Legislature(1999 - 2000)
02/17/1999 01:30 PM Senate HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE
1:30 p.m.
February 17, 1999
MEMBERS PRESENT
Senator Mike Miller, Chairman
Senator Pete Kelly, Vice-Chairman
Senator Gary Wilken
Senator Kim Elton
MEMBERS ABSENT
Senator Drue Pearce
COMMITTEE CALENDAR
Briefing by the Mental Health Trust Authority
relating to SB 31
PREVIOUS SENATE COMMITTEE ACTION
No previous action to report
WITNESS REGISTER
Mr. Nelson Page, Chair
Board of Trustees
Alaska Mental Health Trust Authority
810 N Street
PO Box 91977
Anchorage, AK 99509
Mr. Jeff Jesse, Executive Director
Alaska Mental Health Authority
550 West 7th Avenue, Ste. 1820
Anchorage, AK 99501
Ms. Kay Burrows, Director
Division of Senior Services
Department of Administration
3601 C St., Ste. 310
Anchorage, AK 99503-5984
Ms. Jane Demmert, Executive Director
Alaska Commission on Aging
PO Box 110209
Juneau, AK 99811-0209
Mr. Karl Brimner, Director
Division of Mental Health & Developmental
Disabilities
PO Box 110620
Juneau, AK 99811-0620
Ms. Kathy Carssow, Project Manager
API 2000/The Community Mental Health Project
Anchorage, AK
Mr. Walter Majoros, Executive Director
Alaska Mental Health Board
431 N. Franklin St., Ste. 101
Juneau, AK 99801-1121
Ms. Cristy Willer Tilden
Governor's Advisory Board on Alcoholism
and Drug Abuse
Dillingham
Ms. Caren Robinson, Trustee
Alaska Mental Health Trust Authority
211 4th St., Ste. 108
Juneau, AK 99801
ACTION NARRATIVE
TAPE 99-05, SIDE A
Number 001
CHAIRMAN MILLER called the Senate Health, Education and Social
Services (HESS) Committee to order at 1:30 p.m. and announced that
the Mental Health Trust Authority (MHTA) would present an overview
for the committee.
Number 013
MR. NELSON PAGE, Chair of the Board of Trustees, MHTA, stated that
the objective of today's overview is to discuss the recommendations
for FY 00, both in terms of the budget and in terms of programs. He
said that for each topic on the agenda, he would ask members of the
boards and commissions to come up and provide the committee with
information. He introduced two of the trustees present at the
hearing, Caren Robinson and Phil Younker.
Number 063
MR. JEFF JESSE, the Executive Director of the MHTA, spoke on behalf
of the Governor's Council on Disabilities & Special Education who
had a conflicting meeting outside of Juneau. He stated the council
has focused on outcomes for beneficiaries. Employment continues to
be a major focus because it benefits the individual beneficiaries,
the community and the budget. Many beneficiaries are excellent
employees who are very reliable and appreciative of their
independence and ability to make a living. One employment issue of
concern is the continuation of health care coverage for persons
with disabilities in low-wage jobs. He asked the committee's help
on this issue, and said that having to give up health care coverage
for significant medical needs may make employment not feasible for
many beneficiaries. Initiatives in SB 31 use trust receipts for
trust employment. The council took those funds and leveraged them
to obtain a $2.1 million federal grant. The grant will look at
strategies over the next 3 years to get people with disabilities
back to work. Creating businesses for people with disabilities is
no longer the emphasis. Now, the focus is on getting people in the
worksite, with job coaches to support the employers, and on
teaching them the real job to ensure their success over the long
run. Data will be collected on how many beneficiaries still have
their jobs at 6, 12 or 36 months, to see if the employment programs
are working.
MR. JESSE stated the council's second issue relates to
institutional prevention. The basic rate of pay for employees in
foster homes and group homes is not much higher than entry level at
McDonald's or Burger King. Grantees are having a harder time
maintaining their workforce on a direct care level. There is no
job security or career track, resulting in a lot of turnover in
those positions. He asserted that the quality of that care will
suffer over the long term.
