Improving Mental Health Guardianship: From Prevention to Treatment

Of the 56 experts, 46 (82%) participated in at least one round, of whom 43 (93%) provided input in round 1; 32 (70%) reviewed round-2 charts and discussion boards, with 21 (66%) posting their own discussion comments; and 33 (72%) responded to round-3 questions. Half of the 46 participating experts were women (N=23); 41% (N=19) were hospital-based clinicians and clinical administrators, 28% (N=13) worked at outpatient facilities, and the remaining 30% (N=14) represented legal, advocacy, policy, and forensic organizations.

Although all nine strategies were deemed ethically appropriate, panelists agreed with each other and provided high ratings across all four criteria for only one strategy (Table 1). Experts either disagreed with each other or saw feasibility of the remaining strategies as uncertain, which could be attributed to either the need for more information or that the strategy required more resources. Seven strategies were considered efficient, and six were seen as likely to improve care quality. Table 1 shows the rating results, and Table 2 presents qualitative findings for the three highest-ranked strategies. (Appendix 3 in the online supplement describes the remaining six strategies.)

The highest-ranked strategy—“improve the administrative functioning of the Los Angeles County Office of the Public Guardian (OPG) and the judicial processes in establishing and managing conservatorship”—was the only strategy rated highly on all criteria. The most salient qualitative theme centered on tele-testimony, which could greatly streamline the process by allowing clinicians—and possibly patients—to testify remotely. Clinicians can spend many valuable hours waiting at court and may not be notified of schedule changes in a timely manner. As one expert put it, “Tele-testimony would be very helpful. Our physicians spend an enormous amount of time at D95 [mental health court].” In the process of establishing and managing conservatorship, clinicians have a disincentive to appear in court and occasionally do not appear, which may result in repeated rescheduling, premature expiration of the conservatorship, and case dismissals. Tele-testimony could result in less wasted time, greater clinician availability, fewer trials missed by clinicians, and shorter hospital stays for patients. Allowing patients to testify offsite could also resolve transportation issues that hospitals face in transferring clients to and from court. Experts doubted that current technological capacities were sufficient (i.e., new systems would likely need to be purchased and installed) and noted potential resistance to change and fear of new technology, which was reflected in a lower score on feasibility. Nonetheless, they did not consider these barriers insurmountable, which may explain why this strategy was rated as more feasible than others. Overall, experts thought that the nominal costs for improving technology would considerably improve the process. However, some noted that streamlining would ultimately enable more people to be placed into conservatorship, so the strategy would be a good use of resources only if guardianship capacity increased correspondingly.

Another common theme was the need for improved coordination among public guardians, outpatient clinics, and hospital staff and the difficulty and cost associated with connecting and integrating them. Other less frequent comments focused on the need to reduce OPG caseloads to speed up the process. Some experts stated that in some cases, the California Supreme Court caused bottlenecks, rather than OPG. Generally positive comments expressing overall approval (e.g., “[This strategy] should be implemented”) greatly outweighed negative comments.

The second-highest-ranked strategy was to enhance the ability of full service partnership (FSP) programs or other intensive outpatient teams to identify and serve individuals before they become gravely disabled. FSP teams are modeled on the assertive community treatment model that provides field-based, multidisciplinary, and intensive clinical care to individuals with severe mental illness in California. Experts considered this strategy to be ethically appropriate, likely to have positive impact, and efficient but had concerns about its feasibility. Of all the strategies, however, the FSP approach raised the most concern among experts, who noted that explicit standards of care would need to be established and monitored and that FSP teams would need ongoing high-quality training in best practices. The resources needed to make this strategy successful may have been the reason for the lower feasibility rating. As one expert explained, “Feasibility will depend on the amount of resources available and consistent standards of services and outreach by the FSP service providers.” In addition, with greater outreach comes increased need for services and housing, which are already limited. Although experts liked that this strategy had the potential to provide care in the least restrictive environment possible, they noted the challenges of serving persons who lack insight into their illness or refuse services. This strategy was considered a good use of resources because it could prevent the need for more costly acute services.

The strategy “develop new unlocked outpatient settings for individuals after they have been conserved by expanding and enriching the continuum of unlocked residential environments” was ranked third. Comments indicated that this strategy may increase patient well-being. “Having a supportive place to live is essential to building on the gains of an inpatient stay,” one expert noted. This strategy was also rated positively on all criteria except feasibility, perhaps because of concerns about funding to implement it and the number of services and beds available. As with all outpatient strategies, experts mentioned the complexities of providing mandated care in an outpatient setting and the potential for elopements. They emphasized the need for screening to determine which patients would be successful in an outpatient setting, for outpatient providers to agree to provide mandated medications, and for establishing and monitoring standards of outpatient care.

