New CARE courts a key in fight against homelessness in state, Tulare County

Gov. announced Community Assistance, Recovery, and Empowerment (CARE) Courts to assist homeless people with untreated mental health and substance abuse issues

TULARE COUNTY – Homelessness is as complex as the human mind. It is unique to each individual and there is rarely one moment or underlying issue which can be pinpointed as the thing that thrust someone onto the streets. In some cases, those living without shelter aren’t even clear on the last time they had shelter, can’t distinguish between delusions and reality, and are unaware they may be suffering from an undiagnosed, serious mental illness.

This population of homeless individuals are not only the most in need but in many cases the most treatable with the right combination of therapy, medication and support and the focus of a new statewide program being proposed by the Governor.

On March 3, Gov. Gavin Newsom launched CARE  (Community Assistance, Recovery, and Empowerment) Court, a new policy framework to assist homeless people living with untreated mental health and substance abuse challenges. Standing at a mental health treatment center in San Jose, Newsom said CARE Courts would require counties to provide comprehensive treatment to the most severely impaired and untreated Californians and hold patients accountable to their treatment plan.

“CARE Court is about meeting people where they are and acting with compassion to support the thousands of Californians living on our streets with severe mental health and substance use disorders,” said Governor Newsom. “We are taking action to break the pattern that leaves people without hope and cycling repeatedly through homelessness and incarceration. This is a new approach to stabilize people with the hardest-to-treat behavioral health conditions.” 

The CARE Court framework was created using the evidence that many people can stabilize, begin healing, and exit homelessness in less restrictive, community-based care settings. The plan focuses on people with schizophrenia spectrum and other psychotic disorders, who may also have substance use challenges, and who lack medical decision-making capacity, and advances an upstream diversion from more restrictive conservatorships or incarceration.

This process is designed to treat those individuals that are so sick, they do not know they are sick,” said Natalie Bolin, Deputy Director of Clinical Services for Tulare County Behavioral Health. 

CARE Court does not wait until someone is hospitalized or arrested before providing treatment. CARE Court will provide an opportunity for a range of people, including family members, first responders, intervention teams, and mental health service providers, among others, to refer individuals suffering from a list of specific ailments, many of them unhoused, and get them into community-based services.

CARE Court offers court-ordered individualized interventions and services, stabilization medication, advanced mental health directives, and housing assistance – all while remaining community-based. Plans can be up to 12-24 months. In addition to their full clinical team, the client-centered approach also includes a public defender and a newly created “supporter” position to help individuals make self-directed care decisions.  

At the end of the 12 months, a graduation ceremony will be held by the Court recognizing the successful completion of the program. Even after graduation, the individual remains eligible for ongoing treatment, supportive services, and housing in the community to support long term recovery. 

If a participant cannot successfully complete a Care Plan, they may be referred by the Court for a conservatorship, consistent with current law. For individuals whose prior conservatorship proceedings were diverted, those proceedings will resume under the presumption that no suitable alternatives to conservatorship are available. For individuals whose criminal cases were diverted, those proceedings will resume.

Undiagnosed
Often the first point of contact for homeless individuals and referrals to mental health programs is one of three groups: the Visalia Police Department’s HOPE (Homeless Outreach and Proactive Enforcement) Team, Kings View’s Path program and Tulare County’s MultiDisciplinary Team (MDT).

Noah Whitaker, coordinating director of the MDT, said diagnosing someone who is unhoused with a serious mental illness is difficult. Whitaker said typically those types of evaluations only happen when the patient requests them and only after they are being seen in an outpatient facility after they have already begun treatment. Whitaker said those evaluations are usually held for people able to make their own decisions who are not a danger to themselves and others. The county’s three primary outreach teams only do voluntary evaluations, leaving another gap in the system to determine who would even qualify for CARE Plans or possible forced conservatorships. In the case of one diagnosis, known as anosognosia, people are not even aware they suffer from mental illness, making the issue of seeking treatment or following treatment even more disorienting. 

CARE Courts are more closely associated with addressing those who are gravely disabled and unable to make decisions for themselves. 

