Legislature(2007 - 2008)CAPITOL 106
10/30/2007 03:00 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Substance Abuse and Mental Health Strategies | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
October 30, 2007
3:17 p.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Bob Roses, Vice Chair
Representative Anna Fairclough
Representative Wes Keller
Representative Paul Seaton
Representative Sharon Cissna
Representative Berta Gardner
MEMBERS ABSENT
All members present
OTHER LEGISLATORS PRESENT
Senator Bettye Davis
Senator Fred Dyson
Senator Joe Thomas
COMMITTEE CALENDAR
SUBSTANCE ABUSE AND MENTAL HEALTH STRATEGIES
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to report
WITNESS REGISTER
JEFF JESSEE, Chief Executive Officer
Alaska Mental Health Trust Authority (AMHTA)
Department of Revenue
Anchorage, Alaska
POSITION STATEMENT: Presented an overview on behalf of the
Alaska Mental Health Trust Authority (AMHTA).
WILLIAM HOGAN, Deputy Commissioner
Office of the Commissioner
Division of Behavioral Health
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Presented background on the existing
systems of care within the Department of Health & Social
Services (DHSS).
MELISSA STONE, Director
Division of Behavioral Health
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Presented a PowerPoint report titled
"Behavioral Health in Alaska".
GORDON HANES, Vice President
Behavioral Services Division
Southcentral Foundation (SCF)
Anchorage, Alaska
POSITION STATEMENT: Presented a report on behalf of
Southcentral Foundation (SCF).
DWAYNE PEEPLES, Deputy Commissioner
Office of the Commissioner
Department of Corrections (DOC)
Juneau, Alaska
POSITION STATEMENT: Presented a report from the Department of
Corrections (DOC).
COLLEEN PATRICK-REILLY, Mental Health Clinician
Department of Corrections
Anchorage, Alaska
POSITION STATEMENT: Provided additional information from the
Department of Corrections (DOC).
SUSAN OHMER, Executive Director
Petersburg Mental Health Services, Inc.
Petersburg, Alaska
POSITION STATEMENT: Presented a report from the Petersburg
Mental Health Center.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:17:02 PM.
Representatives Wilson, Roses, Fairclough, Keller, Seaton,
Cissna, and Gardner were present at the call to order. Also in
attendance were Senators Davis, Dyson, and Thomas.
^Substance Abuse and Mental Health Strategies
3:17:29 PM
CHAIR WILSON announced that the only order of business would be
a presentation regarding Alaska's mental health care history and
the challenges of providing behavioral health care.
3:21:00 PM
JEFF JESSEE, Chief Executive Officer, Alaska Mental Health Trust
Authority (AMHTA), Department of Revenue, informed the committee
that Alaska's behavioral health system is severely challenged to
meet the needs of the state. However, a positive step toward
moving forward has been taken in the recognition of the
connection between mental health and substance abuse. This
recognition has resulted in the critically important realignment
of the administrative and budget structures to reflect
behavioral health, which integrates both substance abuse and
mental health services. This is critical because of the need
for providers to work together, and also because of the large
overlap of people with co-occurring disorders. In the past,
procedures have prevented people from getting the integrated
care that is needed. However, there are still challenges to be
met; for example, funding mechanisms still reflect the past
systems for delivering care and are not meeting the needs of
today. In fact, mental health systems grew up under a medical
model and can still be successfully billed under a primary third
party mechanism like Medicaid. But, unlike mental health,
substance abuse services are poorly reimbursed by the Medicaid
system. Mr. Jessee reminded the committee that, a number of
years ago, the state refinanced the vast majority of general
fund mental health and substance abuse grants into the Medicaid
program in order to achieve the benefits from leveraging the
funds. There were problems with this and AMHTA advised that the
Medicaid program is a dependent-creating entity because a
patient must demonstrate a permanent disability; a health system
that gives an incentive for a patient to declare permanent
disability is not desirable. Also, with Medicaid dependence,
patients are dependent upon federal policy decisions. The
federal government is very concerned with the cost of Medicaid
and thus is systematically ratcheting back on eligibility and
reimbursements, which will result in additional expense to the
state budget. Additionally, when funding for care is dependent
on Medicaid, providers must wait for people to get worse and
destitute before they can be served. Intervention and
prevention grants no longer exist. This is not an issue of
whether the state will pay for services or not; the state will
pay for the needs of these patients, either through the
behavioral health system or through the Department of
Corrections (DOC) and in emergency room visits. These costs are
often unreimbursed and are spread across the rest of the system
of care. Nevertheless, he expressed his belief that there is a
promising future.
