Legislature(2015 - 2016)CAPITOL 106

04/02/2016 01:30 PM HEALTH & SOCIAL SERVICES

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02:02:36 PM Start
02:04:00 PM Presentation: "aces" by Dr. Matthew Hirschfeld
02:30:24 PM Presentation: Citizen Review Panel
02:32:18 PM Presentation: "aces" by Dr. Matthew Hirschfeld
02:42:11 PM HCR21
03:08:38 PM Presentation: Citizen Review Panel
04:19:27 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Time Change from 12:15 p.m. --
+ Presentations: TELECONFERENCED
- "ACEs" by Dr. Matthew Hirschfeld
- Citizen Review Panel
Moved HCR 21 Out of Committee
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 2, 2016                                                                                          
                           2:02 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Representative Paul Seaton, Chair                                                                                               
Representative Neal Foster                                                                                                      
Representative Louise Stutes                                                                                                    
Representative David Talerico                                                                                                   
Representative Geran Tarr                                                                                                       
Representative Adam Wool                                                                                                        
MEMBERS ABSENT                                                                                                                
Representative Liz Vazquez, Vice Chair                                                                                          
COMMITTEE CALENDAR                                                                                                            
PRESENTATION: "ACEs" by DR. MATTHEW HIRSCHFELD                                                                                  
     - HEARD                                                                                                                    
HOUSE CONCURRENT RESOLUTION NO. 21                                                                                              
Urging  Governor  Bill  Walker  to join  with  the  Alaska  State                                                               
Legislature  to  respond  to the  public  and  behavioral  health                                                               
epidemic  of  adverse  childhood experiences  by  establishing  a                                                               
statewide  policy   and  providing   programs  to   address  this                                                               
     - MOVED HCR 21 OUT OF COMMITTEE                                                                                            
PRESENTATION: CITIZEN REVIEW PANEL                                                                                              
     - HEARD                                                                                                                    
PREVIOUS COMMITTEE ACTION                                                                                                     
BILL: HCR 21                                                                                                                  
SHORT TITLE: RESPOND TO ADR. VADAPALLIERSE CHILDR. HIRSCHFELDOOD                                                                
SPONSOR(s): REPRESENTATIVE(s) TARR                                                                                              
02/05/16       (H)       READ THE FIRST TIME - REFERRALS                                                                        
02/05/16       (H)       HSS, FIN                                                                                               
WITNESS REGISTER                                                                                                              
MATTHEW HIRSCHFELD, M.D.                                                                                                        
Chair, All Alaska Pediatric Partnership                                                                                         
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Presented "A Systemic Approach and the                                                                   
Economic Benefits of Identifying and Treating Family Trauma.                                                                    
TREVOR STORRS, Executive Director                                                                                               
Alaska Children's Trust                                                                                                         
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  During the hearing of HCR 21, testified in                                                               
support of the legislation.                                                                                                     
DON ROBERTS                                                                                                                     
Kodiak, Alaska                                                                                                                  
POSITION STATEMENT:  Testified during discussion of HCR 21.                                                                   
PATRICK ANDERSON, Senior Research Fellow                                                                                        
Sealaska Heritage Institute                                                                                                     
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  During the hearing of HCR 21, offered                                                                    
support for the legislation.                                                                                                    
MAUREEN HALL, School Nurse                                                                                                      
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  During the hearing of HCR 21, offered her                                                                
experiences regarding the legislation.                                                                                          
DR. DIWAKAR VADAPALLI, Chair                                                                                                    
Citizens Review Panel                                                                                                           
Institute of Social and Economic Research, Professor                                                                            
University of Alaska Anchorage                                                                                                  
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Presented a PowerPoint titled, "Alaska                                                                   
Citizen Review Panel, and Annual Update."                                                                                       
CHRISTY LAWTON, Director                                                                                                        
Central Office                                                                                                                  
Office of Children's Services                                                                                                   
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered questions during the presentation                                                               
of the Citizens Review Panel.                                                                                                   
ACTION NARRATIVE                                                                                                              
2:02:36 PM                                                                                                                    
CHAIR PAUL  SEATON called  the House  Health and  Social Services                                                             
Standing   Committee    meeting   to    order   at    2:02   p.m.                                                               
Representatives  Stutes, Talerico,  Tarr, Wool,  and Seaton  were                                                               
present at the  call to order.  Representative  Foster arrived as                                                               
the meeting was in progress.                                                                                                    
^Presentation: "ACEs" by Dr. Matthew Hirschfeld                                                                               
         Presentation: "ACEs" by Dr. Matthew Hirschfeld                                                                     
2:04:00 PM                                                                                                                    
CHAIR SEATON announced that the  first order of business would be                                                               
an "ACEs" presentation by Dr. Matthew Hirschfeld.                                                                               
2:04:07 PM                                                                                                                    
MATTHEW  HIRSCHFELD,  M.D.,  All  Alaska  Pediatric  Partnership,                                                               
Chair,  said that  he is  an Anchorage  pediatrician and  advised                                                               
that All  Alaska Pediatric  Partnership has  been working  in the                                                               
area  of  adverse childhood  experiences  and  issues related  to                                                               
child  abuse  and  neglect  in Alaska,  and  the  partnership  is                                                               
interested in  ACEs.   He turned  to slide 1,  and noted  that in                                                               
working with  other organizations,  the question  is how  to work                                                               
together to  decrease these adverse childhood  experiences in the                                                               
DR. HIRSCHFELD  turned to  slide 2,  "The Developing  Brain," and                                                               
said  this slide  clearly  shows what  can  happen under  extreme                                                               
neglect.  He  pointed out that the brain on  the right side shows                                                               
a very  different brain  from the  normal brain.   The  holes are                                                               
called  ventricles  and  are  much   larger  on  the  brain  that                                                               
underwent extreme neglect,  the brain is much smaller,  and it is                                                               
organized differently.   He extended  that this child  will never                                                               
be able  to develop  to their  full potential  having experienced                                                               
extreme  neglect, but  this  brain damage  can  happen anytime  a                                                               
child  is exposed  to bad  things happening  to them,  especially                                                               
with children  between zero and 3-5  years of age.   In the event                                                               
the neglect  is ongoing  for a  long period  of time,  that child                                                               
exposed to those bad things  happening to them will never develop                                                               
to their  potential.  As  a pediatrician and  as a member  of the                                                               
All  Alaska Pediatric  Partnership,  he said  the  intent is  for                                                               
children to develop to their full potential.                                                                                    
2:07:02 PM                                                                                                                    
DR. HIRSCHFELD turned to slide  3, "Evidence," and explained that                                                               
Dr.  V. Felitti  lectured in  Juneau  in February  and also  gave                                                               
great talks  all over town.   Dr. Felitti is the  chief author of                                                               
"The  Adverse  Childhood  Experience  Study -  ACEs  Study,"  and                                                               
things that happen to very  young children can permanently affect                                                               
their   health,   permanently   affect   their   mental   health,                                                               
permanently affect  whether they can  hold jobs, and more.   This                                                               
is  known through  a landmark  study  beginning in  1998, by  Dr.                                                               
Felitti.  He advised that it  was a collaboration between CDC and                                                               
Kaiser  Permanente in  San  Diego where  17,000  adults with  the                                                               
average age of 57, were surveyed.   He pointed out that by having                                                               
adults in the  Kaiser Permanente system there is  access to their                                                               
medical records.                                                                                                                
DR. HIRSCHFELD  turned to slide 4,  "Adverse Childhood Experience                                                               
Study," and related that Dr. Felitti  wanted to look at 10 events                                                               
that  could happen  in childhood  and  then relate  those to  the                                                               
health of the adults he was surveying.   He then read the list of                                                               
10  events  surveyed, and  explained  that  Dr. Felitti  asked  a                                                               
series of questions around these 10 events.                                                                                     
DR. HIRSCHFELD  turned to  slide 5,  "ACE: Prevalence  data," and                                                               
advised that  Dr. Felitti found that  approximately two-thirds of                                                               
the adults surveyed reported having  at least one of those things                                                               
