Legislature(2015 - 2016)CAPITOL 106
04/02/2016 01:30 PM House HEALTH & SOCIAL SERVICES
Note: the audio ![]()
and video ![]()
recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
| Audio | Topic |
|---|---|
| Start | |
| Presentation: "aces" by Dr. Matthew Hirschfeld | |
| Presentation: Citizen Review Panel | |
| Presentation: "aces" by Dr. Matthew Hirschfeld | |
| HCR21 | |
| Presentation: Citizen Review Panel | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| *+ | HCR 21 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
April 2, 2016
2:02 p.m.
MEMBERS PRESENT
Representative Paul Seaton, Chair
Representative Neal Foster
Representative Louise Stutes
Representative David Talerico
Representative Geran Tarr
Representative Adam Wool
MEMBERS ABSENT
Representative Liz Vazquez, Vice Chair
COMMITTEE CALENDAR
PRESENTATION: "ACEs" by DR. MATTHEW HIRSCHFELD
- HEARD
HOUSE CONCURRENT RESOLUTION NO. 21
Urging Governor Bill Walker to join with the Alaska State
Legislature to respond to the public and behavioral health
epidemic of adverse childhood experiences by establishing a
statewide policy and providing programs to address this
epidemic.
- MOVED HCR 21 OUT OF COMMITTEE
PRESENTATION: CITIZEN REVIEW PANEL
- HEARD
PREVIOUS COMMITTEE ACTION
BILL: HCR 21
SHORT TITLE: RESPOND TO ADR. VADAPALLIERSE CHILDR. HIRSCHFELDOOD
EXPERIENCES
SPONSOR(s): REPRESENTATIVE(s) TARR
02/05/16 (H) READ THE FIRST TIME - REFERRALS
02/05/16 (H) HSS, FIN
WITNESS REGISTER
MATTHEW HIRSCHFELD, M.D.
Chair, All Alaska Pediatric Partnership
Anchorage, Alaska
POSITION STATEMENT: Presented "A Systemic Approach and the
Economic Benefits of Identifying and Treating Family Trauma.
TREVOR STORRS, Executive Director
Alaska Children's Trust
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HCR 21, testified in
support of the legislation.
DON ROBERTS
Kodiak, Alaska
POSITION STATEMENT: Testified during discussion of HCR 21.
PATRICK ANDERSON, Senior Research Fellow
Sealaska Heritage Institute
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HCR 21, offered
support for the legislation.
MAUREEN HALL, School Nurse
Juneau, Alaska
POSITION STATEMENT: During the hearing of HCR 21, offered her
experiences regarding the legislation.
DR. DIWAKAR VADAPALLI, Chair
Citizens Review Panel
Institute of Social and Economic Research, Professor
University of Alaska Anchorage
Anchorage, Alaska
POSITION STATEMENT: Presented a PowerPoint titled, "Alaska
Citizen Review Panel, and Annual Update."
CHRISTY LAWTON, Director
Central Office
Office of Children's Services
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Answered questions during the presentation
of the Citizens Review Panel.
ACTION NARRATIVE
2:02:36 PM
CHAIR PAUL SEATON called the House Health and Social Services
Standing Committee meeting to order at 2:02 p.m.
Representatives Stutes, Talerico, Tarr, Wool, and Seaton were
present at the call to order. Representative Foster arrived as
the meeting was in progress.
^Presentation: "ACEs" by Dr. Matthew Hirschfeld
Presentation: "ACEs" by Dr. Matthew Hirschfeld
2:04:00 PM
CHAIR SEATON announced that the first order of business would be
an "ACEs" presentation by Dr. Matthew Hirschfeld.
2:04:07 PM
MATTHEW HIRSCHFELD, M.D., All Alaska Pediatric Partnership,
Chair, said that he is an Anchorage pediatrician and advised
that All Alaska Pediatric Partnership has been working in the
area of adverse childhood experiences and issues related to
child abuse and neglect in Alaska, and the partnership is
interested in ACEs. He turned to slide 1, and noted that in
working with other organizations, the question is how to work
together to decrease these adverse childhood experiences in the
state.
DR. HIRSCHFELD turned to slide 2, "The Developing Brain," and
said this slide clearly shows what can happen under extreme
neglect. He pointed out that the brain on the right side shows
a very different brain from the normal brain. The holes are
called ventricles and are much larger on the brain that
underwent extreme neglect, the brain is much smaller, and it is
organized differently. He extended that this child will never
be able to develop to their full potential having experienced
extreme neglect, but this brain damage can happen anytime a
child is exposed to bad things happening to them, especially
with children between zero and 3-5 years of age. In the event
the neglect is ongoing for a long period of time, that child
exposed to those bad things happening to them will never develop
to their potential. As a pediatrician and as a member of the
All Alaska Pediatric Partnership, he said the intent is for
children to develop to their full potential.
2:07:02 PM
DR. HIRSCHFELD turned to slide 3, "Evidence," and explained that
Dr. V. Felitti lectured in Juneau in February and also gave
great talks all over town. Dr. Felitti is the chief author of
"The Adverse Childhood Experience Study - ACEs Study," and
things that happen to very young children can permanently affect
their health, permanently affect their mental health,
permanently affect whether they can hold jobs, and more. This
is known through a landmark study beginning in 1998, by Dr.
Felitti. He advised that it was a collaboration between CDC and
Kaiser Permanente in San Diego where 17,000 adults with the
average age of 57, were surveyed. He pointed out that by having
adults in the Kaiser Permanente system there is access to their
medical records.
DR. HIRSCHFELD turned to slide 4, "Adverse Childhood Experience
Study," and related that Dr. Felitti wanted to look at 10 events
that could happen in childhood and then relate those to the
health of the adults he was surveying. He then read the list of
10 events surveyed, and explained that Dr. Felitti asked a
series of questions around these 10 events.
DR. HIRSCHFELD turned to slide 5, "ACE: Prevalence data," and
advised that Dr. Felitti found that approximately two-thirds of
the adults surveyed reported having at least one of those things
happening to them, which Dr. Hirschfeld described as a pretty
astounding number. This was a middle-class group of people
being surveyed in San Diego and most of the people had at least
gone to college if not graduated from college and he found that
a huge number of people had been exposed to this as a child.
Interestingly, approximately one-third of the people had zero
yes answers to any of the questions, and all of those people
were quite a bit healthier across all measures.
DR. HIRSCHFELD turned to slide 6, "Health Measures Now Linked to
Adverse Childhood Experiences Score" and said that they were
looking at this huge list of things that can happen to a person
as an adult. Essentially, he pointed out, if a bad thing
happens to a person as a child they are at increased risk for
heart disease, asthma, cancer, sexually transmitted diseases,
suicide, depression,. In fact, he explained, as the number of
yes answers increases, a person's risk of having one of the
listed diseases as an adult goes up step-wise as well. He
described it as a fascinating piece of public health because
that is rarely seen. The link between a high adverse childhood
experience score or answering yes to the questions, and the risk
of having a suicide attempt is actually stronger than the risk
between smoking and lung cancer. Basically, he related every
time a person looks at a bad health outcome that can happen to
an adult, it can be linked back to bad things happening as a
child. He described it as strong data that has been supported
in hundreds of studies over the last 20 years, and the question
today is how to decrease these yes answers in Alaska in order to
decrease the risk of an unhealthy population as adults.
2:10:54 PM
DR. HIRSCHFELD turned to slide 7, "2013 Alaska BRFSS" said that
through the Behavioral Risk Factor Surveillance System (BRFSS)
survey, Alaska has now started to measure ACEs and the Alaska
population. He advised that Patrick Sidmore, the data guru for
Alaska ACEs, with one year of data discovered that for all
Alaskan adults, the state has about the same percentage of
people as the San Diego folks do with zero yes answers to those
questions, and noted that those people are much healthier than
the people who answered yes to the questions. Interestingly, he
commented, Alaska has people answering yes to those questions
more often, and Alaska has more people with four or five plus
yes answers to the adverse childhood experiences questions.
Therefore, Alaska has two-thirds of the people that say yes to
those questions, but Alaska's population is skewed so that
Alaskans' answer yes more often. Which means that, overall,
Alaska's population will not be as healthy because there are so
many bad things happening to children.
2:12:20 PM
CHAIR SEATON asked Dr. Hirschfeld to explain the header on the
slide and whether the first column of percentages is the number
that reported 1 yes, and so on.
DR. HIRSCHFELD replied that the top score is the ACE score - 0,
1, 2, 3, 4, 5+.
CHAIR SEATON noted there are no numbers on there, and he just
wanted clarification.
DR. HIRSCHFELD explained that on the top line is Alaska's
population at 10.8 percent of 5+ bad things happening to them as
children. Alaska has more people in Alaska that say they've had
5+ things happening to them as children than many other states.