Our study is the first to critically examine the viability of strategies to improve the guardianship process in Los Angeles County. It incorporated diverse expert perspectives to produce recommendations applicable in other settings. Improving administrative functioning and judicial processes was the only strategy that panelists agreed on and rated highly on all four criteria. Experts perceived some opportunities that could greatly streamline the conservatorship process and make better use of scarce resources through technology. The Los Angeles Superior Court has already made strides toward paperless systems and records for mental health court proceedings and routinely uses tele-testimony in criminal proceedings (26), as the California Court Technology Advisory Committee (formerly called Task Force) recommended 25 years ago (27). However, at the time this panel was conducted, Los Angeles County had not yet to used tele-testimony for LPS conservatorship proceedings (26). A recent survey of 333 California judicial officers found that 85 had used video technology in court proceedings, but only five had used it in conservatorship, guardianship, and mental health proceedings (27). Video testimony was deemed a particularly beneficial potential improvement, and most judicial officers were satisfied with its use during proceedings (27). Courts that do not use this technology should consider its potential for speeding up conservatorship trials, preserving clinician availability, and providing more timely care to individuals in need.

Strategies that expanded the use of community-based services were generally rated highly. These strategies include increasing the quality and assertiveness of outpatient treatment and fostering access to high-quality, unlocked residential settings. Although panelists endorsed tenets of deinstitutionalization and community integration in this way (28, 29), some uncertainty about feasibility of community-based services may be explained by the commonly voiced concern that, until an individual is in a conservatorship, providers lack the authority to provide involuntary treatment. Panelists who raised concerns about community-based services pointed out that the very purpose of conservatorship is to care for those who will not voluntarily engage in needed services. However, proponents of community-based services suggested that with screening to identify appropriate patients, many patients could be successful in a stepped-down environment. Experts were more confident about the ability of outpatient settings to be successful once individuals had been placed in a conservatorship, arguing that it is necessary for outpatient settings to have the added authority that court orders confer or that a period of treatment in a hospital is generally appropriate for someone awaiting a conservatorship determination. Although our panelists indicated that increased capacity was needed at all levels of care, they felt that the high cost of locked IMD beds might add burden to an already underresourced system and draw resources away from less restrictive community-based settings. Nonetheless, increasing the number of locked IMD beds was seen as one of the two most efficient strategies.

Underlying the challenges of providing court-mandated care in unlocked community settings is the ongoing ethical and practical problem of providing involuntary treatment while preserving the patient’s right to the least restrictive environment possible. As our results show, the dominant qualitative theme pertained to appropriate levels of care and supervision, and experts carefully weighed each strategy against its perceived impact on individual autonomy. Pursuing legislative changes was the least desirable strategy in part because experts were concerned that it could impinge on individual rights by increasing the use of restrictive settings. Experts also cautioned that strategies to increase the use or capacity of locked IMDs must carefully consider patients’ right to receive care in the least restrictive environment.

For almost all strategies, experts noted the need to ensure the existence of high-quality services and processes for oversight and accountability. In particular, outpatient settings need to have established standards of care, evidence-based approaches to treatment, and external monitoring. Experts also noted that FSP teams can vary widely in quality and suggested that access to updated training and consistent adherence to best practices would improve the overall quality of the services. Their perception is confirmed by the literature, with a recent study of 93 California FSP teams finding large variation in implementation practices and philosophical approaches to housing placement and consumer choice (30).

We used an innovative online modified-Delphi expert panel approach that allowed us to solicit input from diverse experts on ways to improve the conservatorship process in Los Angeles County. Although our expert sample was large, only 33 of the 46 experts provided their round-3 ratings used to rank-order the strategies; however, attrition is typical for Delphi panels (31). Although diverse, our panel was dominated by medical professionals, with less than a third of experts representing legal, advocacy, policy, and forensic organizations. Finally, although our study focused specifically on Los Angeles County and on the strategies that have been discussed in this county, we believe the findings could be useful for other localities that serve individuals with serious mental illness through similar guardianship mechanisms. For example, establishing telecommunication court services and expanding the continuum of psychiatric services are likely to benefit mental health consumers regardless of locale.

Our results suggest a role for holistic reform that encompasses all stages of the guardianship process for individuals with mental illness who are gravely disabled. The three highest-ranked strategies were for interventions before, during, and after the conservatorship process, indicating readiness for improvements across all stages. Since our study, the Los Angeles County Department of Mental Health has already undertaken initiatives that address experts’ priority areas (32). For instance, it has expanded the availability of unlocked outpatient residential settings able to serve persons in conservatorship and implemented a “conservatee FSP” program to increase the number of individuals in conservatorship living in the community served by an FSP team that coordinates with the OPG. A comprehensive quality improvement process is underway within the FSP program to ensure enrollment of individuals at risk for grave disability and to increase accountability to outcomes. As counties across California and the nation seek strategies to address high rates of chronic homelessness among individuals with mental illness, guardianship as a mechanism to engage hard-to-reach individuals will continue to be a key piece of a comprehensive mental health strategy (33).

The authors thank Dr. Jonathan Sherin, Ms. Kei Nagao, and Ms. Anna Bruce for their commitment to advancing this work. They are also grateful to the following members of the DMH+UCLA Public Partnership for Wellbeing team for their important contributions: Dr. Patricia Lester, Ms. Gita Cugley, Mr. Joseph Mango, Dr. Nichole Goodsmith, Ms. Jaclyn Resnick, Dr. Lisa Davis, Dr. Caryn Bernstein, Ms. Elizabeth Mackey, Ms. Nancy Alfaro, and Ms. Sacha Fernandez. The authors express their gratitude to all participants in the expert panel.