ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  April 30, 2019 3:04 p.m. MEMBERS PRESENT Representative Ivy Spohnholz, Co-Chair Representative Tiffany Zulkosky, Co-Chair Representative Matt Claman Representative Harriet Drummond Representative Geran Tarr Representative Sharon Jackson MEMBERS ABSENT  Representative Lance Pruitt COMMITTEE CALENDAR  HOUSE BILL NO. 89 "An Act relating to the prescription of opioids; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of podiatry; relating to the practice of osteopathy; relating to the practice of nursing; relating to the practice of optometry; and relating to the practice of pharmacy." - HEARD & HELD PRESENTATION: ALASKA CITIZEN REVIEW PANEL - HEARD PRESENTATION: OFFICE OF CHILDREN'S SERVICES - CITIZEN REVIEW PANEL RESPONSE - HEARD PREVIOUS COMMITTEE ACTION  BILL: HB 89 SHORT TITLE: OPIOID PRESCRIPTION INFORMATION SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ 03/11/19 (H) READ THE FIRST TIME - REFERRALS 03/11/19 (H) HSS, FIN 04/04/19 (H) HSS AT 3:00 PM CAPITOL 106 04/04/19 (H) Heard & Held 04/04/19 (H) MINUTE(HSS) 04/09/19 (H) HSS AT 3:00 PM CAPITOL 106 04/09/19 (H) -- MEETING CANCELED -- 04/11/19 (H) HSS AT 3:00 PM CAPITOL 106 04/11/19 (H) -- MEETING CANCELED -- 04/16/19 (H) HSS AT 3:00 PM CAPITOL 106 04/16/19 (H) Heard & Held 04/16/19 (H) MINUTE(HSS) 04/23/19 (H) HSS AT 3:00 PM CAPITOL 106 04/23/19 (H) Scheduled but Not Heard 04/25/19 (H) HSS AT 3:00 PM CAPITOL 106 04/25/19 (H) Scheduled but Not Heard 04/30/19 (H) HSS AT 3:00 PM CAPITOL 106 WITNESS REGISTER MIRANDA DORDAN, Intern Representative Ivy Spohnholz Alaska State Legislature Juneau, Alaska POSITION STATEMENT: On behalf of Representative Spohnholz,  sponsor, introduced the committee substitute for HB 89, Version S. J.P. OUELETTE, Chair Alaska Citizen Review Panel Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint presentation entitled, "Alaska Citizen Review Panel," dated 4/30/19. NATALIE NORBERG, Director Central Office Office of Children's Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Provided a PowerPoint presentation entitled, "Office of Children's Services - Citizen Review Panel Response 2018-2019," dated 4/30/19. ACTION NARRATIVE 3:04:08 PM CO-CHAIR ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:04 p.m. Representatives Spohnholz, Jackson, Claman, Tarr, Drummond and Zulkosky were present at the call to order. HB 89-OPIOID PRESCRIPTION INFORMATION  3:05:15 PM CO-CHAIR ZULKOSKY announced the first order of business would be HOUSE BILL NO. 89, "An Act relating to the prescription of opioids; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of podiatry; relating to the practice of osteopathy; relating to the practice of nursing; relating to the practice of optometry; and relating to the practice of pharmacy." 3:05:31 PM CO-CHAIR SPOHNHOLZ moved to adopt the committee substitute (CS) for HB 89, labeled 31-LS0421\S, Fisher, 4/18/19, as the working document [Version S]. CO-CHAIR ZULKOSKY objected for discussion purposes. 3:06:08 PM MIRANDA DORDAN, Intern, Representative Ivy Spohnholz, Alaska State Legislature, introduced the committee substitute for HB 89, Version S. She advised of a typographical error on the document [included in the committee packet] entitled, "Explanation of Changes" as follows: Section 7. AS 47.47.040(24) should read Section 7. AS 47.37.040(24). Ms. Dordan then paraphrased from the document, which read [original punctuation provided]: Section 7. AS 47.47.040 (24) On page 8, line 30: The phrase "?and maintain current information?" was added. From page 8, line 30 to page 9, line 1: The phrase "?for purposes of patient education, a onepage, printable handout in 12-point font?" was added. On page 9, line 3-4: The phrase "?the information must be written in plain language that can be easily translated into other languages commonly spoken in the state?" was added. These changes make stipulations for the Department of Health and Social Services to keep the opioid handout regularly updated. The requirement of the minimum 12-point font was added to ensure that the opioid handout can be easily read. The provision of plain language that can be easily translated into other languages commonly spoken in Alaska was added in order to ensure that the information will be accessible to all patients, not just those who speak and read English. MS. DORDAN, in response to Co-Chair Zulkosky, restated the correct section is: Section 7. AS 47.37.040 (24). REPRESENTATIVE DRUMMOND pointed out on the Explanation of Changes document, "From page 8, line 30 to page 9," should read: "From page 8, line 31 to page 9." She suggested the ["printable handout" on page 8, line 31 of the CS] could depict symbols and graphics the Department of Health and Social Services (DHSS) may find in the "international language of medicine." 3:10:12 PM CO-CHAIR SPOHNHOLZ directed attention to an "info graphic document" [slide 11, entitled, "Section 7: Visual Aid," of a PowerPoint presentation entitled, "House Bill 89: Opioid Addiction Risk Disclosure" provided to the committee on 4/4/19] that was included in the committee packet and that was prepared by DHSS in request to a bill introduced in the Thirtieth Alaska State Legislature. She said the document uses [graphics] and language to ensure it is easy to understand and translate; in fact, she has been informed by practitioners who serve immigrant populations, and parts of rural Alaska where English is not always a patient's first language, the document must be easy to translate and accessible to all. REPRESENTATIVE TARR questioned whether there is a fiscal note attached to HB 89. CO-CHAIR SPOHNHOLZ acknowledged there is a forthcoming fiscal note that will be attached to the bill in the amount of $14,200 to pay for the cost of regulations. 