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February 2018 Advocacy Update
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4/19/2018 at 8:42:40 PM GMT
Posts: 7
February 2018 Advocacy Update

California ACEP Continues to Fight for Better Access to Mental Health Care

By Elena Lopez-Gusman and Kelsey McQuaid-Craig, MPA

California emergency departments (EDs) struggle on a daily basis to provide effective, appropriate, and timely care to mental health patients. Inadequate community mental health resources, lack of access to psychiatrists and other mental health professionals, unclear laws and regulations, and poor coordination of care lead to suboptimal care for the mentally ill. The disproportionate ED resources devoted to patients with acute psychiatric emergencies leads to disruptions in care, crowding, and delays impacting all patients and staff in the ED.


Patients brought in on a 5150 hold, and therefore requiring a mental health evaluation prior to ED discharge, must often wait hours to days for a mobile psychiatric emergency team to arrive and/or must be transferred to a designated psychiatric facility. Arranging transfers can be extremely difficult. Beds are limited and some psychiatric hospitals refuse transfers of uninsured or Medi-Cal patients. Geriatric and pediatric beds are even more limited, leading to even longer boarding times in EDs for these vulnerable populations.

Improving psychiatric care has been a priority for the Chapter, and a 2013 survey of Chapter members about the status of emergency psychiatric care in California reaffirmed just how badly reform was needed. Approximately 60% of survey respondents reported an average boarding time of over 12 hours for mental health
patients. We also observed varying degrees of access to psychiatric resources and
inconsistent application of the Lanterman Petris Short (LPS) Act across counties.

It was in this context that the Chapter joined with the California Hospital Association (CHA) and the California Psychiatric Association (CPA) in 2015 to co-sponsor AB 1300 (Ridley-Thomas) to alleviate some of the obstacles in providing emergency psychiatric care. AB 1300 was defeated in 2016, but out of its defeat came a productive series of stakeholder discussions that allowed us to find common ground with other organizations interested in improving mental health care. Those meetings led to the introduction of two of our 2017 sponsored bills: AB 451 by Assembly Member Joaquin Arambula, MD and AB 1119 by Assembly Member Monique Limόn.

Chapter members report that when they are treating patients with mental illness, they often have limited access to health records for their patients. AB 1119 (Limόn) clarifies that providers do not need to obtain patient consent to share mental health information for treatment purposes in an emergency. This bill was signed into law by Governor Brown and will make it easier for emergency physicians to restart dedication and communicate with a patient's existing mental health provider.

AB 451 (Arambula) seeks to remove barriers for patients who need additional psychiatric services and require transfer to a psychiatric hospital to receive a higher level of mental health care.

Our 2013 member survey revealed that, almost universally, hospitals require voluntary patients to be on a 5150 hold prior to accepting transfer of that patient from the ED. There is no such mandate in law; in fact, the law clearly favors voluntary treatment. This requirement by hospitals places an unnecessary barrier to care for patients who seek treatment voluntarily. AB 451 clarifies that hospitals may not require a patient to be on a 5150 hold as a condition of accepting transfer of that
patient from an ED.

Chapter members also reported psychiatric hospitals routinely ask the insurance status of a patient before determining if they will accept the transfer. Similar to EMTALA, California law prohibits patient dumping and ensures that everyone who comes to an ED is treated for their emergency medical condition, regardless of their ability to pay. Because not all hospitals have the capability – due to lack of available specialists or capacity - to treat every condition, this law also requires hospitals to accept transfers of patients with emergency medical conditions from another hospital. Hospitals are expected to accept an appropriate transfer of an unstable patient and cannot ask about payment until the patient is both medically and psychiatrically stabilized. AB 451 ensures that this law also applies to acute psychiatric hospitals.

After concerns were raised by the Service Employees International Union (SEIU) about the portion of AB 451 pertaining to 5150 holds, we agreed to amend the bill to remove that section. Before we were able to amend the bill, AB 451 was held on the Senate Appropriations Suspense File and did not move forward in 2017. The bill will be eligible to be heard during the 2018 Legislative Session and we are committed to moving forward with the agreed upon amended language.

As we learned in 2015 with AB 1300, sometimes dividing the bill into smaller parts leads to a more successful outcome. In this vein, California ACEP will be sponsoring separate legislation to prohibit hospitals from requiring a patient who is voluntarily seeking mental health care to be placed on a 5150 hold as a condition of accepting transfer of that patient from an ED. We are determined to change current practice by hospitals, which places undue civil liberties restrictions on patients
seeking this care voluntarily.

Additionally, California ACEP will be sponsoring legislation in 2018 to clarify that a copy of a 5150 form and the use of an electronic signature on a 5150 form are valid. In some counties, patients have been denied care because their accompanying 5150 form was not an original. The law is silent on whether this is required and, unfortunately, has led to inconsistent interpretations among counties. This is a dated practice in an age where electronic signatures are widely accepted as binding and secure for various legal and medical documents, including most prescriptions. Original signature requirements add additional time and bureaucratic obstacles to helping patients receive urgently needed mental health care.

While these sponsored bills will not solve all of the problems with delivery and access to mental health care, they will have an impact on the patients seen every day in your EDs. These legislative actions do not happen in a vacuum. At the same time, our Mental Health Work Group is assembling a toolkit for medication initiation in the ED and de-escalation techniques. We continue to engage in stakeholder
meetings with the Steinberg Institute, NAMI California, Disability Rights California, the California Psychiatric Association, and others to find ways to improve access to mental health treatment.

The Chapter is committed to improving mental health care in California’s EDs. We remain focused on the goal to decrease the excessive boarding time and delays mental health patients endure. No matter the outcome of our sponsored legislation, we will continue to fight for better care for our patients.

Kelsey McQuaid-Craig, MPA
Director of Policy and Programs
California ACEP

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