Legislature(2019 - 2020)GRUENBERG 120
03/06/2020 01:00 PM House JUDICIARY
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| Audio | Topic |
|---|---|
| Start | |
| HB148 | |
| HB290 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 290 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | HB 148 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
HOUSE JUDICIARY STANDING COMMITTEE
March 6, 2020
1:03 p.m.
MEMBERS PRESENT
Representative Matt Claman, Chair
Representative Harriet Drummond
Representative Gabrielle LeDoux
Representative Laddie Shaw
Representative Sarah Vance
MEMBERS ABSENT
Representative Chuck Kopp
Representative Louise Stutes
COMMITTEE CALENDAR
HOUSE BILL NO. 148
"An Act relating to solemnization of marriage."
- MOVED HB 148 OUT OF COMMITTEE
HOUSE BILL NO. 290
"An Act establishing an alternative to arrest procedure for
persons in acute episodes of mental illness; relating to
emergency detention for mental health evaluation; and relating
to licensure of crisis stabilization centers."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 148
SHORT TITLE: MARRIAGE WITNESSES
SPONSOR(s): REPRESENTATIVE(s) CLAMAN
04/29/19 (H) READ THE FIRST TIME - REFERRALS
04/29/19 (H) STA, JUD
02/20/20 (H) STA AT 3:00 PM GRUENBERG 120
02/20/20 (H) Heard & Held
02/20/20 (H) MINUTE(STA)
02/27/20 (H) STA AT 3:00 PM GRUENBERG 120
02/27/20 (H) Moved HB 148 Out of Committee
02/27/20 (H) MINUTE(STA)
02/28/20 (H) STA RPT 5DP 1DNP
02/28/20 (H) DP: HOPKINS, THOMPSON, STORY, FIELDS,
KREISS-TOMKINS
02/28/20 (H) DNP: VANCE
03/02/20 (H) JUD AT 1:00 PM GRUENBERG 120
03/02/20 (H) Scheduled but Not Heard
03/04/20 (H) JUD AT 1:00 PM GRUENBERG 120
03/04/20 (H) Heard & Held
03/04/20 (H) MINUTE(JUD)
03/06/20 (H) JUD AT 1:00 PM GRUENBERG 120
BILL: HB 290
SHORT TITLE: ALTERNATIVE TO ARREST: MENTAL HEALTH CTR.
SPONSOR(s): REPRESENTATIVE(s) CLAMAN
02/24/20 (H) READ THE FIRST TIME - REFERRALS
02/24/20 (H) JUD, FIN
03/06/20 (H) JUD AT 1:00 PM GRUENBERG 120
WITNESS REGISTER
SOPHIE JONAS, Staff
Representative Matt Claman
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Explained the Sectional Analysis for HB 290
on behalf of Representative Claman, prime sponsor.
STEVE WILLIAMS, Chief Operating Officer
Alaska Mental Health Trust Authority
Department of Revenue
Anchorage, Alaska
POSITION STATEMENT: Offered a PowerPoint presentation on the
Crisis Now Model.
ALBERT WALL, Deputy Commissioner
Office of the Commissioner
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Offered an explanation on the 1115
Behavioral Health Waiver, pertaining to HB 290.
TIMOTHY QUIGLEY PETERSON, MD
Bartlett Regional Hospital
Juneau, Alaska
POSITION STATEMENT: Offered testimony in support of HB 290.
RAY MICHAELSON, Program Officer
Healthy Minds Focus Area
Mat-Su Health Foundation
Wasilla, Alaska
POSITION STATEMENT: Offered testimony in support of HB 290.
GENNIFER MOREAU-JOHNSON, Director
Division of Behavioral Health
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Offered testimony in support of HB 290 and
answered questions pertaining to the proposed legislation.
ACTION NARRATIVE
1:03:02 PM
CHAIR MATT CLAMAN called the House Judiciary Standing Committee
meeting to order at 1:03 p.m. Representatives Claman, Drummond,
LeDoux, Shaw, and Vance were present at the call to order.
HB 148-MARRIAGE WITNESSES
1:03:41 PM
CHAIR CLAMAN announced that the first order of business would be
HOUSE BILL NO. 148, "An Act relating to solemnization of
marriage."
1:04:10 PM
REPRESENTATIVE DRUMMOND moved to report HB 148 out of committee
with individual recommendations and the accompanying fiscal
notes. There being no objection, HB 148 was reported from the
House Judiciary Standing Committee.
HB 290-ALTERNATIVE TO ARREST: MENTAL HEALTH CTR.
[Contains discussion of HB 86 and HB 181.]
1:04:37 PM
CHAIR CLAMAN announced that the final order of business would be
HOUSE BILL NO. 290, "An Act establishing an alternative to
arrest procedure for persons in acute episodes of mental
illness; relating to emergency detention for mental health
evaluation; and relating to licensure of crisis stabilization
centers."
1:05:10 PM
CHAIR CLAMAN noted that there would be invited testimony from
experts on the proposed legislation, who were well-suited for
answering any questions the committee might have, and he asked
the committee to refrain from asking questions until after
invited testimony.
1:05:34 PM
CHAIR CLAMAN passed the gavel to Representative Drummond.
1:05:40 PM
CHAIR CLAMAN presented HB 290, as prime sponsor. He stated that
people living with serious mental health disorders or emotional
difficulties are subject to periodic recurring psychiatric
emergencies or crises that require prompt medical attention and
stabilization. He said that factors such as lack of timely
access to essential services and support, substance use
disorders, unstable housing and homelessness, and poverty
exacerbate these crises. He said that in Alaska, and across the
nation, challenges are faced in how to address people in crises;
current treatment options for those in crises are concentrated
at either end of the behavioral health continuum of care, with
long-term outpatient treatment options at one end of the
spectrum and intensive inpatient treatment options at the other
end.
CHAIR CLAMAN expressed that when comprehensive community-based
mental health services are insufficient, the burden of dealing
with those in crisis often falls on individuals and
organizations whose primary duties lie outside the traditional
scope of psychiatric destabilization. He stated that police
officers, hospital emergency departments, correctional
facilities, and social services providers are often on the front
line of dealing with those experiencing a behavioral mental
health crisis. He stated that these individuals and
organizations are already at capacity in dealing with their
primary functions in public safety, health, and nonbehavioral
health services.
CHAIR CLAMAN stated that HB 290 would be the first step in
adding a much-needed intermediate treatment option for those
suffering from a mental health or substance abuse crisis.
Created by the National Association of State Mental Health
Program Directors (NASMHPD), the National Council for Behavioral
Health, RI International, and suicide prevention groups make up
the Crisis Now Model. He said that the Crisis Now Model is a
type of community-based intervention to better serve those
experiencing intermediate mental health crises. He explained
that these facilities are open 24 hours a day, 7 days a week,
365 days a year, are staffed by mental health professionals, and
have a "no wrong door" approach that is designed to provide
prompt mental health evaluation and stabilization. He said that
crisis stabilization centers have already proven to be a
successful community tool in other states, including Arizona and
Washington.
CHAIR CLAMAN stated that he and several other people went to
Peoria, Arizona, a suburb of Phoenix, in December and visited a
Crisis Now Center to see how the system works. He explained
that he was able to observe how police officers are able to drop
people off at the door, how the center is able to take people
in, and how treatment proceeds. He said that the centers have
recliners instead of beds, because no one can stay for more than
24 hours. He expressed that the Crisis Now Model has
dramatically improved public safety response and mental health
access to treatment. He expressed that everyone he has spoken
with, who has been to Arizona to observe the centers, is
uniformly impressed with the effectiveness of the project and
how well it serves the people in need of assistance. He said
that there are currently no facilities like this in Alaska, and
HB 290 would authorize the Department of Health and Social
Services (DHSS) to write regulations to permit and license
crisis stabilization centers in Alaska.
