Children and Families (DCF) administers a statewide system of safety-net services for substance abuse and mental health (SAMH) prevention, treatment and recovery for children and adults who are otherwise unable to obtain these services. SAMH programs include a range of prevention, acute interventions (e.g. crisis stabilization), residential treatment, transitional housing, outpatient treatment, and recovery support services. Services are provided based upon state and federally-established priority populations. Behavioral Health Managing Entities In 2001, the Legislature authorized DCF to implement behavioral health managing entities (ME) as the management structure for the delivery of local mental health and substance abuse services. 6 The implementation of the ME system initially began on a pilot basis and, in 2008, the Legislature authorized DCF to implement MEs statewide.7 MEs were fully implemented statewide in 2013, serving all geographic regions. 1 World Health Organization, Mental Health: Strengthening Our Response, https://www.who.int/news -room/fact-sheets/detail/mental- health-strengthening-our-response (last visited January 24, 2024). 2 Centers for Disease Control and Prevention, Mental Health Basics, http://medbox.iiab.me/modules/en- cdc/www.cdc.gov/mentalhealth/basics.htm (last visited January 24, 2024). 3 Id. 4 National Institute of Mental Health (NIH), Mental Illness, https://www.nimh.nih.gov/health/statistics/mental-illness (last visited January 24, 2024). 5 Id. 6 Ch. 2001-191, Laws of Fla. 7 Ch. 2008-243, Laws of Fla. STORAGE NAME: h0915.CFS PAGE: 2 DATE: 1/30/2024 DCF currently contracts with seven MEs for behavioral health services throughout the state. These entities do not provide direct services; rather, they allow the department’s funding to be tailored to the specific behavioral health needs in the various regions of the state. 8 Coordinated System of Care Managing entities are required to promote the development and implementation of a coordinated system of care.9 A coordinated system of care means a full array of behavioral and related services in a region or community offered by all service providers, participating either under contract with a managing entity or by another method of community partnership or mutual agreement.10 A community or region provides a coordinated system of care for those with a mental illness or substance abuse disorder through a no-wrong-door model, to the extent allowed by available resources. If funding is provided by the Legislature, DCF may award system improvement grants to managing entities. 11 MEs must submit detailed plans to enhance crisis services based on the no-wrong-door model or to meet specific needs identified in DCF’s assessment of behavioral health services in this state.12 DCF must use performance-based contracts to award grants.13 There are several essential elements which make up a coordinated system of care, including: 14 Community interventions; Case management; Care coordination; Outpatient services; Residential services; Hospital inpatient care; Aftercare and post-discharge services; Medication assisted treatment and medication management; and Recovery support. A coordinated system of care must include, but is not limited to, the following array of services:15 Prevention services; Home-based services; School-based services; Family therapy; Family support; Respite services; Outpatient treatment; Crisis stabilization; Therapeutic foster care; Residential treatment; Inpatient hospitalization; Case management; Services for victims of sex offenses; Transitional services; and Trauma-informed services for children who have suffered sexual exploitation. 8 DCF, Managing Entities, available at https://www.myflfamilies.com/services/samh/provIders/managing-entities, (last visited January 24, 2024). 9 S. 394.9082(5)(d), F.S. 10 S. 394.4573(1)(c), F.S. 11 S. 394.4573(3), F.S. The Legislature has not funded system improvement grants. 12 Id. 13 Id. 14 S. 394.4573(2), F.S. 15 S. 394.495(4), F.S STORAGE NAME: h0915.CFS PAGE: 3 DATE: 1/30/2024 DCF must define the priority populations which would benefit from receiving care coordination. 16 In defining priority populations, DCF must consider the number and duration of involuntary admissions, the degree of involvement with the criminal justice system, the risk to public safety posed by the individual, the utilization of a treatment facility by the individual, the degree of utilization of behavioral health services, and whether the individual is a parent or caregiver who is involved with the child welfare system. MEs are required to conduct a community behavioral health care needs assessment once every three years in the geographic area served by the managing entity, which identifies needs by sub-region.17 The assessments must be submitted to DCF for inclusion in the state and district substance abuse and mental health plan.18 The Baker Act The Florida Mental Health Act, commonly referred to as the Baker Act, was enacted in 1971 to revise the state’s mental health commitment laws. 19 The Act includes legal procedures for mental health examination and treatment, including voluntary and involuntary examinations. It additionally protects the rights of all individuals examined or treated for mental illness in Florida. 