3:27:37 PM
MR. JESSEE stated that AMHTA, in cooperation with the Native
health system, the legislature, and the Denali Commission,
worked very hard on the Bring the Kids Home initiative. By
reinvesting dollars in community services that had been going to
out-of-state services and focusing on results, the number of
kids placed out-of-state has been reduced from 425 to 260. The
same can be done with behavioral health and the DOC. He opined
that the DOC is the largest mental health provider in Alaska and
incurs ever increasing expenses to build additional prisons and
to place prisoners out-of-state. Furthermore, 40 percent of
prisoners experience significant mental illness, 18 percent
experience severe mental illness, and the recidivism rate is
substantially higher for those identified with behavioral health
issues. Mr. Jessee emphasized that these statistics can be
changed with a sufficient investment strategy.
3:30:45 PM
REPRESENTATIVE GARDNER asked whether these changes can come with
a redistribution of existing funds, with the addition of more
funds, or both.
MR. JESSEE stated that the first step is a focused capacity
expansion within the behavioral health system and AMHTA is
capable of developing a plan, similar to the Bring the Kids Home
initiative, to accomplish this. However, very few initiatives
will save a lot of money; what they do is invest in the
community by keeping the funds spent on care within the state.
He advised that the DOC expansion should be used as a benchmark
and to demonstrate that strategic investments in the community
behavioral health system can dramatically reduce long term
capital and operating costs to the state.
3:32:37 PM
CHAIR WILSON observed that the committee is studying possible
solutions for the future.
3:33:10 PM
REPRESENTATIVE CISSNA shared her realization that the state has
had the same problems over the course of many years; alcohol
abuse and climbing suicide rates. She opined that the manner of
the delivery of service is paramount; in fact, if the state
partnered with the people of Alaska and had a different attitude
with services, there would be a huge difference. She then asked
whether legislation can encourage good health among fellow
citizens.
MR. JESSEE replied yes. He stated that encouraging peer support
does not have to be a large expensive government program; in
fact, in Anchorage there is a community emergency system, built
for $15 million by smart investments in community services.
There is a proven track record of accomplishment when
organizations work together and make strategic investments.
3:37:37 PM
WILLIAM HOGAN, Deputy Commissioner, Office of the Commissioner,
Division of Behavioral Health, Department of Health and Social
Services (DHSS), related his background in mental and behavioral
health care. In 2003, DHSS was reorganized so that the Division
of Mental Health and the Division of Alcoholism and Drug Abuse
were merged to create the Division of Behavioral Health.
Additionally, management of Medicaid dollars was given to that
agency and an integrated service delivery system was created
throughout Alaska. The force behind the merger was the
recognition that nearly 60 percent of mental health patients
have co-occurring mental and substance abuse disorders. The
intent behind integration was to develop a system to better
serve those individuals. Previously, substance abuse patients
with mental disorders were referred for mental health treatment
and their addictions were not addressed. Conversely, mental
health patients with addictions were deferred treatment until
their substance abuse disorder was mitigated. This merger
established a system where standardized screening and
comprehensive treatment for both behavioral and mental health is
the reality. Ideally, the agencies are staffed with providers
who are trained to treat both types of conditions and to
facilitate the full continuum from treatment to recovery. In
addition, those designing the merger also envisioned an array of
services, from the smallest villages to large hub communities,
that will begin the first steps of prevention and intervention
before serious problems develop. Mr. Hogan explained that it
was felt that the merger could change the entire system; develop
a model behavioral health statute, and write regulations that
made clear what the eligibility requirements are and what
providers, services, and rates were available. He agreed that,
in some instances providers overly rely on Medicaid due to the
nationwide lack of grant funding currently available for
behavioral health reimbursement. This is a special challenge in
Alaska, where Medicaid payments for adult substance abuse
services are limited. He then focused on performance outcomes;
a system was needed to answer the criticism that money was being
been allocated to services that have no way to illustrate their
effectiveness. Therefore, now DHSS has a mechanism by which
providers can report whether a patient returns to work or
school, has successful relationships, and stays out of the
criminal justice system. Mr. Hogan expressed his value of the
vision of DHSS that was begun in 2003.
