Under the low hum of cold fluorescent lights in a nondescript office park in Orange County, dozens of Californians gathered to find out if they could get help for their loved ones under the state’s new CARE Court system.

Unless that loved one has a medical diagnosis specific to schizophrenia or some other psychotic disorders, the answer was probably not.

The mid-August meeting was one of a series held by a mental health advocacy group in Orange County with the officials in charge of implementing CARE Court starting in October, about what the new system can and cannot do.

“What we’re here to do is share the facts to help manage expectations,” said Veronica Kelley, Orange County’s chief of Mental Health and Recovery Services.

Community Assistance, Recovery, and Empowerment (CARE) Court was Gov. Gavin Newsom’s biggest legislative priority last year — what state lawmakers and local politicians hoped would be one answer to California’s dual, overlapping homelessness and mental health crises.

The new program allows family members and others to petition someone with untreated mental illness into civil courts, where a judge would order a treatment plan and require county mental health departments to provide it.

Backed by millions in new state funds, it’s a mandate for those departments at a time Californians have become increasingly frustrated with one of the most visible consequences of the state’s trenchant homelessness crisis — people with the most severe mental illnesses languishing on the streets.

Counties will be judged on how well they’re able to get people who may be resistant to help inside and into treatment, even though CARE Court is not exclusively a program targeting homelessness. Local mental health officials are warning it won’t be a panacea.

“There’s been a presumption — and this is, to be clear, driven by how the administration talked about CARE Court at the outset — a broad presumption that CARE Court is going to fix homelessness or have a broad impact on the nexus of homelessness and behavioral health,” said Luke Bergmann, director of the San Diego County Behavioral Health Services department.

In reality, he said, it’s “actually going to be a pretty small program. It’s not going to be this thing that dramatically changes homelessness.”

The program aims to walk the line between forced treatment and completely voluntary treatment for those with the gravest needs. Disability rights groups decry it as a violation of a person’s civil liberties, and a potential path toward conservatorship and the loss of legal rights for those who repeatedly decline care.

Annette Mugrditchian, deputy director, speaks to community members about CARE Court, a new program that will be implemented in October of 2023, at the Behavioral Health Training Center in Orange County on Aug. 17, 2023. Photo by Lauren Justice for CalMatters

CARE Court survived a legal challenge from Disability Rights California and other civil rights groups earlier this year. The group sat on a state working group for the program’s implementation and will monitor its rollout.

The program was welcomed by some family members of those with severe mental illness, who have complained the state’s privacy and patients’ rights laws only allow their loved ones to be compelled into treatment when in crisis, trapping them in a revolving door of short-term hospital stays and homelessness.

The first courts will open across the state in about a month. Seven counties, urban and rural, have been deep in preparation to be the first to roll out the program in October.

Los Angeles County, whose roughly 75,000-person unhoused population is the state’s largest, will start the program in December; the rest of the state will follow next year.

Those in the first group — San Francisco, Orange, San Diego, Riverside, Stanislaus, Glenn and Tuolumne counties — have had numerous questions to address, such as:

• Who will find and serve respondents with their CARE Court petition if the respondent is unhoused?
• How can county courts make the paperwork-heavy petition process easy for family members?
• How many mental health treatment beds will counties need to add?
• Where will people live after completing the court-ordered plans?

The state estimates between 7,000 and 12,000 people will qualify. They needn’t be homeless to receive the services, though many who qualify are likely to be unhoused. The state’s homeless population on any given night last year topped 171,000.

A UC San Francisco study of homelessness statewide this year found that more than a quarter of unhoused people had been hospitalized at any point in their lives for a mental health problem; the homeless services authority in Los Angeles has estimated a quarter of the city’s homeless adults has a severe mental illness. But CARE Court is targeted at an even narrower set of diagnoses and circumstances.

So counties are also playing a careful game of “level-setting,” Bergman said, “about what this thing will actually be.”

Still, local officials see the program as an opportunity to get more people into mental health care who haven’t been treated, before their condition deteriorates to the point of being put in conservatorships.

And the state’s Department of Health Care Services says it will be looking out for whether the program reduces emergency room visits, police encounters, short-term hospital stays and involuntary psychiatric holds — and whether it helps people find stable housing.