DR. HIRSCHFELD turned to slide 8, "Adverse Childhood Experience"
offered that this is Alaska's specific data and he likes the
slide because it shows Alaska's percentage relative to five
other states that perform a similar survey as to Alaska. He
pointed out that this is an emotional abuse, physical abuse, and
sexual abuse slide, and the red number is the highest between
Alaska and these five other states. Alaska is number one with
reports of sexual abuse to children, and Alaska is close to the
top for emotional and physical abuse. Therefore, there are many
opportunities in the state to make big changes if the state can
give families and children additional support so these things do
not happen to them. Due to the high sexual abuse rates for
children in the state, sexual abuse is the place to start and
the sexual abuse rates for women is in the 30 percent range and
there are great opportunities to try to decrease sexual abuse
rates, especially in women in the state.
DR. HIRSCHFELD turned to slide 9, "Household Dysfunction" and
said this is where Alaska becomes much higher than the other
five states it is comparing itself to. Especially, he noted, in
substance abuse in the home, separation or divorce, incarcerated
family member, but the state is fairly close to the top in
mental illness in the home and witness to domestic violence.
Alaska has many opportunities to make big changes in the health
of its populations by decreasing these numbers that are
happening to children.
2:15:33 PM
DR. HIRSCHFELD turned to slide 10, "Prevalence of Specific ACEs
Experienced by AN People Compared with Non-AN" offered that the
Alaska Native Medical Center has an epidemiology department and
its epi center took Mr. Sidmore's data and looked at Alaska
Native folks versus non-Alaska Native folks. The red squares
show where Alaska Native folks are statistically significant
from the non-Native folks. Speaking as a doctor working at the
Alaska Native Medical Center and someone interested in tribal
health, these are the areas he would want to focus on to try to
decrease the rates in Alaskan Native people to bring them more
in line with the rest of the state, together with working on the
rest of the state to bring [the numbers] down. He stressed the
importance that no child should be a victim of sexual abuse or
substance abuse in the household, or any of those things.
DR. HIRSCHFELD turned to slide 11, "How Do We Work Together to
Decrease Alaska ACEs?" section of the presentation.
2:16:39 PM
DR. HIRSCHFELD turned to slide 12, "American Academy of
Pediatrics Policy Statement" said he likes to start with big
organizations that are doing things on a national scale and the
American Academy of Pediatrics has decided that ACEs is
interesting to them as well. They have a policy statement where
providers such as family medicine doctors, nurse practitioners,
pediatricians, and anyone who interacts with families should be
actively assisting parents, childcare providers, teachers,
policy makers, and everyone interacting with families to try to
address these persistent and constant problems that are facing
contemporary society, including: criminality, disparities in
health, limited educational achievement, and diminished economic
productivity listed on the slide.
DR. HIRSCHFELD turned to slide 13, "Why Are Providers the Front
Line?" noted that he likes to think of providers as the
frontline because providers have a major opportunity in this
state to make an effect. The slides depict when children are
seen in provider offices, and this slide mirrors immunization,
and children receive lots of immunizations especially when they
are under three years of age, and the immunizations bring
children into provider offices. In that children are going to
the doctor so often, that is a great opportunity for providers
to screen families for things that could be happening at home
that won't be healthy for their children. As the committee
knows, he related, the biggest effect on children and making
them healthier in the future is when their brain is the most
plastic, when their brain is developing rapidly and that is any
child under 3 years of age. When the children come in for
immunizations the provider can do lots of screening for the
family, and do protective corrective action to those families,
and that way the families are healthier, raising healthier
children, and they know how to raise healthier children.
Providers can have a major effect because those families are in
their offices often for children under the age of three for
immunizations.
2:18:45 PM
DR. HIRSCHFELD turned to slide 14, "Parent-Screening
Questionnaires" and explained that people are finally developing
screening questionnaires to look at things that could be
happening in families and adversely affecting children. [He
described the questionnaires] and said that a provider can hand
the parent a questionnaire during the office visit and then
begin having a discussion about any answers that are yes, to get
the families to help raise healthier children. He noted that
the questions on the slide are common and used throughout the
lower-48.
2:19:38 PM
DR. HIRSCHFELD turned to slide 15, "Three Questions - Gets
Almost Everything" and described questionnaires as easy and many
people can use them. He pointed to his Nome practice and
offered that for his families those questionnaires work but they
don't work as well as something else he has started to do in his
practice in Nome. When he has a family that he is a little
worried about, their children are not developing properly, or
the children are acting out in school, or any risk factors for
something that may not be going well at home, he starts having
conversations with families. He also asks the questions listed
on the slide that gets to the abuse questions. In the event a
child has been physically abused, and the mother trusts the
doctor as a provider well enough, she will start answering yes
to the questions which begins a conversation to try to start
getting help for that mother so it doesn't happen again to the
child. Equally important he said, as to whether something has
happened to the child is that the provider really wants to know
whether that has affected the child's behavior. The most
protective thing a child can have is a strong healthy adult
relationship. For example, a child with a great mother and
father is physically abused once and this stressful thing
happened to the child. Although, the parents are able to walk
the child through the situation, give him ways to deal with the
stress, build resilience in the child so even though it was a
stressful event the child was able to tolerate it well because
he had great parents and adult relationship in the family. He
said he is less nervous about that family if the child's
behavior hasn't changed and the family is functioning well.
2:21:40 PM
DR. HIRSCHFELD related that many parents were physically abused
and if their child is physically abused it can trigger strong
memories in a parent. A question he asks is not only has this
event affected the child's behavior, but has that event had any
effect on the parent because that suggests to him that if the
parents are having trouble dealing with this, they will not be
able to help the child deal with it. More help is needed for
that family to not only get the child through the situation but
also counseling for the mother and father to make sure they are
able to handle the situation and walk their child through the
situation. Those two questions appear to get at the abuse
questions well. Those questions do not get at neglect, he asks
the parents whether they have done anything with their child
that is really fun since the last time he saw them. If people
can't think of anything fun they've done with their child in
three to six months since last seen in clinic, he said it makes
him nervous that the child is just sitting in front of the
television and they are not having great interaction in the
family. He opined that those questions appear to get at most of
ACEs, and noted that his families in Nome prefer to have
discussions as they do not do quite as well with a written
survey. Another question he might ask is for the parent to give
him three words that describes their child. In the event a
parent can't think of three nice words to describe their child
and all three of the words have some sort of explicative in it,
he becomes nervous that the family is not functioning well.
This family may need outside help to raise their children in an
effective environment, he said.
2:23:47 PM
DR. HIRSCHFELD turned to slide 16, "Help Me Grow" and explained
that a problem he has with getting providers to use these
screening tools is that there is not an easy way for providers
to refer families to help, and this is a big deal. If the
provider is trying to see 25-35 patients a day and there are
numerous yes answers on one of the screening tools, the provider
oftentimes does not have a lot of time to spend going through
all of the different services available in Alaska to help these
families get healthier. He explained that one of things the All
Alaska Pediatric Partnership is doing in conjunction with the
Maternal and Child Health Section of the state, is building a
referral system called "Help Me Grow" which will allow providers
an easy way to get families help. Help Me Grow was originally
developed in Connecticut and it is now in approximately 26
states and basically, through a single telephone number a family
can call in, talk to a case manager, and the case manager will
help that family work through the paperwork, travel, find a
place the family can be seen, and basically, get the family
connected with services that can help the family. A problem for
many families is that they are not functioning well in raising
their children, and it's hard for them to function well enough
to get access to services. He advised that case managers
associated with the Help Me Grow Program walk families through
this and actively help them access services. It's not a passive
system, he described, and they actually help these families'
access services through a centralized telephone number. It is a
great way for providers to get these families help that is easy
and Help Me Grow loops back to the provider so the provider
knows that the families are accessing the services they need.
He explained that, currently, this program is in the building
stage, and they are hoping to launch the program in the
Anchorage, Mat-Su area sometime in the fall or early winter this
year as a trial. There are many data components to this and
over time they will see whether it makes a major effect on how
providers interact with families to screen for bad things
happening to them, he said.
2:26:22 PM
DR. HIRSCHFELD turned to slide 17, "Care Coordinators provide"
and advised that the slide summarizes his comments regarding the
care coordinators, who are advocates in doing assessment of
needs, follow up, link families into services, and more. He
said he has seen this in action in Orange County, California,
and they are next going to South Carolina to see it in action.
He described it as an inspiring program that families love
because it makes it easy for them to access these services, and
providers love it because it is easy for them to get their
families in.
DR. HIRSCHFELD turned to slide 18, "What Can Policy Makers and
Funders Do?" and acknowledged that these are tight budget times
and there is no money asked here, but in moving forward to
contemplate how to make Alaska healthier by decreasing adverse
childhood experiences. He said he ponders what policy makers
and funders can do, and what voters can advocate for, and one of
the things currently not being is the screening he previously
discussed. In the event the state can get Medicaid and private
insurance companies to cover screening for those families, it
would greatly increase screening performed by providers because
it does take time to go through the written forms and talk to
families about them. Another benefit, he suggested, would be to
support the development of programs such as Help Me Grow. The
program has been shown in every state, where it has been
implemented, to improve family wellness and decrease system
costs. It makes families healthier and they access the health
system much less so it decreases Medicaid costs, he said.
