California Senate Bill 43 (SB 43)

Observable considerations for grave disability (GD) due to mental health symptoms (or a co-occurring severe substance use disorder):

• Unable to articulate a plan for food, clothing, shelter
• Irrational beliefs about food that is available or offered (e.g. poisoned)
• Inability to engage in personal hygiene due to mental health symptoms
• Refusal to utilize food, clothing, shelter when offered resources
• Urinating or defecating on oneself
• Impacted speech: tangential, rambling, difficult to understand (e.g. “word salad”)
• Violent or threatening statements
• Fluctuation between calm and agitation
• Creating a public disturbance
• Yelling obscenities, screaming
• Paranoid or delusional thought content
• Disorganized thought content
• Catatonic/blank stare
• Hallucinating (talking to, hearing voices, responding to unseen others)

In accordance with SB-43, additional observable factors to consider for GD determinations:

Severe Substance Use

• Overwhelming odor of alcohol or marijuana
• Dilated or constricted pupils/bloodshot or watery eyes
• Eyes wide open or droopy, heavy lidded, nodding off
• Unsteady gait/slurred speech/unable to walk or stand by oneself/fumbles simple tasks
• Scratching, picking or clawing at skin (e.g. noticeable sores on face, hands or arms)
• Unintelligible speech: loud, yelling, slurring words
• Multiple/pattern of contacts for similar presentation (intoxication) in 12-month period

Necessary Medical Care

• Not seeking or obtaining necessary medical care due to substance use or mental health symptoms
• Uncontrollable vomiting
• Diminished responsiveness or loss of consciousness
• Potential loss of limb(s) due to untreated condition
• Uncontrolled bleeding
• Coughing or vomiting blood
• Cold/clammy skin
• Seizure/convulsions
• Complaint of severe pain or severe injury
• Non-healing wound, wound care or potential infection
• Extreme or profuse sweating
• Disclosure of untreated co-morbidities

Personal Safety:

• Not tending to personal safety due to substance use or mental health symptoms
• Wandering, walking or running in and out of traffic
• Unhygienic/uninhabitable conditions at home or other home safety issues such as not attending to appliances (e.g., leaving the stove on) due to intoxication or mental health symptoms
• Inability to care for hygiene and cleanliness which could or has led to illness
• Hoarding to an extreme causing safety concerns or hazardous (dangerous) conditions

People with a severe substance use disorder who may have trouble caring for themselves could be detained by peace officers and placed on a 5150 detention. This may result in people with a severe substance use disorder being more likely to receive involuntary treatment or be placed on a conservatorship.

Peace officers will need to make a decision on whether a person meets the expanded criteria for grave disability which is defined as a condition in which a person as a result of a mental health disorder, a severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder, is unable to provide for their basic needs for food or clothing or shelter or access to necessary medical care or personal safety.

Local hospitals and emergency rooms will likely see more people on 5150s brought in for evaluation and treatment. Because emergency rooms are best suited to manage the medical aspects of care associated with substance use disorders (versus the management of behavioral health and social needs), it is anticipated that peace officers will collaborate with Emergency Medical Services in the field to determine who specifically requires emergency medical services, and who can be safely transferred to alternative behavioral health settings such as crisis stabilization units and other sites. A clinical decision will need to make as to whether continued detention is appropriate. Collaborative work will need to be done to mitigate concerns of additional behavioral health “boarding” in the emergency room setting.

Community-based substance use providers will likely have increased requests and contacts from crisis stabilization units, emergency departments, and hospitals for care transitions of clients.

The Community Assistance, Recovery, and Empowerment (CARE) Act program creates a new pathway to deliver mental health and substance use services to people who are diagnosed with schizophrenia or other psychotic disorders and are not engaged in treatment. The intention of the CARE Act Program is to connect people to voluntary treatment through a civil court process.

With SB 43, the CARE Act program will be considered as a less restrictive path to treatment for people who are referred for LPS conservatorship through the Office of the Public Guardian.

At this time, there is no designated State or federal funding to support implementation of SB 43. The County of Orange is pursuing pathways to allow for services to be eligible for Federal and State reimbursement.

Yes it could, if the person meets criteria and does not go into treatment voluntarily. SB 43 broadens who is eligible to be detained for involuntary treatment.

For minors, SB 43 does not change the definition for the first 72 hours of detention pursuant to grave disability, but it does apply to minors if any other detention beyond 72 hours is used. Refer to WIC § 5585.20 and WIC § 5585.25.

Severe substance use disorder is a diagnosis made independent of intoxication. Someone brought in on a 5150 detainment suspected of severe substance use disorder may continue to be detained even after intoxication clears.

