Legislature(2019 - 2020)DAVIS 106

03/05/2020 03:00 PM HEALTH & SOCIAL SERVICES

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Audio Topic
03:06:40 PM Start
03:07:21 PM Presentation: Addressing Gaps in the Crisis Psychiatric Response System
03:49:00 PM HB86
04:32:19 PM HB183
04:57:08 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: Addressing Caps in the Crisis TELECONFERENCED
Psychiatric Response System by
- Dept. of Health & Social Services
- Dept. of Law
Heard & Held
-- Testimony <Invitation Only> --
Heard & Held
-- Testimony <Invitation Only> --
+ Bills Previously Heard/Scheduled TELECONFERENCED
PRESENTATION: ADDRESSING GAPS IN THE CRISIS PSYCHIATRIC RESPONSE                                                            
[Contains discussion of HB 303, SB 238, and HB 304.]                                                                            
3:07:21 PM                                                                                                                    
CHAIR ZULKOSKY announced  that the first order  of business would                                                               
be a  presentation on Addressing  Gaps in the  Crisis Psychiatric                                                               
Response System.                                                                                                                
3:08:13 PM                                                                                                                    
HEATHER  CARPENTER, Health  Care  Policy Advisor,  Office of  the                                                               
Commissioner, Department  of Health  and Social  Services (DHSS),                                                               
relayed  that there  had been  a high-visibility  case which  had                                                               
resulted in  a report  to the courts  on January  21, "Addressing                                                               
Gaps in  the Crisis Psychiatric  Response System."  She  said Ms.                                                               
Kraly would share  an overview and then she would  share the DHSS                                                               
response and plan to implement the order by the judge.                                                                          
3:08:59 PM                                                                                                                    
STACIE  KRALY,   Chief  Assistant  Attorney   General,  Statewide                                                               
Section  Supervisor,  Human   Services  Section,  Civil  Division                                                               
(Juneau), Department of Law, acknowledged  that there had been "a                                                               
long-time  crisis  within  the  acute  psychiatric  care  in  the                                                               
Anchorage area."  She reported that  about a year and a half ago,                                                               
two  lawsuits were  filed:   the Public  Defender Agency  filed a                                                               
claim for individuals  that was predicated upon a  writ of habeas                                                               
corpus; and  the Disability  Law Center of  Alaska (DLC)  filed a                                                               
lawsuit  seeking  injunctive  relief   so  DHSS  would  not  hold                                                               
individuals  in correctional  facilities  longer than  absolutely                                                               
necessary   while  waiting   transportation  to   evaluation  and                                                               
stabilization centers for proper  mental health evaluations.  She                                                               
reported the two  cases were consolidated and the  judge issued a                                                               
61-page decision in late October  2019 granting the relief sought                                                               
by DLC,  while the  relief sought by  the Public  Defender Agency                                                               
was left  open and not  dismissed, even though the  habeas corpus                                                               
petitions  were moot  because the  individuals had  been released                                                               
from  jail.   She added  that there  was still  an open  question                                                               
before  the court  for interim  relief.   The  judge granted  the                                                               
injunction by  DLC, and his  findings articulated that  the State                                                               
of Alaska must  develop a robust plan to meet  these gaps in care                                                               
and to  meet the  challenges that were  identified in  his order,                                                               
which  was released  about six  weeks after  the decision  by the                                                               
court.   She added that  the parties were in  active negotiations                                                               
for settlement.                                                                                                                 
3:12:04 PM                                                                                                                    
MS. CARPENTER  highlighted parts of  the 30-page report  DHSS had                                                               
submitted [included in members'  packets].  She highlighted there                                                               
had  been  many hours  worked  with  stakeholders, including  the                                                               
Alaska State  Hospital and Nursing Home  Association (ASHNHA) and                                                               
the   two  designated   evaluation   and  treatment   facilities,                                                               
Fairbanks Memorial  Hospital ("Fairbanks Memorial")  and Bartlett                                                               
Regional Hospital ("Bartlett")  in Juneau.  She  added that there                                                               
had  been  work with  Department  of  Corrections (DOC)  and  the                                                               
Alaska Mental  Health Trust  Authority (AMHTA).   There  had been                                                               
requests to "not  break what was working in  the Fairbanks region                                                               
and in the Juneau region."   She offered examples for both, which                                                               
included that  individuals are not  allowed at DOC  facilities on                                                               