3:11:41 PM CO-CHAIR ZULKOSKY removed her objection. There being no further objection, Version S was before the committee. CO-CHAIR ZULKOSKY announced HB 89 was held over. 3:12:47 PM The committee took an at-ease from 3:12 p.m. to 3:14 p.m. ^PRESENTATION: ALASKA CITIZEN REVIEW PANEL PRESENTATION: ALASKA CITIZEN REVIEW PANEL  3:14:23 PM CO-CHAIR ZULKOSKY announced the next order of business would be a presentation by the Alaska Citizen Review Panel. 3:14:38 PM J.P. OUELETTE, Chair, Alaska Citizen Review Panel (CRP), informed the committee CRP is a volunteer panel. He introduced a PowerPoint presentation entitled, "Alaska Citizen Review Panel," paraphrasing from slide 1, "Presentation Outline," which read: ? Introduction to the role and purpose of the Citizen Review Panel ? Goals and recommendations from 2017-2018 ? Goals for 2018-2019 ? Improvements in CRP-OCS collaboration ? Way forward MR. OUELETTE paraphrased from slide 2, "Central Purpose," which read: Congress created CRPs to help child protection systems be more responsive to community needs. ? A CRP is a mechanism for public participation in child protection. ? It should facilitate robust and meaningful participation by citizens 1. In diverse roles in child and family welfare 2. Representing all five regions 3. With a shared interest in promoting a healthy and collaborative CPS system MR. OUELETTE noted CRP panelists are primarily professionals working in the child and family welfare system and who have experience living in the system; CRP seeks panelists from all five regions of Alaska who have an interest in collaboration and creating an environment that encourages cooperation. MR. OUELETTE paraphrased from slide 3, "Functions - Mandates," which read: Federal Mandate (42 U.S.C. ? 5106a.(c)): Examine the policies, procedures, and practices of state and local child protection agencies and evaluate the extent to which these agencies are effectively discharging their child protection responsibilities Conduct public outreach both to assess the impact of current policies and procedures, and to solicit public comment on the panel's recommendations. State Mandate (AS 47.14.205): "The CRP shall examine the policies, procedures, and practices of State and local agencies and where appropriate, specific cases, to evaluate the extent to which State and local child protection system agencies are effectively discharging their protection responsibilities." 3:19:17 PM MR. OUELETTE paraphrased from slide 4, "Primary Functions," which read: Review/Evaluate (from statute): ? States' CAPTA Plan ? Child protection standards ? And any other criteria that the Panel considers important Conduct public outreach (from statute): Assess the impact of OCS policies, procedures, and practices on children and families ? This assessment should inform its review function Advocate for (from congressional record): ? Relevant changes based on its review MR. OUELETTE clarified CAPTA is the Child Abuse Prevention and Treatment Act. He paraphrased from slide 5, "Functions - What CRP Does Not Do," which read: ? Comment on proposed or pending legislation ? Get involved in individual cases, contract, or situations ? Micromanage OCS operations ? Program evaluation ? Lobby MR. OUELETTE stressed CRP is not an investigative body but seeks a general consensus of ones' experience with the Office of Children Services (OCS), Department of Health and Social Services (DHSS), and not the circumstances of individual cases. Although the policy of CRP is not to micromanage OCS operations, it does conduct site visits to gather details and provide support. He directed attention to [slide 6] and pointed out the state's system of child protection is a combination of policy, practice, and the needs of children and families; the federal mandate of CRPs is to review a state's policies, determine whether the policies are put into practice, and determine whether the policies are serving the needs of children and families. Speaking from his experience, he said developing recommendations [for change] is a long process; however, CRP will first review the needs of children and families, determine if the practices are effective, identify barriers to practices, and decide whether changes to policy are necessary. He opined the focus of CRP is to garner the collaboration of affected communities, improve [OCS] practices, and find the root causes of systemic problems. 