CHAIR CLAMAN stated that once regulations are in place, it is
anticipated that interested providers will open crisis
stabilization centers in Alaska's communities. He stated that
Steve Williams, from the Alaska Mental Health Trust Authority,
would be providing more information on the Crisis Now Model and
crisis stabilization centers at the conclusion of this
presentation. He said that HB 290 would give public safety
professionals an essential alternative to improve public safety,
and amend the code of criminal procedure to allow police
officers, who have probable cause to arrest an individual, to
elect to take the person to a crisis stabilization center as an
alternative to jail. He explained that using the crisis
stabilization center alternative would require a police officer
to find that a person was experiencing a mental health or
substance abuse crisis, and that treatment at a crisis
intervention center would lead to a better outcome from both a
treatment and public safety perspective. He stated that HB 290
would ensure that even if a person were taken to a crisis
stabilization center, he/she could still be prosecuted for any
related criminal activity.
1:10:24 PM
SOPHIE JONAS, Staff, Representative Matt Claman, Alaska State
Legislature, explained the Sectional Analysis for HB 290 on
behalf of Representative Claman, prime sponsor. She stated that
Section 1 of HB 290 would amend AS 12.25.030 by adding a new
section providing peace officers with an alternative to arrest.
She explained that an officer may, at his/her discretion,
deliver a person to a crisis stabilization center instead of
arresting the person, if the officer believes that the person is
suffering from an acute episode of mental illness or voluntarily
agrees to be taken to a crisis stabilization center. She stated
that taking an individual to a crisis stabilization center, as
provided for in this section, would not bar prosecution of the
individual for alleged criminal activity or on charges for the
original grounds of arrest.
MS. JONAS stated that Section 2 of HB 290 would amend AS
18.65.530(c), which already allows an officer to not make an
arrest with permission from a prosecuting attorney, by adding a
subsection providing that a peace officer is not required to
make an arrest under AS 18.65.530(a), if the officer delivers
the individual to a crisis stabilization center or evaluation
facility. She stated that Section 3 of HB 290 would amend AS
47.30.705 by clarifying that a person who is gravely disabled or
suffering from mental illness and poses immediate harm to self
or others may be delivered to a crisis stabilization center or
to an evaluation center, pursuant to AS 47.30.700.
MS. JONAS explained that Section 4 of HB 290 would amend AS
47.30.710(a) to provide for an examination by a medical
professional within three hours for those brought to crisis
stabilization centers. She stated that Section 5 of HB 290
would amend AS 47.32.010(b) to allow licensing of crisis
stabilization centers under Chapter 32. Section 6 of HB 290
would amend AS 47.32 to add a new section providing for crisis
stabilization center licensure standards. Ms. Jonas stated that
Section 7 of HB 290 would amend AS 47.32.900 by adding a new
paragraph that defines crisis stabilization centers.
1:12:57 PM
REPRESENTATIVE DRUMMOND passed the gavel back to Chair Claman.
1:13:14 PM
CHAIR CLAMAN opened invited testimony on HB 290.
1:13:45 PM
STEVE WILLIAMS, Chief Operating Officer, Alaska Mental Health
Trust Authority (AMHTA), Department of Revenue (DOR), offered a
PowerPoint presentation on the Crisis Now Model, titled
"Enhancing Alaska's Psychiatric Crisis Continuum of Care." He
stated that the work that has been going into the project is not
just the work of AMHTA but includes many partners, such as: The
Department of Health and Social Services (DHSS), the Department
of Public Safety (DPS), the Department of Corrections (DOC),
tribal health organizations, community providers, behavioral
health organizations, local hospitals, and many others.
MR. WILLIAMS, referencing slide 2 of the PowerPoint
presentation, stated that nationally, the Centers for Disease
Control and Prevention (CDC) estimated that approximately 47,000
Americans will die of suicide this year; in Alaska that number
is estimated to be [185], which is about 25 Alaska suicides per
100,000 national suicides. He expressed that often individuals
in psychiatric crises are often first encountered by law
enforcement, which is not the most effective approach for most
situations. He said that the Anchorage Police Department (APD)
reports that 200 of 400 calls it receives a month are for a
behavioral health crisis of some sort and result in the
individuals going to hospital emergency rooms. He said that
nationally, DOC has become the default mental health provider
for individuals.
1:15:59 PM
MR. WILLIAMS, referencing slide 3, stated that the continuum of
behavioral health care has been eroding in Alaska for several
years, despite efforts to "shore up" the system. He expressed
that this has resulted in an inability to provide timely access
to people in psychiatric crises or meet them where they are at,
whether that be in their homes, shelters, or places of
employment. He said that the erosion of the community behavior
health system has led to individuals being diverted to DOC and
hospital emergency rooms, and there has been a reduction in the
capacity at the Alaska Psychiatric Institute (API); ultimately,
individuals in psychiatric crises are not getting the
appropriate treatment in the appropriate settings needed to
address their issues.
MR. WILLIAMS, referencing slide 4, asked, "Would this be the
response and care system you would want, or design, for someone,
an Alaskan, who experiences a cardiac arrest?" He asked whether
anyone would want a uniformed officer, with a gun, to show up on
the street corner to help an individual in such a situation. He
expressed that mental health conditions are medical conditions,
just like cardiac arrest, kidney disease, epilepsy, or asthma.
He stated that the response should not be a law enforcement
individual, it should be someone trained in mental health or
with experience related to mental health conditions.
1:17:57 PM
MR. WILLIAMS, referencing slide 5, suggested that transforming
the psychiatric crisis response system in Alaska has to start
with a no wrong door approach: there must be no refusal and no
eligibility requirements and, if someone calls, the response
must be handled in the appropriate way, with the appropriate
professionals, and the appropriate level of care.
1:19:02 PM
[MR. WILLIAMS played a video that was approximately three and a
half minutes long, pertaining to the Crisis Now Model.]
1:22:41 PM
MR. WILLIAMS, referencing slide 7 of the PowerPoint
presentation, expressed that a true mental health emergency
response system is integrated across a region, a community, and
a state. He stated that it utilizes peers and people with lived
experiences to help a person in crisis to resolve his/her crisis
and move forward. He reemphasized that it requires a no wrong
door, 24/7, 100 percent acceptance policy, and he said there
should be strong coordination across all levels of care.
1:23:19 PM
MR. WILLIAMS, referencing slide 8 of the PowerPoint
presentation, stated that the Crisis Now Model, in terms of
service delivery, partners closely with law enforcement,
embraces recovery, and sees recovery as the outcome for
individuals in crises. He stated that the Crisis Now Model
ensures the safety of the patients and the professionals working
in these settings and incorporates a significant number of
people with lived experience as a part of the recovery and the
services that get delivered. He explained that the Crisis Now
Model is grounded in trauma, informed care, and has a zero-
tolerance goal for suicides.
MR. WILLIAMS, referencing slide 9, pointed out agencies that
have endorsed the Crisis Now Model. He stated that the
Substance Abuse Mental Health Services Administration (SAMHSA)
released its guidelines in the past month on how to respond to
behavioral health crises. He said that SAMHSA highlighted the
Crisis Now Model in its guidelines and the three components of
that model: the crisis call center, the co-response, and the
23-hour crisis stabilization center. Referencing slide 10, Mr.
Williams pointed out that a crisis call center has trained
professionals who can receive calls from individuals in
psychiatric crises and are able to resolve 90 percent of the
issues over the phone. He expressed that for 7 out of the
remaining 10 percent of individuals, the dispatch center will
send out a co-response team, which includes a mental health
clinician and a person with lived experience, and they will
resolve those issues. He stated that the remaining three
percent of individuals require more intensive service and will
be dropped off at a 23-hour crisis stabilization center so that
their needs can be met. He explained that the essential crisis
care principles and practices are: zero suicide, trauma
informed care, and patient and staff safety.
1:26:04 PM
MR. WILLIAMS, referencing slide 11, pointed out a "cross walk"
of current systems as they exist and how they respond to crises.
He highlighted that law enforcement is currently used as the
default response in the behavioral health crisis system, and in
the Crisis Now Model it would be mobile crisis teams. He stated
that typically when law enforcement officers respond, they end
up waiting at the DOC or hospital emergency rooms for up to
several hours for the person to get care in those settings. He
explained that with a 23-hour crisis stabilization center, law
enforcement can drop someone off, and in Maricopa County the
wait time is less than five minutes for a professional from the
crisis stabilization center to greet the individual and take
him/her from the patrol car to the stabilization center. Mr.
