Legislature(2021 - 2022)DAVIS 106
03/08/2022 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB297 | |
| HB172 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 172 | TELECONFERENCED | |
| *+ | HB 297 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 172-MENTAL HEALTH FACILITIES & MEDS
3:46:57 PM
CO-CHAIR ZULKOSKY announced that the final order of business
would be HOUSE BILL NO. 172, "An Act relating to crisis
stabilization centers, crisis residential centers, and subacute
mental health facilities; relating to evaluation facilities;
relating to representation by an attorney; relating to the
administration of psychotropic medication in a crisis situation;
relating to the use of psychotropic medication; relating to
licensed facilities; relating to psychiatric patient rights;
amending Rule 6(a), Alaska Rules of Civil Procedure; and
providing for an effective date."
[Before the committee was CSHB 172(JUD).]
CO-CHAIR ZULKOSKY noted there would be no public testimony today
at the first hearing of HB 172.
3:48:38 PM
STEVE WILLIAMS, Chief Executive Officer, Alaska Mental Health
Trust Authority (AMHTA), Department of Revenue, co-presented a
PowerPoint presentation on CSHB 172(JUD) on behalf of the
sponsor, House Rules by request of the governor. He stated that
currently Alaskans in mental health crises are reliant on first
responders and others to address their needs and access
available resources to resolve these crises. He said that,
while police officers ensure public safety, they are not trained
in the area of mental health, and emergency room or correctional
facility staff are not necessarily trained either. He noted, if
there are no other resources in the community to address an
individual's behavioral health crisis, that person may end up in
a correctional facility.
3:50:19 PM
HEATHER CARPENTER, Healthcare Policy Advisor, Department of
Health and Social Services (DHSS), co-presented a PowerPoint
presentation on CSHB 172(JUD) on behalf of the sponsor, House
Rules by request of the governor. She showed slide 2 of the
PowerPoint ["Transforming a Behavioral Health Crisis System of
Care", included in the committee packet]. She echoed that the
state has a limited amount of designated evaluation and
treatment facilities. She explained that these facilities are
designated by DHSS for inpatient care of individuals
experiencing an acute level of crisis, and they serve
involuntary and voluntary individuals. Currently these
facilities only exist in the following Alaska communities:
Juneau, at Bartlett Regional Hospital, with 12 beds; Fairbanks,
at Fairbanks Memorial Hospital, with 20 beds; the Matanuska-
Susitna Valley, at Matsu Regional Medical Center, with 16 beds;
and Anchorage, at the Alaska Psychiatric Institute (API). She
noted that hospital emergency rooms are often used to serve
individuals when other facilities are full. She described
emergency rooms as being "hectic" and not being "a therapeutic
environment." She pointed out that the information graphic on
slide 2 depicts the current flow for involuntary commitment.
She stressed that the state's behavioral health crisis fits
poorly into the system depicted.
MR. WILLIAMS stated when someone is in a physical health
emergency, it is a given the system will respond and the person
will be taken care of medically. He insisted this is what needs
to happen when someone experiences a behavioral health
emergency. Continuing to slide 3, he stated that the proposed
legislation would put into action a "no wrong door" approach to
stabilization services, and DHSS would be able to designate
facilities for lower levels of care for early intervention
during a behavioral health crisis. He described the two levels
of facilities as a 23-hour and 59-minute crisis stabilization
center and a short-term residential center for care up to 7
days. He stated that the legislation would not only address the
care of people in crisis, but it would also ensure their rights
are protected.
MS. CARPENTER stated that DHSS and AMHTA have been working
together for the last six years to improve the system of care.
She pointed out the building blocks for the system on slide 4.
She mentioned Senate Bill 74, passed during the Twenty-Ninth
Alaska State Legislature, as being a "huge step." To improve
the department's behavioral health system of care, Senate Bill
74 directed DHSS to apply for a Section 1115 Medicaid waiver
("1115 waiver"). She said the 1115 waiver "was a game changer,"
driving down the cost of health care by enabling payment to
providers of critical behavioral health support, which includes
crisis stabilization and crisis residential services. Through
the waiver, gaps are filled, and individuals can be diverted to
the appropriate level of care, instead of the higher level of
care at hospitals. By leveraging the 1115 waiver, she said
that, instead of flying individuals to one of four inpatient
treatment centers, the goal would be to have more treatment
options in all regions of the state. In the end, this would
save the state money. She added that most individuals in a
mental health crisis are treated on a voluntary basis, but there
needs to be an improved crisis response system for those who
cannot seek care on a voluntary basis.