2:28:12 PM
DR. HIRSCHFELD advised that another benefit is to preferentially
support organizations and programs focusing on intervention in
early childhood. He advised that Representative Tarr sponsored
HCR 21 that basically supports any program supporting early
childhood, and it is a huge program that All Alaska Pediatric
Partnership supports. He described it as a great step in the
process of getting early childhood on the radar for everyone in
government because, he stressed, that is where there will be the
most effect to improve the health of Alaska's population in the
next generation.
2:28:46 PM
DR. HIRSCHFELD turned to slides 19 and 20, "What if we Reduced
Alaska's ACE Score by 1/2 Point" and "Reducing Alaska's ACE
Score by 1/2" respectively, and advised that Mr. Sidmore looked
what would happen if Alaska's ACE score was reduced by one-half
point. He then offered a scenario that the average ACE score in
Alaska is 5, and if it is decreased to 4.5 what would happen to
costs in Alaska. He then referred to the next slide, and
advised that Mr. Sidmore looked at six of the diseases listed on
slide 6, obesity rates, number of adults on Medicaid, smoking,
binge drinking, diabetes, and arthritis. In the event of
decreasing the ACE score by one-half point what would happen to
the above diseases, how many would not smoke, binge drink, not
be on adult Medicaid because they had a healthier childhood.
Essentially, Mr. Skidmore showed that Alaska will save
approximately $90 million annually, and that is only looking at
the above six problems. He described $90 million as a low
number relative to all health in Alaska.
2:30:16 PM
DR. HIRSCHFELD turned to slide 21, "What Does $90 Million Buy In
Alaska?" and noted the slide depicts various items such as
homes, kindergarten teachers, police officers, mechanical
engineers, pediatricians, OCS operations, Medicaid costs, and
more.
DR. HIRSCHFELD turned to slide 22, "If Alaska Had ACE Rates
Similar to Arkansas and Vermont the Estimated Reduction in
Number of Alaskan Adults for Each Category of Economic and
Educational Outcome" and advised that the slide depicts specific
decreases for people in Alaska if they decreased their ACE score
by one-half percent.
DR. HIRSCHFELD turned to slide 23, "If Alaska had ACE Rates
Similar to Arkansas and Vermont the Estimated Reduction in
Number of Alaskan Adults for each Category of Behavioral Health
Outcome" and noted that the number of people with depression
would decrease by 9,375 Alaskans, insufficient sleep by 5,195
Alaskans, frequent mental distress by 4,478 Alaskans, and heavy
drinking by 1,464 Alaskans. He described these as big numbers
in a state as small as Alaska, and further described this is a
significant proportion of the population. By decreasing ACEs
and getting families with young children the help they need,
there can be a big change in many of the health outcomes, he
said.
DR. HIRSCHFELD turned to slide 24, "If Alaska had ACE Rates
Similar to Arkansas and Vermont the Estimated Reduction in
Number of Alaskan Adults for each Category of Food Insecurity
Outcome" and advised it refers to people who were hungry and
didn't have any food. That number will be decreased by
approximately 10,103 Alaskans, and the people using government
food programs will decrease by 5,549 Alaskans.
2:32:18 PM
DR. HIRSCHFELD turned to slide 25, "In the brain, as in the
economy, getting it right the first time is ultimately more
effective and less costly than trying to fix it later." Dr.
Hirschfeld explained that James Heckman is a Nobel Laureate
Economist and he looked at a number of different ways to think
about early childhood development and brain development. He
then read Mr. Heckman's quote, as follows:
In the brain, as in the economy, getting it right the
first time is ultimately more effective and less
costly than trying to fix it later.
DR. HIRSCHFELD continued that this ACE data is all about the
current generation and; therefore, 20 years from now the state
doesn't have to build more prisons, build more of a juvenile
justice system, or hire more police. The goal is for the next
generation to be much healthier and save costs in Alaska, he
related.
DR. HIRSCHFELD turned to slide 26, offering his services.
2:33:28 PM
CHAIR SEATON referred to slide 6, and noted that the various
diseases have also been linked to low Vitamin D levels. He
advised that the committee should be looking at the
relationships and causal characteristics being included as well.
This committee has reviewed studies from all over the world
connecting some of those things, he advised.
DR. HIRSCHFELD agreed, and said if a person has 10 yes answers
to those questions, it is not 100 percent that the person will
have heart disease as it is a complex disease and etiology. He
explained, there is just an increased risk for developing all of
these things as the ACE score goes up. He expressed that this
is not a one-to-one relationship and reiterated, it is just an
increased risk as the yes answers go up.
CHAIR SEATON noted that what has been interesting is that the
committee has looked at ACEs over a period of time and what to
do about the scores, yet there have not been many suggestions
policy-wise and that he appreciates Dr. Hirschfeld's
presentation.
2:35:30 PM
REPRESENTATIVE WOOL referred to this presentation and others
where scores are taken and there are correlations with other
illnesses or lifestyles. At the end the day, he said, the
committee is told that if the score goes down a point or one-
half point, all of these other things will go away. Obviously,
he said, the score is just an assessment, and lowering someone's
score is a complex societal lifestyle problem with not just one
curative prescription because these are complex solutions.
DR. HIRSCHFELD agreed, and he said that lowering it one-half
point makes it sound easy but it is incredibly complex to do
that. He explained that a lot of it will be improving access
for families into services that help them, such as alcohol
abuse, smoking cessation, programs that teach parents how to be
better parents, and the ability to access those programs and
develop those programs so families can get the help they need to
solve the problems they are exposing their children to. He
expressed, it is an extremely complex problem and it is money
upfront to save money in the future when the state is in a tough
fiscal environment. Representative Wool was entirely correct,
he stressed, dialing it down one-half point sounds easy but it
is not even a little easy.
2:37:21 PM
CHAIR SEATON surmised that dialing it down one-half point
doesn't mean that he is changing any adult, if they are adverse
childhood experiences it means how many a child had during
childhood. Therefore, he said, the discussion is prevention on
new children to Alaska.
DR. HIRSCHFELD agreed, and he related that this effect won't be
seen for 20 years until those children ... the goal of the
change is to change the zero to 3 year old ACE scores right now.
By the time those children are old enough that's where there
will be a decrease in healthcare costs and behavioral health
costs, and others, he said.
CHAIR SEATON referred to slide 16, "Help Me Grow" and asked
whether they are family functioning tools or assessments.
DR. HIRSCHFELD explained that currently, it is hard for
providers, families, and other people in the state to keep track
of what is available to help families. For example, a family is
screened in at the pediatric practice and it is revealed they
are homeless. As a provider, he does not have a great way to
obtain help for this family so Help Me Grow allows the provider
to give the family a centralized telephone number wherein that
family can call the organization, explain their problem, and the
family will be assigned a case manager who then links them to
the appropriate services to help them find a place to live. He
explained that it is not providing direct service, it is a link
between the family and the services to make that access easier.
He related that one of the hardest things for families not
functioning well is that it is hard for them to access services
due to the paperwork, travel, and time. The Help Me Grow case
managers streamline that process for the families so they can
receive the services they need. Help Me Grow does not provide
services, he reiterated, it links families with the appropriate
services in an active management manner so the families can get
the help they need.
2:40:01 PM
CHAIR SEATON referred to slide 17, "Care Coordinators provide"
assessment of needs and referral to services, care coordination,
and more, and he noted the project "Protect Our Children Now" is
contained within the Medicaid reform bill that was passed out of
this committee. He pointed out that it provides not only
nutrition but also counseling. He offered that he is hopeful
that Dr. Hirschfeld will visit with Dr. Wagner while he is in
South Carolina, and let the committee know of his assessment of
the program Dr. Wagner is conducting, and how it is working in
South Carolina.
DR. HIRSCHFELD said he would do that.
CHAIR SEATON referred to slide 18, and what policy makers and
funders can do from the Medicaid standpoint. He noted that Dr.
Hirschfeld has some care coordination models and he would
appreciate those coming forward together with any suggestions he
may have.
The ACEs presentation was concluded.
HCR 21-RESPOND TO ADVERSE CHILDHOOD EXPERIENCES
2:42:11 PM
CHAIR SEATON announced that the next order of business would be
HOUSE CONCURRENT RESOLUTION NO. 21, Urging Governor Bill Walker
to join with the Alaska State Legislature to respond to the
public and behavioral health epidemic of adverse childhood
experiences by establishing a statewide policy and providing
programs to address this epidemic.
2:42:40 PM
The committee took an at-ease from 2:42 p.m. to 2:43 p.m.
2:43:26 PM
REPRESENTATIVE TARR offered a PowerPoint presentation titled,
"Adverse Childhood Experience," [referred to slides 1-9] and
reminded the committee that these issues had been discussed in
committee previously. She noted that Dr. Hirschfeld's
presentation discussed the origins of the ACEs study and
developing an ACEs score and she said she would skip over those
topics. Previously, members had been asked to take their ACEs
score and pointed out that in asking people to take their ACEs
score it rises awareness and assists in understanding the issues
better. Key findings within the Alaska work is that childhood
trauma is far more common, it lasts over a lifetime, and impacts
generations. Research has shown that approximately $1.4 billion
is spent every year in Alaska on substance abuse related issues
from treatment to the court system to law enforcement, and she
referred to Dr. Hirschfeld's presentation regarding some of the
cost reductions that can be associated with reducing Alaska's
ACEs scores.
