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Q&A: Newsom’s sprawling CARE Court rethinks mental-health services. Can it work for homeless?

Daily News - 1/23/2023

The goal: Take people facing severe mental illness off the street and get them under a roof and into therapy. The means: The courts. The strategy: It’s complicated, expensive and, as yet, untried.

CARE Court is a phrase you’re going to hear a lot in the months and years ahead — especially this week, as Los Angeles County counts its unhoused population during its mammoth annual survey.

Will it be a streamlined new track to leverage the court system and place individuals experiencing extreme mental illness in housing and treatment? Or will it move too fast and cast aside the civil rights of many of its unwary participants? Buckle your seat belts, California.

Gov. Newsom’s bold plan aims to address the state’s mental health crisis.  The concept swept through the Legislature in record time and now is racing along — well, as face as government can race — at a similarly speedy pace as local leaders map out the local applications.

The goal is to empower individuals with schizophrenia, bipolar challenges and other psychotic disorders to enroll in care instead of living on the streets or landing in jail cells.

The CARE Court bill SB1338 was authored by Senators Tom Umberg (D-Santa Ana) and Susan Talamantes Eggman (D-Stockton) and signed into law in September 2022. Seven counties were initially selected to implement CARE Court by Oct. 1, 2023, with the remaining 51 to implement the program a year later.

However, the governor recently announced that L.A. County will be accelerating up its implementation to Dec. 1, 2023. L.A’.s CARE Court will be hosted by the Superior Court for the County of Los Angeles and the Los Angeles County Department of Mental Health will oversee and coordinate its implementation.

CARE Court has been met with great enthusiasm by L.A.’s elected officials including Mayor Karen Bass and county Supervisors Janice Hahn, Hilda Solis and Kathryn Barger, who all praised the accelerated implementation timeline.

But the program has been met with opposition from several advocacy groups – including Human Rights watch and ACLU California –  who believe that using courts to compel treatment will impinge on enrollees’ civil rights. The program, they fear, could also disproportionately impact people of color — who make up the majority of California’s unhoused population.

And although there are strong opinions on both sides, the details on exactly how the courts will work in practice remain murky. The Communications Office for the L.A. Superior Court said further details on its plans for CARE Court implementation will not be available for several months.

So, as L.A. maps out its homeless population anew this week, here is what we do and don’t know about CARE Court so far.

Who is CARE Court for?

CARE Court is for individuals with untreated schizophrenia spectrum or other psychotic disorders. To qualify for the program they must be over 18 and meet the definition of these disorders per the latest Diagnostic and Statistical Manual of Mental disorders.

In addition, the enrollee must either be unlikely to survive safely in the community without supervision or be in need of services to avoid a deterioration that would be likely to result in grave disability or serious harm to the person or others.

Must you be homeless to participate?

No. Being homeless is not a requirement of CARE Court, although it is anticipated that many unhoused individuals will enroll in the program. And concern for mentally ill people surviving on city streets largely propelled the program through the Legislature.

How many people will qualify?

The California Health and Human Services Agency (CalHHS) estimates that between 7,000 and 12,000 individuals may qualify for CARE Court statewide.

In a sweeping annual statistical ritual that can be pivotal in shaping state and federal funding, as well as how local agencies craft their aid and outreach strategies, the Los Angeles Homeless Services Authority will stage its point-in-time audit of unhoused residents this week.

Amid emergency declarations, battles over funding, increasing scrutiny of LAHSA’s effectiveness and politicians facing unprecedented outrage from the public, this could be among the most important audits in the region’s history.

Each year, LAHSA assembles scores of volunteer teams to conduct the survey of people experiencing homelessness — in shelters, on the streets or in vehicles — in most of the county’s cities and unincorporated areas.

Pasadena, Long Beach and Glendale, meanwhile, will compile their own independent surveys this week.

Among the most important reasons for conducting homeless counts is federal funding.

The U.S. Department of Housing and Urban Development requires L.A. County — as well as Pasadena, Long Beach and Glendale — to conduct a survey of the homeless population to receive HUD Continuum of Care Program Competition funding.

