CARE Court Was Supposed to Help Those Hardest to Treat. Here's How It's Going

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hen it rolled out last year in eight counties, CARE Court took aim at one of the state’s most vexing challenges: how to treat people whose illness often makes them believe they are not sick and who, if left untreated, can oscillate between jails, hospitals and homelessness.

Using the weight of a judge’s black robe to nudge county health departments’ doctors in white coats to provide an array of services, the program sought to reach the hardest-to-treat cases.

Now, a year after the program went live in seven counties — San Francisco, Glenn, Tuolumne, Stanislaus, Orange, Riverside, and San Diego — and ten months after it launched in Los Angeles County, petitions appear to be trickling in slower than expected and treatment plans are taking longer to put in place.

And, while Gov. Gavin Newsom, who first introduced the initiative in March 2022, initially said it would target those “living on our streets with severe mental health and substance use disorders,” the number of unhoused people going through the program varies widely from county to county.

State Sen. Tom Umberg, who co-authored the legislation that implemented CARE Court, said the gradual rollout hasn’t come as a complete surprise.

“We’re changing the culture here,” he said. “So, that takes a little time.”

As of mid-September, at least 692 petitions had been filed across seven of the counties in the first cohort, excluding San Francisco, according to data provided by superior court and county health officials. Of those petitions, a little more than a third, or 245, have been dismissed. And nearly one in five, or 121 petitions, have resulted in a CARE Agreement, an official document that details a voluntary treatment regime. There have been six court-ordered, or involuntary, CARE Plans issued.

San Francisco has so far received 42 petitions, said Melanie Kushnir, director of the Collaborative Justice Programs at the San Francisco Superior Courts. Of those, she said roughly half are active, meaning the participant is attending hearings and working toward or enrolled in a CARE Agreement. Citing privacy concerns, Kushnir declined to provide data on the exact number of dismissals or CARE Agreements reached but said there had been no CARE Plans issued.

The state had initially estimated that between 7,000 and 12,000 people would qualify for CARE Court each year once the program was fully implemented. But even accounting for the small number of counties that launched last year, court and public health officials agree the number of petitions is far fewer than expected — prompting opponents to argue the program is wasting taxpayers’ dollars.

According to the California Department of Finance, the state has already allocated $72 million to counties for start-up costs, along with $12 million for ongoing operations in fiscal year 2024–25, which will increase to $47 million in fiscal year 2026–27.

“We feel like the program has already failed,” said Samuel Jain, a senior mental health policy attorney at Disability Rights California, which is among the groups that advocated against CARE Court from the start. “The law doesn’t provide any new services and instead directs the limited resources we have to these expensive court processes.”

But supporters say it’s too early to pass judgment on a program that has yet to be fully implemented. The remaining 50 counties are due to open their own programs by Dec. 1.

“To really make some grand statement about its efficacy in the first 12 months of it rolling out, I think, is a leap for a state with 40 million people,” Dr. Mark Ghaly, the outgoing Secretary of California’s Health and Human Services Agency, told KQED. “But I do think that’s exactly the question that we have to keep in mind.”

The number of petitions varies widely

In Glenn County, with a population of around 29,000, just one petition has been filed as of Sept. 12, and it was ultimately dismissed, said Chris Ruhl, executive officer of the Glenn County Superior Court. Ruhl expects one or two more may be submitted soon and that more will follow as word of the program spreads.

“We generally anticipate there will be an increase in the number of petitions and filings, but we don’t know that for sure,” he said. “We’ll be watching very closely.”

At the other end of the spectrum is Los Angeles County, which, with a population of around 10 million, has seen the most petitions: 268 as of Sept. 18. There, the number of petitions has been steadily increasing, Los Angeles Superior Court Judge Scott Herin said.

“I don’t think it started off like everybody expected, which was an overwhelming flood of cases,” Herin said, adding that the gradual ramp-up was perhaps “more healthy.”

That’s allowed some county behavioral health agencies to reappropriate staff assigned to CARE Court to other needs. In Stanislaus County, which has received 47 petitions, 19 of which have been dismissed, Behavioral Health & Recovery Services Director Tony Vartan said some of his CARE Court staff spent the first four to five months doing outreach with police and sheriff departments, hospital workers and others to build awareness.

“But as we saw that trend of those petitions, we pulled back some of our staff, and we assigned them to areas that needed more work,” he said. “Our staff emphasize where the cases are, regardless of what program we manage. That way, we make sure that the staff are working and they’ve got cases.”

Cases dismissed

Despite the lower-than-expected number of petitions, county behavioral health and court staff say they weren’t surprised to see that more than a third have been dismissed. Dismissal rates vary across the counties, from just over 90% in Tuolumne County, where 10 of 11 cases were dismissed, to a low of 26% in both Riverside and Los Angeles counties.

To be eligible, San Francisco Superior Court Judge Michael Begert said participants need to not only be diagnosed with schizophrenia or another psychotic disorder, but they also must be likely to benefit from services, can’t already be enrolled in services, and must be unlikely to survive without additional support.

“And that’s a small eye in a needle to thread,” Begert said.

Algenib Collin is trying to thread that needle as she looks for any program that might help for her daughter.

Collin applied for CARE Court the day it opened, she said, “I was so desperate.”

For roughly 18 months prior, she had seen her daughter, now 27, rapidly deteriorate on San Francisco’s streets. Collin said she would receive a call from the hospital nearly every other week, reporting her daughter had been placed on a 5150, or a temporary mental health hold, only to be rereleased back into homelessness and addiction.