happening to  them, which  Dr. Hirschfeld  described as  a pretty                                                               
astounding  number.   This  was a  middle-class  group of  people                                                               
being surveyed in  San Diego and most of the  people had at least                                                               
gone to college  if not graduated from college and  he found that                                                               
a huge  number of  people had  been exposed to  this as  a child.                                                               
Interestingly,  approximately one-third  of the  people had  zero                                                               
yes answers  to any  of the  questions, and  all of  those people                                                               
were quite a bit healthier across all measures.                                                                                 
DR. HIRSCHFELD turned to slide  6, "Health Measures Now Linked to                                                               
Adverse  Childhood Experiences  Score"  and said  that they  were                                                               
looking at this  huge list of things that can  happen to a person                                                               
as  an adult.    Essentially,  he pointed  out,  if  a bad  thing                                                               
happens to  a person as  a child they  are at increased  risk for                                                               
heart  disease, asthma,  cancer,  sexually transmitted  diseases,                                                               
suicide, depression,.   In fact,  he explained, as the  number of                                                               
yes  answers increases,  a person's  risk  of having  one of  the                                                               
listed  diseases as  an  adult goes  up step-wise  as  well.   He                                                               
described  it as  a fascinating  piece of  public health  because                                                               
that is rarely  seen.  The link between a  high adverse childhood                                                               
experience score or answering yes  to the questions, and the risk                                                               
of having  a suicide attempt  is actually stronger than  the risk                                                               
between smoking  and lung  cancer.   Basically, he  related every                                                               
time a  person looks at a  bad health outcome that  can happen to                                                               
an adult,  it can  be linked  back to bad  things happening  as a                                                               
child.   He described it as  strong data that has  been supported                                                               
in hundreds of  studies over the last 20 years,  and the question                                                               
today is how to decrease these  yes answers in Alaska in order to                                                               
decrease the risk of an unhealthy population as adults.                                                                         
2:10:54 PM                                                                                                                    
DR. HIRSCHFELD turned  to slide 7, "2013 Alaska  BRFSS" said that                                                               
through the  Behavioral Risk  Factor Surveillance  System (BRFSS)                                                               
survey, Alaska  has now  started to measure  ACEs and  the Alaska                                                               
population.  He  advised that Patrick Sidmore, the  data guru for                                                               
Alaska  ACEs, with  one  year  of data  discovered  that for  all                                                               
Alaskan  adults,  the state  has  about  the same  percentage  of                                                               
people as the  San Diego folks do with zero  yes answers to those                                                               
questions, and  noted that those  people are much  healthier than                                                               
the people who answered yes  to the questions.  Interestingly, he                                                               
commented,  Alaska has  people answering  yes to  those questions                                                               
more often,  and Alaska has  more people  with four or  five plus                                                               
yes  answers  to  the adverse  childhood  experiences  questions.                                                               
Therefore, Alaska  has two-thirds of  the people that say  yes to                                                               
those  questions,  but  Alaska's  population is  skewed  so  that                                                               
Alaskans'  answer yes  more often.   Which  means that,  overall,                                                               
Alaska's population will  not be as healthy because  there are so                                                               
many bad things happening to children.                                                                                          
2:12:20 PM                                                                                                                    
CHAIR SEATON  asked Dr. Hirschfeld  to explain the header  on the                                                               
slide and whether  the first column of percentages  is the number                                                               
that reported 1 yes, and so on.                                                                                                 
DR. HIRSCHFELD replied  that the top score is the  ACE score - 0,                                                               
1, 2, 3, 4, 5+.                                                                                                                 
CHAIR SEATON  noted there are  no numbers  on there, and  he just                                                               
wanted clarification.                                                                                                           
DR.  HIRSCHFELD  explained  that  on the  top  line  is  Alaska's                                                               
population at 10.8 percent of 5+  bad things happening to them as                                                               
children.  Alaska has more people  in Alaska that say they've had                                                               
5+ things happening to them as children than many other states.                                                                 
DR. HIRSCHFELD turned to slide  8, "Adverse Childhood Experience"                                                               
offered  that this  is Alaska's  specific data  and he  likes the                                                               
slide  because  it shows  Alaska's  percentage  relative to  five                                                               
other states  that perform  a similar  survey as  to Alaska.   He                                                               
pointed out that this is  an emotional abuse, physical abuse, and                                                               
sexual abuse  slide, and  the red number  is the  highest between                                                               
Alaska and  these five other states.   Alaska is number  one with                                                               
reports of sexual  abuse to children, and Alaska is  close to the                                                               
top for emotional and physical  abuse.  Therefore, there are many                                                               
opportunities in the  state to make big changes if  the state can                                                               
give families and children additional  support so these things do                                                               
not  happen to  them.   Due to  the high  sexual abuse  rates for                                                               
children in  the state, sexual  abuse is  the place to  start and                                                               
the sexual abuse  rates for women is in the  30 percent range and                                                               
there are  great opportunities  to try  to decrease  sexual abuse                                                               
rates, especially in women in the state.                                                                                        
DR.  HIRSCHFELD turned  to slide  9, "Household  Dysfunction" and                                                               
said  this is  where Alaska  becomes much  higher than  the other                                                               
five states it is comparing itself  to.  Especially, he noted, in                                                               
substance abuse in the home,  separation or divorce, incarcerated                                                               
family  member, but  the  state is  fairly close  to  the top  in                                                               
mental  illness in  the home  and witness  to domestic  violence.                                                               
Alaska has many  opportunities to make big changes  in the health                                                               
of  its   populations  by  decreasing  these   numbers  that  are                                                               
happening to children.                                                                                                          
2:15:33 PM                                                                                                                    
DR. HIRSCHFELD turned  to slide 10, "Prevalence  of Specific ACEs                                                               
Experienced by AN  People Compared with Non-AN"  offered that the                                                               
Alaska Native  Medical Center has an  epidemiology department and                                                               
its  epi center  took Mr.  Sidmore's  data and  looked at  Alaska                                                               
Native folks  versus non-Alaska  Native folks.   The  red squares                                                               
show  where Alaska  Native  folks  are statistically  significant                                                               
from the non-Native  folks.  Speaking as a doctor  working at the                                                               
Alaska  Native Medical  Center and  someone interested  in tribal                                                               
health, these are the  areas he would want to focus  on to try to                                                               
decrease the  rates in Alaskan  Native people to bring  them more                                                               
in line with the rest of  the state, together with working on the                                                               
rest of the  state to bring [the numbers] down.   He stressed the                                                               
importance that  no child should be  a victim of sexual  abuse or                                                               
substance abuse in the household, or any of those things.                                                                       
DR. HIRSCHFELD  turned to slide 11,  "How Do We Work  Together to                                                               
Decrease Alaska ACEs?" section of the presentation.                                                                             
2:16:39 PM                                                                                                                    
DR.  HIRSCHFELD   turned  to  slide  12,   "American  Academy  of                                                               
Pediatrics  Policy Statement"  said he  likes to  start with  big                                                               
organizations that are  doing things on a national  scale and the                                                               
American  Academy   of  Pediatrics  has  decided   that  ACEs  is                                                               
interesting to them as well.   They have a policy statement where                                                               
providers such  as family medicine doctors,  nurse practitioners,                                                               
pediatricians, and  anyone who interacts with  families should be                                                               
actively  assisting   parents,  childcare   providers,  teachers,                                                               
policy makers, and  everyone interacting with families  to try to                                                               
address these  persistent and constant  problems that  are facing                                                               
contemporary  society,  including:  criminality,  disparities  in                                                               
health, limited educational  achievement, and diminished economic                                                               
productivity listed on the slide.                                                                                               
DR. HIRSCHFELD turned  to slide 13, "Why Are  Providers the Front                                                               
Line?"  noted  that  he  likes  to  think  of  providers  as  the                                                               
frontline  because providers  have  a major  opportunity in  this                                                               
state to  make an effect.   The  slides depict when  children are                                                               
seen in  provider offices, and  this slide  mirrors immunization,                                                               
and children  receive lots of immunizations  especially when they                                                               
are  under  three  years  of age,  and  the  immunizations  bring                                                               
children into  provider offices.   In that children are  going to                                                               
the doctor  so often, that  is a great opportunity  for providers                                                               