3:45:00 PM
MELISSA STONE, Director, Division of Behavioral Health,
Department of Health and Social Services, began the presentation
by stating that the mission of the Division of Behavioral Health
is to provide a comprehensive and integrated system that works
from a basis of sound policy, effective practices, and
partnerships. A review of the indicators of behavioral health
conditions and social impact indicates: suicide is the highest
cause of death for youth aged 14 to 19; the highest rate in
Alaska is in the Northwest Arctic; and 72 percent of the
suicides involve drug and alcohol use. Furthermore, suicide
rates across the state are significantly higher for Natives. A
national telephone health survey from 2006 illustrates the
relationship between physical health and behavioral health. She
noted that in Mat-Su, Soldotna, Wrangell, and Petersburg there
is indicated clear partnerships between primary care and
behavioral health. Ms. Stone pointed out that alcohol is the
most widely used substance of abuse among American youth,
although there is concern about methamphetamines and inhalants,
alcohol remains the most prevalent problem nationally and in
Alaska. She referred to the PowerPoint presentation "Behavioral
Health in Alaska" that provided the estimates of behavioral
health conditions throughout the state; the number of Alaskan
adults and children experiencing severe mental illness; those
with mild to severe mental illness; those with substance abuse
problems; and those who did not receive treatment for alcohol
[abuse]. Further, an online survey indicated that mental health
illness is the most significant health related impact on lost
productivity in the workplace. She continued to say that the
national societal cost is higher not to treat those who abuse
alcohol and drugs than to treat them. Costs of the untreated
are spread out and shared by social services, employers,
prisons, hospitals, [the threat to] public safety, and insurance
companies. The percentage of traffic fatalities related to
alcohol is 38.9 percent nationally and 48.6 percent in Alaska.
Societal costs in Alaska are costs to: productivity, the
criminal justice system, the health care system, the public
assistance system, and public safety.
3:52:16 PM
MS. STONE introduced the idea of a comprehensive array of
services throughout the state; the organization of services
breaks down the vast areas of the state into levels 1 through 5,
from the frontier village through the metropolitan areas.
Citizens living in Level I areas expect a community health aide
and itinerant health care services to provide health and social
services; in Level 3, citizens would expect private and
government health care, and a social services system. The
capacity of levels throughout the state, relative to government,
economy, and health and social services access, indicates where
the level of behavioral health care services is warranted. Ms.
Stone stated the DHSS goals of performance based funding: the
assessment of access to an array of services throughout the
state, from prevention to outpatient treatment for substance
abuse and mental health; the comparison of clients served; the
prevalence estimates; and the funding received in each region.
Ms. Stone continued to explain that the current behavioral
health provider system is an integrated system, consisting of
103 behavioral health treatment and recovery providers, 64
prevention and early invention grantees, and a staff supported
psychiatric hospital licensed for 80 beds. In 2007, 5,413
substance abuse clients were served; 9,034 seriously emotionally
disturbed youth were served; 15,384 adults with serious mental
illness were served; 42,000 emergency contacts were made; and
1,231 clients were admitted to the Alaska Psychiatric Institute
(API).
3:57:04 PM
REPRESENTATIVE SEATON asked whether the emergency contacts are
also counted in the number of clients served for various levels
of treatment.
MS. STONE responded that an emergency contact may, or may not,
be a person with a serious illness.
REPRESENTATIVE SEATON surmised then that there may be 20,000
emergency contacts that are not in any other category.
MS. STONE said yes. She clarified that the emergency system is
set up throughout the state for crisis intervention. These
contacts do not necessarily involve a seriously ill mental
patient who is receiving services; the calls are simply a crisis
contact and are counted each time a call is received.
3:58:56 PM
CHAIR WILSON asked whether an emergency room or a clinic's call
for support is counted.
MS. STONE replied yes. A telephone contact may be a client, a
health care provider, an agency, a jail, or a person walking
into a clinic or emergency room.
3:59:55 PM
REPRESENTATIVE ROSES asked whether subsequent referrals were
included in the count.
MS. STONE said no.
4:00:17 PM
MS. STONE continued to explain that the DHSS screening indicates
that 57 percent of clients statewide show signs of a dual
diagnosis. The client satisfaction status review results for
2006 is the collection of aggregate data for the state and
indicates that 78 percent of adults, and 81 percent of youth,
were satisfied with service from the provider. She informed the
committee that consumer satisfaction surveys are compiled from
youth, children, and adults.