Managing expectations

One major uncertainty counties face, officials say, is even knowing how many cases they’ll get.

That’s in part because the law allows a wide range of people to petition for someone to be in CARE Court, including family members, roommates, health care providers, paramedics, hospital officials or homeless outreach workers.

But the list of actual conditions the program targets is narrow, limited to schizophrenia and related illnesses.

That could disappoint those whose loved ones have other diagnoses — and create an unknown amount of work for counties if a flood of those family members file petitions. Behavioral health departments must evaluate each person if it’s not clear whether they qualify for the program.

San Diego County estimates it will get 1,000 petitions in the first year and establish court-ordered treatment plans for 250 people; the remainder likely will either not qualify or agree to services voluntarily, Bergmann said. Orange County expects about 1,400 petitions and anywhere from 400 to 600 treatment plans.

“(CARE Court’s) not going to be this thing that dramatically changes homelessness.”
— Luke Bergmann, director, San Diego County Behavioral Health Services

Officials in Riverside County don’t even have an estimate, citing varying data there on the prevalence of schizophrenia in the unhoused population.

“We really think it’s unknowable,” said Marcus Cannon, the county’s deputy behavioral health director.

Counties want the state to help them manage public expectations. Both Kelley and Cannon said they’ve heard from local leaders who have floated having city workers file petitions for a wide swath of unhoused residents, to get them indoors.

“What the public thinks CARE Court is and what it is are definitely two very different things,” said Michelle Doty Cabrera, director of the County Behavioral Health Directors Association.

In an emailed statement, state Department of Health Care Services spokesperson Sami Gallegos said that counties “are managing public relations among local elected officials and others” to spread the message about who the program is and isn’t for.

After learning of the narrow eligibility criteria at a community meeting in August, Nancy Beltran considered her options.

Beltran, of Anaheim, said she lives with a family member whose psychotic condition caused him to hit another relative in 2020, landing him in the hospital against his will. She said he’s refused treatment and doesn’t believe he’s sick. Another psychotic episode earlier this year didn’t qualify him for hospitalization, she said, because the symptoms weren’t as severe.

“I didn’t want it to get to that point,” she said. “I don’t want him to be incarcerated. I want it to be the least restrictive, least traumatic experience.”

She’s still not sure whether the program is for her family member, because they haven’t gotten a clear diagnosis, she said.

Beltran said she also wishes the program could help a friend, who is already enrolled in therapy sessions for diagnosed schizophrenia, find a place to live. Her friend’s condition, she said, deteriorates because he is unhoused, but he remains on waiting lists for housing. But CARE Court, she was disappointed to learn at the meetings, is only for those with untreated schizophrenia.

Threading a needle

Everyone involved in CARE Court in Orange County — from the judge who would ultimately order treatment to the public defender who will represent respondents to the behavioral health officials responsible for finding, diagnosing and treating them — had the same message for the public: The program will be voluntary.

Critics, however, contend that there’s no way a court process can be voluntary since at some point there is a judge’s order. By law, counties must try at least twice to persuade a respondent to accept treatment before a judge orders it. Even then, the treatment plan, which can include therapy, medication and housing, doesn’t come with much enforcement. Medication can be ordered, but not forcibly administered.

Judge Ebrahim Baytieh speaks to community members about CARE Court, a new program that will be implemented in October of 2023, at the Behavioral Health Training Center in Orange County on Aug. 17, 2023. Photo by Lauren Justice for CalMatters

Over the course of a year, respondents will attend court hearings to see whether they’re adhering to the treatment, and whether the county is providing it. Counties can be fined as much as $1,000 a day for not providing the care; if the person fails to complete treatment they could be considered for conservatorship.

But county officials stressed that’s not the goal.

“We have tried for 40 years in this wonderful country of ours to force people with mental illness” to be treated, Orange County Superior Court Judge Ebrahim Baytieh told family members at another community meeting, in a church in Cypress. “Study after study has found it doesn’t work. We all know there’s no magical answer. But we will be patient, and we will be persistent.”

Kelley’s department is training its workers and peer supporters — people who also have mental illness or have recovered who can help guide a respondent through CARE Court — in a well-regarded communication method called LEAP to persuade respondents to accept care. It will offer services to those in CARE Court under a “whatever it takes” approach, whether it’s a ride to the doctor’s office, help enrolling in food stamps, addiction treatment or temporary housing.