3:56:06 PM
MR. WILLIAMS, referring to slide 5, pointed out the comparison
between the systems of care for physical and behavioral health
emergencies. He spoke about the work done between the
department and stakeholders to redesign the crisis system of
care to serve physical and mental needs. He offered that the
[Crisis Now] model is supported nationally. He listed multiple
organizations that have voiced support and offered that the
model has been proven in other states. He showed slide 6
regarding stakeholder engagement, stating that many individuals
and organizations have come forward in support of this issue.
He stressed that this is vital for the transformation of the
system and improving access to care, as "it's going to take
everyone," not just DHSS and AMHTA.
3:58:05 PM
MS. CARPENTER discussed slide 7, which shows the model for the
new crisis services. She stated that adding these services
would speed up care and leave open emergency room beds for
[physical medical emergencies].
MR. WILLIAMS addressed slide 8, which outlines the features of
the 23-hour and 59-minute crisis stabilization center. He
reinforced this would be the lowest level of intervention for an
individual in an actual facility. The services would be
provided by medical and mental health professionals, as well as
peers and others with real-life experience. The individual
would be received at the door by these providers, who would take
over the care and responsibility from a mobile crisis team, law
enforcement, or emergency medical services (EMS). This transfer
has been reported from other states as being less than 10
minutes. He stated that the goal would be to provide a safe
place to resolve a crisis without unnecessarily using the
highest level of care.
MR. WILLIAMS, moving on to slide 9, stated that short-term
crisis residential centers would be for individuals who require
more treatment because of an acute crisis. These centers would
be similar in terms of team makeup to the crisis stabilization
centers. He stated this would be a higher level of care to
hopefully resolve the crisis and reconnect the individual with
community services and support to maintain the gains made. He
reiterated that a key element would be services provided by
people with lived experience, who could relate to the individual
and help them understand the care that he/she would be receiving
at the location.
4:01:21 PM
He described the graphic [on slide 10] which depicts ten years
of data on the outcomes from the system in Georgia. The data
shows 90 percent of crisis calls were resolved over the phone
with a healthcare professional. For the remainder of the crisis
calls, a mobile crisis team had been dispatched to the
individual to assess the situation. The data shows seven out of
ten of those responses had been resolved in the community, with
no higher level of care or law enforcement needed. For the
three mobile crisis team responses that remained unresolved,
those individuals had been taken to a short-term stabilization
center. He continued that data shows only one out of three of
these situations had been transferred to the crisis residential
center for the seven days of access to treatment. He explained
that, with a system intentionally designed, resources would be
realigned into traditional roles: law enforcement would protect
public safety, investigate cases, write reports, and appear in
court, while mental health professionals would respond to
individuals in crisis.
4:04:03 PM
MS. CARPENTER stated that the involuntary commitment statutes
are found in Title 47 of the Alaska Statutes. The goal with
[CSHB 172(JUD)] would be to add new levels of care without
rewriting Title 47. She stated that DHSS, AMHTA, and
stakeholders had worked to identify the Crisis Now model as the
best path forward for Alaska. The team identified weaknesses
and strengths in the current system and reviewed the model in
action in other states. She stated that AMHTA has worked on the
implementation process of the Crisis Now model within Alaska,
while DHSS has implemented services from the 1115 waiver. She
referenced a lawsuit that DHSS settled with the Disability Law
Center of Alaska. The lawsuit concerned individuals in crisis
who had been held at correction facilities involuntarily. As
part of the settlement, DHSS had been directed to advocate for
statutory changes, as in the proposed legislation. She listed
key points of the proposed legislation: provide for less
restrictive and more immediate systems of care for patients;
create more facilities for patients; take the responsibility for
care away from hospital emergency rooms; provide law enforcement
with more options; and expand the types of first responders.
