SSI, Serious Mental Disorders and RCFEs

The California Legislature passed AB1766 creating H&S Codes 1507.4 (ARFs) and 1569.4 (RCFEs). The new laws require DSS to inform county mental or behavioral health departments on facilities that accept SSI, admit residents with serious mental disorders and the number of beds at each facility. Facilities are not required take SSI or admit residents with serious mental disorders.

Complete DSS’ paperwork, but perhaps you are asking why were these laws necessary? How about some lengthy history for an answer? It is that history that explains why NOW the state is seeking your facility to place persons on SSI with serious mental disorders. You do not have to!

The California Department of State Hospitals (DSH) manages the state’s mental hospitals, totaling just five. In the late 1950s, the state began to remove patients from its mental hospitals into nursing homes and residential care, a process called “deinstitutionalization.”

Under Governor Reagan, California passed the Lanterman-Petris-Short (LPS) Act, enacting a “patient’s bill of rights.” It ended the practice of institutionalizing patients against their will or keeping patients “forever” when they were suitable for community placement. It also virtually abolished involuntary hospitalizations except in extreme cases.

Confinement now required “due process of law.” By the early 1970s, California moved most mentally ill patients out of its hospitals. The LPS Act made it difficult to get them back if patients relapsed or needed additional care. The number of mental hospitals dropped under Reagan and successive governors. Reagan realized his mistake as many of the mentally ill ended up in prison, so he restored funding. However, Governor Jerry Brown made deeper cuts.

Governor Reagan also signed the Community Care Facilities Act in the early 70s creating adult residential facilities for the purpose of accepting the mentally ill into “homelike” environments. Unfortunately, the rush to open ARFs and child-care facilities created more of a ghetto than quality care.
Before Reagan’s steps in California, in 1963, President Kennedy signed the Community Mental Health Act pushing the responsibility of mentally ill patients away from the states and toward the federal government’s programs and hospitals. Shortly after Kennedy signed the Act, he was assassinated, and the Act did not go forward. That left 2,000 community mental health centers with unstable funding. President Carter tried to resurrect the Act, but President Reagan repealed it altogether.

In the 90s, two major court decisions—Coffelt and Olmstead—reinforced the LPS Act and maintained the patient’s bill of rights to due process and release programs. These two decisions forced institutions to find alternative, homelike environments for patients. Many entered assisted living facilities but could not be forced to stay.

The Washington Post reported Governor Brown did severe damage to the mental health system more than any other governor. “The system has deteriorated to the point that thousands of patients are being pushed out of mental hospitals to find their way through the inhospitable worlds of skid rows, flophouses, and county jails.” Brown’s critics said he failed to “fund adequately the state hospitals or the community care facilities since the Reagan years.” Brown vetoed many bills meant to “upgrade hospital staffing standards” and “his repeated refusal to spend large amounts on community care facilities as proof of what [critics] call his malignant neglect of the mentally ill,” the newspaper wrote.

An internal audit of the state’s hospitals found 1,285 suspicious deaths were associated with staff and physician negligence including over medicated patients. Several of the state’s hospitals lost federal accreditation and millions in funding. The term “dumping” came up in the Federal government’s audit of California’s mental hospitals, causing the loss of additional federal funding. In 1972, the Agnews State Hospital near San Jose released 3,800 patients and created a “mental health ghetto.”

According to The Balance, a fiscal watchdog, the state’s policy of “deinstitutionalization” led to annual budgets cuts—since the 1960s. About 16% of former patients ended up in the state’s prisons and are now being released due to Covid-19. More homeless?

The discovery of psychiatric drugs, especially Thorazine, in the 1950s, were thought to assist in the deinstitutionalization of patients. The only approaches up to that time were electroshock therapy, straightjackets, padded cells, hydrotherapy, and lobotomies. Society began to accept that mental illness needed to be treated and “locking people up” was not the right treatment.

A former nurse’s aide in a California veteran’s hospital, Ken Kesey, wrote “One Flew Over the Cuckoo’s Nest” published in 1962. The movie was made in 1975 and turned the public off to the barbaric treatment of shock therapy and lobotomies. In 1965, President Johnson signed social security amendments to fund health care but not mental hospitals resulting in the mentally ill going to nursing homes for payment by the Federal Government, and California’s psychiatric institutions were emptied as a result.

In 2009, the Great Recession forced many states, including California, to cut funding to mental health programs. In 2010, President Obama signed the Affordable Care Act forcing insurance companies to fund treatment for mental health including substance abuse addiction.

Through the years of deinstitutionalization, it became clear it was not appropriate to release the mentally ill into the community and were better served in long-term, in-patient care, but the funding was not there. Courts were more reluctant to “put people away” because of higher court decisions. In 2018, those suffering from mental health issues comprised 40% of the prison population and 20% of the homeless population.

California state hospitals now serve patients “committed” through civil and mostly criminal court action. In 2017, about 91 percent of the 13,000 patients treated by DSH were being held relating to criminal cases, in dispositions including not guilty by reason of insanity, incompetent to stand trial, sexually violent predator, and mentally disordered offender designations. The population was 87 percent male, 42 percent white, 25 percent black, 25 percent Latino, 79 percent were high school dropouts, with only one percent claiming, “some college.” About half of the patients are over 40, 40 percent are diagnosed as schizophrenic disorders, which include mood disorders like mania or depression, 16% diagnosed with paraphilia, a diagnosis of “abnormal” sexual desires; and 20 percent “other” make up the balance. Are these the residents you wish to admit?

Since deinstitutionalization and the subsequent funding cuts, California has worked to replace funding for community mental health services, passing Proposition 63, the Mental Health Services Act, in 2004. The Act imposes a one percent tax on personal income above $1 million, with the revenues used for prevention, early intervention, service needs and ancillary support.