MR. JESSE brought up the council's third issue, substance abuse
treatment for people with multiple diagnoses. The MHTA has
influenced the various boards' awareness of how their population
intersects with other populations. Many beneficiaries have more
than one issue. One effective program deals with the dual
diagnosis of mental retardation and substance abuse, the ARC dually
diagnosed program in Anchorage. It originally started with HUD
funds that were not renewed except for emergency funding to get
them through this fiscal year. The program is currently at risk.
The trustees want to salvage this program, and feel that more of
these programs are needed. The ARCS program has kept a significant
number of people out of the correctional system. Judges will often
place people if they know there is a secure system of support.
Number 173
SENATOR WILKEN asked him the name, and MR. JESSE replied the ARC of
Anchorage. It used to be the Association of Retarded Citizens, but
the consumers didn't want to use "retarded" anymore, so it's now
the ARC of Anchorage.
SENATOR ELTON asked if judicial referral is done the same way they
make a referral to 30 days in jail.
MR. JESSE replied that many of the crimes are not felonies; they
include multiple charges of disturbing the peace, trespassing,
defrauding an innkeeper (when you don't pay for your meal in a
restaurant and walk out). These often get significant jail time
after several charges accumulate. The public defenders and
district attorneys want to divert these people from the criminal
justice system if they have a placement for them. Jail time won't
correct this situation, and the council tries to avoid repeated
admissions to the jail. Programs like the ARC are contacted to see
if there is a slot. In Anchorage, the trust has funded a Jail
Alternative Service (JAS) which picks up misdemeanants at the front
end of their justice system contacts, and diverts them into
programs like the ARC.
MS. KAY BURROWS, Director of the Division of Senior Services, spoke
for the Alaska Commission on Aging. She introduced three of the
commissioners, Marge Hays from Soldotna, Doris Bacus from Kodiak,
and Ella Craig from Anchorage. She said the commission's first
issue relates to Assisted Living. The committee did not receive
the full fiscal work for the Assisted Living rate study recently
released, but she brought those figures along with her today. She
said that Assisted Living is the cornerstone that allows seniors
and adults with disabilities to stay in their homes and
communities. The commission has been successful in expansion, and
now has 90 homes and about 700 beds outside of the Pioneer Home
system. The reason it's a challenge to build more homes in certain
communities involves the rates the State currently spends. The
commission is anxious to look at the whole issue of Assisted
Living, particularly the rates in relation to the budget. Other
recommendations that are a part of the rate study include
educational opportunities for the administrators of homes. This is
a new part of the business, looking at quality issues as well as
budgetary issues.
MS. BURROWS brought up the Guardianship Study, conducted by the
McDowell Group through the trust and recently released. There is
not a budget impact right now, but she said she wants to alert the
committee to the fact that the issue has 4 components. These are
code changes, and legislative changes coming before the committee
relating to current practices and the need for guardianship work.
The second part is oversight monitoring and training; the study
showed that over 90% of the people with guardianships in the state
are beneficiaries of the trust. Seventy-five percent of those are
family guardians, and the commission has not been able to do the
training and oversight to ensure citizens are getting their
guardianship needs met. A summit meeting on guardianship,
comprised of people from the court system, other agencies, private
and public businesses will take place in the next month. Their
findings will be brought before the trust and the committee.
MS. JANE DEMMERT, Executive Director for the Commission on Aging,
spoke to the third issue of the commission, the mental health needs
of the elderly. She referred to page 9 of the commission's Annual
Report FY 98 that graphs Alaska's projected senior population
growth through the year 2015. Issues of mental health are
fundamental to everyone regardless of age. In the past there has
not been linkage between supportive services and mental health
services to older Alaskans, so it was found that less than 1% of
those being served in mental health clinics were older Alaskans.
The point is to work together for more efficient use of resources.
The incentives and urging of the MHTA have brought about some
change. In the trust budget there's a request for the 3rd year
project known as the Mental Health needs of the Elderly. It's a
joint project bringing together the two systems of care -
supportive services and mental health services - for more
integration. Now that it's known those services are needed, the
question is how to sustain it over time using existing mechanisms
for funding. This is in the budget request moving forward now.