to screen  families for  things that could  be happening  at home                                                               
that  won't be  healthy for  their  children.   As the  committee                                                               
knows,  he related,  the biggest  effect on  children and  making                                                               
them healthier  in the  future is  when their  brain is  the most                                                               
plastic, when their  brain is developing rapidly and  that is any                                                               
child  under 3  years of  age.   When  the children  come in  for                                                               
immunizations  the provider  can  do lots  of  screening for  the                                                               
family, and  do protective corrective  action to  those families,                                                               
and  that  way  the  families are  healthier,  raising  healthier                                                               
children,  and  they  know  how   to  raise  healthier  children.                                                               
Providers can have  a major effect because those  families are in                                                               
their  offices often  for children  under  the age  of three  for                                                               
2:18:45 PM                                                                                                                    
DR.   HIRSCHFELD   turned    to   slide   14,   "Parent-Screening                                                               
Questionnaires" and explained that  people are finally developing                                                               
screening  questionnaires  to  look   at  things  that  could  be                                                               
happening  in families  and adversely  affecting  children.   [He                                                               
described the questionnaires]  and said that a  provider can hand                                                               
the  parent a  questionnaire  during the  office  visit and  then                                                               
begin having a discussion about any  answers that are yes, to get                                                               
the families  to help  raise healthier children.   He  noted that                                                               
the questions  on the  slide are common  and used  throughout the                                                               
2:19:38 PM                                                                                                                    
DR.  HIRSCHFELD  turned to  slide  15,  "Three Questions  -  Gets                                                               
Almost Everything" and described  questionnaires as easy and many                                                               
people  can use  them.    He pointed  to  his  Nome practice  and                                                               
offered that for his families  those questionnaires work but they                                                               
don't work as well as something else  he has started to do in his                                                               
practice in  Nome.   When he  has a  family that  he is  a little                                                               
worried  about, their  children are  not developing  properly, or                                                               
the children  are acting out in  school, or any risk  factors for                                                               
something that  may not be going  well at home, he  starts having                                                               
conversations with families.   He also asks  the questions listed                                                               
on the slide  that gets to the  abuse questions.  In  the event a                                                               
child  has been  physically  abused, and  the  mother trusts  the                                                               
doctor as  a provider well  enough, she will start  answering yes                                                               
to  the questions  which begins  a conversation  to try  to start                                                               
getting help  for that mother so  it doesn't happen again  to the                                                               
child.   Equally important he  said, as to whether  something has                                                               
happened to the  child is that the provider really  wants to know                                                               
whether  that  has  affected  the child's  behavior.    The  most                                                               
protective  thing a  child can  have  is a  strong healthy  adult                                                               
relationship.   For  example, a  child  with a  great mother  and                                                               
father  is  physically  abused  once  and  this  stressful  thing                                                               
happened to  the child.  Although,  the parents are able  to walk                                                               
the child through  the situation, give him ways to  deal with the                                                               
stress, build  resilience in the  child so  even though it  was a                                                               
stressful event  the child was  able to tolerate it  well because                                                               
he had  great parents and adult  relationship in the family.   He                                                               
said  he  is  less  nervous  about that  family  if  the  child's                                                               
behavior hasn't changed and the family is functioning well.                                                                     
2:21:40 PM                                                                                                                    
DR. HIRSCHFELD  related that many parents  were physically abused                                                               
and if  their child  is physically abused  it can  trigger strong                                                               
memories in a  parent.  A question  he asks is not  only has this                                                               
event affected the  child's behavior, but has that  event had any                                                               
effect on  the parent because  that suggests  to him that  if the                                                               
parents are  having trouble dealing  with this, they will  not be                                                               
able to  help the child  deal with it.   More help is  needed for                                                               
that family to  not only get the child through  the situation but                                                               
also counseling for  the mother and father to make  sure they are                                                               
able to  handle the  situation and walk  their child  through the                                                               
situation.   Those  two  questions  appear to  get  at the  abuse                                                               
questions well.   Those questions do not get at  neglect, he asks                                                               
the  parents whether  they have  done anything  with their  child                                                               
that is really  fun since the last  time he saw them.   If people                                                               
can't  think of  anything fun  they've done  with their  child in                                                               
three to six  months since last seen in clinic,  he said it makes                                                               
him  nervous that  the  child is  just sitting  in  front of  the                                                               
television  and they  are  not having  great  interaction in  the                                                               
family.  He opined that those  questions appear to get at most of                                                               
ACEs,  and  noted  that  his  families in  Nome  prefer  to  have                                                               
discussions  as they  do  not do  quite as  well  with a  written                                                               
survey.  Another question he might  ask is for the parent to give                                                               
him  three words  that describes  their child.   In  the event  a                                                               
parent can't  think of three  nice words to describe  their child                                                               
and all three  of the words have some sort  of explicative in it,                                                               
he  becomes nervous  that  the family  is  not functioning  well.                                                               
This family may  need outside help to raise their  children in an                                                               
effective environment, he said.                                                                                                 
2:23:47 PM                                                                                                                    
DR. HIRSCHFELD turned  to slide 16, "Help Me  Grow" and explained                                                               
that  a  problem he  has  with  getting  providers to  use  these                                                               
screening tools  is that there is  not an easy way  for providers                                                               
to  refer families  to help,  and this  is a  big deal.   If  the                                                               
provider is  trying to  see 25-35  patients a  day and  there are                                                               
numerous yes answers on one  of the screening tools, the provider                                                               
oftentimes does  not have a  lot of  time to spend  going through                                                               
all of the  different services available in Alaska  to help these                                                               
families get healthier.  He explained  that one of things the All                                                               
Alaska  Pediatric Partnership  is doing  in conjunction  with the                                                               
Maternal and  Child Health  Section of the  state, is  building a                                                               
referral system called "Help Me  Grow" which will allow providers                                                               
an easy  way to get families  help.  Help Me  Grow was originally                                                               
developed  in  Connecticut and  it  is  now in  approximately  26                                                               
states and basically, through a  single telephone number a family                                                               
can call  in, talk to a  case manager, and the  case manager will                                                               
help  that family  work  through the  paperwork,  travel, find  a                                                               
place  the family  can be  seen,  and basically,  get the  family                                                               
connected with services that can help  the family.  A problem for                                                               
many families  is that they  are not functioning well  in raising                                                               
their children,  and it's hard  for them to function  well enough                                                               
to  get  access to  services.    He  advised that  case  managers                                                               
associated with  the Help Me  Grow Program walk  families through                                                               
this and actively help them access  services.  It's not a passive                                                               
system,  he described,  and they  actually  help these  families'                                                               
access services through a centralized  telephone number.  It is a                                                               
great way for  providers to get these families help  that is easy                                                               
and  Help Me  Grow loops  back to  the provider  so the  provider                                                               
knows that  the families  are accessing  the services  they need.                                                               
He explained  that, currently,  this program  is in  the building                                                               
stage,  and  they  are  hoping  to  launch  the  program  in  the                                                               
Anchorage, Mat-Su area sometime in  the fall or early winter this                                                               
year as  a trial.   There  are many data  components to  this and                                                               
over time  they will see whether  it makes a major  effect on how                                                               
providers  interact  with  families  to  screen  for  bad  things                                                               
happening to them, he said.                                                                                                     
2:26:22 PM                                                                                                                    
DR. HIRSCHFELD  turned to slide  17, "Care  Coordinators provide"                                                               
and advised that the slide  summarizes his comments regarding the                                                               
care  coordinators,  who are  advocates  in  doing assessment  of                                                               
needs,  follow up,  link families  into services,  and more.   He                                                               
said he  has seen  this in action  in Orange  County, California,                                                               