Title 47  holds.  She stated  that the plan had  an Anchorage and                                                               
Southcentral Alaska focus due to the input of the stakeholders.                                                                 
MS. CARPENTER talked about the  extensive background of the plan,                                                               
including the history of the  Alaska Psychiatric Institute (API),                                                               
the  history  of  designated  evaluation  and  stabilization  and                                                               
designated  evaluation  and  treatment (DES/DET)  centers.    She                                                               
noted the plan  also included discussion of the  efforts to study                                                               
the  problem and  efforts that  were  implemented, including  the                                                               
1115 waiver and the efforts of  Senate Bill 74 in 2016 to address                                                               
behavioral health  gaps.  She shared  that the 90-day plan  has a                                                               
stipulation that  a statewide DES/DET  coordinator will  be hired                                                               
and work from the Office of  the Commissioner in DHSS.  This will                                                               
consolidate  what  is  currently happening  differently  in  each                                                               
district and  done by the Department  of Law to track  the active                                                               
Title 47 individuals, to determine  how long they are waiting for                                                               
beds, and  to help connect them  to open beds.   She reminded the                                                               
committee that those beds could be at  API or in any of the three                                                               
DET facilities, Fairbanks Memorial  with 20 beds, Mat-Su Regional                                                               
Medical  Center ("Mat-Su  Regional") with  16 beds,  and Bartlett                                                               
with  12 beds.   She  opined this  consolidation would  allow for                                                               
better  response  to  the  partners.    She  explained  that  the                                                               
individual  in  the  Office  of the  Commissioner  would  have  a                                                               
different relationship with providers;  instead of working with a                                                               
paralegal, he/she  would be  working "with  somebody who  is more                                                               
health focused and very responsive."                                                                                            
3:15:31 PM                                                                                                                    
MS.  KRALY, in  response to  Representative Spohnholz,  explained                                                               
there  were two  contractual  arrangements with  providers.   She                                                               
said a DES facility is a  shorter-term facility, as are in Bethel                                                               
and Ketchikan.   Those  facilities offer  a robust  mental health                                                               
evaluation to determine whether  an individual meets the criteria                                                               
for a 30-day commitment, although  people are generally only kept                                                               
in these facilities for seven days.   She explained that DET is a                                                               
more  robust  system,  as mentioned  earlier,  where  individuals                                                               
could be committed  for 30 days.  She added  that a commitment of                                                               
longer than 30 days is usually at API.                                                                                          
3:16:30 PM                                                                                                                    
MS.  CARPENTER  directed attention  to  the  "Fiscal Summary  for                                                               
Settlement"  [included  in  members' packets]  which  included  a                                                               
budget amendment  submitted for  fiscal year  2021 (FY  21) which                                                               
would be funded  by Trust authorized receipts as  well as federal                                                               
funds for  the DES/DET  coordinator position.   She  relayed DHSS                                                               
also  proposed  to hire  a  statewide  adult protective  services                                                               
worker dedicated to discharge planning  from hospitals and DOC to                                                               
appropriate placements  for longer  term care or  connection with                                                               
family members.   She shared  an anecdote for  the prioritization                                                               
of vulnerable individuals.   She noted that this  would be funded                                                               
by AMHTA along with federal funds.                                                                                              
3:18:18 PM                                                                                                                    
MS. CARPENTER  reported that the  judge had declared that  it was                                                               
necessary  to  identify  procedures and  mechanisms  to  evaluate                                                               
someone  subject  to  an  evaluation order  who  had  waited  for                                                               
admittance to a  facility to determine whether  that person still                                                               
met  the  evaluation  criteria  or could  be  transported  to  an                                                               
alternative facility.   She shared, "This  was a little bit  of a                                                               
particular  pain point  for our  partner hospitals;  however, the                                                               
department has  proposed our  method of meeting  this is  that we                                                               