3:23:31 PM MR. OUELETTE paraphrased from slide 7, "Changes in CRP Operation," which read: Reorientation of CRP as a public participation mechanism Discussions began early fall 2017 A tentative three-year timeline Elements will include ? Participatory evaluation ? A systems focus ? Robust recruitment and retention strategy ? Data-driven review and outreach ? Collaborative and constructive MR. OUELETTE discussed the renewed interest of CRP panelists and a better relationship between CRP and OCS since 2017. He paraphrased from slides 8 and 9, "Goals 2017 - 2018," which read: ? GOAL 1: Examine the effectiveness of the current administrative review process and whether the changes made in 2015 have improved the system. ? GOAL 2: Examine if 'family reunification' is prioritized as a goal for children in out-of-home care placement, and OCS' efforts in pursuit of 'family reunification'. ? GOAL 3: Examine OCS' efforts in finding relatives for placement of children in foster care. GOALS 2017- 2018 ? GOAL 4: Expand public outreach in collaboration with efforts under the Tribal-State strategic plan. ? GOAL 5: Strengthen the panel through aggressive recruitment of new members, enhanced website, and tools to reach diverse groups of stakeholders. MR. OUELETTE, regarding Goal 1, reminded the committee in 2015 a change was made in the administrative review process to a more efficient process, thus CRP sought to review the change. Regarding Goal 2, CRP found the pursuit of family reunification differed between regions of the state. Regarding Goal 3, he said the goal is much improved due to better relationships with Tribal partners. Regarding Goal 4, he said there are regional differences in community investment. Regarding Goal 5, he said CRP is developing its website and is recruiting panelists. 3:28:04 PM MR. OUELETTE paraphrased from slide 10, "Recommendations 2017 - 2018," which read: Overall, CRP recommendations fall into five categories: ? Quality Assurance ? Management ? Practice ? Public participation ? CRP's role and function MR. OUELETTE paraphrased from slide 11, "Improve Administrative Review Process," which read: Recommendation 1: The Panel recommends that OCS not transition to a judicial review process as was proposed but fine-tune the current administrative process to make it more comprehensive. ? ACTION: Ensure that case workers are present during review; and maintain flexibility in scheduling so that there is maximum participation from interested parties. MR. OUELETTE explained the previous administrative review process collected a lot of information and brought parties together, but there was not consensus as to whether it was serving its purpose, which is "a box checking session, to make sure that everything was on track where it was supposed to be and feedback could be given if it wasn't." So, a judicial administrative review process was proposed; however, every region opposed a judicial administrative review process and CRP concurs. In response to Representative Tarr, he further explained a team decision making (TDM) process is meant to allow parties to share information; however, the purpose of an administrative review process is not to share information, and the change was to shorten the process. He said the change was not clearly communicated to CRP or to those participating in the administrative review process; he pointed out the administrative review process does need to provide communication between family members, and participation with all parties and professionals involved, such as biological parents, foster parents, and guardians ad litem (GALs). CO-CHAIR SPOHNHOLZ surmised the administrative review process is designed to "make sure that we've ... checked all the boxes that we're supposed to be checking, along the way, but people weren't really clear about what the process was for ...." MR. OUELETTE said correct. He acknowledged miscommunication created confusion over a process that really mattered, such as providing constructive and supportive feedback. 3:32:29 PM MR. OUELETTE paraphrased from slide 12, [continued from slide 11, "Improve Administrative Review Process"] which read: ACTION: Evaluate the case-continuum for opportunities to build rapport and collaboration among all stakeholders if this (unintended, but crucial) objective is no longer being met during the Administrative Review (AR) ? ACTION: Ensure case workers are provided with constructive and supportive feedback in how to better achieve compliance. ? ACTION: Develop and implement a training on the AR process be developed and delivered for case workers and families to better understand the scope and goals for AR and what should be the anticipated outcomes that follow from an AR. MR. OUELETTE stated CRP also recommended OCS develop training on the administrative review process to ensure parties understand and participate in the process. He paraphrased from slides 13 and 14, "Improve Outcomes for Family Reunification," which read: Recommendation 2: The Panel recommends that OCS take the following measures: ? ACTION: OCS should target recruiting efforts to workers with life experience in or near the regions they will be serving. ACTION: OCS should provide orientation and training that explains the often overlooked cycle of trauma children endure when separated from their families, and the reason family reunification is a priority. OCS supervisors and trainers should encourage a strengths- based approach to working with parents. ? ACTION: OCS should support and train workers to practice early intervention / in-home efforts to prevent removal. We suggest drawing from the experience of more seasoned workers who do this very well in their regions to provide mentorship opportunities MR. OUELETTE, regarding the first action, said from his experience removal of a child can be prevented when people are aware of the alternatives, which happens in regions where family connections are strong. Regarding the second action, he opined this has always been implicit in policies and procedures, but not in philosophy and practices, and [removal] should truly be the last resort. 