She clarified that the legislation would not interfere with a
police officer's authority, change the statutory authority to
administer medication, change the statutory authority for who
can order an involuntary commitment, or reduce the rights of an
adult or juvenile in crisis.
MR. WILLIAMS explained the graphic on slide 13, illustrating the
"current flow" for involuntary commitment. He noted that law
enforcement is currently the default response to an emergency
call. At this point, the choices for law enforcement for these
individuals are a hospital emergency room, jail, or emergency
hold. He explained that an emergency hold entails putting the
individual in handcuffs in the back of a police vehicle until an
appropriate place for the individual is found. He stated that
none of these options are productive. He expressed confidence
that the proposed legislation would redesign the system. He
clarified that law enforcement and EMS would not be taken out of
the system, but they would not be the default. He suggested
that the implementation of the system would not have to be
linear, as the resources in communities would be diverse.
4:11:26 PM
MR. WILLIAMS moved to slide 15 which outlines the flow for the
statutory changes. He reiterated that law enforcement and EMS
would still be part of the equation, but these resources would
not be the default. He stated that the goal would be to take
the individual to the appropriate care to resolve the crisis in
a way that is less restrictive.
MS. CARPENTER spoke to the changes made in the committee
substitute in the last committee of referral [exhibited on slide
16]. She said a key change had been made to the definition of
"peace officer," aligning it with current definitions found
elsewhere in the statutes. The language removed from this
definition has been used to create a new definition for a
"health officer". She listed some of the other changes which
include: the length of stay at a short-term crisis residential
center would change from five to seven days; concerning patient
rights, the 72-hour clock would start when an individual enters
any crisis center; the court would be required to notify any
guardian if a patient had a hearing; the seven-day hold would
begin at the time of initial retainment, no matter the facility;
and DHSS and AMHTA would collect data and issue reports on
patient harm, restraint, and resolution. She added that these
reports would bring together a group of diverse stakeholders to
investigate and discuss the topic and the process in Alaska and
other states. The group would propose needed changes to
regulations and statute. She said a key part of this process
would include robust public comment. She stated that, once the
legislation is signed into law, there would be one year to come
back to legislature with recommendations and an action plan
forward.
4:15:54 PM
CO-CHAIR ZULKOSKY asked committee members to exercise some
restraint with questions, as three invited testimonies were yet
to be heard.
4:16:22 PM
REPRESENTATIVE SPOHNHOLZ expressed enthusiasm for the
legislation. While the committee's focus has been the
stabilization centers, she questioned how the crisis call
centers and mobile crisis teams would fit into the funding
stream with the 1115 waiver.
4:17:57 PM
GENNIFER MOREAU-JOHNSON, Director, Division of Behavioral
Health, Department of Health and Social Services, stated that
the 1115 waiver reimbursement would currently be for the mobile
crisis response and both types of crisis centers but not for the
call center. She indicated that work needs be done to
understand the access to the Medicaid administration funding for
the call center. She affirmed that the call center would not be
funded.
4:19:34 PM
REPRESENTATIVE KURKA expressed concern about taking freedom from
someone who is having a mental crisis. He expressed interest in
the comparison of due process rights proposed in the legislation
with the due process rights in the criminal justice system.
4:20:52 PM
STACIE KRALY, Director, Civil Division, Department of Law,
explained that she does not practice law in the civil justice
system, and a more concrete answer on an "apples to apples"
comparison between civil commitment for the Crisis Now model and
the criminal justice system would need to be supplied after the
hearing. She stated that the civil commitment process is a
constitutional exercise of the federal government to empower the
police at the state and federal level. Due process is provided
at all different levels within this system. In the proposed
legislation due process would include the right to an attorney
and a court hearing. She suggested that the similarities would
be, at the time of admission, counsel would be appointed, and a
judicial review of the decisions would be made. In addition,
the individual would receive a list of entitled rights, and the
guardian or parents would be notified. She continued that due
process protections would be added and included in this system,
as they exist under Title 47 of the Alaska Statutes. She stated
that it is important to note one major difference: an attorney
would always be appointed, present, and available in the civil
commitment arena, while in the criminal arena it would be based
on indigency, and some individuals may not be eligible for court
appointed counsel.