REPRESENTATIVE TARR explained that HCR 21 calls on the
legislature and the governor to work together to do more on
policy level changes. Last year, the legislature worked hard on
Erin's Law and Bree's Law, and the legislature discussed ACEs
through those bills. She then stressed the importance of
keeping that conversation going this year, to keep the
conversation going as more awareness needs to be developed with
education and some of this can be done without funding. She
pointed to slides 6-9, and advised that these are some of the
opportunities for prevention, and that during the interim the
committee will continue looking at policy alternative. In
working through the implementation of Erin's Law and Bree's Law,
she wants to make sure the legislature is part of the effort to
build a statewide network of people concerned about the issues
and come together.
2:45:57 PM
REPRESENTATIVE TARR advised there are 27 letters of support from
organizations across the state, such as the Children's Trust,
Suicide Prevention Council, Mental Health Board, Best
Beginnings, and also approximately 200 hundred individuals
signed petitions from different early learning conferences she
attended, from the Dr. Felitti event, and from the "Go Blue Day"
Child Abuse Prevention rally yesterday. In bringing all of
these groups together, she noted that her hope is to bring
together a network of people to determine that it isn't just
about spending more money on something, but more about having a
deeper understanding of these ACEs issues, and its impacts.
ACEs is about connecting the dots and within the letters of
support there are individuals working on mental health, early
learning, substance abuse, or suicide prevention. In
understanding ACEs it brings a new opportunity for connecting
the dots between the negative health outcomes and looking back
at the origins and determining what the origins of those
problems are.
REPRESENTATIVE TARR referred to an additional slide in the
committee packets from the All Alaska Pediatric Partnership
regarding ACEs accumulation and read, "Young Alaskans have
acquired HALF of their accumulated ACEs by the age of 3." She
explained that it speaks to the importance of the early
intervention programs. As Dr. Hirschfeld discussed,
pediatricians and other health care providers can be frontline
in that effort, and she added that early education folks such as
Best Beginnings are working on early education. There was a
time it was believed there was a protected wall around the fetus
and that the mother smoking and drinking was okay. It was also
believed that children in the pre-verbal times were unimpressed
by things, and that events could be happening around them and
there wasn't a big impact. To put this in context, she related,
the study referenced was published in 1989, and when thinking
about how recent that's been for people to learn about that data
and then start doing their own research, there really hasn't
been an opportunity to implement it into the state's policies in
a manner that can be implemented to have a tremendous impact.
This slide shows that a lot of the bad stuff is happening at the
time people previously believed children would not be impacted
by the behaviors around them, or even be aware of violence or
substance abuse, she said.
2:49:23 PM
REPRESENTATIVE TARR related that building awareness is part of
the effort that can be accomplished without funding a new
program, and through the efforts this month of child abuse
prevention and organizations hosting many different activities
sharing information and, hopefully, get more people involved.
Working with educators and practitioners and the government in
creating policy alternatives is the next step, she remarked.
2:49:56 PM
REPRESENTATIVE FOSTER expressed his support and that he
appreciated Dr. Hirschfeld's presentation and learning of his
efforts in his practice in Nome as it makes it more tangible for
him.
REPRESENTATIVE TARR related that these are long term investments
and as Dr. Hirschfeld related, within every step along the way
the state has opportunities to work with children when they are
in school, and that there are screening tools when meeting with
families. One big opportunity is just in changing the language
when there is a child with behavioral problems. The child
acting out is not asked what is wrong with them, but rather the
child is asked what happened to them. Things like this give her
hope and that even without a lot of funding, moving toward
something where most of it is simply understanding the
opportunities, and the different places that can be engaged in
sharing this information.
CHAIR SEATON noted his appreciation for both presentations and
that he found Dr. Hirschfeld's comments interesting because he
was unsure how much the medical community and quasi-medical
community had been involved with those types of care
coordination efforts with families. He related that it is good
to hear that they are not just looking at the child, but the
situation the child is in.
2:52:20 PM
REPRESENTATIVE FOSTER moved to report HCR 21, labeled 29-
LS1398\A out of committee with individual recommendations with
no fiscal notes.
CHAIR SEATON objected for discussion and read into the record
the language on page 3, lines 14-22, as follows:
BE IT RESOLVED that the state's policy decision
acknowledge and take into account the principles of
early childhood brain development and, whenever
possible, consider the concepts of toxic stress, early
adversity, and buffering relationships, and be it
FURTHER RESOLVED that early intervention and
investment in early childhood years are important
strategies to achieve a lasting foundation for a more
prosperous and sustainable state through investing in
human capital; and be it
FURTHER RESOLVED that the Governor join with the
Alaska State Legislature and address the presence of
adverse childhood experiences as factors for many
societal issues and to fund research for statewide
solutions.
CHAIR SEATON opened public testimony
2:52:20 PM
TREVOR STORRS, Executive Director, Alaska Children's Trust, said
the Alaska Children's Trust is focused on the prevention of
childhood abuse and neglect. He related that the Alaska
Children's Trust is also partnering with groups around the
concept of reducing trauma and building resiliency in the child,
the family, and the community. He noted that what has been
presented today is a complex issue and what the committee does
with this information is not about enacting one specific thing,
but it is the framework to help promote the concept of reducing
trauma adversity to not only the child, but a community and
cultures within Alaska. When these issues are addressed, not
only does it save money, it builds communities that can
withstand trauma which is a natural part of the circle of life,
but child abuse and neglect are not a natural part of the circle
of life. It is resiliency that glues that circle together and
the role of the community is to be certain the glue being used
is the strongest and best glue so everyone benefits, he said.
REPRESENTATIVE TARR asked Mr. Storrs to send information to the
committee members about the Resiliency Initiative.
MR. STORRS agreed.
2:56:37 PM
DON ROBERTS described himself as an adult survivor of these
adverse childhood experiences and in listening to the
presentations he noted that the system tends to forget that
there are many adults dealing with this in their lives with no
resources available to them. He agreed that the programs can be
initiated, but they are for children and families and he is 58
years old. He took the ACEs test and had a score of 7, although
it would have been higher if it asked a few other questions.
Adult programs need to be integrated so when adults get into the
system they are not just sidelined due to no services out there
because the legislature didn't put it in, he related. Due to
his adverse childhood experiences, having intimate family
relationships is troublesome because he doesn't want to be the
kind of parents he had where basically his childhood was filled
with anger and violence. He opined that this needs to be
included in the legislation. There are other services, such as
peer support services that are not necessarily part of the
mainstream clinical experience people should be able to use and,
he opined, peer support services are often given short shrift
when they tend to be far more effective in helping people deal
with these issues in their lives.
CHAIR SEATON offered support for his testimony and related that
there is definitely no one point in which addressing these
issues can be stopped.
3:00:28 PM
PATRICK ANDERSON, Senior Research Fellow, Sealaska Heritage
Institute, said he is a Senior Research Fellow in the area of
childhood trauma and health restoration, and has been engaged in
research and advocacy around adverse childhood experiences since
2008 when he was the CEO of an Alaska Native Rural Health
System. As a consequence of his advocacy he is a member of both
the American Indian and Alaska Native Task Force on suicide
prevention and president of the Native American Children's
Alliance (NACA), assisted in the drafting of this resolution,
and that his ACEs score is 6. He described the understanding of
the existence of real and identifiable childhood trauma being
linked to adult health and negative behaviors as an exciting new
arena of public policy. He then referred to Dr. Hirschfeld's
presentation and said that if childhood trauma can be identified
early in a child's life it can be addressed before it becomes a
true problem and prevention becomes a real option because
parents can be taught how to avoid the behaviors that cause the
development of this trauma in children. He referred to the
perception that the resolution addresses early childhood
prevention only, but that was not the intent. He referred to
HCR 21, page 3, lines 14-16, which read:
BE IT RESOLVED that the state's policy decision
acknowledge and take into account the principles of
early childhood brain development and, whenever
possible, consider the concepts of toxic stress, early
adversity, and buffering relationships, and bit it
MR. ANDERSON pointed out that it is directed toward adult health
and behaviors as well as early children's brain development,
health, and behaviors. He advised he has spent the last four or
five years looking for a systemic approach that addresses both
the parenting generation's behaviors and children's behaviors in
a family and community context. Mr. Anderson opined that the
goal is to introduce a program that effectively identifies
behaviors early enough to begin the healing process. Within the
City of Nome, where Dr. Hirschfeld practices, there has been a
discussion in the last few years around ACEs that has advanced
to the point of serious consideration. During the recent
convention of the National Congress of American Indians,
presentations were offered on the topic including a plenary
presentation by Dr. Vincent Felitti. Tribal groups in Alaska
have started the process of understanding and using ACEs and are
following examples from the lower-48. Dr. Ann Bullock is
employed by an Indian tribal health system addressing diabetes
through programs that identified and treated traumatic or toxic
stress. Dr. Donald Warne is an American Indian physician who
has been active through the Great Plains Tribal Chairman's
Health Board in addressing ACEs and there are many other who are
following their lead.
