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Analysis of Georgia's Mental Health Parity Bill Part 1(a): New Life for Mandated Outpatient Care?

There's been a lot of celebration of Georgia's recently passed, and signed by Governor Kemp, Mental Health Parity Bill, or HB 1013 (a strangely dark reference, in my view, to the Form 1013 authorizing involuntary psychiatric commitment). I've been combing through the language as best I can to find the good, and maybe not so good, about this legislation. I'm splitting my analysis into a couple or three parts to keep the focus clean, and I'm not going to touch as much on the first two parts of the Bill, which address insurance coverage and development of the mental healthcare workforce, neither of which is directly in my wheelhouse. Rather, the primary focus will be on Part 3 of the Bill, which addresses matters of involuntary outpatient treatment, as well as some modifications to involuntary inpatient treatment, as well.

Part 1 of this post focuses on much needed changes and emphasis the bill puts on existing (but rarely utilized) statutes authorizing involuntary outpatient treatment. This is an area of the law I have always felt was heavily UNDERutilized, and by that I mean rarely at all. There are few counties in the State that I know of who even have marginal Court oversight of involuntary outpatient individuals, DeKalb County being the most prominent of those. But even DeKalb's powers in that regard were reactive at best, and really differed little from the tools available to providers for 1013ing a potential inpatient candidate. This Bill goes a long way to empower both providers and especially the Probate Court system to become proactive with individuals who need outpatient care but who are unwilling to engage in it.

The Existing Law

Let's start with the existing statutory parameters for involuntary outpatient treatment. Those can be found in O.C.G.A. §37-3-1(12.1): "Outpatient means a person who is mentally ill and (A) [is] not an [involuntary] inpatient [candidate] but who, based on the person's treatment history or current mental status, will require outpatient treatment in order to avoid predictably and imminently becoming an inpatient; (B) who because of the person's current mental status, mental history, or the nature of the person's mental illness is unable to voluntarily seek or comply with outpatient treatment; and (C) in need of involuntary treatment."

How does this differ from the definitional boundaries for involuntary inpatient care? Well, it essentially identifies the revolving door cases; while the person may not be in a place where they are an imminent threat of substantial harm to themselves or others right now, their current condition, along with their history of either potential harm or hospitalization, suggest that it's only a matter of time before the need for inpatient hospitalization comes back around.

In my view (and what I've been trying to get anyone in the system to hear), what O.C.G.A. §37-3-1(12.1) has offered for years is a mechanism for the Courts to short circuit the in-and-out nature of crisis stabilization. Crisis stabilization units (CSUs) have never been an effective venue for the genesis of meaningful treatment. They are too crowded, their providers have too little time to effectuate meaningful change within a patient, and their use of medications has little if any likelihood of sustainability, as a patient is rarely hospitalized longer than a week at a time, not long enough for medications to prove their worth, if any, or to monitor any unwanted effects of said meds. The end result is a relatively traumatic experience for the hospitalized individual, and not a springboard for them to pursue treatment once discharged.

O.C.G.A. §§37-3-81.1, 37-3-92, and 37-3-93 set the procedural groundwork for involuntary outpatient scenarios. These procedures include due process right protections for patients via a hearing and legal counsel, determination by the Court as to whether a person meets the criteria for involuntary treatment after evidence is presented, and structure for Court and provider involvement for an initial period of max one year, with extended periods available upon legitimate reason provided via a hearing by providers before the Court. O.C.G.A. §37-3-94 follows up with requirements for individualized service plans and follow up to ensure progress. These are the bones for what could be a pretty amazing incorporation of the legal system into a very massive problem of repeated hospitalizations and negative interaction with law enforcement.

With the involuntary outpatient statutes, the Probate Court system in Georgia is given the opportunity to both facilitate meaningful, outpatient treatment, and to monitor both the compliance with, and the development of, that treatment plan. It has always been a potential revolution of intervention in a broken system: take individuals out of hospitals, show them what real treatment is, and make them accountable for improving their lives, all while reducing the likelihood that they end up in the criminal justice system.

And yet, if I were to approach Probate Court judges with this seemingly vast landscape for change, I would be (and have been) mostly met with bewilderment. Why? Because these laws have sat stale in the law books for decades. Court involvement on the civil side of mental health treatment has rarely extended beyond the walls of the hospitals, where the Courts are mandated to intervene in cases of lengthy commitments (which are the exception, not the rule). Once a person is discharged, the Courts have generally stepped away, not realizing they had the authority to provide step-down accountability.

This is where the Mental Health Parity law hits a potential home run, and in Part 1(b), I'll go through the changes the new Bill hopes to implement over time.

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