Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_90-cv-00520/USCOURTS-caed-2_90-cv-00520-1344/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983 Prisoner Civil Rights

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8 UNITED STATES DISTRICT COURT 

9 FOR THE EASTERN DISTRICT OF CALIFORNIA 

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17 As required by court order, Apr. 18, 2024 Order, ECF No. 8206, the parties have filed a 

18 Joint Report providing the last proposal for a medical holds exception to the Program Guide 

19 transfer timelines for transfer to the Correctional Clinical Case Management System (CCCMS) 

20 and Enhanced Outpatient Program (EOP) levels of care together with statements of their 

21 respective positions regarding whether the court should require defendants to adopt that proposal 

22 as an addendum to the Program Guide. ECF No. 8216. 

23 I. BACKGROUND 

24 The background relevant to this issue is set out at pages 14 to 17 of the court’s 

25 November 16, 2023 order, ECF No. 8069, and incorporated herein full by reference. In that 

26 order, the court held that a policy conflict between a medical holds policy set out in the HCDOM 

27 and the CCCMS and EOP transfer timelines set out in the Program Guide would have to be 

28 resolved “for defendants to comply with the Eighth Amendment.” Id. at 17. The court directed 

RALPH COLEMAN, et al., 

Plaintiffs, 

v. 

GAVIN NEWSOM, et al., 

Defendants. 

No. 2:90-cv-0520 KJM DB P 

ORDER 

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1 the parties to meet and confer under the supervision of the Special Master “to develop proposed 

2 exceptions to the Program Guide timelines for transfer to CCCMS and EOP levels of care that 

3 comport with other court-approved exceptions to Program Guide transfer timelines and avoid 

4 unnecessary conflict with relevant provisions of the HCDOM [Health Care Departmental 

5 Operations Manual].” Id. at 17. The parties were unable to reach agreement on proposed 

6 exceptions. ECF No. 8090 at 2. Therefore, on April 18, 2024, the court ordered the parties to 

7 submit the outstanding conflict to the court “for review and final resolution.” Apr. 18, 2024 

8 Order, at 4, ECF No. 8206. Specifically, the court directed the parties to “file a joint statement of 

9 their respective final positions as presented in the meet and confer process . . . accompanied by 

10 the last proposal discussed prior to the parties’ determination they could not reach agreement and 

11 a brief statement setting out their respective positions as to whether the court should require 

12 defendants to adopt that proposal as an addendum to the Program Guide.” Id. at 4-5. On April 

13 25, 2024, the parties timely filed the required joint statement. ECF No. 8216. 

14 II. DISCUSSION 

15 The last proposal discussed by the parties is as follows: 

16 If a patient has a medical condition that cannot be treated at the endorsed institution 

17 and the medical condition is deemed more urgent than the mental health treatment 

18 need at or after the time of endorsement, as determined by a joint team of medical 

19 and mental health clinicians, a medical hold shall be ordered. The relative urgency 

20 of the medical and mental health needs, as dictated by the patient’s condition, shall 

21 be continually monitored by the joint team, and mental health staff shall document 

22 in the electronic healthcare record the reasons that the medical need continues to 

23 outweigh the mental health need. At each discussion of the continuing 

24 appropriateness of the medical hold, the joint team shall determine when the next 

25 discussion should take place. Mental health staff shall document the discussion in 

26 the electronic healthcare record, including the names and positions of those who 

27 participated in the discussion, the date and time the discussion occurred, the 

28 determination reached, and the specific rationale for the determination. 

29 If, upon resolution of the medical issue, there are fewer than 30 days remaining on 

30 the original transfer timeline or if the transfer timeline has already expired, the 

31 patient shall be placed on the expedited transfer list and transferred within 30 days. 

32 When a medical hold is removed, the provider removing the hold shall contact the 

33 referring mental health clinician and document the communication of removal of 

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1 the medical hold in a progress note. The [provider responsible] for lifting the 

2 medical hold will notify the C&PR to ensure expedited transfer and the patient shall 

3 be transferred as expeditiously as possible. 

