Legislature(2019 - 2020)DAVIS 106
03/05/2020 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| Presentation: Addressing Gaps in the Crisis Psychiatric Response System | |
| HB86 | |
| HB183 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| += | HB 183 | TELECONFERENCED | |
| += | HB 86 | TELECONFERENCED | |
| + | TELECONFERENCED |
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.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Fiscal Summary for Settlement of 3AN-18-09814CI.pdf |
HHSS 3/5/2020 3:00:00 PM |
Addressing Gaps in the Crisis Psychiatric Response System |
| Addressing Gaps in the Crisis Psychiatric Response System--2 page overview.pdf |
HHSS 3/5/2020 3:00:00 PM |
Addressing Gaps in the Crisis Psychiatric Response System |
| HB183 ver M Supporting Document Combined Letters of Support 3.3.2020.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 183 |
| HB 183 v.S.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 183 |
| CSHB 86 ver U Letters of Support 3.28.19.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 86 |
| Addressing Gaps in the Crisis Psychiatric Response System.PDF |
HHSS 3/5/2020 3:00:00 PM |
Addressing Gaps in the Psychiatric Response System |
| HB 86 Version U Amendment 1.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 86 |
| HB 183 Version S Amendment 1.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 183 |