San Francisco outlines Care Court rollout and SB 43 changes, DPH reports case reviews but no guaranteed holds

Dr. Angelica Almeida, who leads implementation work for the Department of Public Health, told the Health Commission on May 7 that San Francisco launched Care Court in October 2023 and has set up systems to evaluate and file petitions in court for adults with schizophrenia-spectrum diagnoses who are not clinically engaged in treatment.

"Care Court allows for a broad range of petitioners," Almeida said, describing family members, first responders, treatment providers and county behavioral health as potential petitioners. She said the program is intended as an upstream intervention that may order individuals into treatment for up to 24 months when a judge finds the criteria met.

DPH described its operational approach: a consultation line screens potential cases, staff assemble evidence and petitions for the court, and DPH works to engage individuals in voluntary services when possible. "In total, since October, we've had 75 cases come through our Care Court consultation line," Almeida said.

Almeida emphasized that Care Court is narrow in scope. It applies only to adults with a schizophrenia-spectrum diagnosis (excluding, she said, diagnoses such as bipolar disorder or primary major depression) and requires proof that a person is not clinically stabilized and meets criteria such as being unlikely to survive safely in the community without intervention.

She also laid out the program timeline and limits. "From when a petition gets filed to when it's possible to have a court order is at least 4 and a half months," Almeida said, stressing that Care Court is not a rapid emergency remedy and that the department aims to keep cases out of court when less-restrictive options are appropriate.

The presentation shifted to Senate Bill 43, which Almeida said took effect Jan. 1 and amended the Lanterman-Petris-Short Act27s definition of grave disability. The revised definition adds inability to care for personal safety or necessary medical care and expressly permits severe substance use disorder to be a standalone criterion. Almeida gave examples the department will consider under the new law, including repeated near-fatal overdoses and failure to tend wounds that risk limb loss.

Almeida said the Department of Public Health had been involved in 156 cases under the new grave-disability criteria but clarified that involvement does not mean each matter resulted in involuntary holds or conservatorship. "That's not to say that 156 cases have moved toward involuntary holds or even conservatorship," she said, calling the number a measure of cases reviewed rather than outcomes.

Commissioners pressed on enforcement and resources. Commissioner Gerardo asked how Care Court enforces compliance if a person refuses services; Almeida replied there are few direct enforcement mechanisms and that the court relies in part on what she called the "black robe effect" to encourage engagement, while involuntary hospitalization or conservatorship remain separate, more restrictive pathways. Several commissioners asked about bed capacity and the lack of funding for rollout; Almeida and Director Colfax acknowledged the program is unfunded and said DPH has reallocated internal resources to support implementation.

Almeida described training efforts. She said San Francisco has roughly 1,600 individuals authorized to initiate 5150 holds and that the department completed virtual and recorded trainings in December to update authorization requirements and ensure staff understand the SB 43 criteria.

Almeida and commissioners repeatedly framed Care Court and SB 43 as limited, carefully scoped tools meant to expand options for a small group of vulnerable people while emphasizing voluntary care and alternatives such as assisted outpatient treatment and conservatorship when warranted. Almeida closed by noting that the legislation is untested in many respects and that DPH will continue providing guidance and updates as implementation proceeds.

The commission did not take an action on Care Court or SB 43 at the May 7 meeting; staff committed to ongoing reporting and requested continued support from the commission for resource needs.