In four months, the gavel will fall and the state’s first CARE courts will be in session.

Seven provinces opted for an Oct. 1 rollout of the law directing each province to establish special courts, whose judges are empowered to do so

order voluntarily

Treatment plans for individuals with untreated schizophrenia and related disorders.

The CARE Act, signed by Gov. Gavin Newsom, last September, is demanding that counties devise the bureaucratic mechanisms that will support the goal of alleviating an epidemic of serious mental illness on the streets and in communities.

We were deep in the weeds thinking about what the day-to-day lives of the people engaged in this work will be like, said Luke Bergmann, San Diego County’s director of behavioral health.

One of the many challenges of the CARE Act is developing a manageable workflow for disparate groups.

For every person appearing in court, there are the clerks who processed the petitions who initiated the proceedings, the outreach teams who located the person and did the paperwork, the psychiatrists who prepared a treatment plan, the lawyers of the defense who will represent the person, behavioral therapists who will present the plan and the judges who will negotiate its implementation.

In addition, there will be insurance companies that pay for the plan, administrators that manage the paperwork associated with the plan, and health care providers that administer the plan.

The first group of San Diego, Orange, Riverside, San Francisco, Stanislaus, Tuolumne, and Glenn reflects California’s geographic and demographic diversity. Their courts will serve as a model for Los Angeles and the other 50 counties. (LA County opens its court on December 1; the rest of the state has until October 1, 2024.)

Many provinces will be catching up with a crisis that has gone unchecked for decades. County regulators and behavioral health directors describe a neglected system with an unknown number of people potentially eligible for CARE court.

The state estimates that 7,000 to 12,000 people are eligible for a treatment plan. The scope is so wide, officials say, in part because the law allows roommates or relatives to initiate an assessment of a family member suspected of having a serious mental illness.

Some counties are concerned they will be overwhelmed by families who have been unable to seek help caring for people with mental illness due to laws protecting their rights and privacy.

They are also bracing for the frustration of families whose requests are rejected because they don’t meet the criteria set by the law. Those brought before a CARE court must be 18 years of age or older, diagnosed with schizophrenia spectrum and other psychotic disorders, and not currently undergoing treatment.

We’re just not sure who will bring this law to the door, Veronica said

Kelly

Orange County director of behavioral health.

Orange County estimates it will receive petitions from about 1,500 people in the first year, with about 1,000 meeting the court’s criteria. Of those officials, nearly 300 are expected to agree to a treatment plan without having to go to CARE court, leaving 700 for the court to monitor for at least a year.

One of the smaller counties, Stanislaus, has identified 150 people as eligible based on frequent emergency room visits. Other than that, said County Supervisor Terry Withrow, it’s puzzling.

Such estimates are critical for counties needing to hire staff at a time when the state is short of health workers. It will be more difficult to meet that need for rural counties, which have fewer providers that can operate

of

people with an acute mental illness.

In a small province, the workforce will not grow to meet capacity

especially when it comes to administration and management

, said Joe Hallett, behavioral health director for Glenn County, 60 miles north of Sacramento. Instead, we just add these new responsibilities to the existing workload.

Health directors like Hallett look to lawmakers in Sacramento for continued advocacy and support. Glenn County will receive nearly $1.4 million in early allocations.

Start-up funding for the CARE Act was $57 million. The state budgets $26 million to distribute among the first group of counties as they sort out any kinks in implementation. Another $31 million distribution will be distributed to all provinces ahead of full implementation in 2024.

While Orange County received one of the highest allocations at $7.1 million, Kelley is concerned about the legislature’s decision to keep the CARE Act fully funded.

That’s good for a year, she said, but we don’t know for the next year.

Funding behavioral health services was one of the reasons Riverside County signed on early, said Jeff Van Wagenen, the county’s chief executive officer, who claims it has not received state support consistent with population growth. The $6.6 million initial allocation will help, but what comes after year one is unknown.

One of CARE Court’s concerns is that it

could be

be the state’s last unfunded mandate, he said.

Reflected in Sacramento’s budget for CARE Court is the assumption that the initial counties will work out kinks in the legislation so that other counties can start their courts at a lower cost. This means answering some mundane but critical questions not addressed by the law itself.

For example, who should serve the petition and transport people to court?

While behavioral health departments seem like the obvious choice, Bergmann worries that this is the case

a conflict of interest when the body bringing the person to court represents the interests of the party petitioning the court.

Enlisting law enforcement officers for this task is equally problematic for street encounters that likely require more trust than authority, he said.

Building that trust is one of the reasons Orange County is making provisions for its staff to help family members fill out the petitions the court needs to start the intervention.

We imagine a loved one who is at their wits’ end, agitated, frustrated and tired for everything they’ve been through at the moment, Kelley said. So the court staff must be ready for that. We also tried to get a waiver of the $433 filing fee. That is a lot of money.

To help families understand the process, Riverside County is developing an app that charts individual progress through the CARE system. The county can also hold civil hearings at bay so that someone living in Blythe, say, doesn’t have to go to court in Riverside, 170 miles away.

All we need is a table, a chair and a laptop, says Van Wagenen. So we could buy a van and convert it into a mobile courtroom. This would avoid the problem of having to store property or take in pets for people who are homeless.

Homeless people create a unique dilemma for counties who must hold a hearing within two weeks of determining the validity of the applicant’s petition.

We’re going to need more than 14 days to find the person and try to get them to agree to treatment, Kelley said. What if someone has moved to another province? We can’t expand all of our resources to find them. Were not detectives.

Hallett, with Glenn County, has similar concerns. The two-week time frame is really, really fast to find someone, do outreach and process a report, he said. A month would be more reasonable.

Still, lawmakers wrote the law with the intention of pressuring counties to act quickly, forcing counties to meet that timeline or pay a price.

The CARE plan is like a settlement agreement between the county and the respondent, said Jacqueline Wong-Hernandez, chief of policy

officers

for the California State Assn. of provinces. Once a plan is in place, the petitioner drops out and an agreement must be made between the county’s behavioral health department and the court participants.

The stakes for not meeting the 14-day deadline are high. If the court rules that the province is not

–

compliant, a penalty of $1,000 per day per case may be imposed.

Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, calls the provinces’ efforts so far promising. The legislation not only hopes to change the lives of some of the most vulnerable among us, but also represents a cultural shift in the way we do business collectively as a system, which will take time and iteration. Frankly, he said, it’s our responsibility to do better.

While directors of behavior pass the CARE Act, they emphasize that additional work is needed to address broader and deeper behavioral issues in states’ health systems.

We were going too fast, Kelley said. Give us five years, that’s the time it takes the province to build something. Without the infrastructure, these programs will not be as successful as the legislature wants, and we could lose people we could serve in the process.

Newsom hopes to address this shortfall by creating new revenue streams for housing and services, but his proposals depend on voters and will take years to implement.

We were standing at the front door, Bergmann said. We paint it, put in windows, line it with mother-of-pearl, and yet when we walk in we find a building without a roof.