Information regarding substance use and mental health treatments are available by visiting ocnavigator.org, or by calling the OC Links 24/7 at (855) 625-4657.

LPS Conservatorship is for the most severely impaired individuals and involves a court-appointed conservator who can make decisions related to treatment and placement for individuals when they are unable to care for themselves.

• People on a conservatorship receive case management and often reside in congregate care settings such as mental health rehabilitation centers, skilled nursing facilities, and board and care facilities.
• Conservatorship may last for up to one year and is evaluated for renewal annually.

The person would be transported to an LPS Designated facility – likely an emergency room or hospital (or an alternative site designated as LPS by the County) – for evaluation and treatment for up to 72 hours. After the 72 hours expires, a few different things could happen: 

• The person could be released if the person does not continue with treatment; (e.g., they are no longer considered “gravely disabled");
• The person is released from the hold and enters voluntary treatment; or
• The person continues to receive involuntary treatment by being placed on a 5250 hold for up to 14 days

An LPS Designated Facility is a facility that complies with all applicable regulations established by the California Department of Health Care Services (DHCS) and the California Department of Public Health Licensing & Certification (CDPH), including all legal requirements applicable to its license and/or certification to provide evaluation and treatment services for persons who, as a result of a mental health disorder are dangerous to self or others, or gravely disabled due to a mental health or severe substance use disorder. A designated facility is licensed or certified as a mental health treatment facility or hospital, which may include but is not limited to a licensed general acute care hospital, a licensed psychiatric hospital, licensed psychiatric health facility, or a certified crisis stabilization unit. Other types of facilities may be recommended for designation to the Orange County Board of Supervisors by the Orange County Behavioral Health Director and approved by DHCS. A Designated Facility complies with statutory requirements of Welfare and Institutions Code, Community Mental Health Services, Division 5, and regulatory requirements of Title 9, California Code of Regulations (CCR), Division 1, Chapter 3, Article 4, Section 541, and Chapter 4, Articles 3, 5, 5.5 and 6 and complies with staffing regulations identified in Title 9, CCR, Division 1, Chapter 3, Article 10, Section 663. A Designated facility must also maintain at least one approved LPS Trainer at all times who shall work onsite as an LPS Trainer at only that facility and be available for consultation to that facility’s Designated Individuals.

For clients on behavioral health holds, the crisis stabilization unit will arrange transportation with contracted ambulance companies.

An individual can be transported to any LPS Designated facility. If the individual has a medical or psychiatric need that is beyond what the crisis stabilization unit can provide, law enforcement is trained to take them to a hospital. Law enforcement may call the crisis stabilization unit prior to help determine if the crisis stabilization unit is the appropriate destination.

Law enforcement and the County follow WIC 5150.

If the client is on an involuntary hold, this is allowable under the Emergency Medical Treatment & Labor Act (EMTALA). The hospital will coordinate with the CSU and determine that the referral is appropriate and that the client’s medical needs are able to be met at the CSU.

Generally transportation services are covered by Medi-Cal Managed Care Plans though procedures may differ from plan to plan.

A client is not required to be put on a hold before being transported, per WIC 5150, WIC 508, Section 1799.115 to the Health and Safety Code. 

The regulations related to transportation are outlined in the WIC 5150, WIC 508, Section 1799.115 to the Health and Safety Code, and EMTALA.

Refer to the EMTALA Quick Sheet for more information.

If you have a question that is not answered here, please email SB43@ochca.com.

Yes, the criteria that must be met for a designated individual in this case MD/ER to discontinue a 5150 hold for danger to self or others or gravely disability due to a severe SUD (includes impairment by chronic alcoholism), or a co-occurring mental health disorder and a severe SUD, is if the patient is not a danger to self or others or gravely disabled due to the aforementioned and is able to provide for their basic personal needs for food, clothing, shelter, personal safety, or necessary medical care.

Any Designated Individual can discharge a hold in a designated emergency room. Only a designated psychiatrist can discontinue a hold in an inpatient designated facility. If a designated psychologist is also involved in the treatment either of them can discontinue a hold on inpatient but they must consultant with one another. If there is a disagreement, the medical director makes the decision.

In a non-designated facility (emergency room or medical floor) without a Designated Individual present, the hold is not in place. However, if the facility is detaining a patient who arrived on a 5150 and they meet criteria and are being held beyond 72 hours then the patient must be reassessed by a professional the hospital deems qualified to decide if the patient continues to be DTSO/GD. Those are your 5256(b) patients.