Williams, referencing slide 12, pointed out some of the
successes in Maricopa County, which were highlighted in the
video he had shown earlier.
1:28:12 PM
MR. WILLIAMS, referencing slide 13, asked, "What is going on in
Alaska?" He stated that in 2018, the conversation about the
Crisis Now Model started when then division director, Randall
Burns, had just come back from a conference on the East Coast,
had heard about the model, and started engaging entities,
including AMHTA, on how the model could be implemented in
Alaska. He said that the current default response system is,
for the most part, inappropriate and most expensive. He said
that another "big thing" that happened in 2018 was that DHSS
submitted its application for the 1115 Behavioral Health Waiver
to the Centers for Medicare and Medicaid Services (CMS) for
approval. He explained that that is important because many of
the services provided by the Crisis Now Model are outlined in
the waiver application. He highlighted the work that many
people at DHSS had done over the past few years in getting the
application approved and ensuring that a piece of the financial
foundation would be in place to implement the Crisis Now Model.
MR. WILLIAMS stated that in 2019, AMHTA worked in partnership
with DHSS to look at what it would take to implement the Crisis
Now Model in Alaska. He said that AMHTA procured a contract
with RI International, which operates some of the Crisis Now
Model pieces in Maricopa County, to come to Alaska and meet with
three urban hubs in Anchorage, Fairbanks, and the Matanuska-
Susitna ("Mat-Su") Borough and perform community assessments of
the gaps in needs for what it would take to employ the Crisis
Now Model. He explained that the consultants spent a week in
each community, met with representatives for several days, and
at the end of the week there was a debriefing and identification
of next steps. He said that the result of that work was a
consultative report released in December of 2019 [hard copy
included in the committee packet]. He said the report outlined
14 recommendations, 6 of which are listed on slide 14 of the
PowerPoint presentation. He said that AMHTA had just procured a
contract to provide project management for up to three years,
with each of the three communities and their partners, to
identify the steps needed to implement the Crisis Now Model. He
asked whether the deputy commissioner would like to comment on
the services outlined in the waiver.
1:31:44 PM
ALBERT WALL, Deputy Commissioner, Office of the Commissioner,
Department of Health and Social Services, offered an explanation
on the 1115 Behavioral Health Waiver ("the 1115 waiver"),
pertaining to HB 290. He stated that the proposed legislation
was arriving "at a very timely fashion," because the first phase
of the waiver had been accepted and the department was "putting
out" the second phase of the waiver. He expressed that up until
this point in the history of Alaska, there had been no crisis
stabilization facility types, and no means of payment for them
should they exist. He stated that now, with the 1115 waiver,
there was a way to pay for those facilities. He referenced
three graphs [hard copies included in the committee packet],
explaining that the differences between them were the age
differences at the top, as the 1115 waiver is separated into
three target groups by age. He said that there are three types
of services: grant-funded, Medicaid state plan, and 23 new
services offered under the 1115 waiver. He explained that up
until the acceptance and implementation of these new service
types, there would not have been the means to pay for a crisis
stabilization center with no partial hospitalization, 23-hour
holds, and other things of that nature. He explained that the
1115 waiver is coinciding in a timely fashion with the
legislation proposed under HB 290, and there will now be a
payment mechanism for the services that would be delivered
through the proposed model.
1:33:58 PM
MR. WILLIAMS continued with the PowerPoint presentation.
Referencing slide 14, he pointed out 6 of the 14 broad-based
recommendations from the Crisis Now consultative report. He
said that the elements required to fully implement the Crisis
Now Model were identified early on in multiple community
conversations, as they would be great for urban communities but
need continued conversations on the implementation in rural
communities. He stated that something AMHTA, the committee, and
many others are interested in is how to create accountability
and what the performance metrics are for the Crisis Now Model.
Referencing slide 15, he explained that AMHTA had sponsored a
group of 26 individuals to go to Maricopa County and meet with
the operators of the Crisis Now Model. He said that pictured on
the slide was a subacute crisis stabilization center, which
would be the location for someone who was not stabilized within
23 hours and needed a more acute level of care.
1:35:26 PM
MR. WILLIAMS, referencing slide 16, pointed out several entities
that had sent representatives on the site visit to Maricopa
County. He explained that there is broad-based interest and
support moving forward, and these entities will be required to
lay out the plan and develop and implement the services long
term. He noted that AMHTA sponsored this trip, but many other
people have gone on separate trips to look at the Crisis Now
Model, including various legislators, local law enforcement, and
DHSS through the Milbank Memorial fund. Mr. Williams,
referencing slide 17, pointed out some of the highlights
reported back from the AMHTA sponsored site visit. He said that
it was important to be able to see how the model works, to talk
to local law enforcement in Maricopa County to see their
benefits and hear their support, and to understand what did not
work previously and how well things work now. He said that it
helped AMHTA connect with what needs to happen in terms of
policy regulation and statute in Alaska to make the Crisis Now
Model effective.
MR. WILLIAMS, referencing slide 18, stated that the next steps
moving forward would involve a project management team picking
up the work that has been started to look into the 14 broad-
based recommendations from the report, start to develop a plan
for how to implement the Crisis Now Model in three communities,
and continue to work with local health providers to get the
model up and running in Alaska.
1:37:36 PM
MR. WILLIAMS, referencing slide 19, stated that AMHTA has been a
partner in the process and will continue to be. He expressed
that AMHTA will be involved in consultations and project
management support. He stated that the trustees recently
approved $2.6 million of new funding to help forward these
efforts. He thanked AMHTA staff Katie Baldwin, Senior Program
Officer; Eric Boyer, Program Officer; and Travis Welch, Program
Officer, who have all worked closely with partners to help the
Crisis Now Model move forward.
1:39:09 PM
TIMOTHY QUIGLEY PETERSON, MD, Bartlett Regional Hospital,
offered testimony in support of HB 290. He stated that he has
been an emergency physician in Juneau for 31 years, and one of
the things he has seen happen over that time is that more people
with anxiety and depression have been treating those issues with
drugs and alcohol, which can sometimes unmask psychiatric
illnesses, and as a result hospitals are seeing more cases of
psychiatric illness. He stated that the system as designed, as
said earlier, is straightforward. He explained that most people
with behavioral health emergencies are brought to the Bartlett
Regional Hospital emergency room by the Juneau Police Department
when it is determined that someone needs to be "assessed." He
said that this leads to a "whole gamut" of people who are
brought to the hospital. As an example, he stated that there
will be times when a schizophrenic person who was on his/her
medication(s) and feeling good will not fill his/her
prescription, slowly decompensate, see a police officer, freak
out because of previous issues with law enforcement, and then
end up in the emergency room with a security guard and a police
officer on each extremity while he/she is injected with
medicine, just to keep him/her safe, when all that person really
needed was a medicine refill. He said that he thinks that is a
good example of why the emergency room is a bad place to take
people "like this." He said that if someone were suicidal it
would be a different scenario.
DR. PETERSON stated that security and nursing staff end up
spending a lot of time being diverted to help with these
situations and not doing the jobs that they are assigned to do.
He stated that emergency rooms are noisy and chaotic places, and
many people with mental health issues do not do well in that
environment. He stated that he speaks for the American College
of Emergency Physicians (ACEP) in Alaska, in that it is thankful
for legislative support to API, because the bed capacity was "up
to 50 or something from a year ago." He said that there will be
times that someone will need a bed in Juneau and have to sit in
the emergency room for a day or two, because someone from up
North was sent down in a Medivac, at great expense, and is
taking up a bed. He said that these individuals are "just in a
bed, on the floor, get brought a meal, and someone stands there
and looks at them." He said that this is a big expense for the
hospital and the system does not work very well, which he said
he thinks is clearly outlined by the recent presentation and the
proposed legislation.
1:42:23 PM
REPRESENTATIVE DRUMMOND remarked that she is on the House Health
and Social Services Standing Committee, which had spoken the day
before about the psychiatric beds that are being made available
at Bartlett Regional Hospital, Fairbanks Memorial Hospital, and
in Anchorage, and she asked whether those beds are "full."