SENATOR WILKEN expressed that MS. DEMMERT AND MS. BURROWS were
integral members of the long-term care task force, and they did an
excellent job of advising the lay members on the issues. He said
he wanted to thank them publicly for their help.
MR. PAGE responded that he read and was impressed by the long-term
care task force report, and he thanked Senator Wilken and other
legislators for their hard work. He commented that Assisted Living
is an issue before the trust authority as a budget recommendation
by not just the Commission on Aging, but the Governor's Council,
for example. The trust tries to winnow down the budget process
before the committee ever sees any budget recommendations. This
recommendation resulted from a lot of consideration, in order to
maintain the integrity of the Assisted Living system, and to move
forward.
SENATOR WILKEN asked Mr. Page if he is aware of CHAIRMAN MILLER'S
bill to address Assisted Living. MR. PAGE responded that he's
aware of it and wanted to stress the importance.
MR. CARL BRIMNER, Director of the Division of Mental Health &
Developmental Disabilities introduced Ms. Kathy Carssow, Project
Manager coordinating the replacement of API. He will discuss one
issue regarding the statutory change, and Ms. Carssow will talk
about the services and implementation.
Number 327
MR. BRIMNER stated they are trying to create a new system in the
Anchorage bowl area replacing the aging API and downsizing the
hospital from its present 79 beds to 54 beds. Many partners have
been involved in this process, including the division, the trust
authority, the Alaska Mental Health Board, and the Division of
Alcohol and Substance Abuse. He referred to the handout listing
their three objectives: the replacement of the building; the
development of community services to assist with the reduction in
number of beds, including private treatment alternatives to
hospitalization; and to make statutory changes in designated
evaluation and treatment (DET). DET is for those people needing
services in a private hospital setting for in-patient psychiatric
services.
MR. BRIMNER emphasized the goal is to build a better emergency
mental health system, and to improve the response to substance
abuse and mental health crises.
Number 360
MS. CARSSOW referred to their report titled The Community Mental
Health Project/API 2000, and stated that API is 35 years old and
has been functionally obsolete for over a decade. It has asbestos
problems and less than five years of service life remaining. It
would not be economical to renovate it. Two other reasons why this
project needs to happen now include the one-time federal funding
secured by Senator Stevens for the project; and the decrease in
federal participation and support of API starting in FY 2001
because of the Federal Reapportionment Act. The state has two
choices: make up the difference of $4.8 million by 2003 in order
to continue the operation of API in the present facility at the
present level of service; or develop private community-based
services eligible for other funding sources like Medicaid, and
downsize API.
MS. CARSSOW said that a recurring question is why Anchorage is the
focus of the project. Eighty-five percent of those admitted to API
live in Southcentral Alaska. Unless the new and expanded services
are in place to serve Anchorage residents with mental health
emergencies, the need for API beds won't be reduced. They wouldn't
be able to downsize by 25 fewer beds. The new smaller building
would benefit all Alaskans requiring hospitalization by providing
an improved facility in a more therapeutic setting. Currently
emergency services are available in Anchorage, but a clearly
defined way for people in crisis to get help is lacking.
MS. CARSSOW described the single point of entry to mental health
services. It would give the individual in crisis access to
enhanced crisis respite care, preventing hospitalization. In
respite care, people are stabilized and assisted in transitioning
back into community outpatient follow-up care. The individual
would also have access to enhanced detoxification and dual
diagnosis treatment, other alternatives to hospitalization at API.
These programs reduce future hospitalizations by getting people
into treatment following crisis. The single point of entry would
also be the doorway to access designated evaluation and treatment
(DET) services. Other Alaska regions as well as Anchorage
residents would have access to private hospitals for DET. It also
would be the doorway to API, a new facility providing quality
treatment, safety and privacy in a therapeutic environment.
MS. CARSSOW stated that it would also create new alternatives, and
enhance existing private alternatives to using API for extended
care for the chronically mentally ill. API now provides
residential care to people who need long-term treatment because
they're difficult to place outside of a very restrictive
environment. She said their objective is to reduce the demand for
7 long-term care beds by improving the capability of private
providers to care for these individuals. Target dates focus on the
year 2000: April 1, 2000 for the new single point of entry system
and the downsizing of API.