Here are the homeless survey dates this week:

LAHSA | Jan. 24-26:

Glendale | Jan. 26

Long Beach | Jan. 26

Pasadena | Jan. 24-Jan. 25:

Southern California News Group’s coverage this week:

Sunday: The homeless count impacts complex issues that place it under an even more intense spotlight this year. They include the governor’s move to connect those who lack permanent shelter with mental health services in “CARE Courts”; emergency declarations by the city of Los Angeles and L.A. County and a new, popular Los Angeles mayor who is not waiting for a honeymoon period to tackle the crisis.

Monday: While some consider the count a precise gathering of statistics, others call it a rough “guesstimate” at best; a close look at the strengths and weaknesses of the count’s methodology shows that reality lies somewhere in between.

Today: Gov. Newsom’s CARE Court strategy aims to reinvent getting mental health care to people who need it, especially people living on the street. How will it work?

Coming Tomorrow: The Los Angeles Homeless Services Authority will kick off its annual point-in-time homeless count on Tuesday. We’ll be there for the launch.

—

How does someone end up in CARE Court?

According to according to CalHHS, an individual is referred to CARE Court by a petitioner:

A family member, guardian or roommate;

A first responder or clinician;

An authorized representative of the county behavioral health services, adult protective services or Indian health services/tribal courts;

Or the individual themselves.

Individuals may also be referred to CARE Court from ongoing conservatorship proceedings or misdemeanor proceedings, if they are ruled to be mentally incompetent per Section 1370.01 of the Penal Code.

What about people who face court challenges already?

Individuals who are referred to CARE Court will have their misdemeanors waived upon enrollment. Unlike other types of misdemeanor diversion programs, traditional court proceedings will not resume if an individual drops out of CARE Court

“When you’re in CARE Court, you’re not in the criminal court and to the extent that there are potential charges, those should be dismissed,” said Umberg, in an interview with the Southern California News Group. “Ultimately, what we hope to have accomplished is take that person and to return them to the greatest degree of normality as as possible.”

What happens in CARE Court?

Once a petition is filed an initial appearance must be scheduled within 14 days. Each respondent is offered legal counsel and may also choose a voluntary supporter, such as a friend or family member, to help guide them through the court process.

A second hearing on the merits of the petition is then scheduled within 14 days of the initial appearance at which point the presiding judge decides whether the individual qualifies for CARE Court. If they qualify, the court then orders the behavioral health agency to work with the individual, their legal counsel and supporter to come up with an appropriate care plan, which the individual must agree to.

Once the court signs off on a treatment plan, there will be status review hearings at least every 60 days for a year. In the 11th month the court will hold a hearing to decide if the individual is on track to graduate CARE Court or if their treatment plan should be extended for up to a year.

What is a treatment plan? Is medication included?

A treatment plan includes a combination of community-based mental health services, medication and housing/social service resources.

CARE Court is specifically targeted for individuals with conditions that would benefit strongly from antipsychotic medication. This type of medication treats delusion, hallucination and disorganization – all symptoms that prevent individuals with schizophrenia spectrum and other psychotic disorders from exercising sound judgment.

But will CARE Court force people to accept medication? And do other things against their will?

No. Compliance with the court-mandated treatment is voluntary. CARE Court cannot forcibly administer any prescribed medication per existing California law.

Civil rights organizations are still very worried about how CARE Court will impinge on people’s rights especially considering the fact that people of color make up the majority of the state and county’s homeless population.

“The harms of the “CARE Court” framework will inevitably fall hardest on Black, brown, and Indigenous people, who are routinely misdiagnosed with serious mental health disabilities. The plan would perpetuate racial disparities though an adversarial court process that does nothing to address the underlying structural conditions that lead to houselessness,” wrote Eve Garrow, ACLU California homelessness policy analyst & advocate, and Kath Rogers, staff Attorney, economic justice in a June 2022 blog post.

Umberg said that there are two main ways that CARE Court will work to protect individual’s civil liberties.

“There is no coercive treatment here, number one,” said Umberg. “Number two, we’re going to have to keep data to make sure that this doesn’t skew to adversely impact populations who have been adversely impacted in the past by inadequate medical care.”

What are the consequences for failing to comply with a treatment plan?

In truth, there are not many. CARE Court is part of the civil court system and cannot enforce any criminal charges.