and they  are next going to  South Carolina to see  it in action.                                                               
He  described  it as  an  inspiring  program that  families  love                                                               
because it makes  it easy for them to access  these services, and                                                               
providers  love it  because  it is  easy for  them  to get  their                                                               
families in.                                                                                                                    
DR. HIRSCHFELD  turned to slide  18, "What Can Policy  Makers and                                                               
Funders Do?" and  acknowledged that these are  tight budget times                                                               
and  there is  no  money asked  here, but  in  moving forward  to                                                               
contemplate how  to make Alaska  healthier by  decreasing adverse                                                               
childhood experiences.   He  said he  ponders what  policy makers                                                               
and funders can do, and what  voters can advocate for, and one of                                                               
the things  currently not  being is  the screening  he previously                                                               
discussed.  In  the event the state can get  Medicaid and private                                                               
insurance  companies to  cover screening  for those  families, it                                                               
would greatly  increase screening performed by  providers because                                                               
it does  take time to  go through the  written forms and  talk to                                                               
families about them.  Another  benefit, he suggested, would be to                                                               
support the  development of programs such  as Help Me Grow.   The                                                               
program  has  been  shown  in  every state,  where  it  has  been                                                               
implemented,  to  improve  family wellness  and  decrease  system                                                               
costs.   It makes families  healthier and they access  the health                                                               
system much less so it decreases Medicaid costs, he said.                                                                       
2:28:12 PM                                                                                                                    
DR. HIRSCHFELD advised that another  benefit is to preferentially                                                               
support organizations  and programs  focusing on  intervention in                                                               
early childhood.   He advised that  Representative Tarr sponsored                                                               
HCR  21  that basically  supports  any  program supporting  early                                                               
childhood, and  it is  a huge program  that All  Alaska Pediatric                                                               
Partnership supports.   He described  it as  a great step  in the                                                               
process of getting  early childhood on the radar  for everyone in                                                               
government because, he stressed, that  is where there will be the                                                               
most effect to  improve the health of Alaska's  population in the                                                               
next generation.                                                                                                                
2:28:46 PM                                                                                                                    
DR. HIRSCHFELD  turned to slides 19  and 20, "What if  we Reduced                                                               
Alaska's  ACE Score  by  1/2 Point"  and  "Reducing Alaska's  ACE                                                               
Score by 1/2"  respectively, and advised that  Mr. Sidmore looked                                                               
what would happen  if Alaska's ACE score was  reduced by one-half                                                               
point.  He then offered a  scenario that the average ACE score in                                                               
Alaska is 5, and  if it is decreased to 4.5  what would happen to                                                               
costs  in Alaska.    He  then referred  to  the  next slide,  and                                                               
advised that Mr. Sidmore looked at  six of the diseases listed on                                                               
slide 6,  obesity rates, number  of adults on  Medicaid, smoking,                                                               
binge  drinking,  diabetes,  and  arthritis.   In  the  event  of                                                               
decreasing the ACE  score by one-half point what  would happen to                                                               
the above  diseases, how many  would not smoke, binge  drink, not                                                               
be  on adult  Medicaid because  they had  a healthier  childhood.                                                               
Essentially,   Mr.  Skidmore   showed  that   Alaska  will   save                                                               
approximately $90 million  annually, and that is  only looking at                                                               
the  above six  problems.   He  described $90  million  as a  low                                                               
number relative to all health in Alaska.                                                                                        
2:30:16 PM                                                                                                                    
DR. HIRSCHFELD turned to slide 21,  "What Does $90 Million Buy In                                                               
Alaska?"  and  noted the  slide  depicts  various items  such  as                                                               
homes,   kindergarten  teachers,   police  officers,   mechanical                                                               
engineers,  pediatricians, OCS  operations,  Medicaid costs,  and                                                               
DR.  HIRSCHFELD turned  to slide  22,  "If Alaska  Had ACE  Rates                                                               
Similar  to  Arkansas  and Vermont  the  Estimated  Reduction  in                                                             
Number  of  Alaskan Adults  for  Each  Category of  Economic  and                                                               
Educational Outcome" and advised  that the slide depicts specific                                                               
decreases for people in Alaska  if they decreased their ACE score                                                               
by one-half percent.                                                                                                            
DR.  HIRSCHFELD turned  to slide  23,  "If Alaska  had ACE  Rates                                                               
Similar  to  Arkansas  and Vermont  the  Estimated  Reduction  in                                                             
Number of Alaskan  Adults for each Category  of Behavioral Health                                                               
Outcome"  and noted  that the  number of  people with  depression                                                               
would  decrease by  9,375 Alaskans,  insufficient sleep  by 5,195                                                               
Alaskans, frequent  mental distress by 4,478  Alaskans, and heavy                                                               
drinking by  1,464 Alaskans.   He described these as  big numbers                                                               
in a  state as small as  Alaska, and further described  this is a                                                               
significant  proportion of  the population.   By  decreasing ACEs                                                               
and  getting families  with young  children the  help they  need,                                                               
there can  be a  big change  in many of  the health  outcomes, he                                                               
DR.  HIRSCHFELD turned  to slide  24,  "If Alaska  had ACE  Rates                                                               
Similar  to  Arkansas  and Vermont  the  Estimated  Reduction  in                                                             
Number of  Alaskan Adults  for each  Category of  Food Insecurity                                                               
Outcome"  and advised  it refers  to people  who were  hungry and                                                               
didn't  have  any  food.    That  number  will  be  decreased  by                                                               
approximately 10,103  Alaskans, and  the people  using government                                                               
food programs will decrease by 5,549 Alaskans.                                                                                  
2:32:18 PM                                                                                                                    
DR.  HIRSCHFELD turned  to slide  25, "In  the brain,  as in  the                                                               
economy,  getting it  right  the first  time  is ultimately  more                                                               
effective and  less costly  than trying  to fix  it later."   Dr.                                                               
Hirschfeld  explained  that James  Heckman  is  a Nobel  Laureate                                                               
Economist and  he looked at a  number of different ways  to think                                                               
about  early childhood  development  and brain  development.   He                                                               
then read Mr. Heckman's quote, as follows:                                                                                      
     In the brain, as in the economy, getting it right the                                                                      
        first time is ultimately more effective and less                                                                        
     costly than trying to fix it later.                                                                                        
DR.  HIRSCHFELD continued  that this  ACE data  is all  about the                                                               
current generation  and; therefore, 20  years from now  the state                                                               
doesn't  have to  build more  prisons, build  more of  a juvenile                                                               
justice system,  or hire more police.   The goal is  for the next                                                               
generation  to be  much healthier  and save  costs in  Alaska, he                                                               
DR. HIRSCHFELD turned to slide 26, offering his services.                                                                       
2:33:28 PM                                                                                                                    
CHAIR  SEATON referred  to slide  6, and  noted that  the various                                                               
diseases  have also  been linked  to low  Vitamin D  levels.   He                                                               
advised   that   the  committee   should   be   looking  at   the                                                               
relationships and causal characteristics  being included as well.                                                               
This  committee has  reviewed  studies from  all  over the  world                                                               
connecting some of those things, he advised.                                                                                    
DR. HIRSCHFELD  agreed, and said if  a person has 10  yes answers                                                               
to those  questions, it is not  100 percent that the  person will                                                               
have heart disease  as it is a complex disease  and etiology.  He                                                               
explained, there is just an  increased risk for developing all of                                                               
these things  as the ACE score  goes up.  He  expressed that this                                                               
is not  a one-to-one relationship  and reiterated, it is  just an                                                               
increased risk as the yes answers go up.                                                                                        
CHAIR SEATON  noted that  what has been  interesting is  that the                                                               
committee has  looked at ACEs over  a period of time  and what to                                                               
do about  the scores,  yet there have  not been  many suggestions                                                               
policy-wise   and   that    he   appreciates   Dr.   Hirschfeld's                                                               
2:35:30 PM                                                                                                                    
REPRESENTATIVE  WOOL referred  to  this  presentation and  others                                                               
where  scores are  taken and  there are  correlations with  other                                                               
illnesses  or lifestyles.    At the  end the  day,  he said,  the                                                               
committee is  told that if  the score goes  down a point  or one-                                                               
half point, all  of these other things will go  away.  Obviously,                                                               
he said, the score is  just an assessment, and lowering someone's                                                               