4:23:27 PM
REPRESENTATIVE MCCARTY, addressing slide 13, questioned whether
currently an ex parte order would be needed to move an
individual from a [23-hour and 59-minute] hold to the next level
of care.
MR. WILLIAMS answered in the affirmative.
REPRESENTATIVE MCCARTY addressed slide 15 and the timeframe. He
voiced the understanding that, if needed, an individual would be
put on a 72-hour hold, but he/she must leave the crisis
stabilization center within the 23-hour and 59-minute limit. He
questioned the location of the individual before he/she would be
evaluated for the 7-day hold.
MR. WILLIAMS clarified that the 23-hour and 59-minute hold would
be a part of the 72-hour timeframe. The 72-hour time limit
would begin with a notice for a scheduled hearing. If at any
point the individual no longer meets the criteria to be held,
then he/she would be released.
REPRESENTATIVE MCCARTY, with a follow-up question, stated that
his understanding is a judge must determine the status of the
individual.
MS. KRALY confirmed that Mr. Williams is correct. The 72 hours
would be a timing mechanism. She stated that upon admission, a
clock would start, and a hearing must be held within 72 hours.
She added that weekends and holidays would not be included in
the timeframe. She stated that the 72-hour timeframe would not
be a benchmark. If an individual stabilizes, based on a
clinical determination, he/she could be released, and a judge
would not be involved. A judge would be required only if,
within 72 hours, it is determined the individual needs more care
on an involuntarily basis.
CO-CHAIR ZULKOSKY reminded committee members that the
legislation will come back before the committee, and she moved
to invited testimony.
4:28:53 PM
MARK REGAN, Legal Director, Disability Law Center of Alaska,
spoke to Representative Kurka's previous question concerning due
process. He related that the Alaska Supreme Court holds that
the current civil commitment process is "based on a probable
cause finding at the start that you are gravely disabled or
because of a mental illness, likely to harm yourself or others."
He stated that this is the standard. He continued that, per the
proposed legislation, an ex parte order would hold the
individual in place for 72 hours. The Alaska Supreme Court
issues that this is constitutional only because there would be a
right to a prompt hearing within 72 hours. He supplied that the
burden would be on the state to have the individual held any
longer. The difference in the criminal system would be that a
person could be arrested and taken into custody before any
involvement with a judge. He stated that the systems would work
in the same way, but HB 172 would allow for the prompt
appointment for an attorney and a prompt hearing before a judge.
4:32:24 PM
MR. REGAN, concerning the aforementioned lawsuit, stated that
the Disability Law Center and public defenders brought the
lawsuit because individuals had been deprived of liberty under
the old system. He expressed the belief that it would be
tempting to blame API, but he explained that API did not have
the capacity to routinely take people for civil commitment
evaluations for the 72-hour period; therefore, individuals ended
in jail or hospital emergency rooms. He continued that API was
only one part of a stressed system. During the breakdown of API
in the winter of 2018 and 2019, individuals had been held at the
Anchorage correctional complex. He stated that a video tour of
the complex from intake to evaluation shows "it is a grim
system." He added that home videos can sometimes come across
dark, but the complex was "a sterile, stark place and not
therapeutic at all." He added that other individuals in the
state were being held in emergency rooms awaiting transportation
to API. He maintained that the key point is these are not
therapeutic, psychiatric-oriented places which could help an
individual resolve a short-term crisis. He said, "If you are
greatly disabled or likely to harm yourself, you ought to be at
a place that is better able to help you." He articulated that
this is the reason the lawsuit endorsed the idea of Crisis Now
facilities, so people could get short-term treatment without
waiting in jails and hospitals. He stated that the law center
supports HB 172 because "people have a basic right to ... a
happier, friendlier place that does more to treat you." He
suggested that the problems at API had affected hundreds of
Alaskans, and there should be a better system.