While some individuals may be eligible for referral to CARE Court from misdemeanor proceedings, their charges will be waived upon enrollment and proceedings will not resume if they fail to comply with their treatment plan.

The sole “threat” that the CARE Court system contains is referral to conservatorship proceedings if an individual refuses to comply with their court-mandated treatment plan. Conservatorship places care over an individual’s treatment in the hands of a court-appointed conservator.

However, the bar to qualify for a conservatorship is extremely high – an individual must meet the definition of gravely disabled, meaning they are unable to provide for their basic food, clothing and shelter needs due to mental illness.

Nevertheless, civil and disability rights organizations believe this is a very serious threat. In a June 2022 letter to the Legislature representatives from 16 such organizations — including Human Rights watch, ACLU California and the National Homeless Law Center — wrote that this is one of the reason’s why CARE Court should be reconsidered.

“This creates a direct route to conservatorship – a legal determination that deprives a person of the right to choose where to reside, to make medical decisions, to vote, to decide social and sexual contacts and relationships, and other fundamental rights,” stated the letter. “By targeting unhoused people with diagnoses of schizophrenia and other psychotic disorders, CARE Court will only repeat California’s racially discriminatory history.”

So, then what will be the motivation for people to complete CARE Court?

This is a reasonable question — because there are not many as “sticks” as there are “carrots” in the program. Instead, the court will largely rely on the incentives of housing and services that come with a treatment plan in addition to the encouragement of an enrollees designated supporter.

Umberg believes that this will be a powerful combination.

“So you’ll have housing, mental health care and you’ll have a supporter and that’s buttressed with the support of family members,” he said. “If nothing else, it (CARE Court) will be a motivator to not go back to living under a bridge.”

Umberg also said that making sure CARE Courts differ from traditional court environments and are a a welcoming place for enrollees will be essential to their success.

“Many who have been homeless, many who have been afflicted with mental illness have been in the court system, maybe been in jail, and it’s (court) not been a very welcoming place,” said Umberg. “So we need to do a very good job of making sure that this is a supportive environment.”

How will housing be provided as part of a treatment plan?

This is another vague area of the CARE Court Bill and something that individual counties will have to figure out for themselves.

It will certainly be a big challenge in L.A. County, which is already at the epicenter of the state’s affordable housing crisis and has a lengthy waiting list for any permanent supportive housing units.

According to the CalHHS, enrollees may be eligible for clinically enhanced interim or bridge housing, licensed adult and senior care facilities, supportive housing, or housing with family and friends.

Sen. Umberg said he does know precisely what will qualify as counties having fulfilled the requirement to provide housing under CARE Court, but said he was opposed to congregate shelters being used as the housing resources.

“The purpose of the program is to put you in a stabilized situation. So for example, a shelter is not a stabilized situation,” said Umberg. “I will intervene legislatively to make sure that that won’t qualify.”

CARE Court also stipulates that enrollees should be prioritized for housing placements, but does not set specific requirements for how this prioritization should work.

This is one of the many details that the county will need to figure out by the Dec. 1 deadline for opening L.A.’s CARE Court.

“I think that there are three significant challenges that we have to meet and housing is certainly one of those three,” said Umberg.

“The other two are the capacity in terms of qualified mental health professionals,” he added, “and training the judges so we can provide the most successful environment for this to succeed, because you’ve got behavioral health culture and you’ve got the culture of the court. Those are very, very different cultures.”

Will it all work?

Stay tuned. No state has ever attempted such a large scale program to address mental illness nor focused on using courts as mechanism to do so. And with even Umberg, the bill’s author, unsure of the implementation details, there is a great amount L.A. County must figure out by Dec. 1.

An easier question to answer is: Is it needed?

The 2022 L.A. County Homeless Count revealed that around 40% of unhoused individuals self-report experiencing serious mental illness or substance use problems.

A separate study from the California Policy Lab pegged the proportion of unhoused individuals with severe mental illness at 50%.

Not to mention that the isolation, stress and fear generated by the pandemic strained an already stretched thin regional mental health system.

With neither severe mental illness mental illness nor homelessness easing significantly any time soon, it’s clear a new approach is needed.

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