will use  a provider agreement  to hire  a pool of  mental health                                                               
professionals that  can be  dispatched to  a non-DET  facility to                                                               
reevaluate individuals  who have been  waiting ... over  48 hours                                                               
for admission  into a longer-term  facility."  She noted  DOC was                                                               
excited  to  have a  mechanism  to  help  with  this need.    She                                                               
reported that this  would be funded in  partnership with $300,000                                                               
from AMHTA and $300,000 from the general fund.                                                                                  
3:19:50 PM                                                                                                                    
REPRESENTATIVE TARR asked whether  the pool of professionals were                                                               
an "on-call" group, and what type of services would be provided.                                                                
3:20:12 PM                                                                                                                    
MS. CARPENTER said that was exactly what had been envisioned.                                                                   
3:20:30 PM                                                                                                                    
MS. CARPENTER  moved on to report  that DHSS would order  the API                                                               
wait  list by  priority, with  clinical factors  in mind,  rather                                                               
than chronologically.   She reported  that as the  department had                                                               
been ordered to focus on  the respondents at DOC facilities, DHSS                                                               
would partner  with DOC to  create a process for  notification to                                                               
DHSS for Title  47 admissions before the court  order was issued.                                                               
She  stated  the  DES/DET coordinator  would  assist  in  finding                                                               
appropriate evaluation  placements outside  DOC and  local jails.                                                               
She  opined that  this would  be a  "pretty simple  form for  our                                                               
partners" at DOC;  however, there was not  an automatic mechanism                                                               
to know  whether "they  have somebody sitting  in a  DOC facility                                                               
that has  been titled."  She  declared that it was  the intention                                                               
of DHSS  to meet the goals  of the court for  persons not charged                                                               
with  a crime  but  suffering from  acute  psychiatric needs  and                                                               
waiting  in a  DOC facility;  however, DHSS  could not  guarantee                                                               
this in  all cases.   She offered  the example that  sometimes in                                                               
Rural Alaska, the  local jail may be the only  safe place to hold                                                               
someone  until   transportation  could  be  arranged   to  a  hub                                                               
community or larger city.   She noted that Governor Mike Dunleavy                                                               
had introduced  three bills to  "help address that process":   HB
303 and SB 238,  regarding involuntary commitment procedures; and                                                               
HB 304, regarding psychiatric  examinations commitment and sanity                                                               
for  criminal cases.   In  response to  Representative Spohnholz,                                                               
she deferred to  Deputy Commissioner Wall to  describe the intent                                                               
behind the governor's bills.                                                                                                    
3:23:17 PM                                                                                                                    
ALBERT  WALL, Deputy  Commissioner, Office  of the  Commissioner,                                                               
Department  of  Health  and  Social   Services,  in  response  to                                                               
Representative  Spohnholz,  explained  that  HB 303  and  SB  238                                                               
addressed the two types of  involuntary commitment to psychiatric                                                               
hospitals.   One  was a  psychiatric  commitment performed  under                                                               
Title  12  for  a  criminal  procedure, while  the  other  was  a                                                               
psychiatric  commitment  performed under  Title  47  for a  civil                                                               
procedure.   He declared  there had  been longstanding  issues on                                                               
both sides  concerning who  had custody of  the patient  and what                                                               
the  procedure was  for that  commitment process.   He  explained                                                               
that  Title 12,  the  criminal procedure,  had  a requirement  in                                                               
statute  that  the  evaluation  be  performed  by  two  certified                                                               
forensic psychologists.   He  declared that  the State  of Alaska                                                               
had never  been able to  comply with  the statute, as  there were                                                               
only about  275 certified forensic  psychologists in  the nation,                                                               
and none in  Alaska.  He explained that the  proposed bill was an                                                               
effort  to make  Alaska  statute  more in  line  with what  other                                                               
states do.                                                                                                                      
3:24:53 PM                                                                                                                    