1:42:56 PM
DR. PETERSON answered that Bartlett Regional Hospital has 12
dedicated psychiatric beds in a locked unit, and they are almost
always full. In response to a follow-up question from
Representative Drummond, he stated that the program has been in
place for 15 or 18 years, and was designed to be regional so
that people from all over the region, including Ketchikan,
Petersburg, Angoon, and many others could receive care closer to
home. He said that as it works currently, though, there will be
times where there are Juneau residents up North, and Mat-Su
residents down South. In response to another follow up
question, he explained that the patient is put wherever a bed
happens to be. He said that there is a ranking list at API for
patients trying to be admitted. There was a teenage boy in
Kodiak who was in the hospital waiting for a bed for 10 or 11
days, and his position on the list kept changing and no one
could figure out what was happening. He said that those kinds
of people will probably get their medicine if they are in the
hospital, but they will not receive any therapy or resources to
help them adapt back as a functioning member of the world. He
said that by the time these individuals get to the mental health
unit, their mental health conditions may have stabilized, but
their abilities to cope and function have not. He said that
this results in shorter admissions for those patients, which
makes them more likely to "bounce back" and creates a revolving
door of the same people back for treatment four to six weeks
later.
1:44:37 PM
CHAIR CLAMAN asked whether Juneau had created a crisis
intervention unit, and whether it was currently operating at
Bartlett Regional Hospital.
DR. PETERSON replied that there is not currently a unit like the
Crisis Now Model. He explained that currently Bartlett Regional
Hospital has an on-call mental health practitioner, who will
come to the emergency room three to five times in a 12-hour
shift to assess someone who comes in with a mental health issue.
He said often the people admitted are depressed, off their
medications, or "back in town after a bad divorce elsewhere, and
they don't even know where to turn." He said that often the
staff at the emergency room are not qualified to help these
people, although they try their best, and the hospital is set up
to take care of heart attacks and strokes, among other things.
1:46:08 PM
RAY MICHAELSON, Program Officer, Healthy Minds Focus Area, Mat-
Su Health Foundation, offered testimony in support of HB 290.
He stated that he oversees all projects that are related to
behavioral health. He said that the Mat-Su Health Foundation
shares co-ownership with the Mat-Su Regional Medical Center, and
it invests a portion of the profits from the hospital back into
the community in order to improve the health and wellness of
Alaskans living in the Mat-Su area. He said that he supports
the proposed legislation to change Alaska statute to allow for
the creation of crisis stabilization services as an alternative
to arrest for people suffering behavioral health crises. He
expressed that the Mat-Su Health Foundation supports the
proposed legislation, because it would pave the way for some of
Alaska's most vulnerable residents to receive medical evaluation
and care in lower-cost settings than hospital emergency
departments, which would result in better outcomes and
tremendous cost savings.
MR. MICHAELSON stated that he appreciated hearing about the
trips to Maricopa County, as he was fortunate enough to be
included on one of those trips. He expressed that the cost
savings over time were impressive, as well as the number of law
enforcement hours saved with the psychiatric boarding. He said
that the potential to divert inpatient stays for acute mental
health would be quite impactful on a financial basis. He said
that the prevalence of mental health and substance abuse
problems is increasing in Alaska, and the savings could be
significant for the state by having a crisis stabilization
option for law enforcement. He stated that the average annual
growth rate for visits to the Mat-Su Regional Medical Center
Emergency Department, by patients with a behavioral health
diagnosis, grew 20 percent from 2015 to 2017, due in part to the
opioid epidemic and the shortage of outpatient access. He said
that from 2014 to 2017 the number of behavioral health
assessments required for patients in a crisis in the emergency
department grew from 349 annually to more than 1,000.
MR. MICHAELSON stated that HB 290 would allow police officers to
bring patients to a crisis stabilization center in Mat-Su,
instead of to the Mat-Su Regional Medical Center or the Mat-Su
Pre-Trial Facility. He said that in 2013, the "Mat-Su Community
Health" needs assessment allowed Mat-Su residents to rank the
health issues that they were most concerned about, and the top
five issues were all related to mental health and substance
abuse. He said that as a follow up to the community health
needs assessment, there was a Mat-Su Behavioral Health
environmental scan, in which policies were looked at that could
address barriers to access to care and improve the behavioral
health systems. He stated that one recommendation from that
report was to add a crisis stabilization center to the
behavioral health continuum of care; however, current Alaska
statute does not allow for that to happen, and HB 290 would
change that. He said that additional recommendations out of the
behavioral health environmental scan included the crisis line
and mobile crisis services. He summarized that system changes,
such as the proposed legislation would allow, would alleviate
suffering for people in behavioral health crises, while
delivering significant cost savings, especially for Alaska's
Medicaid program. He reiterated that the Mat-Su Health
Foundation is in strong support of HB 290 and urges the passage
of the proposed legislation.
1:50:21 PM
CHAIR CLAMAN closed invited testimony on HB 290.
1:50:40 PM
REPRESENTATIVE LEDOUX asked whether anyone other than police
officers would be allowed to take people to "crisis
intervention" centers, under the proposed legislation.
1:51:04 PM
MR. WILLIAMS replied that anyone would be served and admitted,
by various sources, to a crisis stabilization center. He said
that if he were in a mental health crisis, then he could seek
services there himself, a family member could assist him in
getting there for services, or Emergency Medical Services (EMS)
could drop him off; it would not be limited to law enforcement.
REPRESENTATIVE LEDOUX asked whether crisis stabilization centers
exist currently in Alaska, whether the current law requires
another law to allow police officers to take people to crisis
stabilization centers, or whether they exist at all.
1:52:01 PM
CHAIR CLAMAN remarked that they do not exist - "period."
1:52:07 PM
MR. WILLIAMS clarified that there is the Providence Psychiatric
Emergency Department, in Anchorage, which was constructed as a
piece of the new API and was supposed to be the single point of
entry. He explained that it has eight beds in Anchorage, and it
tries to stabilize people within 23 hours, but it is inadequate.
He added that while the service is critical, it is a slightly
different model from what is being operated in Maricopa County,
specifically around the use of peers as a key component of
services.
1:52:54 PM
REPRESENTATIVE LEDOUX asked whether the Providence Psychiatric
Emergency Department is a lock-down facility and remarked that
she didn't think it was a place to which someone could just go
for 24 hours.
MR. WILLIAMS replied that he was not going to get into the
specifics of whether it is a lock-down facility, but he knows
that the model is based on trying to stabilize someone in less
than 24 hours and, if not, make a recommendation for someone
going to API or a higher level of care in other communities.
1:53:42 PM
REPRESENTATIVE DRUMMOND remarked that Mr. Williams' presentation
resulted in bringing questions to mind. She stated that she
serves on two other committees, in which she is hearing of an
overwhelming need for mental health services. She said that the
proposed crisis stabilization center seems to be at the center
of a continuum of care issue that Alaska has. She stated that
the day before in the House Health and Social Services Standing
Committee, testimony had been heard regarding HB 86, regarding
mental health and contract bids. She said that in the House
Special Committee on Education, they were talking about the
Department of Education and Early Development's (DEED's)
approach to teaching children who come to school with Adverse
Childhood Experiences (ACES), with trauma informed awareness.
She stated that high school students are asking for a mental
health curriculum, and that is being addressed through HB 181.
She said that former Governor Bill Walker's administration had a
"cross-department summit" in Anchorage in Fall 2018, where it
was acknowledged that quite a few State of Alaska employees
suffered or acquired secondary trauma through their work as
public safety officers, working with dysfunctional families in
the Office of Children's Services (OCS), or working with
suicidal people in all kinds of situations.
REPRESENTATIVE DRUMMOND asked who would be tying all these
topics together. She remarked that it "can't be up to me as a
legislator, who just happens to be on the right three committees
to pull this together." She stated that she had just been
assigned to the House Judiciary Standing Committee, as well as
Representative Vance, and this was opening her eyes to the needs
across the state. She expressed that the biggest issue missing
from the presentation Mr. Williams had given pertained to
education, and she asked, "What about the children?" She
remarked that there were people from the University of Alaska
who were on the trip to Maricopa County, but there was nothing
about DEED or school districts included in the presentation, and
she asked how children would be addressed under the proposed
legislation.