score is a  complex societal lifestyle problem with  not just one                                                               
curative prescription because these are complex solutions.                                                                      
DR.  HIRSCHFELD agreed,  and he  said that  lowering it  one-half                                                               
point makes  it sound  easy but  it is  incredibly complex  to do                                                               
that.   He explained that  a lot of  it will be  improving access                                                               
for  families  into services  that  help  them, such  as  alcohol                                                               
abuse, smoking cessation,  programs that teach parents  how to be                                                               
better  parents, and  the ability  to access  those programs  and                                                               
develop those programs so families can  get the help they need to                                                               
solve  the problems  they are  exposing  their children  to.   He                                                               
expressed, it  is an  extremely complex problem  and it  is money                                                               
upfront to save money in the future  when the state is in a tough                                                               
fiscal environment.   Representative  Wool was  entirely correct,                                                               
he stressed,  dialing it down  one-half point sounds easy  but it                                                               
is not even a little easy.                                                                                                      
2:37:21 PM                                                                                                                    
CHAIR  SEATON  surmised  that  dialing  it  down  one-half  point                                                               
doesn't mean that  he is changing any adult, if  they are adverse                                                               
childhood  experiences  it means  how  many  a child  had  during                                                               
childhood.  Therefore,  he said, the discussion  is prevention on                                                               
new children to Alaska.                                                                                                         
DR. HIRSCHFELD agreed,  and he related that this  effect won't be                                                               
seen  for 20  years  until those  children ...  the  goal of  the                                                               
change is to change the zero to  3 year old ACE scores right now.                                                               
By  the time  those children  are old  enough that's  where there                                                               
will  be a  decrease in  healthcare costs  and behavioral  health                                                               
costs, and others, he said.                                                                                                     
CHAIR  SEATON referred  to slide  16,  "Help Me  Grow" and  asked                                                               
whether they are family functioning tools or assessments.                                                                       
DR.  HIRSCHFELD   explained  that  currently,  it   is  hard  for                                                               
providers, families, and other people  in the state to keep track                                                               
of what is available to help  families.  For example, a family is                                                               
screened in  at the  pediatric practice and  it is  revealed they                                                               
are homeless.   As a  provider, he does not  have a great  way to                                                               
obtain help for  this family so Help Me Grow  allows the provider                                                               
to give  the family a  centralized telephone number  wherein that                                                               
family can call the organization,  explain their problem, and the                                                               
family will  be assigned a  case manager  who then links  them to                                                               
the appropriate services  to help them find a place  to live.  He                                                               
explained that it  is not providing direct service, it  is a link                                                               
between the family  and the services to make  that access easier.                                                               
He  related that  one  of  the hardest  things  for families  not                                                               
functioning well is  that it is hard for them  to access services                                                               
due to  the paperwork, travel, and  time.  The Help  Me Grow case                                                               
managers streamline  that process  for the  families so  they can                                                               
receive the  services they need.   Help Me Grow does  not provide                                                               
services, he  reiterated, it links families  with the appropriate                                                               
services in an  active management manner so the  families can get                                                               
the help they need.                                                                                                             
2:40:01 PM                                                                                                                    
CHAIR SEATON  referred to slide  17, "Care  Coordinators provide"                                                               
assessment of needs and referral  to services, care coordination,                                                               
and more, and he noted the  project "Protect Our Children Now" is                                                               
contained within the Medicaid reform  bill that was passed out of                                                               
this  committee.   He  pointed  out  that  it provides  not  only                                                               
nutrition but  also counseling.   He offered  that he  is hopeful                                                               
that Dr.  Hirschfeld will visit  with Dr.  Wagner while he  is in                                                               
South Carolina, and  let the committee know of  his assessment of                                                               
the program  Dr. Wagner is conducting,  and how it is  working in                                                               
South Carolina.                                                                                                                 
DR. HIRSCHFELD said he would do that.                                                                                           
CHAIR SEATON  referred to  slide 18, and  what policy  makers and                                                               
funders can do  from the Medicaid standpoint.  He  noted that Dr.                                                               
Hirschfeld  has  some  care  coordination  models  and  he  would                                                               
appreciate those coming forward  together with any suggestions he                                                               
may have.                                                                                                                       
The ACEs presentation was concluded.                                                                                            
        HCR 21-RESPOND TO ADVERSE CHILDHOOD EXPERIENCES                                                                     
2:42:11 PM                                                                                                                    
CHAIR SEATON announced  that the next order of  business would be                                                               
HOUSE CONCURRENT  RESOLUTION NO. 21, Urging  Governor Bill Walker                                                               
to  join with  the Alaska  State  Legislature to  respond to  the                                                               
public  and  behavioral  health  epidemic  of  adverse  childhood                                                               
experiences  by establishing  a  statewide  policy and  providing                                                               
programs to address this epidemic.                                                                                              
2:42:40 PM                                                                                                                    
The committee took an at-ease from 2:42 p.m. to 2:43 p.m.                                                                       
2:43:26 PM                                                                                                                    
REPRESENTATIVE  TARR offered  a  PowerPoint presentation  titled,                                                               
"Adverse  Childhood Experience,"  [referred  to  slides 1-9]  and                                                               
reminded the  committee that these  issues had been  discussed in                                                               
committee   previously.     She  noted   that  Dr.   Hirschfeld's                                                               
presentation  discussed  the  origins   of  the  ACEs  study  and                                                               
developing an ACEs  score and she said she would  skip over those                                                               
topics.   Previously, members had  been asked to take  their ACEs                                                               
score and  pointed out that in  asking people to take  their ACEs                                                               
score it rises awareness and  assists in understanding the issues                                                               
better.   Key findings within  the Alaska work is  that childhood                                                               
trauma is far more common, it  lasts over a lifetime, and impacts                                                               
generations.  Research has shown  that approximately $1.4 billion                                                               
is spent every  year in Alaska on substance  abuse related issues                                                               
from treatment  to the court  system to law enforcement,  and she                                                               
referred to  Dr. Hirschfeld's presentation regarding  some of the                                                               
cost  reductions that  can be  associated with  reducing Alaska's                                                               
ACEs scores.                                                                                                                    
REPRESENTATIVE  TARR   explained  that   HCR  21  calls   on  the                                                               
legislature  and the  governor to  work  together to  do more  on                                                               
policy level changes.  Last  year, the legislature worked hard on                                                               
Erin's Law  and Bree's  Law, and  the legislature  discussed ACEs                                                               
through  those  bills.    She then  stressed  the  importance  of                                                               
keeping  that   conversation  going   this  year,  to   keep  the                                                               
conversation going as  more awareness needs to  be developed with                                                               
education and  some of  this can  be done  without funding.   She                                                               
pointed to  slides 6-9, and  advised that  these are some  of the                                                               
opportunities  for prevention,  and that  during the  interim the                                                               
committee  will  continue  looking  at policy  alternative.    In                                                               
working through the implementation of  Erin's Law and Bree's Law,                                                               
she wants to  make sure the legislature is part  of the effort to                                                               
build a  statewide network of  people concerned about  the issues                                                               
and come together.                                                                                                              
2:45:57 PM                                                                                                                    
REPRESENTATIVE TARR advised there are  27 letters of support from                                                               
organizations  across the  state, such  as the  Children's Trust,                                                               
Suicide   Prevention   Council,   Mental   Health   Board,   Best                                                               
Beginnings,  and  also   approximately  200  hundred  individuals                                                               
signed petitions  from different  early learning  conferences she                                                               
attended, from the Dr. Felitti event,  and from the "Go Blue Day"                                                               
Child  Abuse Prevention  rally  yesterday.   In  bringing all  of                                                               
these  groups together,  she  noted  that her  hope  is to  bring                                                               
together  a network  of people  to determine  that it  isn't just                                                               
about spending more  money on something, but more  about having a                                                               
deeper  understanding  of these  ACEs  issues,  and its  impacts.                                                               
ACEs  is about  connecting the  dots  and within  the letters  of                                                               
