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