1:56:42 PM
MR. WALL answered that the behavioral health system of care has
been in disarray in Alaska for quite some time, and DHSS is
aware of that. He stated that it has traditionally been funded
through a blend of grants through non-profit organizations and
Medicaid services in a limited fashion. He advised that the
behavioral health system was designed years ago and has not
evolved with the current situation in health care, and it needs
to do so. He stated that there is a broad discussion and a plan
for changing that system, and crisis stabilization is a piece of
that change. He said that Representative Drummond was correct,
there are many elements to the system. He said that DHSS has
had conversations with EED recently at a summit in Mat-Su,
around school-based services and education, and is looking
specifically at opportunities in that area. He related that
Mat-Su has a behavioral health program in its school system that
is running very well. He stated that Senator von Imhof brought
that group together, and DHSS is glad to be a part of it.
MR. WALL stated that there is a very broad-based discussion
around the implementation of care. He explained that SAMHSA has
a continuum of care that has been developed over time, which has
tremendous amounts of research and clinical thought behind it,
and when a state looks at what its behavioral health system
should look like, it compares its system to that continuum of
care. He stated that it is evident where gaps in service exist
in Alaska, and DHSS is actively looking to fill them. He said
Alaska's service of care has been driven for a long time on the
end of "expense of acuity," as shown in the video clip and
explained by Mr. Williams previously. He said that there is a
tendency to hold on to a behavioral health problem until there
is an absolute emergency, and deal with it in either an
emergency room or acute psychiatric setting.
1:59:38 PM
GENNIFER MOREAU-JOHNSON, Director, Division of Behavioral
Health, Department of Health and Social Services, offered
testimony in support of HB 290 and answered questions pertaining
to the proposed legislation. She addressed a question from
Representative Drummond pertaining to adverse childhood
experiences. She explained that the three graphics, referenced
earlier by Mr. Wall, show the three populations targeted by the
1115 waiver: the substance use disorder population, the mental
health population, and the at-risk families. She said that the
idea of the 1115 waiver is to drive down the cost of care and
provide appropriate care where needed. She stated that at-risk
families are in the section in which multi-generational returns
on services provided are being investigated. She explained that
the point of entry for at-risk families at the early-
intervention end of the continuum is entirely based on adverse
childhood experiences; the data comes from the Alaska
Longitudinal Child Abuse and Neglect Linkage Project, which came
out of the Division of Public Health (DPH).
MS. MOREAU-JOHNSON said that Jared Parrish, an epidemiologist,
established "stressors" - indicators that would likely result in
child abuse and neglect - which are the criteria for at-risk
families. He worked with [the department] to "crosswalk" the
indicators from his study to diagnostic codes. She said that
there are 17 criteria, including: homelessness, incarcerated
parents, substance use, and atypical parenting situations. She
said that the services available through home-based family
therapy are specifically targeted as protective factors to
ameliorate the impact of adverse childhood experiences. She
stated that the federal government approved this, because a
study from the Alaska Mental Health Board demonstrated that the
number of adverse childhood experiences have a correlation to
Medicaid expenditure, and it saves money to reduce the impact of
ACES.
2:01:47 PM
REPRESENTATIVE DRUMMOND asked for clarification on what SAMHSA
is.
2:02:06 PM
MR. WALL answered that SAMHSA is the Substance Abuse Mental
Health Services [Administration], which is a branch of the
federal government. He said that he could provide a link to a
good modern continuum of care.
2:02:28 PM
REPRESENTATIVE VANCE remarked that the Medicaid expansion has
increased the obligation Alaska has in its "portion of carrying
that burden," which has affected the budget. She asked what the
1115 looks like "in comparison to that," and how it would affect
future growth. She expressed that the visible mental health
issues are only "the tip of the iceberg," and asked for
explanation on the services that might be needed.
2:04:02 PM
MR. WALL answered that DHSS would be happy to make itself
available to answer specific questions by members of the
committee at any time. He stated that the history of behavioral
health in the state is funded primarily through a combination of
behavioral health grants, which are generally funded and have no
federal match attached to them, and the Medicaid portion, which
is limited, administratively burdensome, and costly. As an
example, he said that traditionally services provided under
clinic services and rehabilitation ("rehab") for behavioral
health are billed in small increments of time, which requires a
great deal of paperwork and has a limited amount of
reimbursement with a lot of administrative overhead. He said
that the 1115 waiver pays for services in a different way, which
is in a bundled fashion, requires a lot less administrative
overhead, and allows DHSS to access the federal match for it as
well.
MR. WALL explained that the plan for a move to the 1115 waiver
has been around since Senate Bill 74 was passed [in 2016, during
the Twenty-Ninth Alaska State Legislature]. He said that grants
have been reduced over time, so the general fund has gone down,
and the Medicaid pieces have been used to fill in where needed.
He said that overall, healthcare is costly and tends to
increase. He explained that DHSS is actively engaged in cost
containment and has addressed the 1115 waiver from a cost
containment point of view.
2:06:18 PM
MS. MOREAU-JOHNSON pointed out that her department is in
contract with an actuarial firm and is working very closely to
do analysis around expenditures and, as Mr. Wall had described,
the actuaries are monitoring the situation with the idea being
that if there is an uptick in the consumers of these services,
it will be at the lower end of the cost of care.
2:06:47 PM
REPRESENTATIVE VANCE asked whether the type of additional care
that would be needed for 30 percent of patients, as described by
Mr. Wall previously, would be "API type of care," and whether
there are preparations in place for an increase in volume.
2:07:21 PM
MR. WALL answered that the numbers being used came from the
crisis intervention stabilization model out of Arizona and are
specific to Maricopa County and reflect how many stabilizing
interventions were made during a specific time. He said that as
mentioned previously, 90 out of 100 of those cases would be
stabilized over the phone. He said that the remaining cases
would not necessarily require an API level of care, meaning they
would end up in a stabilization center, but that is not
precluding an inpatient level of care because some of those
cases "do go, but those were not included in that number of
three." He explained that the three sets of numbers used were
for those that were stabilized in a call center, those that were
stabilized by mobile behavioral health teams, and those that go
to a stabilization center.
2:08:17 PM
CHAIR CLAMAN remarked that this means that 90 percent are
stabilized on the phone, 7 percent are stabilized by mobile
teams, and 3 percent are stabilized in a crisis stabilization
center. He said that within the 3 percent is a smaller
percentage that will go to what would be called an API in
Alaska, to an involuntary commitment setting for longer care
treatment than can be received in a 23-hour window.
MR. WALL replied that that is potentially correct. He pointed
out that solving a problem on the phone is astronomically less
expensive than doing it in an emergency room.
2:09:00 PM
REPRESENTATIVE VANCE asked how many central locations DHSS was
looking into, given how large Alaska is and the rural areas that
are in the state.
2:09:23 PM
MR. WALL answered that the process would be phased in over time
and there is a rural application, which DHSS is working on with
tribal partners. He expressed that an exciting thing about
going to Maricopa County was that a tribal liaison was available
to answer questions. He said that while Arizona is not the same
as Alaska, there are remote areas, such as a tribal village at
the bottom of the Grand Canyon, that are only accessible by
mule. He stated some of the ways that this model was adapted to
Arizona could potentially be adapted for the model in Alaska.
He said that there are different ways to handle mobile teams,
like in the village mentioned before. He explained that all the
adults were trained, and the phone was traded amongst them. He
said that there are interesting applications that can be applied
in Alaska, and he mentioned that Arizona has Medicaid approved
transportation for horses. He added that he was not suggesting
that would be applied in Alaska. He explained that there are
different ways to adapt for rural areas as needed, and DHSS will
be working towards that. He said that the initial push will be
for urban areas, as they have the highest volume of cases, and
DHSS will be looking to put up a full system that is sustainable
in those areas and then work with other areas.