4:01:59 PM
REPRESENTATIVE GARDNER asked when the satisfaction surveys are
collected after treatment.
MS. STONE answered that the surveys are mailed to clients
annually.
4:02:46 PM
MS. STONE spoke again about the success of the Bring the Kids
Home initiative. She then pointed out that the telemedicine
delivery of psychiatric care is important to reach rural areas
of the state. A brief discussion of the challenges to care
begins with the shortages of qualified providers, and directors,
in the workforce.
4:04:12 PM
REPRESENTATIVE CISSNA asked whether there is adequate funding
for health care training programs.
MS. STONE deferred this question to Mr. Jessee.
4:05:07 PM
MS. STONE acknowledged that a further challenge is performance
based funding; the need to be accountable is recognized by
providers and requires changes in the way they do business. In
2009, there will be more data available on which to base
decisions for performance based granting. Other challenges to
providing care include: geographic challenges; distribution of
grants throughout the regions to provide an array of services;
economies of scale; outreach; and transportation. Outreach and
transportation are necessary costs uncompensated by Medicaid.
The significance of cultural differences, particularly when
standardizing data and accounting for patient care down to the
minute, is great. Finally, Ms. Stone pointed out the challenge
of balancing support and accountability with providers.
Providers are running businesses that are becoming more complex
and challenging; it is important to support providers so that
they can provide service and thrive in order to meet needs of
the people across the state.
4:09:33 PM
GORDON HANES, Vice President, Behavioral Services Division,
Southcentral Foundation (SCF), presented his review of the
Alaska Native health care system and the emerging opportunities
that are possible when SCF is able to partner with the state.
He reminded the committee of the legislative landmarks that are
the keys to understanding the Native health care system: the
Alaska Native Claims Settlement Act (ANCSA); the Indian Self-
determination and Education Assistance Act of 1975, Public Law
93-638, that provides tribes three options for the delivery of
health care; and the Indian Health Care Improvement Act, Public
Law 94-437.
4:12:30 PM
CHAIR WILSON asked which option for the delivery of health care
was chosen under the Indian Self-determination and Education
Assistance Act.
MR. HANES answered that the Alaska Native tribes elected to
compact health care with the government.
4:12:49 PM
MR. HANES further highlighted key dates. The SCF was chartered
by the state in 1982 under the direction of the Cook Island
Region, Inc., (CIRI). He explained that SCF is the designated
tribal health care authority and is responsible for the health
care functions for that region. In 1994, the Alaska Native
Tribal Health Compact was established to begin self-governance
over the federal financial health care resources designated for
the Indian people and Alaska Natives. Mr. Hanes pointed out
that the Alaska Native Tribal Health Consortium (ANTHC) was
formed in 1997 and provides specialty medical care, community
health services, construction of water and sanitation
facilities, information technology, training and educational
support, and further statewide Indian Health Service (IHS)
functions. In addition, with SCF, ANTHC co-owns and co-manages
the Alaska Native Medical Center. He noted that ANTHC is owned
by all Alaska Natives and their regional corporations. He
compared the early days of Southcentral Foundation with today
and stated that SCF's annual budget is $150 million. Further,
SCF owns and operates the Alaska Native Primary Care Center
(PCC) on the campus of the University of Alaska, Anchorage
(UAA). Thirty percent of all Alaska IHS beneficiaries are
active users of SCF facilities.
4:16:28 PM
MR. HANES continued to explain that the Behavioral Services
Division of SCF includes two out-patient clinics, residential
treatment for adolescents, group homes for adolescents,
transitional living support, and a residential treatment program
for pregnant women and new mothers, a day treatment center for
the mentally ill, an elder program, and two head start programs.
SCF sources of revenue come from IHS compacting funds, Medicaid,
federal grants, and the small state grants that open the door to
Medicaid. Mr. Hanes stated that IHS funds are disbursed
annually on a regional basis and SCF is struggling to provide
services for those who are coming into the Anchorage area from
other regions.
4:18:55 PM
CHAIR WILSON asked for a breakdown of the third party revenue.
MR. HANES answered that third party revenue consists of
Medicaid, Medicare, and private insurance. In response to a
question, he further clarified that IHS money is an annual
appropriation that SCF augments with third party revenue.