3:34:33 PM REPRESENTATIVE JACKSON asked about the general differences between the regions in Alaska related to family reunification. MR. OUELETTE advised there are many complexities within each region that create barriers to family reunification, such as the landscape, history of trauma, leadership, and [OCS] staff who do not have an investment in the region in which they are working. In the most remote regions, local recruitment is difficult; CRP is working with OCS to strengthen recruitment. Of the five regions, the Western and Northern regions experience the most difficult situations; the Anchorage region has a lot of resources; there have been improvements the Southcentral region due to provisions of House Bill 151 [passed in the Thirtieth Alaska State Legislature]; the Southeast region benefits from collaboration with Tribes. REPRESENTATIVE JACKSON urged OCS to share successful models with all regions. MR. OUELETTE agreed. 3:40:29 PM CO-CHAIR SPOHNHOLZ returned attention to the administrative review process and asked for an explanation of the first action shown on slide 12. MR. OUELETTE explained the old administrative review process provided more time and opportunity for parents to communicate with GALs and caseworkers; the new process is impersonal and short. If this vital communication is not a function of the administrative review process, OCS must provide a new opportunity for family participation. CO-CHAIR SPOHNHOLZ questioned whether the objective of the administrative review process is just to review documents. MR. OUELETTE expressed his understanding the administrative review process is box checking activity that is required prior to federal review that identifies where OCS is achieving objectives in a case; however, caseworkers complain the administrative review "only identifies places where we're failing." CO-CHAIR SPOHNHOLZ related caseworkers feel OCS operations in the recent past have lacked utility and support for overworked caseworkers; she pointed out the aforementioned progress [in the Southcentral region] stems from House Bill 151, by which the state chose to lower caseloads and invest resources to support caseworkers and staff. 3:45:20 PM MR. OUELETTE continued to slides 15 and 16, "Strengthened Cultural Competency," which read: Recommendation 3: The Panel recommends that OCS leadership look in to identifying the cultural differences that can contribute to bias among OCS workers and minorities, then find ways to improve their cultural competency. ? ACTION: This can be done through more observation, listening, and engagement, as well as targeted and evidence-based trainings like "Healthy Families" and "Knowing Who You Are." ? ACTION: Cultural competency training from local village councils or other tribal training partners to build from a collaborative foundation between OCS and the tribes and give caseworkers an opportunity to engage with tribal representatives establishing better lines of communication for achieving ICWA objectives. ? ACTION: Collaborate with tribes to ascertain if and where the ICWA specialist could leverage relationships with local elders and community leaders to help case workers develop effective strategies for community engagement and interaction with Tribal resources MR. OUELETTE noted all OCS employees receive cultural competency training but lack training in region-specific cultural competency. Region-specific cultural competency achieves two objectives: knowing the landscape and people where you work, and collaboration with Tribes. He said [the actions] were developed in response to Tribal partners who indicated the knowledge of elders was underutilized and not understood by those outside of their culture. CO-CHAIR ZULKOSKY related during one of the initial meetings of the House Special Committee on Tribal Affairs, the committee heard rural Alaska and the Alaska Native community are not a monolithic culture; she appreciated CRP's acknowledgement of the importance of cultural orientation and region-specific cultural understanding. She cautioned those within the Alaska Native community believe one can always grow one's knowledge and may prefer the concept of cultural understanding to one of cultural competency. MR. OUELETTE said CRP understands the complexity of the 227 federally recognized Tribal entities in Alaska, and their diversity, and he gave an example. 3:51:23 PM MR. OUELETTE paraphrased from slide 17, "Increased Community Engagement," which read: Recommendation 4: CRP to facilitate the constructive exchange of vital information between stakeholders increasing collaboration. ? ACTION: Encourage local/regional OCS leadership to help arrange and facilitate townhall or "talking circle" type meetings during each site visit that the CRP conducts in 2018-2019. MR. OUELETTE said recommendation 4 was challenging and CRP held one very successful talking circle in Wasilla with OCS leadership, professionals, and panelists. REPRESENTATIVE TARR asked Mr. Ouelette to clarify stakeholder engagement related to recommendation 4. MR. OUELETTE said stakeholders include other service providers outside OCS who may or may not have cooperative relationships with OCS. The talking circle format led to a meaningful discussion of solutions. REPRESENTATIVE TARR suggested expanding the group of shareholders may bring further understanding to all parties of those individuals who need services. MR. OUELETTE said, "... I would agree with you. I think that probably lies a bit beyond the scope of the CRP ...." 