support  there are  individuals working  on mental  health, early                                                               
learning,   substance  abuse,   or   suicide   prevention.     In                                                               
understanding  ACEs it  brings a  new opportunity  for connecting                                                               
the dots  between the negative  health outcomes and  looking back                                                               
at  the  origins  and  determining  what  the  origins  of  those                                                               
problems are.                                                                                                                   
REPRESENTATIVE  TARR  referred  to  an additional  slide  in  the                                                               
committee  packets  from  the All  Alaska  Pediatric  Partnership                                                               
regarding  ACEs  accumulation  and  read,  "Young  Alaskans  have                                                               
acquired HALF  of their accumulated ACEs  by the age of  3."  She                                                               
explained  that  it  speaks  to   the  importance  of  the  early                                                               
intervention   programs.       As   Dr.   Hirschfeld   discussed,                                                               
pediatricians and  other health  care providers can  be frontline                                                               
in that effort, and she added  that early education folks such as                                                               
Best  Beginnings are  working on  early education.   There  was a                                                               
time it was believed there was  a protected wall around the fetus                                                               
and that the  mother smoking and drinking was okay.   It was also                                                               
believed that  children in the pre-verbal  times were unimpressed                                                               
by things,  and that  events could be  happening around  them and                                                               
there wasn't a big impact.   To put this in context, she related,                                                               
the study  referenced was  published in  1989, and  when thinking                                                               
about how recent that's been for  people to learn about that data                                                               
and  then start  doing their  own research,  there really  hasn't                                                               
been an opportunity to implement  it into the state's policies in                                                               
a manner  that can  be implemented to  have a  tremendous impact.                                                               
This slide shows that a lot of  the bad stuff is happening at the                                                               
time people  previously believed  children would not  be impacted                                                               
by the  behaviors around them,  or even  be aware of  violence or                                                               
substance abuse, she said.                                                                                                      
2:49:23 PM                                                                                                                    
REPRESENTATIVE TARR  related that  building awareness is  part of                                                               
the  effort  that  can  be accomplished  without  funding  a  new                                                               
program,  and  through the  efforts  this  month of  child  abuse                                                               
prevention  and organizations  hosting many  different activities                                                               
sharing  information and,  hopefully, get  more people  involved.                                                               
Working with  educators and practitioners  and the  government in                                                               
creating policy alternatives is the next step, she remarked.                                                                    
2:49:56 PM                                                                                                                    
REPRESENTATIVE  FOSTER   expressed  his   support  and   that  he                                                               
appreciated  Dr. Hirschfeld's  presentation and  learning of  his                                                               
efforts in his practice in Nome  as it makes it more tangible for                                                               
REPRESENTATIVE TARR related that  these are long term investments                                                               
and as  Dr. Hirschfeld related,  within every step along  the way                                                               
the state has  opportunities to work with children  when they are                                                               
in school, and  that there are screening tools  when meeting with                                                               
families.  One  big opportunity is just in  changing the language                                                               
when  there is  a  child  with behavioral  problems.   The  child                                                               
acting out is  not asked what is wrong with  them, but rather the                                                               
child is asked what happened to  them.  Things like this give her                                                               
hope  and that  even  without  a lot  of  funding, moving  toward                                                               
something  where   most  of  it   is  simply   understanding  the                                                               
opportunities, and  the different places  that can be  engaged in                                                               
sharing this information.                                                                                                       
CHAIR SEATON  noted his appreciation  for both  presentations and                                                               
that he  found Dr. Hirschfeld's  comments interesting  because he                                                               
was  unsure  how much  the  medical  community and  quasi-medical                                                               
community   had  been   involved   with  those   types  of   care                                                               
coordination efforts with  families.  He related that  it is good                                                               
to hear  that they  are not  just looking at  the child,  but the                                                               
situation the child is in.                                                                                                      
2:52:20 PM                                                                                                                    
REPRESENTATIVE  FOSTER  moved  to  report  HCR  21,  labeled  29-                                                               
LS1398\A out  of committee  with individual  recommendations with                                                               
no fiscal notes.                                                                                                                
CHAIR SEATON  objected for  discussion and  read into  the record                                                               
the language on page 3, lines 14-22, as follows:                                                                                
          BE IT RESOLVED that the state's policy decision                                                                     
     acknowledge  and take  into account  the principles  of                                                                    
     early   childhood  brain   development  and,   whenever                                                                    
     possible, consider the concepts  of toxic stress, early                                                                    
     adversity, and buffering relationships, and be it                                                                          
          FURTHER RESOLVED that early intervention and                                                                        
     investment  in  early  childhood  years  are  important                                                                    
     strategies to  achieve a lasting foundation  for a more                                                                    
     prosperous and  sustainable state through  investing in                                                                    
     human capital; and be it                                                                                                   
          FURTHER RESOLVED that the Governor join with the                                                                    
     Alaska State  Legislature and  address the  presence of                                                                    
     adverse  childhood  experiences  as  factors  for  many                                                                    
     societal  issues and  to  fund  research for  statewide                                                                    
CHAIR SEATON opened public testimony                                                                                            
2:52:20 PM                                                                                                                    
TREVOR STORRS, Executive Director,  Alaska Children's Trust, said                                                               
the  Alaska Children's  Trust  is focused  on  the prevention  of                                                               
childhood  abuse  and  neglect.    He  related  that  the  Alaska                                                               
Children's  Trust  is  also partnering  with  groups  around  the                                                               
concept of reducing trauma and  building resiliency in the child,                                                               
the  family, and  the community.   He  noted that  what has  been                                                               
presented today  is a complex  issue and what the  committee does                                                               
with this information  is not about enacting  one specific thing,                                                               
but it is  the framework to help promote the  concept of reducing                                                               
trauma  adversity to  not only  the  child, but  a community  and                                                               
cultures within  Alaska.   When these  issues are  addressed, not                                                               
only  does  it  save  money,   it  builds  communities  that  can                                                               
withstand trauma which  is a natural part of the  circle of life,                                                               
but child abuse and neglect are  not a natural part of the circle                                                               
of life.   It is resiliency  that glues that circle  together and                                                               
the role  of the community is  to be certain the  glue being used                                                               
is the strongest and best glue so everyone benefits, he said.                                                                   
REPRESENTATIVE TARR asked  Mr. Storrs to send  information to the                                                               
committee members about the Resiliency Initiative.                                                                              
MR. STORRS agreed.                                                                                                              
2:56:37 PM                                                                                                                    
DON  ROBERTS described  himself  as an  adult  survivor of  these                                                               
adverse   childhood  experiences   and   in   listening  to   the                                                               
presentations  he noted  that  the system  tends  to forget  that                                                               
there are  many adults dealing with  this in their lives  with no                                                               
resources available to them.  He  agreed that the programs can be                                                               
initiated, but  they are for children  and families and he  is 58                                                               
years old.  He took the ACEs test  and had a score of 7, although                                                               
it would  have been  higher if  it asked  a few  other questions.                                                               
Adult programs need to be integrated  so when adults get into the                                                               
system they are  not just sidelined due to no  services out there                                                               
because the  legislature didn't put  it in,  he related.   Due to                                                               
his  adverse   childhood  experiences,  having   intimate  family                                                               
relationships is  troublesome because he  doesn't want to  be the                                                               
kind of parents  he had where basically his  childhood was filled                                                               
with  anger and  violence.    He opined  that  this  needs to  be                                                               
included in the  legislation.  There are other  services, such as                                                               
peer  support  services that  are  not  necessarily part  of  the                                                               
mainstream clinical experience people should  be able to use and,                                                               
he opined,  peer support  services are  often given  short shrift                                                               
when they  tend to be far  more effective in helping  people deal                                                               