4:37:39 PM
REPRESENTATIVE SPOHNHOLZ asked for a description of the
appointment of the guardian, as well as the attorney, to
advocate on behalf of the patient.
MR. REGAN explained he cannot speak to guardianship, as the law
center is not responsible for this piece of the legislation, but
he can speak to the appointment of the attorney. He referenced
past issues concerning assigned attorneys, which left patients
"stuck" in emergency rooms or jails, with the sense that no one
would be looking out for them. If an individual is in acute
mental crisis, the need for a lawyer may not be evident to this
individual. He stated that a lawyer would give the individual a
sense of an upcoming resolution, especially for the first 72-
hour hearing. At that time, a decision would be made whether to
hold the individual longer at a crisis residential center.
MR. REGAN, in response to a follow-up question, apologized, but
reiterated that he could not speak on the appointment of a
guardian or guardianship.
4:40:58 PM
HELEN ADAMS, MD, Emergency Medical Physician, Alaska Chapter of
Emergency Physicians, testified in support of CSHB 172(JUD).
She expressed the opinion that, as in the entire nation, Alaska
is experiencing a mental health crisis, and the state does not
have the capacity to care for the increase in mental health
emergency room visits. She explained that the open-door model
would be helpful because, in her experience, the majority of
these people are desperate for help. She stated that within the
four years of working in Anchorage, she only had one upset
patient who requested an attorney. She voiced her opinion that
many emergency care rooms are equipped to deal with a variety of
crises, as Anchorage has an appropriate seven-bed unit for
mentally ill patients. But she added that when patients are
moved into the general emergency room area, there is very little
control over the noise and exposure to other patients. Patients
are able to [easily escape from emergency rooms], which in the
end involves security staff. She maintained that this is not
the best place to care for these patients.
4:43:24 PM
DR. ADAMS continued that a more appropriate clinical environment
would be better support for these patients. The evidence from
other states is that an individual in crisis would deescalate
more quickly in the appropriate environment. Plus, this type of
environment would require less intervention, and there would be
less stress on the patient, and all involved. She stated that a
23-hour and 59-minute stabilization system is practical because
when an individual comes in, often he/she is very intoxicated
and should not be alone. The individual needs to be in an
environment where he/she can become sober and be assessed. She
stated that the majority of those patients want to leave once
they are sober. She emphasized that the patients who are
required to transfer to residential crisis centers are the
minority, and HB 172 would be a good opportunity to expand care
for these patients, otherwise the problem will be ongoing.
4:45:08 PM
DR. ADAMS, in response to Co-Chair Zulkosky, voiced her opinion
that the proposed legislation would provide for actual physical
places in Alaska where care for these patients could be
provided. She referenced her experience in Anchorage, where the
backlog had been so extreme, some patients were held for hours
in the back of a police vehicle in the hospital parking lot.
She indicated that she would physically go to the parking lot
and assess the patient to make sure the patient was physically
safe. She voiced the opinion that this is a major problem, as
ideally a patient would be admitted immediately and put into a
room with a padded bed on the floor with no potential harmful
hardware in the room. The individual would be seen quickly by a
mental health clinician, and a recommendation would be made.
She acknowledged that unfortunately this ideal standard of care
is more often seen only in the minority of cases. Instead,
individuals are placed in a room with equipment which has to be
moved, and a technician has to sit and monitor the person, as
he/she cannot be left alone. This process limits the resources
and the overall ability for the emergency room situation to run
efficiently. The technicians normally assist nurses, so nurses
end up stressed. She stated that, overall, the system does not
work effectively, and medical patients are not getting the care
they need, and this contributes to overburdening of the health
system as a whole. She stated that HB 172 would allow for a
more appropriate and concentrated use of mental health services.
4:48:55 PM
JAMES COCKRELL, Commissioner, Department of Public Safety (DPS),
offered the support of CSHB 172(JUD) personally and
professionally. He added that DPS fully supports the proposed
legislation. He stated that "we've got to do better" for
individuals who are suffering from mental health issues. He
spoke briefly about his personal experience and a family member
who went to jail after a "mental collapse." He insisted that
individuals should not be sent to the emergency rooms, as
hospitals are understaffed. He spoke about instances of
policemen driving around for hours with handcuffed individuals
in the back of their vehicles, because there was nowhere to take
a person in a mental health crisis. He reiterated that "we just
need to do it."