4 ECF No. 8216-1 at 20, as modified by ECF No. 8216 at 3-4. Two disputes remain: “(1) the 

5 scope of the review by the joint medical and mental health team concerning the reasonableness of 

6 the medical hold when weighing it against the need to transfer the patient to a mental health 

7 program; and (2) whether there is a need for an oversight mechanism of the joint medical and 

8 mental health teams’ reviews.” ECF No. 8216 at 4. 

9 The first dispute arises from plaintiffs’ proposal that the exception include language to 

10 require the joint medical and mental health team to determine both that the medical need is more 

11 urgent than the mental health need and that the medical need cannot be treated at any institution 

12 that has the appropriate level of mental health care to which the patient has been referred. Id. at 

13 7. Specifically, plaintiffs propose the exception include the following language: 

14 If the medical condition is deemed more urgent than the mental health treatment 

15 needed, and the joint team determines that the medical condition cannot be 

16 appropriately treated at a CCCMS or EOP institution where the patient would 

17 otherwise be transferred, a medical hold shall be ordered in accordance with current 

18 policy if one is not already in place, or an existing medical hold may be maintained. 

19 If the medical condition is deemed more urgent than the mental health treatment 

20 need, but the joint team determines that the condition may be treated appropriately 

21 at a CCCMS or EOP institution, the medical hold shall be lifted. 

22 Id. at 13. 

23 Defendants object to this proposal principally due to the many complexities that attend 

24 institutional placement decisions. See id. at 7-8. Defendants suggest the balancing test they 

25 proposed is the same as that found in three other medical exception policies the court has 

26 approved. Id. at 8. Plaintiffs contend medical exceptions for compliance with transfer timelines 

27 to psychiatric inpatient programs (PIPs) and from desert institutions include provisions similar to 

28 the one they propose here. Id. at 13. 

29 The CCCMS and EOP mental health programs are the largest in the California 

30 Department of Corrections and Rehabilitation’s (CDCR) Mental Health Services Delivery System 

31 (MHSDS). CCCMS programs are offered at twenty-eight of CDCR’s thirty-two prison 

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1 institutions, and EOP programs are offered at nineteen prisons. See Summary of Mental Health 

2 Population by Institution and Level of Care (H1) (provided by Coleman Special Master from 

CDCR Secure Website for Monthly Reports).1 3 As defendants explain, prison administrators 

4 consider several factors in deciding to which institution an inmate-patient should be transferred. 

5 See id. at 7-8. Absent violation of constitutional standards, the court defers to the judgment of 

6 prison officials in such administrative decisions. Cf. Bell v. Wolfish, 441 U.S. 520, 547-48 

7 (1979). The court accepts defendants’ position that the proper focus of this medical hold 

8 exception is on whether necessary medical care can be provided at the institution to which an 

9 inmate-patient has been endorsed for transfer and therefore will not require the additional 

10 language proposed by plaintiffs. 

11 Plaintiffs also suggest the medical exception policy should “incorporate an oversight 

12 mechanism to ensure that the joint teams’ balancing discussions are occurring as required and that 

13 their decision-making processes are appropriately documented.” ECF No. 8216 at 14. 

14 Defendants object to this proposal on the grounds that none of the other court-approved 

15 exceptions include similar oversight provisions and that such oversight is unnecessary and 

16 counterproductive in this context. Id. at 9-10. Plaintiffs contend the exception must include some 

17 auditing or oversight mechanism to ensure the ongoing monitoring required by the exception 

18 actually occurs and transfers to mental health units are not unconstitutionally delayed. Id. at 15. 

19 As noted above, this dispute has arisen in the context of the ongoing data remediation 

20 process. The data remediation process is central to defendants’ development of an adequate 

21 quality management system, “a required part of the remedy in this action.” ECF No. 8069 at 2. 

22 Defendants represent they can include data on the medical hold exceptions approved by this order 

23 as drill-down data for the indicators for these transfer timelines, ECF No. 8040 at 7, and they 

shall do so.2 24 

25 ///// 

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 The court takes judicial notice of this document. See Fed. R. Evid. 201(b). 

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 The court anticipates the drill-down data collected for these indicators will be sufficient to 

replicate the Special Master’s monitoring in this area; if it is not the Special Master will bring that 

to the attention of the parties and, if necessary, the court. 