Number 418
MR. BRIMNER reiterated their 3 goals listed on the last page of the
report. He explained the third goal deals with statutory changes
to the DET program. The current statute needs a change to clarify
when the state can pay and will not pay in situations where someone
is eligible for services and we're the payer of last resort.
Under the current statutes, individuals receiving in-patient
services that the state can pay for, enter on an involuntary basis.
It's both administratively and clinically responsible to allow
those people that meet the involuntary statute criteria, but who
wish to stay in the hospital on a voluntary basis, to do so. One
of the administrative reasons is that an individual who meets the
criteria, but is not allowed to have a choice to be there on a
voluntary basis, must go through the justice system, involving
attorneys and the court system. This may not be necessary if an
individual is willing to stay there on a voluntary basis when they
meet the criteria. It would not expand services in any way, and it
would reduce costs related to the legal system. He stated the hope
that legislation will be introduced soon, and will be looking for
support for it.
Number 445
CHAIRMAN MILLER asked if the Administration or an individual
legislator will be introducing it. MR. BRIMNER replied it will be
a legislator.
SENATOR ELTON asked about 85% of the client population being in
Anchorage. Are they in Anchorage because that's currently where
the best services are, creating a magnet that pulls them out of
their own communities?
MS. CARSSOW responded no. Half the population of the state lives
in Anchorage. The residents have become reliant on API and
alternative services like DET haven't been developed, except in
Juneau, Sitka and Fairbanks by private hospitals.
SENATOR ELTON asked if single point of entry means Anchorage. MS.
CARSSOW replied yes. It will direct people to the most appropriate
and cost efficient service as opposed to direct access to API. The
demand for API is affected by not having a clear route to
alternatives.
SENATOR ELTON asked if Mr. Brimner's division would be the
gatekeeper for checking out the alternative services and their
costs.
MR. BRIMNER answered that the single point of entry could be the
state, or a contract or grant to a provider in the Anchorage area.
The utilization review process would look at all the individuals
going through the system to see that they received the appropriate
service. The inappropriate situations would be corrected. The
state would be the reviewer on an on-going basis.
DET services will be expanded to other communities outside of
Anchorage, allowing maintenance of people closer to their homes.
Number 484
MR. PAGE interjected that API will be a "Catch-22" situation for
the state if it does nothing: the state will incur additional
costs because the federal disproportionate share funds are going
away. The trust feels it's appropriate to take affirmative steps
now with the new hospital and the new system better oriented to
serve the beneficiaries.
Number 500
MR. WALTER MAJOROS, Executive Director of the Alaska Mental Health
Board, gave members a printed copy of his remarks. By statute the
board has specific responsibilities for planning and advocacy,
including mental health parity, which is parity in insurance
coverage for people with mental illnesses vs. people with physical
illnesses. Senator Wilken helped establish the Mental Health
Parity Task Force (MHPTF)last year. It was funded by the trust
authority and its completed report will be distributed soon. The
board is also mandated to do program review of individual mental
health programs as well as API. The board is helping develop an
integrated quality assurance system. Another statutory duty is to
make budgetary recommendations to the trust. The rigorous process
includes input from many mental health consumers and focus groups.
Over 50% of the board is composed of consumers and family members.
Seven of its thirteen members are consumers, and four of those are
direct primary mental health consumers. The board believes in
consumer leadership in all aspects of the system.
The board's responsibility is to people who are mentally ill or
seriously emotionally disturbed, including children and adults.
Prevalence estimates indicate 14,700 children and youth with
serious emotional disabilities (10% of the population of that age
group); 25,600 adults (6.3% of the state's population in that age
group); and 4,200 people who would either be institutionalized or
homeless. The total is 44,500 individuals. Those receiving public
mental health services are estimated at 50% of those adults, and
1/3 of the children and youth.
MR. MAJOROS reviewed 4 areas of priority concern for the board for
the last 2 years that drive its planning and budgeting process.
These include support for a smaller API, and outcomes and quality
assurance, including development of one unified set of indicators
and performance measures funded by the trust authority. An
integrated quality assurance system developed for community-based
programs is currently in place, and will eventually include API and
all state-funded mental health programs and DET facilities.