“So that could be, for example, a person who is experiencing hallucinations and is darting out into traffic as a result of those hallucinations, or they believe that their food has been poisoned by others and they then don’t eat anything at all,” Whitaker said. 

There are an estimated 1,000 people experiencing homelessness in Tulare County, according to Kings/Tulare Homeless Alliance’s 2020 Point In Time survey, the most recent headcount locally. About 40% are afflicted with mental illness and disabilities and 30% suffer from substance abuse. When asked why they were homeless, Tulare County’s unhouse residents listed drugs or alcohol as the second highest reason behind unemployment, followed by an argument with family and mental health. When asked what was keeping them homeless, those surveyed ranked mental illness and substance abuse as the top and third highest reason. 

Miguel Perez, executive director of the Kings/Tulare Homeless Alliance, said it is difficult to know how many of that 40% would be diagnosed with a severe psychosis if the law’s intention is to specifically treat those considered on the  schizophrenia spectrum, having psychotic disorders and those who lack medical decision making capacity. The Rand Corporation estimates about 9.3% of the Southern San Joaquin Valley are dealing with serious psychological issues. Perez said it is difficult to diagnose disorders in the field because the people have so many other basic needs to meet first, such as shelter, food, hygiene and trust in institutions, which can only be built on a one-on-one basis and slowly over time. The only hope of a quicker diagnosis is if someone is taken to the Emergency Department for treatment. 

He said many of Tulare County’s unhoused residents are deeply affected by mental illness and require intensive services but are not willing to accept services. 

“This isn’t something that will solve homelessness but it might be something helpful for some of the individuals we know living in our area,” Perez said.

Unhoused
Being able to evaluate them properly and diagnose their disorder is difficult without housing, the first step in stabilizing a person’s living situation and a foundational place to provide services going forward, both before and after a diagnosis. 

Perez, who worked with the Tulare County Housing Authority for eight years, said those individuals at a crossroads of mental health and substance abuse have the highest barrier of entry into housing. Because their drug use is driven by their mental illness, he said there aren’t any types of housing set up to treat both issues simultaneously. 

Housing is an important component of CARE Court—finding stability and staying connected to treatment, even with the proper support, is next to impossible while living outdoors, in a tent or a vehicle. Whitaker said there are four basic levels of care for those with mental health needs. Those needing the highest level of treatment, supervision and care, known as acute care, would be placed at a State Mental Hospital, the closest one being in Coalinga, Calif. Those needing subacute care would be placed into a residential locked facility, such as Crestwood Behavioral Health in Bakersfield, and residential restricted facilities like Kaweah Health’s Mental Health Hospital in Visalia, where residents are only allowed to leave the facility under supervision. A lower acuity form of managed care for those with mental illness are community residential services such as board and care, which provide meals, manage medications and have a dormitory feel. Whitaker said he is only aware of one of those facilities in all of Tulare County. Known as TLC, which stands for Transitional Living Center, the facility is located in Visalia and offers intensive case management services and structured but individualized programming. The lowest level of care would be independent living, where you would share a two-room apartment with another patient and there is an on-site office with resources specific to people on their journey through mental health.

“They would be placed to add whatever is the level of facility that best serves their needs in the least restrictive way possible,” Whitaker said.

There is a statewide shortage of beds at every level in California and the lack of beds is the most dire in San Joaquin Valley, according to a recent report by the Rand Corporation, a nonprofit thinktank. Including state hospitals, the Southern San Joaquin Valley has 278 acute beds, 1,532 subacute beds and just 59 community residential beds. Those numbers might sound like a lot but most of these facilities are full or expected to fill rapidly as the need continues to grow. The Southern San Joaquin region – which includes 1.8 million adults in Fresno, Tulare, Kings, Kern and Inyo counties – only has 15% capacity in acute care beds, 31% in subacute facilities and just 3% in low acuity beds, where the average length of stay is between 1-4 years. The region also has the highest number of people with serious mental illness compared with the rest of the state. The report also noted half of the facilities did not respond to questions and that the state needs to clean up its list of active and inactive licensed facilities to provide a more accurate count of beds in each area. By comparison, Los Angeles County has a shortfall of 5.2 subacute beds per 100,000 adults while the Southern San Joaquin Valley has a shortfall of 17.2 subacute beds, more than three times the need. The need for beds statewide is expected to grow by 1.7% per year. 