REPRESENTATIVE CLAMAN asked whether  the current standard was for                                                               
both psychiatrists and psychologists.                                                                                           
3:25:00 PM                                                                                                                    
MR.  WALL  clarified,  "That  is correct."    He  explained  that                                                               
although the  statute allowed for either,  even the psychiatrists                                                               
working at  API or a similar  facility may not feel  qualified in                                                               
the  area   of  forensics   specifically  and   would  disqualify                                                               
REPRESENTATIVE  CLAMAN  asked  whether  the  number  of  forensic                                                               
psychiatrists was even smaller.                                                                                                 
MR.  WALL expressed  his agreement.   He  explained the  proposed                                                               
bill dealing  with the  civil involuntary  process was  about the                                                               
"who  and when"  for the  custody of  a patient.   He  stated, as                                                               
there had been some unclear  practice for when DHSS custody would                                                               
begin in the evaluation process,  the proposed bill would clarify                                                               
that this  would begin  at the time  the evaluation  takes place.                                                               
The proposed  bill would  also clarify that  DET should  have the                                                               
full 72 hours  for the evaluation process, as it  often took this                                                               
much time  for a  patient in  crisis to  stabilize enough  for an                                                               
effective evaluation.                                                                                                           
3:27:25 PM                                                                                                                    
MS. CARPENTER  continued with  the presentation.   She  said DHSS                                                               
recognized  that full  implementation of  the plan  would require                                                               
the continuation of "several  pieces," including forward movement                                                               
with  hospital  partners  to  make  improvements  to  the  entire                                                               
Behavioral Health  system.  The  department plans to  engage with                                                               
hospitals  and  other front  line  behavioral  providers on  best                                                               
practices and to  ensure that tele-psychiatry is  available.  She                                                               
said  hospitals requested  that the  department connect  [API] to                                                               
the Emergency  Department Information  Exchange (EDIE)  system so                                                               
that  emergency  room  (ER) doctors  can  find  prior  medication                                                               
information for  a patient.   She added that DHSS  would continue                                                               
to support  a full continuum  of care, including the  new options                                                               
for crisis  stabilization.  She  reported there was  an extensive                                                               
list of  these considerations  on pages  21 and  22 of  the plan.                                                               
She added  that DHSS  had recommended two  changes to  the Alaska                                                               
Court System for amendment of court forms.                                                                                      
3:28:52 PM                                                                                                                    
REPRESENTATIVE  TARR  asked  whether  the  best  practices  would                                                               
include   discussion   about   improvement  for   the   grievance                                                               
MS.  CARPENTER replied,  "Absolutely."   She said  DHSS was  also                                                               
speaking with the ASHNHA.                                                                                                       
MS.  CARPENTER suggested  a modification  for  the two  different                                                               
notifications  of  rate  forms  into one  form,  so  the  DES/DET                                                               
coordinator could encourage  its use by the partners.   She added                                                               
DHSS had  also asked the Alaska  Court System to change  its form                                                               
for ordering  an individual to be  treated or placed at  API or a                                                               
DET facility.   She explained  that currently, the judge  had the                                                               
discretion to  determine which facility,  which she  opined could                                                               
limit the options  when attempting to quickly place  a patient in                                                               
an available bed.   She said DHSS was asking that  this be a more                                                               
generic form, so the coordinator  could find the most appropriate                                                               
placement in conjunction with the partners.                                                                                     
3:31:12 PM                                                                                                                    
CHAIR ZULKOSKY asked whether the  DET facilities are able to have                                                               
a patient within their purview for up to 30 days.                                                                               
MS. CARPENTER  offered her understanding that  the DET facilities                                                               
do take  the 30-day commitments  and would likely move  a longer-                                                               