20 The Department of Children and Families (DCF) is responsible for the operation and administration of the Baker Act, including publishing an annual Baker Act report. According to the Fiscal Year (FY) 2021- 2022 Baker Act annual report, over 170,000 individuals were involuntarily examined under the Baker Act; of those, just over 11,600 individuals were 65 years of age or older. This age group is the most likely to include individuals with Alzheimer’s disease or related dementia. Receiving Facilities and Involuntary Examination Receiving Facilities Individuals in an acute mental or behavioral health crisis may require emergency treatment to stabilize their condition. Emergency mental health examination and stabilization services may be provided on a voluntary or involuntary basis.21 Individuals receiving services on an involuntary basis must be taken to a facility that has been designated by Department of Children and Families (DCF) as a receiving facility. Receiving facilities, often referred to as Baker Act receiving facilities, are public or private facilities designated by DCF to receive and hold or refer, as appropriate, involuntary patients under emergency conditions for mental health or substance abuse evaluation and to provide treatment or transportation to the appropriate service provider.22 A public receiving facility is a facility that has contracted with a managing entity to provide mental health services to all persons, regardless of their ability to pay, and is receiving state funds for such purpose.23 Funds appropriated for Baker Act services may only be used to pay for services to diagnostically and financially eligible persons, or those who are acutely ill, in need of mental health services, and the least able to pay. 24 Crisis Stabilization Units 16 S. 394.9082(3)(c), F.S. 17 S. 394.9082(5)(b), F.S. 18 S. 394.75(3), F.S. 19 The Baker Act is contained in Part I of ch. 394, F.S. 20 S. 394.459, F.S. 21 Ss. 394.4625 and 394.463, F.S. 22 S. 394.455(40), F.S. This term does not include a county jail. 23 S. 394.455(38), F.S 24 R. 65E-5.400(2), F.A.C. STORAGE NAME: h0915.CFS PAGE: 4 DATE: 1/30/2024 Crisis Stabilization Units (CSUs) are public receiving facilities that receive state funding and provide a less intensive and less costly alternative to inpatient psychiatric hospitalization for individuals presenting as acutely mentally ill. CSUs screen, assess, and admit individuals brought to the unit under the Baker Act, as well as those individuals who voluntarily present themselves, for short-term services. CSUs provide services 24 hours a day, seven days a week, through a team of mental health professionals. The purpose of the CSU is to examine, stabilize, and redirect people to the most appropriate and least restrictive treatment settings, consistent with their mental health needs. 25 Individuals often enter the public mental health system through CSUs. Managing entities must follow current statutes and rules that require CSUs to be paid for bed availability rather than utilization. Although involuntary examinations under the Baker Act have recently been decreasing statewide, the population of Florida continues to grow, and there are counties where the number of involuntary examinations remain the same or are slightly increasing, while some receiving facilities within communities are closing. There has been some demonstrated success with mobile response teams diverting individuals from the receiving facilities, resulting in those persons who are admitted to a receiving facility for an involuntary examination having higher acuity and longer lengths of stay. Involuntary Examination An involuntary examination is required if there is reason to believe that the person has a mental illness and, because of his or her mental illness, has refused voluntary examination, is likely to refuse to care for him or herself to the extent that such refusal threatens to cause substantial harm to that person’s well-being, and such harm is unavoidable through help of willing family members or friends, or will cause serious bodily harm to him or herself or others in the near future based on recent behavior. 26 An involuntary examination may be initiated by: A court entering an ex parte order stating that a person appears to meet the criteria for involuntary examination, based on sworn testimony; 27 or A physician, clinical psychologist, psychiatric nurse, an autonomous advanced practice registered nurse, mental health counselor, marriage and family therapist, or clinical social worker executing a certificate stating that he or she has examined a person within the preceding 48 hours and finds that the person appears to meet the criteria for involuntary examination, including a statement of the professional’s observations supporting such conclusion. 28 Unlike the discretion afforded courts and medical professionals, current law mandates that law enforcement officers must initiate an involuntary examination of a person who appears to meet the criteria by taking him or her into custody and delivering or having the person delivered to a receiving facility for examination.29 When transporting, officers are currently required to restrain the person in the least restrictive manner available and appropriate under the circumstances. 30 The officer must execute a written report detailing the circumstances under which the person was taken into custody, and the report must be made a part of the patient’s clinical record. The report must also include all emergency contact information for the person that is readily accessible to the law enforcement officer, including information available through electronic databases maintained by the Department of Law Enforcement or by the Department of Highway Safety and Motor Vehicles. Involuntary patients must be taken to either a public or a private facility that has been designated by DCF as a Baker Act receiving facility. Under the Baker Act, a receiving facility has up to 72 hours to examine an involuntary patient.31 During that 72 hours, an involuntary patient must be examined by a physician or a clinical psychologist, or by a psychiatric nurse performing within the framework of an established protocol with a psychiatrist at a facility, to determine if the criteria for involuntary services 25 S. 394.875, F.S. 26 S. 394.463(1), F.S. 27 S. 394.463(2)(a)1., F.S. The order of the court must be made a part of the patient’s clinical record. 28 S. 394.463(2)(a)3., F.S. The report and certificate shall be made a part of the patient’s clinical record. 29 S. 394.463(2)(a)2., F.S. The officer must execute a written report detailing the circumstances under which the person was tak en into custody, and the report must be made a part of the patient’s clinical record. 30 Id.