CHAIR WILSON surmised that a problem is created when regional
money does not follow a patient to Anchorage or another urban
area.
MR. HANES said that, unfortunately, [the funding] is a federal
issue.
4:20:29 PM
REPRESENTATIVE CISSNA related that costs are increasing in rural
areas; for example, Dillingham mail cost increased $1 per pound.
Managers of rural health facilities complain that, even with
increased administration costs, there is still population
growth, although some areas are losing the breadwinners. She
also pointed out that, especially in the university medical
area, the number of patients is weakening the capacity for
service.
MR. HANES noted that SCF has determined that a disproportionate
number of elders, with their higher medical expenses, are moving
to urban areas.
4:22:51 PM
MR. HANES informed the committee that the federal government's
appropriations to fund American Indian and Alaska Native health
care are far below what is provided to other populations and has
been for quite some time. Further information on funding
revealed that the Federal Medical Assistance Percentage (FMAP),
Early & Periodic Screening, Diagnosis and Treatment (EPSDT) and
continuing care agreements are the basis for the funding that
enables SCF to provide services. FMAP reimburses to the state a
portion of Native health cost to Medicare. As a part of
Medicaid reform, the Pacific Health Policy Group identified $220
million currently paid to non-tribal providers for services to
tribal members.
REPRESENTATIVE GARDNER surmised that the state could save money
if tribal organizations were providing services to tribal
members.
CHAIR WILSON clarified that a doctor, providing service through
SCF, would receive payment from Medicaid and not the state.
4:26:17 PM
MR. HANES continued to explain that EPSDT is a federal law that
requires that all Medicaid eligibles, under the age of 21,
receive early and periodic screening and treatment. He reported
that Alaska has not been meeting this requirement; in fact, the
state Medicaid office established continuing care agreements in
order to improve screening rates. These agreements provide
cost-based reimbursement for screening and treatment and have
resulted in the present success in identifying Medicaid
eligibles, registration, and screening. When these services are
provided by a tribal organization, there is no cost to the
state.
4:28:10 PM
CHAIR WILSON asked whether a physician, working under SCF,
maintains independence.
MR. HANES said that he would discuss this subject later in the
report.
4:28:41 PM
REPRESENTATIVE FAIRCLOUGH informed the committee that American
Indians and Alaska Natives are disproportionately represented in
populations with pre-diabetes symptoms. She asked whether pre-
diabetes checks are performed even though the screening is not
covered.
MR. HANES expressed his belief that EPSDT is for Medicaid
eligibles under 21, and thus a complete screening, one that
seeks to identify pre-diabetic conditions, is done.
REPRESENTATIVE FAIRCLOUGH asked whether diabetes is more
prevalent in Alaska due to the high rate of obesity. She said
she was glad for EPSDT screening and that there has been
pressure on the state to consider including pre-diabetes
screening in insurance coverage; money would be saved in the
long run. She expressed her interest in the success rate of
pre-diabetes screening for youth.
MR. HANES stated that he could provide that information.
4:31:09 PM
MR. HANES related that the EPSDT screening began at below the
state average; now, Alaska is well above the state average for
eligibles under 21.
4:32:06 PM
REPRESENTATIVE FAIRCLOUGH asked for the number of children,
under 21, that are insured versus those who have access to
health care. She recalled that testimony from DHSS has been
unable to provide the exact number of Native Alaskans, under 21
years of age, who have access to care; specifically the contrast
of how many youth, 21 and under, whom have access to service
versus how many are insured for service.
MR. HANES agreed that eligibility is very different than access;
however, he felt that the information could be determined
through the regional corporations.
REPRESENTATIVE FAIRCLOUGH made a formal request for the
aforementioned information.
CHAIR WILSON concurred.
MR. HANES said SCF would try.
4:35:13 PM
REPRESENTATIVE CISSNA observed that the tribal health consortium
has a huge responsibility; however, in many very small
communities, telemedicine provides better care than in Anchorage
because everyone is working together, at one time, with the
screening information. She asked whether there has been an
effort to put together the current status of health care on a
community-by-community basis.
MR. HANES agreed about the difficultly of coordinating care. He
acknowledged that telemedicine is a growing entity and
behavioral care is pushing ahead with telepsychiatry resulting
in exciting outcomes.