MR. ANDERSON referred to the Behavior Risk Factor Surveillance
System (BRFSS) and emphasized that Alaska Natives have a 4 or
more ACEs at a rate which is almost double that of the non-
Native population according to BRFSS. As a result, many of the
Alaska Native communities view this area as a priority to
address. When Dr. Felitti was in Juneau, they took the
opportunity to meet with Governor Bill Walker, Lieutenant
Governor Byron Mallott, Commissioner Dean Williams of the
Department of Corrections, and Jay Butler the Alaska Chief
Medical Officer. They briefed Governor Walker on this issue,
made him aware of the legislation, and asked Governor Walker to
support it. Mr. Anderson opined that this resolution has great
potential for encouraging a wider discussion of ACEs in Alaska
and if it leads to more programing to address prevention,
earlier intervention, and healing that would be fantastic. He
then asked that the committee pass HCR 21 out of committee and
encouraged the adoption of the resolution by the legislature.
3:05:58 PM
MAUREEN HALL, School Nurse, said she is a school nurse in Juneau
and she fully supports this resolution because [nurses] daily
see children on the frontline in their offices. These children
typically have a high ACEs score, and are seen most often which
carries over into adult medicine when they leave the school
setting. These individuals, she said, are the heaviest users of
the health care system, are most apt to have poor educational
outcomes, and end up engaging with the criminal justice system.
As far as the savings being 20 years down the road, she argued
that the savings will be immediate because those children will
not be as sick as their peers when they have a lower ACEs score.
It will prevent a lot of the adversity and they'll be healthier,
and be better able to learn once they do get to school. She
pointed out that this is important in raising awareness
throughout our state, and she would like every school in the
state become a trauma informed school, as well as Alaska's
communities. By every police officer and teacher understanding
how the adverse childhood experiences affect a person, she
opined that it would go a long way toward preventing and
increasing awareness, and helping that person be more successful
down the road.
CHAIR SEATON removed his objection. There being no objection,
HCR 21, Version 29-LS1398\A, with no fiscal notes, passed from
the House Health, Education and Social Services Standing
Committee.
^Presentation: Citizen Review Panel
Presentation: Citizen Review Panel
3:08:38 PM
CHAIR SEATON announced that the final order of business would be
a presentation by the Citizen Review Panel (CRP).
DR. DIWAKAR VADAPALLI, Chair, Citizens Review Panel, Institute
of Social and Economic Research, Professor, University of Alaska
Anchorage, said he is an assistant professor of public policy at
the Institute of Social and Economic Research (ISER) at the
University of Alaska Anchorage. He turned to slides 1-3 and
explained the makeup of the panel, the presentation outline, and
the panel's federal and state mandates. The Citizens Review
Panel's (CRP) mandate is to evaluate the policies and practices
of what translates in Alaska to be the Office of Children's
Services (OCS) from a community perspective, and to perform
public outreach in the process.
3:11:00 PM
DR. VADAPALLI turned to slides 4-7, and advised that the primary
functions of the Citizens Review Panel (CRP) is to evaluate OCS
against its own 5 year Child Abuse Prevention and Treatment Act
(CAPTA), some federal and state child protection standards, and
any other criteria the panel considers important. The panel is
also required to conduct public outreach both to inform the
public of child protection policies and procedures, and also to
collect input on these policies from stakeholders. Throughout
the state there are five regional OCS offices, 19 field offices,
and 500 employees of which 283 are frontline workers with
approximately 32 percent of these workers turning over every
year, and its operating budget is approximately $150 million.
At this point, he said, it would be meaningful to consider the
tasks the panel is asked to perform, the resources at its
disposal to operate at a $100 thousand annual budget, and that
the panel members donate an average of approximately 300-400
hours each year. He acknowledged that these as tight budget
times for the state, and that in FY2016 the panel's budget was
cut by $18 thousand yet the work remains the same. The CRP does
not do the following: comment on proposed or pending
legislation; get involved in individual cases, contracts, or
situations; micromanage the OCS operations, conduct program
evaluations, and lobby. Over the last couple of years the panel
worked hard to analyze its calendar to streamline the work flow,
and during the last year it conducted three public meeting site
visits with numerous interviews, met every month with OCS
leadership, presented its annual report to various stakeholders,
and attended the CRP National Conference.
3:16:08 PM
DR. VADAPALLI turned to slide 8, "Recommendation 1: Intake
Policy" and advised that each year the panel begins with a set
of goals, and each goal relates to one or more components of
OCS's practice model or operations. Each goal is explored on
both the policy front and practice front, and it notes gaps
between stated policy and current practice. In addition, there
are many things the panel follows, and a few things it comes
across that are either OCS initiatives or concerns from others.
The recommendations within the annual report are based upon
these additional issues of interest to the panel. He advised
that the next few slides include all of the recommendations from
the panel from last year, and within the accompanying letter the
panel submitted to the committee, it summarized OCS's response
to each of the recommendations.
3:17:49 PM
CHRISTY LAWTON, Director, Central Office, Office of Children's
Services, Department of Health and Social Services, said she was
available for questions.
3:17:57 PM
DR. VADAPALLI returned to slide 8, and pointed out it is the
first recommendation of the panel last year, and that the panel
examined specific intake policies for two years in a row. The
panel chose this goal because during the course of its site
visits, individuals commented that children are being left in
unfit conditions because a large number of cases are screened
out combined with the high turnover of frontline workers, which
makes the screening process burdensome and unpredictable. After
examining the policy and practice of intake, the panel made
several recommendations and OCS accepted all recommendations and
OCS is in the process of implementing several of them.
Currently, OCS intake is in transition from a regional structure
to a central structure with all calls fielded by a smaller group
of centrally located workers. The panel was informed that OCS
is waiting on a manager being hired to direct the operations.
CHAIR SEATON referred to the change to opt-out of receiving
follow up on the case, and asked him to explain the
recommendation.
DR. VADAPALLI replied that the panel noticed that when someone
reports a child is being maltreated, the intake worker was not
required to ask the reporter whether they wanted to know what
happened in response to their report. He described the
recommendation more as an opt-in where the reporter is required
to ask whether the reporter would like to be informed of OCS's
response to the report because many individuals complained that
they reported over and over again and nothing would happen. The
OCS related that that is a current option, and the panel
recommended that there should be a response to the reporter
unless the reporter opts-out and does not want a response.
CHAIR SEATON asked whether that policy is being implemented now
and whether it appears to be more effective in obtaining
community support for the program, rather than distrust that
nothing happens after a report of a child's maltreatment.
3:21:45 PM
MS. LAWTON answered that OCS believes that recommendation will
assist the general public and its large majority of mandated
reporters to be clear about what is happening, because it may
have not been clear that that option was available in prior
cases. She noted that some of the changes are still pending
because OCS is bringing on a manager who will oversee intake
operations and some of the details are being worked out, but it
is a positive change.
REPRESENTATIVE TARR referred to the [third] bullet on slide 8,
"Uniformly implement the current pilot project of having a
supervisor reviewing cases after 10 screened-out PSRs" and asked
Ms. Lawton to explain the pilot project. She pointed out that
there are people who frequently report that are potentially
abusing reporting due to ongoing custody issues and would like
to have a better understanding.
MS. LAWTON responded that during the last several years OCS has
piloted several new practices around intake where it escalates
reports to regional managers to evaluate whether it is
appropriate for screen-out. This is looking at the obviously
prior reports OCS has received and the likelier potential that
new reports will keep coming if it doesn't intervene.
Certainly, over the years OSC has heard complaints that it waits
too long to intervene, so OCS started looking at that and trying
to ... if they have 10 they are not automatically screened-in,
it is just getting another pair of eyes to look at them in the
context of the whole picture. She advised that the division has
some pilot projects wherein it is paying particular attention to
the zero to 12 months, whether there have been prior reports,
whether there is an infant in the home, whether there is going
to be a screened-out recommendation by the intake worker, and
those are escalated as well. The division is still evaluating
how well these various pilots have been working and their
effectiveness before implementing a statewide policy, although
much of it will be implemented because there have been some
positive changes. She continued that with the additional sets
of eyes reviewing the report, OCS believes it is intervening
with the right families and at the right time, which is key to
avoiding repeat maltreatment in the future.
3:24:18 PM
REPRESENTATIVE WOOL asked her to describe what PSR and screen-
out means.
MS. LAWTON answered that the PSR is Protective Services Report
which is what is created when a reporter calls and lodges an
allegation. Those reports are then screened-out or screened-in
and each time a reporter calls regardless of whether OCS
believes it is something to investigate, it is documented and a
report is created. A decision is then made as to whether it
meets the criteria for a screened-in which will then generate an
investigation. In the event it is a screened-out, there is no
further follow up, and no notification to the family, she
explained.