3:56:16 PM REPRESENTATIVE JACKSON supported the use of the talking circle format; she cautioned a lack of communication brings misunderstanding, and strongly urged for enhanced communication within communities. MR. OUELETTE agreed and gave an example in Sitka. He paraphrased from slides 18 and 19, "Worker Burnout and Vacancies," which read: Recommendation 5: Recruiting, supporting, and retaining workers that have the skills, character, community investment, and resilience to serve the needs of Alaskan families is key. ? ACTION: Tighten OCS hiring policies in the following ways: Acquire or develop a tool that screens job applicants for resiliency. Require applicants have field-related experience and/or education. ? ACTION: OCS should provide wellness support for staff including on-site counseling, education and training in secondary traumatic stress at least annually, and mandatory self-care including supportive check-ins with supervisors, breaks, and walks/exercise. MR. OUELETTE acknowledged recommendation 5 is "a tall order." Although, at one time there was a philosophy to hire persons who were not helpful, OCS is now holding vacancies when it is not satisfied with the applicants for a position. In regard to the second action, he said CRP addresses this issue in its 2018-2019 priorities. 4:01:32 PM MR. OUELETTE paraphrased from slide 20, "Improve Centralized Intake," which read: Recommendation 6: While regions are adapting to what may be an irreversible change, there are still significant concerns about the efficacy of the current intake process. Stakeholders across the regions shared frustration over the inconsistency of the process and the intake worker's inability to facilitate necessary actions in a region they are unfamiliar with in a timely manner. ? ACTION: Equip centralized intake workers with region-specific resources and a concise standardized assessment tool for prioritizing calls based on already existing OCS policies and procedures. MR. OUELETTE said the transition to centralized intake intended to make OCS management more feasible for the state; however, there were many complaints due to slow responses to inquiries and the lack of consistency with services. Currently, most problems have been addressed and most people are satisfied with the centralized intake process. He paraphrased from slide 21, "Progress on 2017 - 2018 Goals," which read: ? 2017 was, we hope, the pinnacle of a tumultuous period for OCS involving much public scrutiny, incredibly high worker turnover, lack of (though growing) collaboration and communication between OCS and CRP, and internal frustration with statewide changes such as admin review and centralized intake. ? Many of the recommendations went unaddressed and appear under new headings for 2018-2019 as the CRP reimagined its role moving from "watchdog" to broker and facilitator of effective communication while remaining critically objective. MR. OUELETTE acknowledged OCS is receptive to criticism from CRP. He paraphrased from slide 22, "Moving into 2018 - 2019," which read: Acknowledging the crisis OCS was facing, the CRP adapted our approach to site visits looking deeper into core contributing factors leading to burnout, turnover, backlogged IA's, and less-than-optimal results for children and families. ? We developed this year's goals to address the relationship between worker wellness, community collaboration and best efforts toward family reunification. ? We began pre-site-visit teleconferences to collaborate with leadership toward a fruitful site visit. MR. OUELETTE opined worker wellness, and community collaboration, contribute to better outcomes of helping families, but are often overlooked. In fact, he characterized OCS [caseworkers] as similar to a traumatized family because they endure secondary trauma and work under difficult circumstances, and caseworkers need a mechanism for support. He further explained pre-site-visits help caseworkers prepare for a site-visit; previously, CRP visits were "almost like a surprise visit" and were not effective. Although there were concerns, pre-site-visits ensure effective communication and collaboration. 4:05:43 PM MR. OUELETTE paraphrased from slides 23 and 24, "Goals for 2018 - 2019," which read: ? GOAL 1: Assess Family Reunification Efforts & Best Practices What are practices that are working well in the regions to promote family reunification and how can we replicate that in other regions? What are barriers workers and families face to moving toward reunification? What needs to be done to eliminate those barriers? ? GOAL 2: Evaluate OCS Staff Wellness Efforts and Community Engagement What efforts are in place to promote wellness, safety, healthy office culture, and community engagement (particularly in remote regions)? How can the CRP help promote wellness among staff? ? GOAL 3: Region-Specific/Culturally-Appropriate Training for OCS Staff What are current requirements for staff? What offerings available through tribal partners? How can the CRP facilitate better communication and collaboration with tribal partners in this area? ? GOAL 4: Awareness of Tribal-State Strategic Plan At what levels do different staff engage with the Plan? Are the efforts coming from the Plan tangible to stakeholders? ? GOAL 5: Coordinate Panel Activities & Improve Panel Participation Streamline regular schedule for panel activities. Focus recruitment efforts on regions outside of Anchorage. MR. OUELETTE explained goal 1 is a change in CRP's line of questioning from a focus on policies and procedures; this change has resulted in more response and cooperation from OCS caseworkers and community partners. He gave one example of how CPR addressed goal 2 at the office in Anchorage. Regarding to goal 3, he noted CRP's efforts to share resources with other entities in the Western region. Regarding goal 4, he said there is limited engagement with the strategic plan; however, CRP continues to support Tribal-state collaboration. Regarding goal 5, he noted CRP is represented by a panelist from every region but Southeast. 