with these issues in their lives.                                                                                               
CHAIR SEATON offered  support for his testimony  and related that                                                               
there  is  definitely no  one  point  in which  addressing  these                                                               
issues can be stopped.                                                                                                          
3:00:28 PM                                                                                                                    
PATRICK  ANDERSON,  Senior  Research  Fellow,  Sealaska  Heritage                                                               
Institute, said  he is a  Senior Research  Fellow in the  area of                                                               
childhood trauma and health restoration,  and has been engaged in                                                               
research and advocacy around  adverse childhood experiences since                                                               
2008  when he  was  the  CEO of  an  Alaska  Native Rural  Health                                                               
System.  As a consequence of his  advocacy he is a member of both                                                               
the  American Indian  and  Alaska Native  Task  Force on  suicide                                                               
prevention  and  president  of  the  Native  American  Children's                                                               
Alliance  (NACA), assisted  in the  drafting of  this resolution,                                                               
and that his ACEs score is  6.  He described the understanding of                                                               
the  existence of  real and  identifiable childhood  trauma being                                                               
linked to adult health and  negative behaviors as an exciting new                                                               
arena of  public policy.   He then  referred to  Dr. Hirschfeld's                                                               
presentation and said that if  childhood trauma can be identified                                                               
early in a  child's life it can be addressed  before it becomes a                                                               
true  problem  and  prevention  becomes  a  real  option  because                                                               
parents can be  taught how to avoid the behaviors  that cause the                                                               
development  of this  trauma in  children.   He  referred to  the                                                               
perception   that  the   resolution  addresses   early  childhood                                                               
prevention only,  but that was  not the  intent.  He  referred to                                                               
HCR 21, page 3, lines 14-16, which read:                                                                                        
          BE IT RESOLVED that the state's policy decision                                                                       
     acknowledge  and take  into account  the principles  of                                                                    
     early   childhood  brain   development  and,   whenever                                                                    
     possible, consider the concepts  of toxic stress, early                                                                    
     adversity, and buffering relationships, and bit it                                                                         
MR. ANDERSON pointed out that  it is directed toward adult health                                                               
and  behaviors as  well as  early  children's brain  development,                                                               
health, and behaviors.  He advised  he has spent the last four or                                                               
five years  looking for a  systemic approach that  addresses both                                                               
the parenting generation's behaviors  and children's behaviors in                                                               
a family  and community  context.  Mr.  Anderson opined  that the                                                               
goal  is  to  introduce  a program  that  effectively  identifies                                                               
behaviors early enough to begin  the healing process.  Within the                                                               
City of  Nome, where Dr.  Hirschfeld practices, there has  been a                                                               
discussion in  the last few  years around ACEs that  has advanced                                                               
to  the  point  of  serious consideration.    During  the  recent                                                               
convention  of   the  National  Congress  of   American  Indians,                                                               
presentations  were  offered on  the  topic  including a  plenary                                                               
presentation by  Dr. Vincent  Felitti.   Tribal groups  in Alaska                                                               
have started the process of  understanding and using ACEs and are                                                               
following  examples  from  the  lower-48.   Dr.  Ann  Bullock  is                                                               
employed by  an Indian tribal  health system  addressing diabetes                                                               
through programs  that identified and treated  traumatic or toxic                                                               
stress.   Dr. Donald  Warne is an  American Indian  physician who                                                               
has  been  active  through the  Great  Plains  Tribal  Chairman's                                                               
Health Board in addressing ACEs and  there are many other who are                                                               
following their lead.                                                                                                           
MR. ANDERSON  referred to the  Behavior Risk  Factor Surveillance                                                               
System (BRFSS)  and emphasized  that Alaska Natives  have a  4 or                                                               
more  ACEs at  a rate  which is  almost double  that of  the non-                                                               
Native population according  to BRFSS.  As a result,  many of the                                                               
Alaska  Native  communities  view  this area  as  a  priority  to                                                               
address.    When  Dr.  Felitti  was  in  Juneau,  they  took  the                                                               
opportunity  to  meet  with   Governor  Bill  Walker,  Lieutenant                                                               
Governor  Byron  Mallott,  Commissioner   Dean  Williams  of  the                                                               
Department  of  Corrections,  and  Jay Butler  the  Alaska  Chief                                                               
Medical Officer.   They  briefed Governor  Walker on  this issue,                                                               
made him aware  of the legislation, and asked  Governor Walker to                                                               
support it.   Mr. Anderson opined that this  resolution has great                                                               
potential for  encouraging a wider  discussion of ACEs  in Alaska                                                               
and  if  it  leads  to more  programing  to  address  prevention,                                                               
earlier intervention,  and healing that  would be fantastic.   He                                                               
then asked  that the committee pass  HCR 21 out of  committee and                                                               
encouraged the adoption of the resolution by the legislature.                                                                   
3:05:58 PM                                                                                                                    
MAUREEN HALL, School Nurse, said she  is a school nurse in Juneau                                                               
and  she fully  supports this  resolution because  [nurses] daily                                                               
see children on  the frontline in their offices.   These children                                                               
typically have a  high ACEs score, and are seen  most often which                                                               
carries  over into  adult  medicine when  they  leave the  school                                                               
setting.  These individuals, she  said, are the heaviest users of                                                               
the health  care system,  are most apt  to have  poor educational                                                               
outcomes, and end  up engaging with the  criminal justice system.                                                               
As far  as the savings being  20 years down the  road, she argued                                                               
that the  savings will be  immediate because those  children will                                                               
not be as sick as their peers  when they have a lower ACEs score.                                                               
It will prevent a lot of  the adversity and they'll be healthier,                                                               
and be  better able  to learn once  they do get  to school.   She                                                               
pointed  out   that  this  is  important   in  raising  awareness                                                               
throughout  our state,  and she  would like  every school  in the                                                               
state  become  a trauma  informed  school,  as well  as  Alaska's                                                               
communities.   By every police officer  and teacher understanding                                                               
how  the  adverse  childhood experiences  affect  a  person,  she                                                               
opined  that  it  would  go  a long  way  toward  preventing  and                                                               
increasing awareness, and helping  that person be more successful                                                               
down the road.                                                                                                                  
CHAIR SEATON  removed his objection.   There being  no objection,                                                               
HCR 21,  Version 29-LS1398\A, with  no fiscal notes,  passed from                                                               
the  House   Health,  Education  and  Social   Services  Standing                                                               
^Presentation: Citizen Review Panel                                                                                           
               Presentation: Citizen Review Panel                                                                           
3:08:38 PM                                                                                                                    
CHAIR SEATON announced that the  final order of business would be                                                               
a presentation by the Citizen Review Panel (CRP).                                                                               
DR. DIWAKAR  VADAPALLI, Chair,  Citizens Review  Panel, Institute                                                               
of Social and Economic Research,  Professor, University of Alaska                                                               
Anchorage, said he is an  assistant professor of public policy at                                                               
the  Institute of  Social  and Economic  Research  (ISER) at  the                                                               
University  of Alaska  Anchorage.   He turned  to slides  1-3 and                                                               
explained the makeup of the  panel, the presentation outline, and                                                               
the  panel's federal  and state  mandates.   The Citizens  Review                                                               
Panel's (CRP) mandate  is to evaluate the  policies and practices                                                               
of  what translates  in Alaska  to  be the  Office of  Children's                                                               
Services  (OCS)  from a  community  perspective,  and to  perform                                                               
public outreach in the process.                                                                                                 
3:11:00 PM                                                                                                                    
DR. VADAPALLI turned to slides  4-7, and advised that the primary                                                               
functions of the  Citizens Review Panel (CRP) is  to evaluate OCS                                                               
against its own  5 year Child Abuse Prevention  and Treatment Act                                                               
(CAPTA), some  federal and state child  protection standards, and                                                               
any other criteria  the panel considers important.   The panel is                                                               
also  required to  conduct  public outreach  both  to inform  the                                                               
public of child  protection policies and procedures,  and also to                                                               
collect input  on these policies  from stakeholders.   Throughout                                                               
the state there are five  regional OCS offices, 19 field offices,                                                               
and  500  employees  of  which 283  are  frontline  workers  with                                                               
approximately  32 percent  of these  workers  turning over  every                                                               