4:37:43 PM
MR. HANES discussed an on-going pilot project between SCF and
the state that looks at managed behavioral health care for
tribal beneficiaries. Another specific partnership, the Bring
the Kids Home Initiative and the Residential Psychiatric
Treatment Center (RPTC) development, is the result of
unprecedented partnerships between the Denali Commission, the
state, and a tribal organization. The RPTC will bring care for
kids, 40 percent of which are Native, home to Alaska.
Furthermore, care provided by in-state tribal organizations will
reap financial and health benefits to the state. The projected
opening for the RPTC, located in Eklutna, is two years from now.
He concluded by emphasizing the importance of FMAP, EPSDT,
continuing care agreements, and the state's partnership, to the
SCF and its efforts to provide services.
4:41:48 PM
DWAYNE PEEPLES, Deputy Commissioner, Office of the Commissioner,
Department of Corrections (DOC), informed the committee that the
DOC operates 12 in-state facilities and is one of five states
that operate unsentenced jail services and sentenced prison
services in all facilities except for Spring Creek in Seward;
additionally, prison services are leased at Red Rock
Correctional Center in Arizona. The incarcerated population is
beginning to accelerate in the number of bookings and will
likely hit 38,000 bookings and 22,000 offenders, in and out,
which is up from about 16,000 offenders in 2001. He mentioned
that, historically, DOC experiences spikes such as now, and
included in that percentage is a higher percentage of bookings
from the mentally ill. He explained that services provided by
DOC include mental health clinicians, or contractors, in all
facilities and telepsychiatry. He stated that there is a total
of 43 staff in the mental health field. In fact, there are two
major acute mental health units; one at the Anchorage jail with
28 beds, and one at the Hiland facility with 18 beds. There are
three sub-acute units: Spring Creek in Seward, Hiland Mountain,
and Palmer Correctional. He stated that the mental health
release programs target individuals returning to society so that
they may receive support systems in the mental health
environment in order to stop recidivism. Some of increases in
bookings are associated with the increased failure of released
inmates in a community setting. Mr. Hogan stated that the DOC
can lay claim to being the largest single mental health care
provider; a draft study of the DOC and mental health inmates
revealed that approximately 40 percent to 43 percent of the
inmate population would qualify for mental health care under the
trust. This is growth from a previous benchmark of about 35
percent. He continued to say that the mental health staff has
about 12,000 mental health inmate contacts annually and there
has been a 40 percent jump in mental health contacts from 2001
through 2006. Many inmates have had previous contact with the
Alaska Psychiatric Institute (API); in fact, approximately 15
percent of the mentally ill offenders have been admitted to API
at one time. He concluded that the increase of former API
patients in the offender population is due to inadequate
community housing and poor follow-up with drugs and services to
the mentally ill.
4:49:19 PM
MR. PEEPLES stated that the DHSS is attempting to qualify
existing clients for pre-release by establishing Medicaid
eligibility under the social security system; in fact, it is
trying to put more effort in providing outpatient pre-release
planning and services.
4:49:47 PM
COLLEEN PATRICK-REILLY, Mental Health Clinician, Department of
Corrections, informed the committee that she has seen some
positive changes by the DOC. She explained that the DOC now has
in place four targeted mental health release programs. One is
for felony offenders who are going to be released on felony
probation or parole and who have a psychotic disorder. This is
a mandatory program and staff work closely with probation
officers and community providers to establish effective programs
to prevent new offenses. In addition, there is the Anchorage
Mental Health Court; DOC manages the Jail Alternative Services
(JAS) portion of that program which has a total caseload of 80.
She noted that the committee will probably be approached to
expand the service provided by the Anchorage Mental Health
Board. There is also (indisc.) mental health court program that
operates with a broad diagnostic caseload. Also, Ms. Patrick-
Reilly described a new initiative called Assess, Plan, Identify,
Coordinate (APIC) and that is based on a national best practices
initiative through the national New Freedom Commission on Mental
Health. In 2007, APIC funds will be used to include other
agencies with contracts for management and services. She said
that the DOC feels strongly that interagency collaboration is a
key component for success. APIC will link individuals to
services, medication, housing, and benefits, and will begin
assisting inmates pre-release and after release. Community
providers will continue services directly with the beneficiary.
Ms. Patrick-Riley stated that the state has a real problem with
connecting individuals to the appropriate array of community-
based services, including safe and sober housing; currently
there is no halfway or transitional housing that is acceptable
for mentally ill and behaviorally challenged individuals.