3:25:03 PM
DR. VADAPALLI turned to slide 9, "Recommendation 2: In-Home
Services" and explained that in-home services has been a
challenge for OCS for a while, and the panel has noticed this
consistently over several years. Most alarmingly two years ago
the panel found that the in-home services workers in one region
found the caseload humanly impossible, and the panel reported it
last year. Therefore, the panel looked into in-home services to
determine where the challenges lay, and the graph on the slide
shows the percentage of in-home and out-of-home cases over the
period 2011-2014 broken down by OCS region. Within the last OSC
five year plan, it identified a goal to develop a model of in-
home services for rural areas, and that goal continued into the
current Child and Family Services Plan (CFSP). Although, he
said, OCS has a clear goal in its plan the panel noticed there
were no clear outcomes identified, thereby, being unable to
assess whether it made its goal, or made satisfactory progress
on the goal. The panel recommended that OCS constitute an
internal task force to address its new in-home services model
and identify specific measurable clear outcomes so it can assess
periodically on the progress being made. In response, OCS
indicated it wanted to persist with the existing model that its
(indisc.) new increased opportunities for stakeholders to play a
meaningful role in providing home services. Currently, he
noted, the panel has seen new developments on the enrollment of
tribal entities in providing in-home services. The panel
strongly believes that identifying additional more specific
measurable outcomes is certainly important regardless of who the
service provider is, whether it is through a contract, or OCS
directly providing the services.
CHAIR SEATON asked for an explanation of what the new in home
services model is and what services those are in relationship to
OCS.
3:28:14 PM
MS. LAWTON replied that typically in-home services is viewed as
an opportunity to work with a family less formally than through
foster care. When OCS is working with a family and the child
remains in-home the child could be in the state's legal custody
but more often than not is not in the state's custody because
OCS had investigated and found some concerns, wherein the parent
agrees they are have a problem but is willing to work with OCS
to please not take custody of their child. In the event the
parent is truly motivated and genuine in their efforts and OCS
believes it can keep the child safe in the home while working
with the parent, OCS will try to open the case for in-home
services without having to file a petition and go to court.
Currently, and what OCS has done for many years, she explained,
is that when a case is opened for in-home services on an ongoing
basis, it is assigned to a case worker similar to any other case
that is transferred from the investigative worker to an ongoing
family services worker. The struggle OCS has had and the
recommendation from the panel over the years, is that OCS's
model hasn't been completely successful, particularly in rural
Alaska. She related that the challenge has been that its case
workers are trained to be more of the middle man, organizer,
coordinator of services, and are not the direct service provider
in those cases. The case workers do not provide the parenting
classes, therapy for the parent or child, they don't go in-home
and do intensive family based engagement because OCS trains them
to connect families to resources. In rural Alaska, where there
are not many providers, the challenge has been that OCS does not
have a mechanism to train its staff to play all of those roles.
It's been a challenge, and what OCS is currently trying to do
and what it addressed in response to the recommendation, is put
forth that perhaps OCS is not the best suited to provide in-home
services due to the large portion of crisis driven work that OCS
does.
2:30:24 PM
MS. LAWTON pointed out that typically in-home services takes
place between the case worker and the family when there is no
legal involvement, thereby, it does not bring in the court's
oversight, the other legal parties, and all of the other people
that ensure those cases move forward. Those families often do
not receive as much attention as they need because the case
worker is trying to meet the demands of all of the other cases
of children in foster care. The division believes that some of
its non-profit social services organizations and its tribal
entities would be far better suited to serve these families in a
less formal intervention. Also, she commented, those families
may be more likely to engage with them than with an OCS worker
to begin with. She advised she is looking at sending out a
letter of interest to explore this idea, and that OCS has been
talking with its tribal entities as well. Many of them have
been working for a number of years to create and build the
infrastructure to provide in-home services to these families
that are at risk. She stressed that OCS has so many challenges
to work on within its agency, it would like to find a way to get
services to these families via other entities that may be better
equipped than OCS.
3:31:38 PM
CHAIR SEATON referred to slide 16, and Dr. Hirschfeld's
presentation regarding the Help Me Grow program, and that
appears to be a family functioning tool with case management.
He asked whether the department has looked into these models
that would be similar to telehealth and the coordination of
services, especially in rural Alaska where there is little
access to services.
MS. LAWTON answered that she was unaware whether OCS has a lot
of that going on and that she is not familiar with Help Me Grow,
although it is on her list to speak with Dr. Hirschfeld. Many
of the rural families are connected to their tribal health
organizations that can provide some of those services. Most of
the department's standard-type services that the families OCS
sees are needs around parenting, around substance abuse, and she
opined there was not much availability in terms of creative
access. Although, she noted, currently there is effort through
behavioral health, and with Medicaid expansion that she is
hopeful there will be far more opportunities for access that
doesn't look like the standard urban setting access, but there
is an area for growth there.
CHAIR SEATON noted that within the telehealth presentation, it
found that there was a far better compliance rate with substance
abuse, counseling and such because people just could not make it
to the appointments. Possibly OCS could do that through some of
the telehealth data the committee received, and he offered to
steer Ms. Lawton to the telehealth presentation. He pointed out
that whether the issue was behavioral health or compliance with
a substance abuse program, the telehealth compliance rates were
approximately 80 percent higher, which included urban Alaska
because people can miss the bus or whatever.
3:34:27 PM
REPRESENTATIVE WOOL noted that certain aspects of treatment had
a stigma and possibly people didn't want to go in and see
certain kinds of providers, but if they are in the comfort of
their own home they do not have to interact with anyone
publically.
CHAIR SEATON added that most of it was visual through a computer
or iPad or similar. He noted his surprise at the data on the
compliance rates, and that it appears the state keeps going
through these cycles because it has problems with getting
compliance throughout a full program.
3:35:21 PM
DR. VADAPALLI returned to slide 9, and drew the committee's
attention to the last bullet point which read, "Identify
additional, more specific measurable outcomes." He advised that
the panel had several discussions with OCS regarding applying
measurable outcomes to access programs as they move along trying
to do the work it is mandated to do. He added that that has
been a problem with the in-home services and a recommendation is
that any new models must have an accompanying set of measurable
outcomes.
CHAIR SEATON asked whether the department felt this was
meaningful and doable moving forward in designing the program.
MS. LAWTON said that certainly if OCS is putting dollars out
through grants or contracts, by some means it will build in
measures of accountability. Certainly, she related, Dr.
Vadapalli brings much expertise to this area and OCS would
appreciate his crafting assistance when OCS gets to that point.
3:36:48 PM
DR. VADAPALLI turned to slide 10, "Recommendation 3: IA Backlog"
and said that Initial Assessment (IA) backlog has been a
challenge for several years and it is the second step of a case
after the initial screen-in. The process, he explained, is that
a reporter calls in and the report is screened-in or screened-
out, in the event the report is screened-in there is an initial
assessment conducted by an IA worker. He noted there are
several different types of scenarios where an IA can quickly be
concluded, or can be delayed over time. Given how busy OCS
frontline workers are, and how much they have on their plates,
it's not uncommon that some of these are overdue. Anything that
needs to be addressed right away are addressed to the best
possible extent, but there are several that just sit there and
don't get closed in time. Obviously, he pointed out there is
concern about what is happening with these children while a case
is open but nothing is moving. However, the number of backlog
IAs ran up to approximately 4,000 statewide in 2012. This
happens approximately every 4 years because OCS puts all of its
resources to quickly close all pending IAs once every 4 years,
and 2016 is that 4 year cycle and the numbers were creeping up.
The panel recommended that OCS have a structured plan to address
this and dig into the nature of the IA cases that are backlogged
by 30, 60, 90, or 120 days. The division came up with a system
internally and it included mostly trying to keep up with the
regional managers and unit supervisors to make sure that the
cases are closed on time. Although, that is obviously not
working as they hoped. The recommendation is to come up with a
system that is a structural solution to this and to understand
it better and get a solution, he said.
3:39:42 PM
CHAIR SEATON asked whether there is an explanation for the 4
year cycle.
MS. LAWTON replied that in terms of root cause, she does not
think there is any mystery, and to be clear when discussing
backlog, the backlog is in the completion of the final paperwork
and writing up the summary of what happened and issuing the
final letter that goes to the family. She expressed that this
is the key issue OCS feels badly about because parents
absolutely are entitled to receive notification that the case
has been closed and the ultimate finding. However, when the
work load is such that staff are getting too many reports than
they can possibly keep up with, the paperwork always moves to
the bottom of the list because the workers are going to go out
and see the people in person and assess each child's safety.
She related that [there may be backlog] until OCS has more
balance in terms of the work load and the number of staff
available to address the issue and giving worker more tools
because currently all of the staff have to basically perform
duplication of documentation in almost everything they do.