The task will take time.

At the community meetings, Kelley and her colleagues repeatedly described a pilot program she ran as behavioral health director in San Bernardino County. The program took referrals from family, police or other community members who wanted to prod those who were resistant into mental health treatment.

The time it took for county workers using the LEAP method to persuade respondents to enter treatment varied, Kelley said. But on average, she said it took 20 visits if a respondent was housed — and 40 visits if they were unhoused. Visit times varied, from a few minutes to a whole day, so the whole process could take weeks or months, Kelley said.

The timetables set by law for CARE Court are much tighter.

If counties initially determine a client won’t agree to treatment, they get 14 days to try again before the next court hearing. Kelley said the judges in her county are sympathetic toward those concerns, but not all counties will get such flexibility.

“I can’t do 40 face-to-face visits in 14 days,” she said.

Civil rights advocates balked at the counties’ suggestion that any program involving the pressure of the judicial system, even a non-criminal court, could be voluntary.

“If you’re trying to engage somebody, and there’s a petition that involves a court,” there’s less hope of building genuine trust, said Keris Myrick, a mental health advocate who lives with schizophrenia and a board member of Disability Rights California.

The group is particularly concerned the court process could be ineffective or harmful among Black residents, who are overrepresented both in California’s homeless population and among people diagnosed with schizophrenia.

Myrick, who is Black, said she has been subject to involuntary treatment, and described harrowing experiences during which she was handcuffed in the back of a police car or strapped down to a gurney for hours before a doctor visited. She said one thing that actually helped her recover was having a peer supporter who was also African American and related to her experiences, eventually persuading her to get treatment on her own terms.

“What the public thinks CARE Court is and what it is are definitely two very different things.”
— Michelle Doty Cabrera, director, County Behavioral Health Directors Association

She later ran a peer support program in Los Angeles County and trained workers in the county mental health department. Myrick says the state needs to expand those services, as well as housing and social supports to help people live stable lives, without the threat of a judicial order.

Alex Barnard, a sociologist at New York University who has studied involuntary mental health treatment in California, is skeptical about whether the state can appease both civil libertarians and those who want more aggressive treatment. But he said the program’s mandate of a year of persistent engagement is promising.

“If CARE Courts works, it will probably be because of that,” he said. “It creates some accountability on the provider to keep trying to work with somebody who might be very challenging, and elsewhere in the system would just have their file closed out.”

Long-term resources

Those implementation questions are among a list of other practical hurdles counties face for the program to be successful.

There’s long-term funding. The first seven counties were given $26 million in one-time state grants to start the programs; some have estimated annual costs of the services themselves will far exceed those allotments.

The state says most services will be covered by Medi-Cal or private insurance, and expects counties to submit reimbursement requests, including the costs of going to court or finding respondents.

But the nationwide shortage of behavioral health workers has made it a challenge for some departments to hire. In San Diego County, Bergmann’s department plans to add 55 new staff, including 10 clinicians, for CARE Court. Only 35% have been hired so far, a spokesperson said.

And there’s housing and beds, which all agree is crucial to making treatment a success.

Health officials believe most people who qualify for CARE Court will need a more intensive treatment placement in the beginning, while some may be able to be placed in residential facilities or their own apartments after being stabilized.

But there are shortages across that spectrum. A 2021 Rand analysis found the state is short more than 4,700 psychiatric inpatient treatment beds and nearly 3,000 residential facility beds such as board-and-cares — long-term housing for people with severe mental illness and one option for respondents to live after they complete CARE Court.

Included in last year’s state budget was nearly $1 billion in new funding for counties to expand temporary housing placements for those with mental illness, with priority given to people in CARE Court.

Orange County and some others are using the grants to open new treatment beds. In San Diego, Bergmann’s department will use the money to pay for board-and-care placements. But significant new infrastructure will take years to complete. Over the past five years, Bergmann said, the county has lost a fifth of those residential facilities.

“In the near term, those funds will help us help people with the fewest resources to compete more” for placements, he said. “It’s not going to all of a sudden create a net increase in infrastructure.”

Marisa Kendall contributed to this reporting.

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