2:10:56 PM
MS. MOREAU-JOHNSON remarked that the 1115 waiver is designed
around regions, and the idea is to develop capacity in every
region. She said that there will be monitoring across every
region in the state, and there is a contract with an
administrative services organization tasked with building
capacity and doing continual gap analyses where services are
missing. She said that the idea is not just to build up
services in Anchorage, Fairbanks, and Mat-Su and fly people in,
but to serve people within their hub communities as much as
possible. She said that AMHTA helped fund an infrastructure gap
analysis, which should be released by March 15, 2020, in which
it went to every regional hub and visited 75 providers across
the state to talk about services.
2:11:56 PM
REPRESENTATIVE VANCE remarked that she noticed that the fiscal
notes included health facilities, licensing certification,
Medicaid services, and trooper detachments, but did not have any
information regarding facilities and the "RTC," or response
team. She asked whether someone could talk more about the
fiscal notes for these things.
2:12:45 PM
MR. WALL answered that all those things have not yet been
determined. He said that DHSS is in the process of working with
the bill sponsor and is happy to work on the proposed
legislation as it develops. He stated that there are some
service lines within the Crisis Now Model that will require
licensure, while others will not. He said that some of the
service lines could be handled through regulation, some could be
handled by a service provider "standing it up and doing it," and
others would have to be put into statute.
2:13:19 PM
CHAIR CLAMAN remarked that his understanding of the RI
International model and experiences in Phoenix, Arizona, in
terms of funding the crisis intervention center, is that the
organization that runs it is able to fund operations through
"billables," although there may be some capital expense when
getting started. He suggested that Mr. Wall or Mr. Williams
might be able to give more information on who would build a
crisis center once permission is in place.
2:13:54 PM
MR. WALL replied that that is true, the model is designed to be
a billable service. He said that there are different levels of
service and the call center, mobile crisis teams, and the crisis
stabilization centers are three separate lines of service. He
said that in Maricopa County each line of service is handled by
a different type of organization, and they are all handled in a
slightly different manner. He added that in Maricopa County
services are run under managed care, and it is a slightly
different model from what would be seen in Alaska.
2:14:36 PM
MR. WILLIAMS remarked that he thinks it is important for the
committee and anyone watching the meeting to understand that
these are the beginning phases of looking at what it will take
to implement the Crisis Now Model in one to four communities,
which is why there is project management under contract to start
working and do the proformas for the costs that will be
associated with capital facility costs and operations. He said
that as work is done to identify how to implement the Crisis Now
Model to meet the needs of local communities, that information
will become clearer and will be readily available as it is
generated.
2:15:30 PM
REPRESENTATIVE LEDOUX asked for clarification on what an 1115
waiver is.
2:15:48 PM
MR. WALL answered that there is standard Medicaid under federal
statute, and there are different ways that requirements can be
waived for standard Medicaid, which are applied for through
several different types of waivers. He said that Alaska already
has some waivers in the state, and that Senior and Disabilities
Services (SDS) operates under a complex 1915(c) waiver. He said
that the 1115 waiver is a section in federal law that can be
applied to in order to get certain requirements waived. He said
that there are basically two types of waivers: one waives how
to become eligible, and the other waives the types of services
involved and how to pay for those services. He expressed that
it is a complex system.
2:17:02 PM
CHAIR CLAMAN remarked that a large measure of what is seen with
an 1115 waiver is that primarily federal funds pay for treatment
services, whether that be for substance abuse, mental health
disorders, or psychiatric issues. He said that there is more
than one type of waiver in terms of what treatment is provided,
but largely federal funds are used, because it is an expansion
of Medicaid, and the people who are eligible for that do not
typically have insurance; a waiver allows them to get treatment.
He expressed that if he explained that incorrectly, then there
were two people present who could offer a correction.
MR. WALL remarked that the 1115 waiver is not a "standard
package." He explained that many states have an 1115 waiver and
they all look vastly different, and sometimes the waivers do not
even pertain to mental health. He said that the reason Arizona
has been talked about so much, and people went there to study
the model, is because the waiver there is the closest of any
state to the waiver in Alaska, although they are still different
from one another. He expressed that Ms. Moreau-Johnson is the
DHSS's expert on waivers, and she could explain in more detail.
2:18:19 PM
MS. MOREAU-JOHNSON remarked that Mr. Wall had described the 1115
waiver correctly. She said that the way she likes to look at it
is that the 1915(c) waiver, which SDS has purview over, is for
individuals waiving a level of care; individuals waive the level
of care they would otherwise receive in a nursing facility. She
said the 1115 waiver is the federal government allowing, through
the section of Title 19 that Mr. Wall had described, to waive
the rules of the program; therefore, instead of an individual
waiving something, it is the program rules that are being
waived. She said that to Chair Claman's point, many people
served by [the Division of] Behavioral Health fit in to the
expansion population, which is "round numbers of 90/10 match,
the 90 percent federal, 10 percent state match." She said that
Chair Claman was correct in saying that any population can fit
into that, and when looking at the populations, "the different
people being served will have varying federal matches attached
to their eligibility."
2:19:28 PM
REPRESENTATIVE LEDOUX asked, "What rules are getting waived?"
2:19:36 PM
MS. MOREAU-JOHNSON answered that there are several rules being
waived. She said that Representative LeDoux's question is like
the question that led to how the design of the waiver was
approached, and she asked, What do we want to waive? She said
that one of the primary rules that was waived was the rule of
comparability in Medicaid. She said that under traditional
Medicaid through the state plan, any service that is offered
must be available to any Medicaid eligible person. She
expressed that her department wanted to target populations, so
the comparability rule was waived, and populations were designed
around data that showed who tend to be high consumers. She
explained that one of the cost-containment strategies is to
target the populations that tend to be at the high end of care
and design services to keep them.
REPRESENTATIVE LEDOUX expressed that her understanding was that
anyone could be accepted to a crisis stabilization center under
the proposed legislation, and she said she found it confusing
that Ms. Moreau-Johnson was now saying it would be targeted
towards certain populations.
MS. MOREAU-JOHNSON answered that Representative Ledoux was
right to be confused and said that the populations she was
explaining are the populations that are eligible for Medicaid
coverage. She explained that the difference is between the
model and the services being proposed in the 1115 waiver. She
said that services will be covered when a claim comes through
and will be paid for through Medicaid, for anyone who is
Medicaid eligible and meets the qualifications. She said that
the Crisis Now Model has 100 percent acceptance, and the phone
doesnt get answered with the question, What is your Medicaid
ID number? The phone gets answered with, What do you need?
2:21:37 PM
MR. WALL commented that it is important to separate what crisis
stabilization is from the 1115 waiver. He explained that the
1115 would be used as a vehicle to provide payment for a certain
group of people. He said that this does not meant that the 1115
waiver is crisis stabilization, as they are two different
things. He said there are people with regular Medicaid and
people with no payment capacity whatsoever, and all kinds of
people will be able to go to a crisis stabilization center and
be served. He said that the mechanism that was used to set it
all up in the first place was the 1115 waiver. He summarized
that it is somewhat complex, and the two are separate entities.
2:22:31 PM
REPRESENTATIVE DRUMMOND, referencing the three charts provided
by DHSS, remarked that the blue stuff is the 1115 waiver. She
asked for clarification on what are we getting and what is it
costing? She mentioned grant funding and asked whether this
was how behavioral health used to be administered. She said
that she had heard someone mention earlier that the patchwork
is not working, so were fixing it. She asked whether the
Medicaid state plan is general fund dollars, and the other
services federal dollars.
MR. WALL answered that Ms. Moreau-Johnson has been giving
presentations on that very topic to the DHSSs partners in many
legislative settings for the past year, and offered his
understanding that she would be happy to give the presentation
to Representative Drummond. He said that the presentation is
approximately an hour and it might be better to do it on the
side.
2:23:49 PM
MS. MOREAU-JOHNSON remarked that Representative Drummonds
question pertains to funding across the three different colors
on the charts. She said that the grant lines are funded through
some federal grants and some state funded grants. She explained
that the orange bars on the chart are the Medicaid state plan,
which is the match mentioned earlier; the federal match is drawn
down in varying amounts depending on the eligibility group being
served. She expressed that the problem with the state plan is
that the services allowed come straight out of Title 19,
referred to earlier by Mr. Wall, which is a list of services
that is very limited in nature, and behavioral health has not
traditionally fit into that list very well. She said that
another rule that was waived through this process was to get
away from the medical model, which allowed for the design of
more services that people will be willing to engage with and are
more appropriate in the behavioral health world.