Without dedicated housing for individuals with significant behavioral health needs, this proposal will likely not be successful,” Bolin said. “The state must be focusing on building out bed capacity for today and future needs.”

Whitaker said Tulare County has made some inroads on providing housing for the homeless, including those with mental health issues. Through project Home Key, state funding provided to convert hotels to permanent housing units for the homeless, the county is in the process of developing 106 housing units for the homeless. The units are split between Sequoia Village, formerly the Sequoia Lodge, in Visalia and Madson Gardens, formerly 99 Palms turned Tagus Gardens, in Tulare. Sequoia Village room conversions, which involve adding kitchenettes to each hotel room, began this month and should be completed by this fall. Madson Gardens room conversions are scheduled for completion by summer 2023.

Low barrier navigation centers, generally known as homeless shelters, have already been built in Porterville (Porterville Welcome Center), have identified a site in Visalia (on Dinuba Boulevard across from Riverway Sports Park), and a work in progress in Tulare.  

“We’ve got a good amount of folks that have vouchers in hand right now and there’s no place for them to go,” Whitaker said.

Unfit for Jail
Sheriff Mike Boudreaux said CARE Courts may give law enforcement another tool in the tool box when it comes to the difficult task of addressing homelessness. Being homeless isn’t a crime, but doing illegal drugs and setting fires for warmth in public places are, meaning it is difficult to separate law enforcement from the issuing of mental illness among the homeless. 

“I think it’s a great step forward if it does what the language says it will do,” Boudreaux said. 

The sheriff estimated about 40% of inmates in the county jail need mental health counseling, medications for diagnoses and behavioral therapy which can’t be properly provided in jail. Boudreaux said jails and prisons are not the place to house the mentally ill or those with substance abuse issues because they lack the resources and to get those people the services they need in the proper setting. 

“I feel we should be bringing back mental health institutions,” Boudreaux said. “I would like to see some money go towards that. I’m a big advocate to try and get more and more mental health care.”

There are also at least 40 inmates in the county jail right now who are incapable to stand trial and are awaiting further instructions on whether they should be released or transferred. Boudreaux went on to say State Mental Hospitals, residential locked facilities and other institutions for those suffering from severe psychosis, are already at capacity with little hope of any capacity opening up in the near future.

“There are people in my jail system that should not be in my jail system,” Boudreaux said. “We need help with those people, but I applaud that we are at least taking the first steps.”

Even so, the new CARE law is meant to catch people before incarceration, often during misdemeanor arrests, and those people don’t generally end up in jail. Boudreaux said the difficulty of mental health calls, when someone is a danger to others, is that law enforcement officers are not the correct people to handle that situation. 

“I don’t think mental health should be a law enforcement issue,” Boudreaux said. “ And I don’t think homelessness is a law enforcement issue. But we still have to respond. I don’t think you’re ever going to be able to eliminate the law enforcement on it. But we definitely need to start putting more resources into the other components.”

Boudreaux said his hope is the new framework will provide post release care for those being picked up and then released for misdemeanor drug crimes. He said he doesn’t believe those struggling with mental health and drug addiction should be stacked into former hotels unless there’s going to be constant supervision to help them stay sober, take their medications and attend their appointments as part of the CARE Plans. He said those living in supervised environments are less likely to relapse and return to the streets. All of that will take a significant investment into mental health services, which he says is a greater crisis among the homeless population than COVID-19 but receives a fraction of the funding. No real change can happen without ramping up acute, sub-acute and community-based residential settings in every county. 

“How soon can those things be built?,” Boudreaux asked. “Quite frankly, we can’t build anything fast enough.”