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1 Finally, the parties dispute whether the medical holds exception policy approved by this 

2 order must be included in the Program Guide. The court has approved all other medical hold 

3 exceptions as addenda to the Program Guide. See Dec. 15, 2017 Order, ECF No. 5750, Sept. 27, 

4 2019 Order, ECF No. 6295, Sept. 17, 2019 Order, ECF No. 6296. Defendants contend that 

5 requiring the medical holds exception to be included in the Program Guide is inconsistent with 

6 the court’s February 7, 2022 order, ECF No. 7456, which relieved the parties of the obligation to 

7 file annual updates to the Program Guide, and that the exception will be adequately integrated 

8 into the relevant remediated data indicators. Id. at 10-11. Plaintiffs contend the exception 

9 “necessarily modif[ies] the current Program Guide transfer requirements” and should be included 

10 as an amendment to those transfer requirements to avoid unnecessary conflicts or confusion. Id. 

11 at 15. 

12 In its February 7, 2022 order, the court discontinued the parties’ obligation to file annual 

13 updates to the Program Guide. ECF No. 7456 at 4. In making that order, the court anticipated it 

14 would give final approval to a list of continuous quality improvement tool (CQIT) indicators by 

15 the end of 2022 and that such final approval would obviate the need for further Program Guide 

16 updates. Id. Final approval of the list of CQIT indicators is delayed pending completion of the 

17 ongoing data remediation process. The court recently clarified that while its February 7, 2022 

18 order “relieved defendants of their obligation to notify the court of administrative updates,” the 

19 court did not affect defendants’ obligation to comply with court orders to implement the Program 

20 Guide. May 20, 2024 Order at 5, ECF No. 8243. The medical hold exception approved by this 

21 order substantively modifies defendants’ obligations under the Program Guide with respect to 

22 transfer timelines to CCCMS and EOP by authorizing certain delays in compliance with those 

23 transfer timelines. The Program Guide must be amended accordingly, and the policy approved by 

24 this order shall be included as an addendum to the operative version of the Program Guide. 

25 III. CONCLUSION 

26 In accordance with the above, the court approves defendants’ final proposal for the 

27 medical holds exception to the Program Guide transfer timelines for transfer to the Correctional 

28 Clinical Case Management System (CCCMS) and Enhanced Outpatient Program (EOP) levels of 

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1 care discussed by the parties and including the agreed upon resolution for expedited transfers, as 

2 follows: 

3 If a patient has a medical condition that cannot be treated at the endorsed institution 

4 and the medical condition is deemed more urgent than the mental health treatment 

5 need at or after the time of endorsement, as determined by a joint team of medical 

6 and mental health clinicians, a medical hold shall be ordered. The relative urgency 

7 of the medical and mental health needs, as dictated by the patient’s condition, shall 

8 be continually monitored by the joint team, and mental health staff shall document 

9 in the electronic healthcare record the reasons that the medical need continues to 

10 outweigh the mental health need. At each discussion of the continuing 

11 appropriateness of the medical hold, the joint team shall determine when the next 

12 discussion should take place. Mental health staff shall document the discussion in 

13 the electronic healthcare record, including the names and positions of those who 

14 participated in the discussion, the date and time the discussion occurred, the 

15 determination reached, and the specific rationale for the determination. 

16 If, upon resolution of the medical issue, there are fewer than 30 days remaining on 

17 the original transfer timeline or if the transfer timeline has already expired, the 

18 patient shall be placed on the expedited transfer list and transferred within 30 days. 

19 When a medical hold is removed, the provider removing the hold shall contact the 

20 referring mental health clinician and document the communication of removal of 

21 the medical hold in a progress note. The provider responsible for lifting the medical 

22 hold will notify the C&PR to ensure expedited transfer and the patient shall be 

23 transferred as expeditiously as possible. 

24 The medical holds exception approved by this order shall be included as an Addendum to the 

25 Program Guide. The CQIT indicators for transfers to CCCMS and EOP programs shall be 

26 designed to capture drill-down data on the medical holds exception approved by this order. 

27 IT IS SO ORDERED. 

28 DATED: June 17, 2024. 

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