MS. MOREAU-JOHNSON stated that all the services in the orange
and blue on the charts are Medicaid dollars, which fit in as a
revenue source for the people providing a service in crisis
stabilization when provided to someone who is Medicaid eligible.
She said that she does not want the 1115 to be a distraction
from HB 290, but said that the reason it is important is because
it will be a primary funding source for the proposed
legislation. She said that she thinks approximately 80 to 85
percent of the costs in Arizona were covered by Medicaid.
2:25:36 PM
REPRESENTATIVE VANCE asked for clarification on whether the
intent for HB 290 is just to establish a procedure so that the
process of setting up mechanisms in Alaska for an alternative to
arrest can begin and would not directly impact setting up the
crisis stabilization centers.
2:26:17 PM
CHAIR CLAMAN answered that Representative Vance was partially
correct and HB 290 would do two things. First, in the criminal
code it would provide an alternative to arrest option for
officers. Second, it would give DHSS the authority to write the
regulations that would allow for it to start standing up the
process. He said that the timeframe he foresees is that if the
proposed legislation were to pass in the current session, it
would take DHSS 6 to 12 months to get the regulations in place,
and the goal would be to have regulations in place so that by
the next fiscal year, meaning the beginning of 2022, one or more
of these facilities could be started in one of the communities
that have been described. He stated that the finer details
would be left to regulations, and without the statutory change
that specifically allows for DHSS to have crisis stabilization
centers within its range of care options, the process of
drafting the regulations to make that possible cannot begin.
2:27:46 PM
REPRESENTATIVE VANCE asked how much training police officers
have, regarding mental illness, to be able to make an
identification, and she asked whether DHSS thinks it is adequate
given the high number of mental crises in Alaska.
2:28:09 PM
CHAIR CLAMAN responded that he did not want to speak for police
officers, although he said he has been in contact with public
safety and local police departments in the state, and the answer
he has heard is that police officers do receive training in
dealing with mental health and substance abuse crises. He
stated that the reality is that the population police officers
see every day is people having mental health and substance abuse
issues. He said that the police officers are not trained as
psychologists, but they must make these decisions as part of
their work daily, as that is what they are dealing with.
2:29:10 PM
MR. WILLIAMS commented that the training academies do cover
mental health issues in a very small piece of their overall
training, and there are communities that have crisis
intervention team training. He said that AMHTA has worked with
communities in Anchorage, Fairbanks, and Juneau. He stated that
the Mat-Su Health Foundation and AMHTA have worked with the
troopers in the Palmer and Wasilla police departments to provide
a more intensive 40-hour crisis intervention team training, for
which officers and other first responders voluntarily agree to
apply. He explained that the intent is never to train a police
officer to be a clinician but to be able to recognize whether a
situation requires more work and questions of the individual or
those around him/her.
2:30:13 PM
REPRESENTATIVE VANCE stated that she had met a man that day from
a rural village in a region that has the highest rate of suicide
in Alaska. She asked whether there was a partnership to work
with the Village Public Officer Safety Program (VPSO) and
whether it was possible to have that community as part of the
first regional model, as it currently has the greatest need for
intervention.
2:30:56 PM
MR. WALL replied that DHSS works with every region, particularly
around behavioral health emergencies and crises, and he
reiterated that this model would first be rolled out in an urban
setting, because the infrastructure necessary to run it requires
that. He explained that it would then be adapted to each region
and work would be done to put the model in place, including with
the VPSO structure.
2:31:27 PM
REPRESENTATIVE LEDOUX asked whether anything is anticipated to
be between the crisis stabilization center and API, meaning
something that could take care of people for a few days instead
of committing them to API indefinitely.
2:32:04 PM
MR. WILLIAMS answered that the model in Arizona, its three
components having been discussed earlier, has a fourth component
that had not yet been discussed. He said that this component is
a subacute unit, and if someone cannot be stabilized in a 24-
hour period and needs a higher level of care, then he/she can be
referred there or to other services like API, if required.
2:32:39 PM
CHAIR CLAMAN remarked that for the short term in Alaska, because
the state is trying crisis stabilization first, someone who is
not stabilized in the first 23 hours would likely be sent to API
or an equivalent. He expressed that in the long term, a goal
would be to have the next level of care in place.
2:32:57 PM
REPRESENTATIVE LEDOUX asked Mr. Williams what the role of AMHTA
would be in paying for the proposed facilities.
2:33:25 PM
MR. WILLIAMS answered that over the past 25 years AMHTA has had
the role of helping to identify and invest in a model that can
enhance the system of care and improve outcomes for Alaskans.
He said that AMHTA provides funding to explore that and acquire
continued project management and consultation. He expressed
that as the pieces of standing up and operating the components
of the proposed model come into play, he anticipates AMHTA would
be playing a role in that as well.
2:34:21 PM
REPRESENTATIVE DRUMMOND, referencing Representative Ledouxs
question about what happens between crisis stabilization and
API, asked where the subacute treatment fits on the chart, with
acute being the third column, outpatient services being the
second column, and residential and inpatient being the third
column. She asked whether subacute would be before acute, or
after.
2:34:43 PM
MR. WALL answered that it could be a bit of both. He said that
traditionally there is something in behavioral health, or even
in respite services for surgeries and such, that are called
step-down units. He said that someone can either be in a
step-down unit prior to going to a higher level of acuity or be
in one after he/she is discharged from a higher level of acuity.
He said that it is a level of service that needs to be further
developed in Alaska. The situation is evolving as things move
forward, and the plan is to eventually put everything into
place.
2:35:25 PM
REPRESENTATIVE DRUMMOND commented that it did not surprise her
to see all the costs related to mental health issues. She
remarked that private health insurance has not covered mental
health costs for years. She said that the program DHSS is in
might provide a few sessions of counseling, but certainly not
inpatient mental health services. She expressed that she is
glad to see society waking up to the fact that there are all
kinds of issues, particularly that ACES result in medical costs
later in life. She said that Dr. Vincent Felitti had been in
Alaska several years ago and introduced ACES, which he had
discovered accidentally in a long-term nutritional study that he
had done with Kaiser Permanente on thousands of patients. She
said that is when DEED started talking about how to incorporate
ACES into its understanding of how children learn.
2:36:52 PM
REPRESENTATIVE LEDOUX, referencing fiscal notes [hard copies
included in the committee packet], remarked that the fiscal note
from healthcare services says that crisis stabilization centers
will require state licensure, periodic surveys, ad hoc
inspections, and will require two full-time registered nurse
positions to fulfill these requirements. She asked whether this
was normal, in respect to licensing. As an example, she asked
whether nurses would be sent as par for the course if the
Providence Psychiatric Emergency Department or API were
inspected.
2:37:59 PM
MR. WALL answered that there are a variety of different surveys
and inspections that are done on facilities. Some require
clinical review, and those that do will have clinical personnel,
like a nurse, to perform them. He said that there are other
types of surveys that do not require clinical review, but those
are compliance surveys that pertain to physical structure and
procedure. He said that in the case of the proposed legislation
there would be a need for clinical review.
REPRESENTATIVE LEDOUX remarked that the zero-fiscal note from
the Office of the Commissioner stated in its analysis that DPS
will need funding support to train officers in crisis
intervention and mental health first aid, and she asked whether
that is something that DPS does already.
MR. WALL replied that the fiscal note is from the Department of
Public Safety, thus he would defer questions about it to that
department. He said that there are a couple of different ways
to handle the licensure and certification process, that would
affect a fiscal note.
2:39:32 PM
REPRESENTATIVE LEDOUX remarked that she was curious as to why it
would take different training to refer someone to one of the
centers under the proposed legislation when officers are already
taking people to API.