Unable
If housing can be ramped up to meet home realty and affordable housing demands, those who are severely mentally disabled or have severe substance abuse issues and are unable to make their own decisions could potentially be forced into a CARE plan by a judge. 

Known as forced conservatorships, making people wards of the state when they are a danger to themselves and others is an extremely difficult process. District Attorney Tim Ward said his peers throughout the state have long advocated for a more streamlined way to get those people the help they need but who refuse to accept it. 

“We’ve been talking about this for a long time,” Ward said. “It’s very, very hard to get a conservatorship over someone in California.”

Similar to the former drug courts, which have successfully operated in Tulare County for decades, CARE Courts are attempting to streamline the process for conservatorships if the individual is unable to make their own decisions or follow a treatment plan. Drug Court offered those sentenced to jail time for drug crimes the opportunity to instead enter a one-year program where they were required to attend AA or NA meetings five nights per week, find a sponsor, appear before the judge handling their case once per week, and attend drug counseling sessions once per week. They also provide wrap-around services such as working with the Probation Department to obtain their general education degree and with Employment Connection to find a job. On some occasions, the program also works with local dentists to provide free dental services to restore teeth rotted by meth or gums corroded by cocaine. As recovery addicts progress through the program court appearances are dropped to once every other week, and meetings go down to four nights per week. A graduation ceremony, with as many as 400 people at one time, is held once per year to celebrate their sobriety, their freedom and expunged record.

Unfortunately, Drug Court was severely undercut with the passing of Proposition 47, a 2014 statewide initiative that reclassified many non-violent felonies to misdemeanors in order to reduce the state’s prison population. Because most drug crimes, with the exception of manufacturing, sales and distribution crimes, were now misdemeanors so there was not a threat of prison or serious jail time, a major consequence of not seeing the year-long Drug Court program through. Ward said Drug Court enrollment has dropped by 80% since Prop. 47 passed. 

“I think the CARE Courts are right on point,” Ward said.  

Prior to Prop. 47, Boudreaux said those arrested for drug crimes were held long enough to detoxify and then placed in substance abuse and addiction counseling while awaiting appearance before a judge. If and when they were released, Boudreaux said those people would at least be on a path to recovery instead of just looking for another high. 

“They would be released back out on the street, at least with a fighting chance,” Boudreaux said. “If we release you while you’re going through withdrawals, the first thing you are going to do is to go use drugs, because you don’t want to go through horrible withdrawals.”

Unfunded
CARE Courts don’t actually exist yet because the legislature hasn’t passed a law to create the state mandate requiring counties to provide the program and allocate funding. But it’s getting closer. On April 9, State Senators Thomas Umberg (D-Santa Ana) and Susan Talamantes (D-Stockton) introduced Senate Bill 1338 and Assemblymember Richard Bloom introduced Assembly Bill 2830, a mirror of the senate bill.

“Sadly, the status quo provides support only after a criminal justice intervention or conservatorship. CARE Court is a paradigm shift, providing a new pathway for seriously ill individuals before they end up cycling through prison, emergency rooms, or homeless encampments,” Newsom said.

All counties across the state will be required to participate in CARE Court under the proposed laws. If local governments do not meet their specified duties under court-ordered Care Plans, the court will have the ability to order sanctions and, in extreme cases, appoint an agent to ensure services are provided.

At this time, no new additional funding has been dedicated specifically to CARE Court for Behavioral Health, however there is language in AB 1338 about reimbursement of costs for a state mandated program,” Bolin said.

The Governor is providing $10 billion statewide for community behavioral health services building on the 2021 budget which included $12 billion in new funding to create new community based residential settings and long-term stable housing for people with severe behavioral health conditions. Additionally, the Governor’s proposed 2022-23 budget includes $1.5 billion to support Behavioral Health Bridge Housing, which will fund clinically enhanced bridge housing settings that are well suited to serving CARE Court participants. 

“It is unknown what type of funding will be needed to fund this new proposal,” Bolin said. “There are a lot of unknown areas of this new proposal to be able to answer if there is enough funding to run the program.”

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