4:52:18 PM
REPRESENTATIVE MCCARTY shared his personal experience working on
a crisis mobile team. In Kodiak he experienced an individual
who was in crisis that did not receive timely transportation to
API. He stated that the individual eventually received
services, but their rights had been infringed upon, and the
courts became involved. He voiced approval for the proposed
legislation but offered that he did not understand the flow, in
regard to the clock-start time, [as exemplified on slide 5]. He
expressed the opinion that a person in crisis could be lost in
the system, which would result in the infringement of rights.
4:55:41 PM
MS. KRALY explained that, upon admission to a crisis
stabilization center, there would be a notice of arrival which
triggers the 72-hour clock. The notice of arrival would go to
the court, and an attorney would be appointed. The court would
set a hearing and provide the guardian with that information.
She stated that every 24 hours the court would be notified as to
the status of an individual in the facility and of any transport
[to another facility]. A court hearing would be held if the
individual objects to being held or has any questions. She
stated that this would be the importance of appointing an
attorney and guardian early, because additional judicial review
could be requested. She stated that in this process, or flow,
the court would issue the ex parte hold for the admission to the
crisis residential center, so the court would be involved
immediately. She reviewed that when an individual stays more
than the 23-hour and 59-minutes in the crisis stabilization
center, the court would become involved, evidence would be
presented, and a recommendation would be made. Upon admission
to the crisis residential facility, she stated, a notice of
arrival or notice of rights would be reported to the attorney
and guardian. She asserted that this would be the process to
make sure no one is lost in the system.
4:58:19 PM
MS. KRALY, in response to a follow-up question, affirmed
Representative McCarty's understanding of the process. In
response to Co-Chair Zulkosky, she agreed that there is a
natural tension in the current system between the mental health
treatment component of a civil commitment and the role law
enforcement plays. She stated that the proposed legislation
would not take law enforcement out of the process, but it would
radically minimize the involvement law enforcement has in the
psychiatric mental health system. She continued that "all of us
agree, get that criminal law enforcement component out of the
psychiatric level of care." She stated that the legislation
would change a multiple hour drive for law enforcement into a
10-minute drop off at a center, where the individual would be
treated by mental health professionals. She suggested that
tension between law enforcement and the mental health system
would be mitigated and reduced.
5:03:00 PM
MS. KRALY, in response to Representative Spohnholz, explained
that guardianship is a legal process outlined in Title 13 of the
Alaska Statutes. She stated that guardians are appointed by a
judge, and it is a formal legal process. She said that there
are two types of guardianships, public and private. The Office
of Public Advocacy would appoint public guardians. She stated
that in the last committee of referral it was determined that an
individual who has suffered a behavioral crisis most likely
would already have a guardian, public or private. She said that
guardians have a unique role, as they assume the same
responsibilities as a parent. A guardian with a ward has the
ability to advocate and communicate with the healthcare provider
in the mental health system to facilitate treatment, voluntary
or otherwise. While the guardian does not have the right to
administer medication for their ward, he/she could testify in
support of treatment with psychotropic medication. She said
that a guardian would facilitate communication with a ward, and
it would be "like having a parent on your side." In response to
a follow-up question, she deferred to Ms. Carpenter.
MS. CARPENTER, in response, explained that in the proposed
legislation the main change would be the strengthened
communication level [with the guardian]. She said that
currently there is no requirement that guardians be notified by
the court; the proposed legislation would require the guardian
be notified of the time and place of a hearing. In response to
a follow-up question, she affirmed that a patient's rights would
be strengthened with this notification.
5:06:38 PM
REPRESENTATIVE KURKA recalled that, in the last committee of
referral, there had been concern about how to contact the
guardian. He questioned whether the court would keep a list of
guardians.
MS. CARPENER responded that the court has the only list of all
public and private guardianships.
5:07:19 PM
CO-CHAIR ZULKOSKY announced that HB 172 was held over.