3:40:45 PM
MS. LAWTON continued that the workers go out in the field and
talk to the family and write on a tablet, they then come back
and have to document it. She described this as a duplication of
efforts that OCS simply does not have the time for them to be
doing. Unfortunately, the financial aspects of getting laptops
and the security issues from an IT perspective, it's just not
something OCS has in the cards for probably a number of years
until OCS will have the funding to do that. Until that time,
the cycle is just that when OCS diverts all attention to a
problem, generally, it makes headway and some improvement, but
typically OCS has more problems at any given time than it does
resources to focus on all of them. She opined that the cycle is
more reflective that the numbers grow and OCS decides
"everything is going to this until we get this settled," it then
goes back to trying to address everything else, and the numbers
creep again. Particularly, she noted, with IA workers and
investigators because they are almost always the newest to the
agency, and the greenest to working in child welfare, and
typically are the employees quickly trying to move from their
jobs to family services which tends to be a more predictable day
schedule and work load. She remarked that they are the least
skilled and the least trained employees dealing with the crisis
in your face child maltreatment issues every day.
3:42:23 PM
REPRESENTATIVE SEATON surmised that OCS hasn't gotten to using
Siri to type out the reports yet. He referred to 2012 when
extra workers were added, and said in looking at the budget each
time there is a vacancy the legislature takes the positions and
doesn't refill them. He asked whether that is happening as
well.
MS. LAWTON offered that the legislature has been very supportive
of OCS over the years in getting it new positions, but it hasn't
kept up with the pace, and OCS continues to struggle with the
turnover. She noted that if OCS could solve the worker turnover
issue, which is largely driven by the work load, it wouldn't
need more staff and it could do a far more effective job. This
is a challenge every state in the country is facing with the
backlog and that those paperwork functions tend to always be at
the bottom of the list. The division has actually been asked to
present in some states about how Alaska has been able to, with
some frequency, get the backlog fixed. Unfortunately, OCS has
not been able to devise a sustainable effort, she said.
3:43:55 PM
DR. VADAPALLI turned to slide 11, "Recommendation 4: Foster
Care" and advised that previously the panel had not looked into
foster care issues, and since it is a huge area of OCS's work it
looked into how the recruitment and retention efforts for foster
families were going. The panel noticed that recruitment efforts
were not uniform across the state and there were no outcome
measures; therefore, he related, there was no clear message on
what the need was, how many foster families were needed, what
the target of recruitment is, and when will OCS know when it
gets there. The recommendation was to clearly identify outcome
measures with appropriate channels for communicating a clear
message with the approximate number of resource families needed.
The division responded that it is working with the Center for
Resource Families that provides training for foster families to
make progress on identifying measures and giving a clear
message. The Center for Resource Families understands the
challenge OCS has in trying to identify the exact need at any
point in time because children are always coming in or out. The
panel believes that an approximate number can certainly be
identified, he remarked.
3:46:08 PM
CHAIR SEATON referred to the outcome measures and asked whether
he meant the chart [on the slide] and what the outcome measures
the panel is looking for are.
DR. VADAPALLI responded that essentially OCS put a lot of plans
together at a reasonable level in terms of recruiting and
retaining foster families. Although, many of those sub-goals
within the plan did not have any sort of outcome measures, and
it was not clearly identified when OCS will know it had attained
success, what is the goal here, and when it will know the goal
has been achieved.
3:47:45 PM
DR. VADAPALLI turned to slide 12, "Recommendation 5: Employee
Survey" and said this is an example of something that comes up
during the year but is not necessarily a part of the work plan.
He pointed out that there is an annual employee survey and the
survey results are summarized and passed across the agency for
supervisors to use to make revisions on various things. Two-
three years ago when the panel started looking into the survey
it noticed that the results were not summarized in a manner that
supervisors could make decisions. Ms. Lawton disagreed with
him, he said, and she advised that OCS is using it and that the
summarized results are useful. Two years later the panel had
the same challenge and asked for data and the data was (indisc.)
for the last two years. Last year the survey instrument was
passed on to the panel for comment and it provided feedback on
how questions could be changed and the panel's list of changes
did not make it into the instrument before the survey was
conducted. He explained that the recommendation is about
restructuring the OCS employee survey and the way the surveys
are summarized which is important due to the total turnover of
32 percent over the last decade among the frontline workers. It
is important to know how the workers feel about certain things
and the published document on line does not separate out
responses from those frontline workers. This year OCS asked the
panel to assist and because he is a professor at UAA, his class
is conducting the survey in collaboration with OCS this year.
3:50:46 PM
CHAIR SEATON asked whether the survey results are internal
surveys.
DR. VADAPALLI replied that this is an internal staff survey but
the results are summarized for the public's purposes and are on
the OCS website for the entire state. He opined that by
grouping all of the frontline workers into one group and
examining just their responses will help OCS in identifying
specific reasons for this high turnover and possibly identify
solutions. This year CRP restructured the survey quite a bit,
although it did not change the questions or add any new
questions because this is the first time that OCS, CRP, and the
graduate class from UAA are collaborating so that is a lot of
change in the way the survey was administered in the past. They
agreed not to add any new questions and maybe get the process
right so next year additional questions may be added or
different questions asked. The report will be a CRP report so
it will be a public report and all members of the committee will
receive a copy, he said.
3:52:31 PM
CHAIR SEATON asked whether the collaboration was working well in
trying to get at the survey of the initial intake workers.
MS. LAWTON said she would wait to see the results of the survey
and the overall response rate because there certainly could be
value in some of the restructure, and the questions are
fundamentally all the same. The division obviously sees value
in gathering information from its staff population in total and
it hadn't been particularly narrowing in on those frontline case
workers when looking at how to deal with the turnover. She said
it will be interesting to see what the results will say and what
that means for future years.
3:53:24 PM
DR. VADAPALLI turned to slide 13, "Recommendation 6: Workload"
and noted that a consistent message from the frontlines was the
challenge of workload management. In 2006 and 2012, two
workload studies recommended that OCS measure workers' workload
on a regular basis and that its workload balancing tool only
allowed senior managers to allocate resources and assign work
between offices. The workload balancing tool did not allow
workload assessment as recommended by either of the workload
studies. He advised that the agency can make some progress if
there is a clear tool to assess workload on an ongoing basis.
In response, OCS reported that it is working with the National
Child Welfare Workforce Institute to examine caseloads and
workloads, and is also working with a national consultant in
examining prior workload studies to determine what the next
steps could be.
3:55:02 PM
REPRESENTATIVE TARR asked whether other opportunities had been
looked into. For example, the Rasmuson Foundation has a program
that offers sabbaticals for non-profits, executive directors,
with the thinking regarding retention is to give someone a
period of time to refresh. She asked whether there are other
supportive things the legislature should be considering or have
been done elsewhere that may help reduce the turnover.
MS. LAWTON responded that OCS is always looking to those
opportunities and she is on a number of national lists serves,
and probably every week a state inquires, "who's doing something
that's working" in this area. Currently, the State of Alaska
together with the University of Alaska Anchorage is part of a 5
year grant it received in working with the National Child
Welfare Workforce Institute, and that there is a lot of dialogue
happening there. She opined there are not any magic bullets,
and OCS periodically meets with human resources and personnel to
go back over questions previously asked before because sometimes
the questions change over time in state government. During the
meetings they try to determine whether there could be
flexibility with "this," or whether they could do something that
the state hasn't done. For example, OCS has seen success in an
office that, historically, had significant difficulties in
recruiting at St. Mary's in the western region outside of
Bethel. The division has employed an alternative work schedule
such that the employees work one week on and one week off. It
is not exactly the same as the Alaska State Troopers, but the
workers at St. Mary's have stayed for approximately two years.
Although, one worker recently turned over but the other worker
is still there. A thought for Bethel, with the four new
positions the division recently received, is basing the
employees out of Anchorage and then being deployed to Bethel one
week on and one week off. Although, she noted, that is not
ideal from a community perspective, if the workers stay as long
as what is being seen with the folks at St. Mary's they actually
will become just as familiar as though they were living in those
communities and there won't be the current turnover. The
division is always scanning nationally to determine whether
anyone has anything going on that is new or innovative, but
there's not many magic bullets out there on this.
3:58:07 PM
REPRESENTATIVE TARR asked whether there was the ability to offer
loan forgiveness or bonuses for individuals if they, after a
five year period ... she opined that the goal is not to
incentivize someone to stay just because they are looking to get
extra dollars and not doing a good job. She asked whether any
of those come up on those lists serves.
3:58:37 PM
MS. LAWTON opined that they have come up and nationally there
was an initiative for social workers that was more focused on
licensed clinical social workers working in rural areas or in
Indian health organizations where there were opportunities for
loan forgiveness. There hasn't been such an opportunity in
Alaska with state child welfare workers, and she said she has
talked with the personnel folks and asked that in the event
there was money in the budget whether OCS could offer small
bonuses for staying another year. She has also looked at
whether the salary rate could be increased for those workers who
perform investigations and initial assessments because, she
reiterated, those tend to be the greenest workers with no
experience. The division actually needs the most seasoned
people performing those jobs because there are less eyes, less
oversight, less collaboration, and they are entirely on their
own. At this point, OCS has not been able to find an avenue for
that in Alaska with its current structure or budget.
3:59:46 PM
DR. VADAPALLI added that attention on recruitment and retention
is important and those are considerable challenges for OCS, but
this recommendation is really about the tools available for
managers, supervisors, and workers to manage their workload.