term patient to API.                                                                                                            
CHAIR  ZULKOSKY  asked  about   the  discharge  and  coordination                                                               
process  for patients  arriving  from other  parts  of the  state                                                               
after an extended stay at either API or another facility.                                                                       
MS. CARPENTER explained  that when an individual  was admitted to                                                               
a  DET facility  with  a Title  47, DHSS  would  ensure that  the                                                               
transportation was paid.  For  example, Bartlett would often send                                                               
a hospital staff member as  a travel companion with an individual                                                               
[in its  Mental Health  Unit] to  ensure the  patient was  on the                                                               
final plane  to his/her  home community.   She reported  that the                                                               
Bartlett social  worker would  find out  what the  patient needed                                                               
upon discharge  and would set  up these items with  the providers                                                               
in the patient's  home community to make sure  that the discharge                                                               
was  successful.    She  noted   that  as  often  there  was  not                                                               
compensation  for  this extra  work,  DHSS  had proposed  funding                                                               
administrative grants  for DES  and DET,  pointing out  that this                                                               
was  not compensated  by Medicaid  or the  daily bed  rate.   She                                                               
reported that  DHSS had proposed  $125,000 for each  DES facility                                                               
and $250,000  for each  DET facility, which  was detailed  on the                                                               
included spread sheet [included in  members' packets].  She added                                                               
that DHSS  had also requested  $375,000 for contingency  money to                                                               
incentivize additional DES and DET providers.                                                                                   
CHAIR  ZULKOSKY   asked  whether   Bartlett  had  paid   for  the                                                               
referenced travel  support through "financial  collaboration with                                                               
the state."                                                                                                                     
MS. CARPENTER  answered that the financial  collaboration for the                                                               
transportation  would be  handled by  the Division  of Behavioral                                                               
Health,  while the  rest of  the  discharge planning  was at  the                                                               
expense of the individual providers.                                                                                            
CHAIR ZULKOSKY asked for the  percent of Alaskans discharged from                                                               
a facility not into their home community.                                                                                       
MS. CARPENTER  acknowledged that as  there were a  limited number                                                               
of  facilities,  there   would  be  "a  lot  of   out  of  region                                                               
3:36:26 PM                                                                                                                    
MS. CARPENTER reported  that the plan included  a commitment with                                                               
the  partners for  a timely  implementation of  the "Crisis  Now"                                                               
model, which  she had reviewed in  Arizona.  She reported  on the                                                               
three  legs of  the plan:    an improved  statewide call  center,                                                               
mobile  crisis  teams,  and  crisis  stabilization  with  a  full                                                               
continuum of care.                                                                                                              
MS. CARPENTER  declared that these  were funded through  the 1115                                                               
behavioral health  waiver.  She  noted that there was  a Medicaid                                                               
funding  mechanism  to  fund  the  bulk of  the  services.    She                                                               
reported that  DHSS recognized that successful  implementation of                                                               
the  plan required  several appropriation  item requests  through                                                               
the Alaska  State Legislature.   She stated  that money  had been                                                               
requested   through  a   judgement   and  claims   line  in   the                                                               
supplemental  budget for  crisis  placement provider  agreements,                                                               
$678,000  from  the  UGF  funded with  Medicaid  receipts.    She                                                               
explained that this was for  placements of individuals with civil                                                               
psychiatric needs  in which API  or a  DET facility might  not be                                                               
the  best placement.    She pointed  out  that these  individuals                                                               
could have  complex medical  needs as  well as  behavioral health                                                               
3:38:50 PM                                                                                                                    
MS.  CARPENTER said  DHSS was  requesting disproportionate  share                                                               
(DISH)   hospital   funding,   which  would   be   $4.5   million                                                               
undesignated general  fund (UGF) money matched  with $4.5 million                                                               