4:10:02 PM MR. OUELETTE paraphrased from slides 25 to 27, "Progress on 2018 - 2019 Goals," which read: Our change in approach has Highlighted the strengths and improvements in each region and given honor where due: ? Recognized to state leadership where regional and local leadership has played a significant role in improving outcomes for families Recognized supervisors who model effective and supportive leadership ? Our change in approach has Acknowledged the challenges faced by all stakeholders and contributed to building unity among OCS and its partners. ? Naming and normalizing the stress incurred by those who work directly with families in their greatest time of need ? Providing empathetic and positive feedback from the community to OCS workers ? Communicated to all stakeholders the common goals of OCS and community partners ? Our change in approach has Tailored recommendations for success by collaborating with leadership and seeking out sources of support from community partners. ? Worked with stakeholders to provide tangible solutions to challenges in communication, collaboration, and cultural competency ? Provided OCS leadership with ideas from staff and contact information for support available in the community Resulted in a positive and collaborative relationship between CRP and OCS leading to unprecedented responsiveness, and successful implementation of CRP recommendations. MR. OUELETTE expressed pride in CRP's recognition of those in leadership who have played a role in improving outcomes for families, and he provided examples. He stressed renewed responsiveness from OCS to CRP recommendations is important in order to address issues now. MR. OUELETTE paraphrased from slide 28, "CRP- A Statutory Institution," which read: The CRP is an institution, with a statutory role and responsibility. It is an organization of the state. It facilitates citizen participation. It must cultivate a critical, but constructive lens. It exists to help OCS. Its success depends on its relationship with OCS. MR. OUELETTE added the success of OCS depends on its relationship with its community and Tribal partners. He concluded, urging the committee to take every opportunity to advocate for continued funding for OCS partners and successful health and social service programs. 4:14:07 PM REPRESENTATIVE TARR, Co-Chair Spohnholz, Representative Drummond, Representative Claman, and Co-Chair Zulkosky expressed support for the changes made by CRP. 4:16:48 PM The committee took an at-ease from 4:16 p.m. to 4:20 p.m. ^PRESENTATION: OFFICE OF CHILDREN'S SERVICES - CITIZEN REVIEW PANEL RESPONSE PRESENTATION: OFFICE OF CHILDREN'S SERVICES - CITIZEN REVIEW  PANEL RESPONSE    4:20:17 PM CO-CHAIR ZULKOSKY announced the final order of business would be a presentation by the Office of Children's Services (OCS), DHSS. 4:20:25 PM NATALIE NORBERG, Director, Central Office, OCS, DHSS, provided a PowerPoint presentation entitled, "Office of Children's Services - Citizen Review Panel Response 2018-2019." Ms. Norberg expressed her appreciation for the emphasis on collaboration achieved by CRP in the past year and the work of its volunteer panelists. Further, she said CRP has aligned its goals and priorities more closely with those of OCS, which is helpful. She informed the committee OCS's administrative review process is a federal requirement of its funding through [title IV-E and IV-B of the Social Security Act and the Adoption and Safe Families Act of 1997]. The purpose of the administrative review is to provide third-party oversight of cases; in Alaska and one other state, the administrative review is not incorporated into the state's judicial process. The administrative review ensures that certain criteria are met in a timely manner, such as the development of a case plan. Although the review process is very important, it is very time consuming for staff and previously did not achieve its stated goal. Ms. Norberg said OCS believes if it could focus caseworker time to individually meet with families, Tribal partners when applicable, and GALs, caseworkers could accomplish needed work related to case planning (slide 1). She described the administrative reviews as mini court sessions; however, many of the requirements of the reviews could happen within a court setting, which would be more efficient. Ms. Norberg said OCS seeks to incorporate administrative reviews into the Alaska judicial system, a change that is supported by judges, GALs, defense attorneys, and Tribal partners. As part of the OCS Federal Program Improvement Plan, a judicial review pilot program will be implemented in Fairbanks to demonstrate its efficiency and efficacy (slide 2). CO-CHAIR SPOHNHOLZ asked about the history of Alaska's decision to create its current administrative review process. MS. NORBERG suggested there was concern that a judicial review process would be a burden for the court system; however, she pointed out Alaska needs the court system to be