The criminalization of mental illness is a tremendously important
issue. Last year there were 1,800 inmates with a serious mental
illness at the Department of Corrections, compared to 1,200
admissions at API. The single biggest mental health provider in
the state is the Department of Corrections. He stated that is an
embarrassment to him, and the board wants to change it. Rural and
urban services show tremendous disparities, with the need for more
equitable distribution of resources. Two hundred villages have no
mental health services, and 60 villages have just one part-time
person providing all mental health and substance abuse services.
The board finds this an unacceptable situation. Children and youth
services lack the capacity of adult services because they were
developed later. He brought up the tremendous increase of children
in custody with serious mental health needs, and emphasized that
with the passage of last year's child abuse law, the number of kids
in custody will increase. The system of placements for children is
very fragmented right now.
Funding priorities include the consumer affairs position, who would
be in a senior management position in DHSS, Division of Mental
Health & Developmental Disabilities. The position would help
increase the consumer voice in state policy making. The board also
participates in the Comprehensive Integrated Mental Health Plan.
The board was active in advocating for the women's psychiatric
unit, funded in partnership between the trust authority and the
state. The jail alternative services was promoted initially by the
board, and takes misdemeanants who have been convicted and diverts
them from the 6th Avenue jail into community-based mental health
services. The board also endorsed funding for the Department of
Corrections planner to develop and implement a coordinated plan for
the trust beneficiaries. The board has advocated an expanded rural
human services program, which the trust has funded.
TAPE 99-05,SIDE B
Number 587
MR. MAJOROS continued discussing funding priorities for rural
services. A program would place paraprofessionals in villages
throughout the state to address both mental health and substance
abuse issues in an integrated, dual-diagnosis way. A new project
this year that is funded through the trust trains people to provide
counseling to deaf and hearing impaired people in rural areas.
The board feels enhanced DET services are needed in the Anchorage
area to downsize API, and in rural areas as well. Relating to the
children and youth services issue, the board has advocated and the
trust is funding community residential alternatives like
therapeutic foster care, the treatment of kids in custody; and
secure residential care. Now many children and youth are being
sent out of state because there are no facilities here to meet
their intensive needs. $300.0 is targeted for FAS and related
disorders to do increased diagnostic work, transitional living for
women who come out of alcohol treatment, and to assist school
districts and local communities in screening and assessing high-
risk women.
MR. MAJOROS said the childrens' care coordination model looks like
it is not going to work. The project attempted to develop a new way
of delivering services and blending funding sources. The project's
success was in helping to fund a children's mental health
coordinator position that recently completed a 18-month plan for
children's services. Future funding priorities will be very clear
as they relate to that plan. The board believes in prevention, and
endorses funding for the control group study that will show if the
Healthy Families Control Group approach is effective.
Number 562
SENATOR WILKEN asked Mr. Majoros how mental health is defined, and
how the total of 1,800 people annually in the Department of
Corrections was arrived at.
MR. MAJOROS replied the trust authority funded a study to find out
the numbers of trust beneficiaries, in all four groups, in the
Department of Corrections. The study profiled every facility on a
given day. Some have serious mental illnesses (clinically known as
Access I disorders) and others have personality disorders (Access
II disorders); both are included in the total. SENATOR WILKEN
asked if the 1,800 figure is therefore an extrapolation based on a
snapshot study. MR. MAJOROS said that is correct, but it was also
verified by the clinicians that it is not an anomaly.
Number 546
SENATOR ELTON asked what services are provided. MR. MAJOROS
answered there is at least one mental health clinician at each
facility throughout the state, full-time. There are also intensive
care units. Until recently there was just one unit, at Cook Inlet
Pretrial Facility in Anchorage, for men who have decompensated,
have medication that is not working right, or have acute mental
health needs. Until last year there was no similar facility for
women. Now through the partnership of the trust and the state,
that service also exists for women. There is largely a full
continuum in Corrections, but the department and the board both
feel that many of these people would be better served in the
community, to normalize and live successfully within it, not in an
incarceration setting.