High on fentanyl and possibly other drugs, Collin said her daughter would bang her head against the sidewalk or speak to herself in a language only she could understand.

“My daughter will die if she doesn’t get help,” Collin said. “Believe me.”

However, when it came to determining whether she qualified for CARE Court, the petition was rejected. Collin doesn’t know why, and she may never know. Privacy laws prohibit her from accessing her daughter’s medical records, so she isn’t sure whether her daughter has been formally diagnosed with a psychotic disorder.

The legislation doesn’t include any provision that gives petitioners the right to appeal a judge’s denial, though Ghaly said she could potentially refile the case.

“It’s frustrating,” Collin said. “I don’t want my daughter to die.”

Representatives from the San Francisco Public Health Department declined to be interviewed. Begert said he couldn’t comment on individual cases.

Ultimately, it’s up to the judge to hold public health departments accountable for providing appropriate care, Ghaly said, sharing an anecdote about how officials in San Diego frame the program: “They share with clients that CARE is an approach for the individual to … really get the black robe effect to hold the county accountable. And that’s exactly the way that we had hoped.”

Breaking the pattern

Collin’s experience, however, highlights a disconnect between the way the program was initially described — to, in Newsom’s words from 2022, “break the pattern that leaves people without hope and cycling repeatedly through homelessness and incarceration” — and what was actually written into legislation.

In the first year of the program’s rollout, success rates of getting people who are also experiencing homelessness into the program have varied. In Stanislaus County, for instance, Vartan said roughly 70% of the participants were unhoused before enrolling.

The opposite is true in Los Angeles and Riverside counties, where 30% and 20%–25% of enrollees are experiencing homelessness, respectively, health officials said. In Orange County, the figure is closer to 15%, according to Dr. Veronica Kelley, Director of the Orange County Health Care Agency.

In the former two counties, the majority of petitions have come from family members, health officials said. In Orange County, Kelley said the figure is closer to 40%.

Rather than view this as a failure to reach people who are living outside, Ghaly said he’s actually pleased to see the higher levels of petitions coming from family members on behalf of people who have housing, emphasizing that the goal was not to solve homelessness but to solve the problem of untreated mental illness “upstream.”

“It means that we’re getting to meet them earlier,” he said. “Almost anyone with severe schizophrenia or a psychotic disorder may be at risk of homelessness.”

But, Ghaly acknowledged that because eligibility is narrowly tailored, it may also mean, “We might not see the kind of outcomes that we wanted to see.”

Under the legislation, people whose primary diagnosis is a psychotic disorder are eligible for CARE Court, but those whose psychosis is primarily the result of using drugs are not. Asked whether the state would consider expanding eligibility to include cases of drug-induced psychosis, Ghaly said the question is a “fraught” one.

“If you ask most psychiatrists who take care of patients with these diagnoses and in largely these social circumstances, it’s really hard to tell what came first,” he said. “Was it the substance-use disorder that drove the psychosis? Or, were there underlying psychotic features to some disorder — maybe diagnosed, maybe not — that then drove the substance-use disorder?”

He continued, “Where the state lands at the moment is, there may be a very important population of people who have significant substance-use disorders and these other mental health conditions, who could benefit from CARE. And as we engage with our county partners and the practitioners who are in CARE, we’re asking exactly this question.”

But, even if someone doesn’t end up in CARE Court, health officials say they’re often referred to other programs within the county. And in Orange County, Kelley said 41 out of 95 petitions were dismissed because the client was already receiving services.

“And it would be unethical to remove them from that treatment and stick them over here in court and hope that that works better,” she said.

Ultimately, Ghaly said, that is also part of the point.

“It really is a group of people who didn’t go all the way down the CARE path, but because the CARE pathway was a potential, they got served and supported,” he said.

Building trust

For those who do qualify for CARE Court, the process to reach a voluntary treatment plan or CARE Agreement can be challenging, judges and health officials said. Just building enough trust to get someone to come into court can itself sometimes take two months, Kelley said.

“None of us would be open to a stranger coming up to us and telling us, ‘Come with me to court. I can help you,’” she said. “So, to believe that someone who’s severely impacted by a mental illness would be open to that doesn’t make any sense.”

Kaitlyn Willison, an attorney with Legal Assistance to the Elderly in San Francisco who represents CARE Court participants, said the first step might involve combing the streets to search for people, which takes time. Once the person is found, the next hurdle is building trust.

“That means I need to see them two, three, four times before they go to court,” Willison said. “And the timelines just aren’t set up in a way that allows us as respondents’ counsel enough time to build that really precious trust that we need to best advocate for our clients.”

Umberg said he’s looking into further legislation or possible rule changes within the court system to address the challenges Willison and others have experienced so far.

But Jain, with Disability Rights California, is skeptical. One of those challenges is baked into the nature of the program itself, he said: that it has the potential to veer away from voluntary agreements and into coerced care.

“The bottom line is that the court is a coercive program,” he said.

For Judge Begert in San Francisco, coerced treatment is very much “what we’re trying to avoid.” But, he acknowledged that changing the cultures of both the court system and the mental health care system is no easy task.

“Getting people to change their mindset in a culture that’s very well-formed and static is a hard thing to do,” he said. “You bring the healthcare system into the criminal justice system — or the justice system in general — it starts to act like the justice system. So, that’s always a challenge.”