Furthermore, there are no housing options in the community for
the most seriously mentally ill and behaviorally challenged
individuals. Management after release for these sub-
populations, such as mentally ill offenders who have committed
sex offenses, is not working well.
4:55:38 PM
MS. PATRICK-RILEY continued to explain that the delivery of
services, from 2002 to the present, has changed. She opined
that a reduction in mental health services directly correlate to
the increased DOC booking numbers. The DHSS budget shift to
Medicaid does not target all individuals and even individuals
who are covered by Medicaid lack the level of services that were
available prior to the shift. Thus, DOC is the default provider
of mental health services. She expressed her belief that
agencies are discussing options to improve critically needed
funding for community based services. Ms. Patrick-Riley
continued to explain that agencies have a Memorandum of
Understanding in place to expedite social security applications
for individuals exiting DOC who have severe mental illness; this
program is the first in the nation. Additionally, Alaska was
selected for funding as a SSI/SSDI Outreach, Access and Recovery
(SOAR) Project site; a special program that will assist homeless
mentally ill individuals to complete social security
applications. Ms. Patrick-Riley turned to the subject of the
mental health workforce and said that, in her experience, mental
agencies are losing workers due to the size of caseloads, lower
pay, and challenging clients. She concluded by saying that the
66 percent recidivism rate within the DOC is a community problem
that lessens with the implementation of mental health release
programs.
4:59:34 PM
MR. PEEPLES added that the DOC has three residential substance
abuse treatment program sites: Wildwood, on the Kenai
Peninsula; Red Rock, in Arizona; and Hiland Mountain.
5:00:02 PM
REPRESENTATIVE CISSNA asked for the presenters to send
information on the linkage of what the DOC is doing with the
dual diagnosis with alcoholism. She shared that inmates have a
difficult time getting services, such as Alcoholics Anonymous
(AA), in the correction system.
MR. PEEPLES said that the information will be forthcoming.
5:01:56 PM
MR. JESSEE informed the committee of the possible role of the
AMHTA; it can be the venture capital funder for an initiative
around rebuilding the state's community behavioral health
system. He stated that AMHTA has the experience to provide the
venture capital once the legislature makes the policy decision
to act on this issue. AMHTA can fund studies and front pre-
development costs. He emphasized the challenge of maintaining a
balance between grants and Medicaid; refinancing in mental
health is accepted, but Medicaid is not enough. Sufficient
grant resources are also needed to provide comprehensive
services and early intervention services. Mr. Jessee reiterated
how critical the Native health organizations are in the
successful treatment of behavioral issues in the community.
Substantial funding can be gained by getting Native health
organizations fully engaged as partners with the state and much
more can be done. He turned to the subject of the workforce and
said that there is no way to retain a workforce when salaries
and benefits are limited because of a rate structure that is
decades old. In fact, at least two community mental health
centers are struggling with deficits due to inflation and
increased costs of overhead. The closures of community mental
health centers will be an unwelcome shock to the public welfare.
Secondly, the lack of training programs will continue to
contribute to the statewide 13 percent vacancy rate. At the
Anchorage Mental Health Center there is a 24 percent vacancy
rate due to a rate reimbursement structure that does not support
salaries sufficient to recruit and retain qualified staff. A
further challenge continues to be housing; if not provided with
safe, affordable, and supported housing, those who exit
corrections and API will be returning to the system at a high
percentage. Case management and 24 hour backup is needed for
behavioral health clients to prevent their eviction and
homelessness.
5:08:35 PM
REPRESENTATIVE CISSNA recalled that the state has repeatedly
funded wonderful programs; however, they are episodic, such as
the Alaska Youth Initiative Program (AYIP), and are discontinued
when funding is cut. She emphasized that the legislature must
be educated as to what is needed to continue these programs.
5:11:21 PM
SUSAN OHMER, Executive Director, Petersburg Mental Health
Services, Inc., informed the committee that, in the last 14
years, Petersburg Mental Health has transformed from a satellite
office that served less than 40 people per year to an
independent center serving over 400 people per year. She said
that the center does whatever is necessary to assist clients to
live independently, avoid institutionalization, and function at
the highest level possible. The center receives funding from
the state for operations and also generates revenue from
Medicaid, third party billings, and fundraising. Her agency
works hard and is accountable to the legislature for its funds.