MR. PAGE remarked on the prior treatment of locking up in solitary
confinement the very seriously mentally ill who pose a danger to
themselves and others. He feels it was a medieval way of dealing
with mental illness. It was not until the first womens' mental
health unit opened that the trust could say it had services
available to every category of the population in the Department of
Corrections. The planner position funded over the last few years
has enhanced the trust's ability to do that work. MR. PAGE stressed
that the 1,800 figure for Corrections is "probably some of the
hardest data we have in terms of accuracy" about what's going on in
that population.
Number 520
SENATOR ELTON asked if there were additional resources, would the
judicial system divert these people from the correctional
facilities and into the community programs.
MR. MAJOROS replied absolutely. These people also need living
arrangements, employment, education to be successful within the
community.
MS. CRISTY WILLER TILDEN,Bristol Bay Area Health Corporation,
Dillingham, stated she represents the State Advisory Board on
Alcoholism % Drug Abuse. She introduced several board members
including Alice Johnstone from Sitka, Ann Kitner from Juneau, CJoe
DiMatteo from Anchorage, acting Director Ann Schultz and past
Director Don Dapcevich. She referred to the report on their 14-
month strategic planning process addressing the board's priorities
relative to trust authority funding.
The board's biggest priority is to impact the negative influence of
alcoholism and drug abuse on Alaskans. The indicators in the plan
relate to per capita consumption, DUI convictions, criminal
convictions on alcohol-related charges, alcohol-related injuries
requiring hospitalization, protective custody holds, binge and
chronic drinking rates. There are excellent data for all of these
indicators and a baseline to show the curve that she hopes will be
downward. The board arrived at 18 strategies, with only a few
relating to the work of the trust authority. The board has a
statutory obligation to speak to the trust about the board's
interest in chronic alcoholics with psychosis. Strategy 12
addresses the need for a continuum of care for chronic alcoholics
with psychosis, focusing on long-term care and follow-up on life
domain like housing, finance and health concerns. Another strategy
relates to assisting communities in efforts to coordinate use of
involuntary commitment procedures because they usually involve
someone who's reached the point of chronic alcoholism. One
strategy regards serving currently underserved populations
including the dually diagnosed.
MS. TILDEN concluded by saying those target populations and
strategies in the plan speak to the board's need for continued
funding through the Mental Health Trust Authority.
MS. CAREN ROBINSON in summary remarks for Mr. Page and the Mental
Health Trust Authority, expressed pride in the volunteer boards.
During her two years on the trust board, she has been impressed
with the boards' volunteerism and the staff they are able to hire.
She introduced two staff members of the trust authority: Bill
Herman, a planner who is an expert in budget issues and works with
the Alaska Office on Aging and the Alcohol board; and Mary
Elizabeth Rider, a planner with the department who focuses on the
Governor's Council and the Mental Health Board. MS. ROBINSON
announced that Thursday and Friday the trust authority is meeting
at the Juneau Assembly Chambers. Thursday night at 6:00 the trust
will take public testimony and invites all citizens and consumers
to come. She remarked on the successful collaboration of all the
boards with the Department of Corrections and recognizing the need
for a planner because so many beneficiaries are in Corrections. In
the future the trust authority will need to work with the
Department of Education because many beneficiaries go through the
public education system without getting the kind of help they need.
She said the trust authority would like to update the committee on
the API plan later on. Tom Hawkins, a trustee member and Phil
Younker are resident experts in asset management and the trust
lands. MS. ROBINSON said the trust would also like to return to
discuss the land trades and land development for the committee.
CHAIRMAN MILLER told Ms. Robinson that the committee will schedule
that update in the future. For the information of the committee,
CHAIRMAN MILLER said next Monday's agenda will include Carl Rose,
Association of Alaska School Boards, speaking on the impact of the
new Foundation Formula passed last year, and Senator Leman's SB 27
relating to access to driving school records of a child. On
Wednesday, Commissioner Perdue is tentatively scheduled to give a
brief overview of the Department of Health & Social Services. The
following week the committee will take up as a package SB 56, SB
57, SB 58 and SB 59 -- the bills resulting from the long-term care
task force. He stated he wants to begin working on them and move
them on to Finance. There being no further business before the
committee, CHAIRMAN MILLER adjourned at 2:35 p.m.
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