federal funding.  She pointed out  that there had been a two-year                                                               
appropriation in 2018 of $14 million to expand services.                                                                        
MS. CARPENTER said  DHSS sees DISH as important  for stability in                                                               
psychiatric crisis  response.  She said  Alaska Regional Hospital                                                               
("Alaska Regional")  was able  to get $2  million over  two years                                                               
for a category of DISH  funding called "substance abuse treatment                                                               
provider."    Alaska  Regional   was  qualified  because  of  its                                                               
contract  with  the MyHealth  Clinic,  to  which Alaska  Regional                                                               
referred patients for outpatient  substance abuse treatment.  The                                                               
DISH funding received  was critical to keeping  that clinic open,                                                               
she stated, and  if the DISH funding  ended at the end  of FY 20,                                                               
then analyzation  of services would  need to take place  and only                                                               
some  allowed to  continue.    Ms. Carpenter  offered  by way  of                                                               
example a  social worker who had  been dedicated to the  ER, who,                                                               
without  funding,  would  likely  be shifted  to  assisting  with                                                               
discharge planning  for Medicaid patients with  longer lengths of                                                               
stay.   Telepsychiatry has been  implemented in the past  year to                                                               
complement  the  tele-behavioral  health program,  Ms.  Carpenter                                                               
related, adding that  a behavioral health response  team had been                                                               
put in place with the funding  as well.  Even though DISH funding                                                               
is for  uncompensated care,  all payers  have benefited  from the                                                               
additional positions.                                                                                                           
MS.  CARPENTER  offered as  a  last  example Fairbanks  Memorial,                                                               
which received  $2.2 million to  set up  a single point  of entry                                                               
psychiatric emergency room.   Fairbanks Memorial had  been one of                                                               
Alaska  Regional's  providers for  20  years,  and funds  it  had                                                               
received  for the  single point  of entry  allowed it  to improve                                                               
quality of  care in the  ER with  patients who were  seeking help                                                               
with  behavioral  and  mental  health  services.    In  order  to                                                               
accomplish   this,  Fairbanks   Memorial  had   hired  additional                                                               
personnel   including   social    workers,   security   officers,                                                               
psychiatrists, and legal assistants.   Ms. Carpenter acknowledged                                                               
the work Fairbanks  Memorial had done for  behavioral health, and                                                               
relayed details about the number  of encounters during its single                                                               
point  of entry,  in which  they tripled  the requirement  of its                                                               
3:42:50 PM                                                                                                                    
MS. CARPENTER  related the last  fiscal piece was  increasing DET                                                               
secure  transport   by  $500,000,   which  went  back   to  Chair                                                               
Zulkosky's comment about making  sure there were enough resources                                                               
to get individuals back to their home communities.                                                                              
3:43:09 PM                                                                                                                    
CHAIR ZULKOSKY  asked how many  beds were available  at Bartlett,                                                               
Mat-Su Regional,  and Fairbanks Memorial,  as well as at  the DES                                                               
MS. CARPENTER said she would  follow up with DES information, but                                                               
noted that Fairbanks Memorial had  20 beds, Bartlett 12, and Mat-                                                               
Su 16,  for a total  of 48 beds  outside API.   In response  to a                                                               
follow-up question,  she offered  her understanding that  API had                                                               
50 beds,  but she said she  would get back to  the committee with                                                               
that information.                                                                                                               
3:44:17 PM                                                                                                                    
The committee took an at-ease from 3:44 p.m. to 3:49 p.m.                                                                       

Document Name Date/Time Subjects
Fiscal Summary for Settlement of 3AN-18-09814CI.pdf HHSS 3/5/2020 3:00:00 PM
Addressing Gaps in the Crisis Psychiatric Response System
Addressing Gaps in the Crisis Psychiatric Response System--2 page overview.pdf HHSS 3/5/2020 3:00:00 PM
Addressing Gaps in the Crisis Psychiatric Response System
HB183 ver M Supporting Document Combined Letters of Support 3.3.2020.pdf HHSS 3/5/2020 3:00:00 PM
HB 183
HB 183 v.S.pdf HHSS 3/5/2020 3:00:00 PM
HB 183
CSHB 86 ver U Letters of Support 3.28.19.pdf HHSS 3/5/2020 3:00:00 PM
HB 86
Addressing Gaps in the Crisis Psychiatric Response System.PDF HHSS 3/5/2020 3:00:00 PM
Addressing Gaps in the Psychiatric Response System
HB 86 Version U Amendment 1.pdf HHSS 3/5/2020 3:00:00 PM
HB 86
HB 183 Version S Amendment 1.pdf HHSS 3/5/2020 3:00:00 PM
HB 183