more involved in child welfare cases in response to "pressure we are getting from the federal government right now ... to have more involvement of the courts in our system." Further, early court involvement may alert families to the seriousness of a situation at the beginning of a case, which may result in an earlier permanent resolution of a case. 4:26:15 PM CO-CHAIR SPOHNHOLZ remarked: I'm a little surprised to hear you say that you think that we should have more and earlier court involvement in cases when some of the most exciting work that's being done in child welfare right now is being done in, in more of a collaborative way. ... I'm thinking about the work that's being done with the safe baby [Family Infant Toddler (FIT) therapeutic] court in, out in the Mat-Su valley, and maybe that's an example where the involvement of the court is a positive thing, but they're actually trying to move away from a traditional court model .... MS. NORBERG advised [FIT court] is the model OCS seeks to promote within the court system: having a more collaborative approach with families and also bringing the seriousness of a situation to everyone's attention and impart a sense of urgency. She opined court oversight would hold child welfare workers, and all parties, accountable and would provide clarification of legal issues. The Fairbanks pilot program will draw from lessons learned at FIT court in Mat-Su, "the Kenai model," and "the safe court process in Ketchikan." CO-CHAIR SPOHNHOLZ expressed support for FIT Court. REPRESENTATIVE TARR expressed her concerns about court proceedings, that are not well-understood by parents of children in custody, and occasions when parents are represented by the Office of Public Advocacy (OPA), which is understaffed. MS. NORBERG pointed out the pilot program will develop tools to help families understand the court system, such as an orientation video, and opportunities to ask questions prior to a legal proceeding. She explained the pilot program is based on a model that has been adopted by other states; she stressed OCS seeks to advance the pilot program because it currently employs six fulltime staff to perform an administrative function that could be achieved in a more efficient way. 4:32:25 PM MS. NORBERG continued, noting one of CRP's recommendations is to prioritize family reunification. She said training caseworkers in how to write case plans that promote reunification is important; in fact, nationally, Alaska's rate of reunification ranks above the U.S. average and OCS staff continue to receive annual training (slide 3). In addition, a stable workforce and accessibility to services are two key factors that will improve family reunification rates (slide 4). CO-CHAIR ZULKOSKY returned attention to slide 3 and clarified Alaska's 2018 rate of reunification was 54.5 percent of children exiting foster care. MS. NORBERG said correct. She then directed attention to slide 5 and stated the [section 1115 of the Social Security Act Behavioral Health Demonstration Waiver (1115 waiver)] targets families who are at risk of entering the child welfare system. In fact, the waiver will provide a new continuum of community based, in-home services that Medicaid has not paid for in Alaska before; the services will benefit OCS families who will now receive services nearby or in their homes. Further, OCS has participated in the "statewide gap analysis" to inform providers and recipients. 4:36:36 PM MS. NORBERG turned attention to the [Family First Prevention and Services Act that was included in the Bipartisan Budget Act of 2018]. She restated title IV-E is the primary federal funding source for child welfare services. The Family First Prevention and Services Act (Family First) allows the funding to pay for direct services for children and families who are not yet in the foster care system. This new opportunity means OCS will need to develop a prevention plan using data from the gap analysis and from stakeholders; also, OCS will become a third-payer, for services not otherwise paid through grants or Medicaid, and will seek 50 percent reimbursement for allowable services (slides 6 and 7). REPRESENTATIVE TARR cautioned Alaska does not have the workforce to provide [allowable services listed on slide 7]. MS. NORBERG agreed there is a "workforce issue." However, the state may be reimbursed by 1115 waiver and Family First funding for services provided by lower level technicians and peer support, such as elders and natural helpers, thereby creating access to a wider workforce. 4:40:44 PM REPRESENTATIVE DRUMMOND returned attention to slide 6 and asked who is reimbursing [Alaska and other states] for 50 percent of costs claimed. MS. NORBERG explained OCS will pay upfront costs to providers and will track the outcomes from the services; at billing, Medicaid will be billed first if applicable, and if not, OCS will be reimbursed by the federal government for 50 percent of its costs. Ms. Norberg, returning attention to the preliminary list of allowable services [slide 7], said the services must be evidence-based and proven effective, and not all of the services are available in Alaska at this time. CO-CHAIR SPOHNHOLZ spoke in support of the Parents as Teachers program. 