However, many recent accountability efforts have resulted in
reducing the center's ability to provide services to its
clients, have negatively affected clinical care, and have
weakened the center's effectiveness. Ms. Ohmer explained that
the result of these changes is devastating. She suggested that,
without a base funding for small, regional, mental health
centers, the state must build more prisons and hospitals. Some
of the issues are: revenues have not kept pace with expenses
over the past ten years; unfunded mandates such as the
Management Information System and the onerous Medicaid
documentation requirements; the consolidation of substance abuse
and mental health components that resulted in the loss of staff
and funding yet tripled the number of clients; increasing
administration requirements that have resulted in the
elimination of one clinical position. Her frustration is that
her center will continue to gain auditors and lose clinicians to
serve clients. Ms. Ohmer pointed out that the center must
reduce its clients from 400 to 300 annually, due only to the
additional administrative costs.
5:14:00 PM
MS. OHMER continued to say that, as a director, she is unable to
continue to serve a full caseload and must spend more time on
administrative tasks. She also stressed that her time is
increasingly spent on bolstering the morale of her staff who are
bogged down with administrative demands that are in conflict
with appropriate clinical care. Unlike many rural centers, her
center has had high staff retention and a high employee
satisfaction rate until recently. Furthermore, she pointed out
that the state is moving from a grant based to a performance
based system of funding; what that means for a small center is
that money has been cut based on a formula that is flawed. From
the community perspective, this process does not reflect a
system of accountability, but is a rationale for making budget
reductions. Ms. Ohmer stated that the funding reductions will
further hamper her ability to provide the accounting necessary
to prove results. She cautioned that state accountability
expectations are high, even though there has been little advance
notice given to providers, limited involvement of providers in
developing the system, and no time for providers to build
capacity to respond to the initiative. Ms. Ohmer expressed her
disappointment that funding will be based on criteria that she
did not have sufficient time to prepare for. Furthermore, this
performance matrix system requires accuracy and a validity of
judgment; the variety of environments across the state makes
these judgments very difficult to understand. She emphasized
that one behavioral health center in a small community must
serve all of the community and cannot limit its care to priority
populations. If decision makers are mislead by the measurement
instruments, service to prevent clients from moving into severe
mental illness may end. She emphasized that improving the
quality of behavioral health care statewide is important;
nevertheless, quality improvement should also entail a devotion
of resources and a process of preparation.
5:24:18 PM
MS. OHMER continued to explain that the Division of Behavioral
Health announced that providers need to be nationally
accredited. This action, although welcomed, is another unfunded
mandate placed on local agencies. She observed that providers
are being pulled in opposite directions; staff is working 50
hours per week, including Saturday and Sunday, and is on call 24
hours per day. The reduction of grants will mean that more
cases are refinanced under Medicaid; however, the scope of
Medicaid eligibility is being limited by state budget
constraints. She re-stated that mental health care in the state
will be provided by prisons and hospitals if local centers and
clinics are forced to close. This is the most expensive way to
care for behavioral health constituents. She assured the
committee that everything is being done to ensure accuracy in
accounting, particularly for Medicaid billing. Ms. Ohmer
concluded by saying that providers look to the committee to
consider the issues in funding and to advocate for a reasonable
base amount of funding to support services in the smaller
communities.
5:29:20 PM
REPRESENTATIVE ROSES commented that his investigation into this
new accountability system will continue.
5:29:48 PM
CHAIR WILSON recalled that the grants will pay only for
emergency mental health clients; others are not included. This
results in a low funding base that is not sufficient to cover
clients not in crisis, such as those in schools.
MS. OHMER confirmed that there are priority populations for
services and state grant funds must only be used to provide
services for those priority populations. This system provides a
way for the state to record whether providers are effective and
efficient. However, providers see many clients who need
services, but do not qualify as a member of a priority
population and thus, the center has to raise money in other ways
to support the staff to serve those people. Essentially, the
providers are penalized for providing services that might
prevent those not in priority populations from becoming severely
mentally ill.
5:32:22 PM
REPRESENTATIVE CISSNA recalled visiting Petersburg and seeing
the amazing work being done there and in other communities;
there is a need to make sure that these small health care
clinics survive.
5:33:23 PM
CHAIR WILSON requested, from each presenter, a list of things
that need to be accomplished either with, or without, action by
the legislature.
5:34:32 PM
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 5:34:42 PM.
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