2:39:46 PM
MR. WILLIAMS answered that he did not think that there would be
training required to take someone to one of the proposed crisis
stabilization centers, but there would be basic one-on-one
training as to what could be presenting as a mental health
situation, which allows an officer to have more recognition and
tools to assess a situation and respond appropriately. He said
that it would not be about a clinical diagnosis or whether
training is needed to identify that the deputy commissioner
needs to go to a crisis stabilization center or not. He said
that if an officer were to see that as the appropriate approach,
with or without training, he/she should be able to make that
call on the street.
2:40:38 PM
REPRESENTATIVE SHAW, referencing Representative LeDouxs point,
remarked that he taught at the Public Safety Training Academy,
and over a 400-hour training session for a trooper the academy
will adjust the curriculum accordingly to increase the level of
training that might be needed in a certain area. He said that
currently were looking at a totally different scenario in the
training because of behavioral health issues. He expressed that
he thinks there is a lot more sociological and psychological
training that needs to be established. He said that this was
highlighted in the VPSO program the other day, as it is
currently being worked on to increase the value of the VPSO
program in rural communities. He mentioned one trooper one
riot, saying that one trooper covers ten villages, and without
the VPSO interaction the value of law enforcements behavioral
health support is lost without training. He said that trying to
build the curriculum for the trooper and VPSO program to deal
with behavioral health issues is huge. He expressed that it
must either be added to the training, or some other type of
training will have to be removed. As an example, he said that
constitutional law is taught at the academy, and he suggested a
few hours of that be cut. He expressed that it is difficult to
add a week or two to law enforcement training, because there is
a desire to get the police officers out on the street. He
stated, Get them into a field training program, then, after the
fact, if training becomes available, additional training
relative to behavioral health, then they can actually volunteer
to do that.
2:42:26 PM
REPRESENTATIVE VANCE remarked that the analysis on one of the
fiscal notes says that crisis stabilization centers require
state licensure, and she said that essentially this would be
paying for two full-time Health Facility Surveyors I
[positions]. She asked why this would be needed at this time
for HB 290, considering that it was outlined earlier that the
purpose of the proposed legislation was to allow officers an
alternative to arrest, and allow DHSS to adopt regulations. She
expressed that it seems like that is a step ahead of where
things need to be.
2:43:15 PM
MR. WALL answered that there is some oversight regulatory
control that CMS requires of things that are licensed and paid
for under Medicaid. He said that surveying a facility, whether
it be a hospital, API, or a crisis stabilization center, is
required by CMS to ensure that the facility is in compliance
with the regulations that CMS has over them. He said that the
federal government requires any facility that touches Medicaid
money to be surveyed by health care facility licensing
inspectors on a periodic basis and be able to respond to
complaints from people in that center. He explained that the
positions that would be asked for in the licensure process would
be doing that line of work.
2:44:50 PM
MR. MICHAELSON, in response to a request from Representative
Drummond, restated the statistics he had previously shared
regarding the 20 percent increase in numbers of patients with
behavioral health crises accepted by the Mat-Su Regional Medical
Center Emergency Department between 2015 and 2017 and the
increase in the number of behavioral health assessments that
were required in the emergency department as a result of
behavioral health emergencies, which was from 349 in 2014 to
more than 1,000 in 2017.
REPRESENTATIVE DRUMMOND remarked that it looked like the
behavioral health assessments due to emergencies jumped from
approximately one a day, to around three a day in that three-
year period.
2:47:32 PM
MR. MICHAELSON answered that is correct.
2:47:40 PM
MR. WILLIAMS commented that he wanted to follow up on a question
Representative Drummond had raised at the beginning of the
questions and answers session, inquiring how the proposed model
would relate to intervening with youths and adolescents who are
in psychiatric crises. He expressed that he would like to make
it clear that two of the three components discussed during the
meeting would address youths who are in psychiatric crises. He
said that a youth or adult could call the crisis call center and
a situation could possibly be deescalated over the phone. He
said that the mobile co-response teams could respond to youths
in the community, and in Maricopa County those teams often
respond and intervene at schools, which was learned on the site
visit to Arizona. He said that the crisis stabilization center
is currently targeted towards adults, but that would not
necessarily need to be a limitation going down the line. He
explained that ways could be investigated to adapt the model or
create different approaches for that level of care.
2:49:00 PM
REPRESENTATIVE DRUMMOND commented that 20 years ago there were
no long-term psychiatric beds in the state for a youth in
crisis. She said that since then the North Star Behavioral
Health System has expanded significantly so that youth in crisis
can be hospitalized in state, rather than being sent to Utah or
Texas. She said that progress has been made, but she thinks
those are partially locked facilities. She said that the
Anchorage school district sends teachers to North Star to make
sure the youths are keeping up with their academics, and
regardless how long they are there, they receive those services.
She asked what an intermediate service might look like for
people younger than the age of 21.
MR. WILLIAMS answered that he did not know that he could answer
that question at that time, but he could follow up.
2:50:20 PM
MR. WALL remarked that there are currently several different
levels of care that are available for youths in the state that
fall under that category, such as residential psychiatric
treatment centers. He said that typically when a young person
is sent out of state, he/she is not sent specifically for
psychiatric care, but for complex behavioral health and medical
issues, and he/she would go to a residential psychiatric
treatment center. He stated that depending on the level of
licensure in the laws of that state, the facility may or may not
be a locked facility. He explained that Alaska has suffered
from a lack of continuum of care and bed availability issues,
but there are residential psychiatric treatment centers across
the state and other children services as well. He said there is
a good network of partners to work with, and the association
that works with all of those is the Alaska Association of Homes
for Children, which might be a good asset for answering
questions as well.
2:51:32 PM
CHAIR CLAMAN announced that HB 290 would be held over for
further review.
2:52:16 PM
ADJOURNMENT
There being no further business before the committee, the House
Judiciary Standing Committee meeting was adjourned at 2:52 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 148 v. M 4.29.2019.PDF |
HJUD 3/2/2020 1:00:00 PM HJUD 3/4/2020 1:00:00 PM HJUD 3/6/2020 1:00:00 PM |
HB 148 |
| HB 148 Sponsor Statement 2.28.2020.pdf |
HJUD 3/2/2020 1:00:00 PM HJUD 3/4/2020 1:00:00 PM HJUD 3/6/2020 1:00:00 PM |
HB 148 |
| HB 148 Sectional Analysis 2.11.2020.pdf |
HJUD 3/2/2020 1:00:00 PM HJUD 3/4/2020 1:00:00 PM HJUD 3/6/2020 1:00:00 PM HSTA 2/20/2020 3:00:00 PM HSTA 2/27/2020 3:00:00 PM |
HB 148 |
| HB 148 Supporting Document - Holland America Princess Letter 2.18.2020.pdf |
HJUD 3/2/2020 1:00:00 PM HJUD 3/4/2020 1:00:00 PM HJUD 3/6/2020 1:00:00 PM |
HB 148 |
| HB 148 Fiscal Note DHSS-BVS 2.28.2020.pdf |
HJUD 3/2/2020 1:00:00 PM HJUD 3/4/2020 1:00:00 PM HJUD 3/6/2020 1:00:00 PM |
HB 148 |
| HB 290 ver. S 2.24.2020.PDF |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Sponsor Statement v. S 3.6.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Sectional Analysis v. S 3.6.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Supporting Document - Mat-Su Health Foundation Letter 3.5.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Supporting Document - Crisis Now Alaska Consultation Report 12.13.2019.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Additional Document - DHSS Mental Health Continuum of Care (Individuals 18 Years and Older) 3.6.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Additional Document - DHSS Substance Use Disorder Continuum of Care (Individuals 12 Years and Older) 3.6.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Additional Document - DHSS Mental Health Continuum of Care (At-Risk Children & Adolescents Ages 0-21) 3.6.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Fiscal Note DHSS-HFLC 2.28.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Fiscal Note DHSS-MS 2.28.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Fiscal Note DPS-AST 2.28.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 Fiscal Note LAW-CRIM 2.28.2020.pdf |
HJUD 3/6/2020 1:00:00 PM HJUD 3/11/2020 1:00:00 PM HJUD 3/13/2020 1:00:00 PM |
HB 290 |
| HB 290 PowerPoint Presentation on Crisis Now 3.6.2020.pdf |
HJUD 3/6/2020 1:00:00 PM |
HB 290 |