4:44:35 PM MS. NORBERG continued to the CRP recommendation that OCS staff receive more regional cultural competency opportunities. She observed the state struggles with a high disproportion of Alaska Native children in the child welfare system, and said OCS is committed to sensitivity to the needs of Alaska Natives and to the children and families it serves. The division seeks to avoid cultural biases and thus in the last five to ten years has invested in how to increase sensitivity by offering extensive training on the Indian Child Welfare Act (ICWA); furthermore, a Cultural Humility curriculum is required of all staff to prepare them for ICWA training. Also, OCS is one of the only agencies in the state that received permanent permission to allow Alaska Native Tribal partners on its caseworker and management position hiring teams (slide 8). CO-CHAIR ZULKOSKY asked for a description of the extensive training shown on slide 8. MS. NORBERG said she would provide information on the length of the training; historically, OCS has held two standalone trainings on ICWA, in addition to that which is received by new staff. The Introduction to ICWA has been incorporated into the first three weeks of classroom training received by caseworkers and includes a general overview of the law; she said she would provide further information on the second phase and the total hours of training. The Cultural Humility curriculum is an online training; Knowing Who You Are Training is a two-day standalone training that helps staff discuss racial and ethnic identity and encourages courageous conversations in the work environment. Further, OCS has five regional ICWA specialists and a statewide ICWA coordinator who are available to help staff navigate specific Tribal relations and ICWA issues. 4:49:41 PM CO-CHAIR ZULKOSKY referred to the Alaska Humanities Forum Creating Cultural Competence (C3) education mentorship program for new teachers, in which new teachers are partnered with a member of the local community where they will be teaching. The program has been shown to increase the retention of new teachers in communities and she suggested there may be other mentorship opportunities. Co-Chair Zulkosky related her district is challenged by a low rate of recruitment and retention of OCS staff and recommended, in addition to improvements in training, mentorship of [new OCS staff] with local community or Tribal leaders. MS. NORBERG indicated her interest in Co-Chair Zulkosky's recommendation. She returned to the CRP recommendation to identify relatives for placement of children in foster care and said, since 2014, OCS as seen an increase of approximately 10 percent in the overall number of children placed with relatives, which may not represent a permanent placement. She said OCS seeks to sustain relative placement by changing the upfront payment process for relative placements to ensure stipends are issued to immediately offset the cost of care during the licensing process. In addition, licensed foster parents receive a higher rate of reimbursement than that received through Temporary Assistance for Needy Families (TANF). Other efforts in this regard include automated relative notifications online, identification of relatives through Tribal partners, and new training for supervisors (slide 9). 4:53:20 PM MS. NORBERG turned attention to OCS workforce issues and efforts to improve worker retention. She said the fifty-two new positions that were authorized during the last two fiscal years have begun to stabilize the OCS workforce. Many of the first new positions were assigned to the Mat-Su office and have reduced the previous caseloads of 40 cases per caseworker. Other positions were dispersed statewide; she cautioned about the significant amount of time required to recruit and train staff for a position, especially with the six weeks of training required by House Bill 151. Also, OCS is more cautious about cases that are assigned to new caseworkers when possible (slide 10). Also due to House Bill 151, OCS has instituted a mentorship program which assigns a field mentor to staff in training who will answer questions, provide support, and help staff transition from training to casework. Further, staff exit surveys have indicated OCS fails to provide sufficient supervision, thus OCS is developing more training in support of supervisors and managers through a new coaching program. During the next three years, OCS will focus attention on its managers and new staff; within six to nine months, all of its new positions will be filled and trained, and she expressed hope OCS will begin to reduce its current statewide turnover rate of approximately 50 percent, and regional rates as high as 80-100 percent. She stressed the majority of cases in Alaska are Alaska Native cases - which are under the jurisdiction of ICWA - and thus are more time consuming and require a higher level of service, case management, and support. She concluded, noting OCS seeks to support wellness activities for staff and is working with the administration and the union to develop flexible scheduling, opportunities for additional leave, and longevity and incentive pay for caseworkers (slide 11). 4:59:16 PM REPRESENTATIVE JACKSON returned attention to slide 1 and asked what percentage of the almost 3,000 administrative reviews result in the removal of children from their family. MS. NORBERG clarified administrative reviews are required every six months for children who are already in foster care; administrative reviews are an additional requirement, which is why OCS seeks to incorporate administrative reviews into a judicial review process. 5:00:40 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:00 p.m.