Also, for managers to assess the workload at an individual level
on a regular continuing basis. The frontline workers have
consistently said there is too much to do, no way to prioritize,
and there is no way to take a break, basically, he related.
DR. VADAPALLI turned to slide 14, "Additional Work" and offered
that the panel conducted three site visits and a copy of each
visit report was submitted to the committee. A survey report of
all select ICWA personnel from various tribal entities has been
conducted annually for the last three years regarding their
relationship with OCS on the frontlines. The 2015 and 2016
survey reports found that they rate their local child protection
at 6 out of 10, with 10 being the best. He described it as a
subjective assessment but still useful information to know. The
panel attended the National Citizen Review Panel Conference and
came back "pretty proud" of Alaska's CRP and the structure and
support it receives, the report was submitted to the committee
4:03:03 PM
DR. VADAPALLI turned to slide 15, "National Conference 2017" and
advised that the panel will be attending the 2016 National CRP
Conference in Phoenix. The panel committed to hosting the
National Conference 2017 in Alaska and OCS intends to support it
but is skeptical about the level it can meaningfully support the
CRP's efforts in hosting the conference. He opined that the
conference would be useful to Alaska because it brings in
national expertise and experience to weigh in on Alaska's shoes.
Every time there is a national conference in any state, the
local CRPs receive a lot of focus and expertise is offered by
the national experts. He further opined that this will be
useful for the state in making progress on community engagement
and social child protection.
DR. VADAPALLI turned to slide 16, "Goals for 2015 - 2016" and
offered the ongoing goal of focusing on OCS components, and this
year the panel took a critical look at its own operations to
refine how things have been structured and operating. The goal
being to make it easier for the public to participate and more
meaningful for OCS to utilize as a tool for information to
inform its policies and practices, he said.
DR. VADAPALLI turned to slide 17, "Changes in CRP operation" and
explained the slide depicts changes in the panel's operation and
it adopted an official set of guidelines the panel did not have
in the past. Currently, when the panel meets at the beginning
of the year, which is in August or September, it puts together a
work plan as a set of goals and a clear annual calendar. The
plan is then submitted to OCS to note on its calendars when the
panel plans to produce the product during the year. Public
comments are accepted at the panel's website, and documents and
information are available online except for the panel's meetings
with OCS leadership. The panel's intention is to create a
Public Outreach Plan in the near future and offer a new
recruitment and orientation packet to each new member, he
explained.
4:06:17 PM
REPRESENTATIVE TARR pointed out that there is no legal
requirement the legislature must provide funding or additional
resources to accomplish a CRP recommendation, and asked whether
Alaska is in line with other states and their experiences and
challenges where they want to do more but do not have the
resources.
DR. VADAPALLI responded that her question is the most
challenging question all CRPs have been asking themselves, how
to do what they are expected to do. He offered that a national
model has not been suggested by the federal agencies or any
technical consultants that they hired for technical assistance.
Each panel evolved in whatever way it saw fit for its local
needs. For example, Alaska has one panel and the panel appoints
its own members through a formal recruitment and appointment
process, but many states follow a different template and there
is no national accepted template. Most challenging, he related,
is that there is no model stating the principles of the CRP or
what is expected to be done at the very least, and other than
the federal mandate there is nothing helping CRPs figure out
what they should be doing. Over the last three years, Alaska
CRP has consistently examined its own work and it now follows,
what the panel calls, a participatory evaluation approach due to
reading through several legislative documents and Congressional
hearings documents and what the panel now understands, as a
purpose of CRPs, is that it is to be a conduit for public
participation in child protection. He explained that at the
federal level, the legislation gave the CRPs two specific tools,
to evaluate, and to collect public opinion or public outreach.
He described that as a challenge; however, at the moment the
Alaska CRP stands high on the rank of the other states on the
efficiency and effectiveness scale because it reaches out to
many stakeholders across the state. Most of the Alaska CRP
funding goes to traveling across the state and meeting with
people as it conducts approximately 100 interviews and
approximately 10 focus groups every year through site visits.
4:10:48 PM
The Alaska CRP is the only CRP with such a supportive and clear
relationship with its state legislature and many CRPs are
surprised the panel actually presents to this committee, he
continued that the supportive relationship with OCS is among the
best across the nation. He opined that if the panel makes a
recommendation that is tangible, meaningful, and measureable for
OCS to do something about, then certainly it will take it on.
Although, if the recommendation is vague or too broad or
requires a lot of funding then it is challenging for OCS to do
anything with it. He reiterated that budget cuts are not
pleasant for anyone and it was a surprise that $18,000 was taken
away from the amount allocated for the CRP this year, so it is
cutting back on the number of members going on site visits, and
today he had to testify telephonically.
4:12:41 PM
REPRESENTATIVE WOOL asked whether there is a concern that with
the caseload and workload the frontline workers have and the
turnover, that the number of recommendations may increase the
cause of the workload. Although, recommendations need to be
made and followed, it may be that added reports and added
surveys exacerbates the problem, he said.
DR. VADAPALLI opined that anything that cannot be measured,
cannot be changed. Therefore, if a project is not constantly
assessed, it is unknown where the project is, or the way to go,
or how far it's gone in achieving the desired result. In the
event the director believes a recommendation will add to the
workload, the panel is open to changing its recommendations to
make it more meaningful to the agency. He noted that those
questions happen constantly every month with the OCS leadership
and this is a process that helps both OCS derived benefit from
CRP and it assists the panel in refining its methods and means
in the recommendations it makes. He reiterated that this is a
useful process and the recommendations are not burdensome, and
if they are they should be discussed.
4:14:25 PM
CHAIR SEATON referred to Online Resources for the Children of
Alaska (ORCA) and noted problems such that everything had to be
double entered, or the information had to be typed in, and he
asked what progress had been made with ORCA becoming a more
useable tool.
MS. LAWTON opined that OSC has come a long way with ORCA and
every year enhancements are made to it to make is user friendly,
as well as access to the ORCA help team with any questions.
Features have been changed to reduce the number of things a
worker has to type in and some of those are auto populations.
Currently, there is a lot of duplication because OCS does not
have laptops available for a worker to access ORCA when they are
working in the field and everything must be written by hand.
Court orders will now be directly linked to OCS and entered into
ORCA, and OCS will have the capacity in ORCA, which is a money
issue, to increase space and have the capability to scan more
documents, such as original evaluations reports received from
second parties into ORCA. The department is also working on a
shared initiative such that there would be a vault where secure
information could be scanned.
CHAIR SEATON related that he was happy to hear that because not
long ago it was the bane of the entire department due to so much
time being spent re-entering the same data, or it would be
entered and then there would be a long span of time between
transmission such that the worker had to go do another job and
then come back and enter a few more lines. He asked whether it
was at a point that a person can complete a full report and send
it.
MS. LAWTON answered yes, absolutely, and she said the reality is
that ORCA is now becoming an antiquated system nationally, and
the division has been working with CGI that is the provider of
contract services for the division on ORCA. Soon, nationally,
there will be new data management models out there that will
provide opportunities for states. She explained that the
division bought the whole package from another state and,
consequently, had to take it as is with as license and couldn't
make it their own. She further explained that there will be new
off-the-shelf opportunities where the division can pick and
choose components to create its own system down the road. With
technology advancing at its current rate it may not be ORCA
again but the next time the division starts a new system it will
be light years from where the division is now, she said.
CHAIR SEATON related that it might be one of those big helps for
intake workers, reports, or whatever. He expressed appreciation
to panel for its work and volunteer hours, and that the panel
and division is working together so well to coordinate
improvement to systems.
The Citizen Review Panel presentation was concluded.
4:19:27 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 4:19 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Dr. Hirschfield_ACES-April 2, 2016.pdf |
HHSS 4/2/2016 12:15:00 PM HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| HCR 21 - Support Jorgensen.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Hirschfeld.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Hummel.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support JSPC Hummel.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Kate Burkhart.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Nakamura.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Pastorino.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Roberts Jr..pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support S.Trivette.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Sealaska.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Woodard.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Storrs.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 Sponsor Statement.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 Version A.PDF |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Background_ Reverse Alchemy in Childhood.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Background_CDC-injury prevention and control.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Letter of Support- AECAG.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Fuller.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Douglas.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support G.Trivette.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| Citizen Review Panel_HSS Presentation 03292016.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| CRP-2015-Annual-Report-Appendices.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| Citizen Review Panel_Letter to the House HSS Committee_03282016.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation- HHSS |
| CRP 2015 Annual Report.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| Alaska CRP 2016 ICWA report.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| HCR 21 - Support Abbe Hensley.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Support Gail AK Association for Infant .pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 - Background_The Origins of Addiction.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| BIA-Providers-Conference-Survey-Results-Final-Report.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| HCR 21 Background- ACEs-Accumulation-AAPP.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| HCR 21 Presentation Adverse Childhood Experiences March 2016.pdf |
HHSS 4/2/2016 1:30:00 PM |
HCR 21 |
| ACE'sToxicStress_Patrick Anderson.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |
| ACE'sToxicStress2_Patrick Anderson.pdf |
HHSS 4/2/2016 1:30:00 PM |
Presentation - HHSS |