year,  and its  operating budget  is approximately  $150 million.                                                               
At this  point, he said, it  would be meaningful to  consider the                                                               
tasks  the  panel is  asked  to  perform,  the resources  at  its                                                               
disposal to  operate at a  $100 thousand annual budget,  and that                                                               
the  panel members  donate an  average  of approximately  300-400                                                               
hours  each year.   He  acknowledged that  these as  tight budget                                                               
times for  the state, and that  in FY2016 the panel's  budget was                                                               
cut by $18 thousand yet the work  remains the same.  The CRP does                                                               
not   do  the   following:   comment  on   proposed  or   pending                                                               
legislation;  get involved  in  individual  cases, contracts,  or                                                               
situations;  micromanage  the  OCS  operations,  conduct  program                                                               
evaluations, and lobby.  Over the  last couple of years the panel                                                               
worked hard to analyze its  calendar to streamline the work flow,                                                               
and during the  last year it conducted three  public meeting site                                                               
visits  with  numerous  interviews,  met  every  month  with  OCS                                                               
leadership, presented its annual  report to various stakeholders,                                                               
and attended the CRP National Conference.                                                                                       
3:16:08 PM                                                                                                                    
DR.  VADAPALLI  turned  to slide  8,  "Recommendation  1:  Intake                                                               
Policy" and  advised that each year  the panel begins with  a set                                                               
of goals,  and each  goal relates  to one  or more  components of                                                               
OCS's practice  model or  operations.  Each  goal is  explored on                                                               
both  the policy  front and  practice  front, and  it notes  gaps                                                               
between stated policy  and current practice.   In addition, there                                                               
are many  things the  panel follows,  and a  few things  it comes                                                               
across that are  either OCS initiatives or  concerns from others.                                                               
The  recommendations  within the  annual  report  are based  upon                                                               
these additional  issues of  interest to the  panel.   He advised                                                               
that the next few slides  include all of the recommendations from                                                               
the panel from last year,  and within the accompanying letter the                                                               
panel submitted  to the committee,  it summarized  OCS's response                                                               
to each of the recommendations.                                                                                                 
3:17:49 PM                                                                                                                    
CHRISTY LAWTON,  Director, Central  Office, Office  of Children's                                                               
Services, Department of Health and  Social Services, said she was                                                               
available for questions.                                                                                                        
3:17:57 PM                                                                                                                    
DR. VADAPALLI  returned to  slide 8,  and pointed  out it  is the                                                               
first recommendation of  the panel last year, and  that the panel                                                               
examined specific  intake policies for two  years in a row.   The                                                               
panel  chose this  goal because  during  the course  of its  site                                                               
visits,  individuals commented  that children  are being  left in                                                               
unfit conditions  because a  large number  of cases  are screened                                                               
out combined with  the high turnover of  frontline workers, which                                                               
makes the screening process burdensome  and unpredictable.  After                                                               
examining  the policy  and  practice of  intake,  the panel  made                                                               
several recommendations and OCS  accepted all recommendations and                                                               
OCS  is  in   the  process  of  implementing   several  of  them.                                                               
Currently, OCS intake is in  transition from a regional structure                                                               
to a central structure with all  calls fielded by a smaller group                                                               
of centrally  located workers.   The panel was informed  that OCS                                                               
is waiting on a manager being hired to direct the operations.                                                                   
CHAIR  SEATON referred  to  the change  to  opt-out of  receiving                                                               
follow  up   on  the   case,  and  asked   him  to   explain  the                                                               
DR. VADAPALLI  replied that the  panel noticed that  when someone                                                               
reports a  child is being  maltreated, the intake worker  was not                                                               
required to  ask the  reporter whether they  wanted to  know what                                                               
happened  in  response  to  their   report.    He  described  the                                                               
recommendation more as  an opt-in where the  reporter is required                                                               
to ask  whether the reporter would  like to be informed  of OCS's                                                               
response to  the report because many  individuals complained that                                                               
they reported over and over again  and nothing would happen.  The                                                               
OCS  related  that  that  is  a current  option,  and  the  panel                                                               
recommended  that there  should  be a  response  to the  reporter                                                               
unless the reporter opts-out and does not want a response.                                                                      
CHAIR SEATON asked  whether that policy is  being implemented now                                                               
and  whether  it  appears  to  be  more  effective  in  obtaining                                                               
community  support for  the program,  rather  than distrust  that                                                               
nothing happens after a report of a child's maltreatment.                                                                       
3:21:45 PM                                                                                                                    
MS. LAWTON  answered that OCS  believes that  recommendation will                                                               
assist  the general  public and  its large  majority of  mandated                                                               
reporters to  be clear  about what is  happening, because  it may                                                               
have  not been  clear that  that  option was  available in  prior                                                               
cases.   She noted  that some  of the  changes are  still pending                                                               
because  OCS is  bringing on  a manager  who will  oversee intake                                                               
operations and some  of the details are being worked  out, but it                                                               
is a positive change.                                                                                                           
REPRESENTATIVE TARR  referred to the  [third] bullet on  slide 8,                                                               
"Uniformly  implement  the  current  pilot project  of  having  a                                                               
supervisor reviewing cases after  10 screened-out PSRs" and asked                                                               
Ms. Lawton  to explain the pilot  project.  She pointed  out that                                                               
there  are  people who  frequently  report  that are  potentially                                                               
abusing reporting  due to ongoing  custody issues and  would like                                                               
to have a better understanding.                                                                                                 
MS. LAWTON responded  that during the last several  years OCS has                                                               
piloted several  new practices around  intake where  it escalates                                                               
reports  to   regional  managers   to  evaluate  whether   it  is                                                               
appropriate for  screen-out.   This is  looking at  the obviously                                                               
prior reports  OCS has received  and the likelier  potential that                                                               
new   reports  will   keep  coming   if  it   doesn't  intervene.                                                               
Certainly, over the years OSC  has heard complaints that it waits                                                               
too long to intervene, so OCS  started looking at that and trying                                                               
to ...  if they have  10 they are not  automatically screened-in,                                                               
it is just  getting another pair of  eyes to look at  them in the                                                               
context of the whole picture.   She advised that the division has                                                               
some pilot projects wherein it  is paying particular attention to                                                               
the zero  to 12  months, whether there  have been  prior reports,                                                               
whether there  is an infant in  the home, whether there  is going                                                               
to be  a screened-out  recommendation by  the intake  worker, and                                                               
those are  escalated as well.   The division is  still evaluating                                                               
how  well  these  various  pilots have  been  working  and  their                                                               
effectiveness  before implementing  a statewide  policy, although                                                               
much  of it  will be  implemented  because there  have been  some                                                               
positive changes.   She continued  that with the  additional sets                                                               
of  eyes reviewing  the report,  OCS believes  it is  intervening                                                               
with the  right families and at  the right time, which  is key to                                                               
avoiding repeat maltreatment in the future.                                                                                     
3:24:18 PM                                                                                                                    
REPRESENTATIVE WOOL  asked her to  describe what PSR  and screen-                                                               
out means.                                                                                                                      
MS. LAWTON  answered that the  PSR is Protective  Services Report                                                               
which is  what is  created when  a reporter  calls and  lodges an                                                               
allegation.   Those reports are then  screened-out or screened-in                                                               
and  each  time  a  reporter  calls  regardless  of  whether  OCS                                                               
believes it is  something to investigate, it is  documented and a                                                               
report is  created.   A decision  is then made  as to  whether it                                                               
meets the criteria for a  screened-in which will then generate an                                                               
investigation.   In the event it  is a screened-out, there  is no                                                               
further  follow  up,  and  no notification  to  the  family,  she                                                               
3:25:03 PM                                                                                                                    
DR.  VADAPALLI  turned to  slide  9,  "Recommendation 2:  In-Home                                                               
Services"  and  explained  that   in-home  services  has  been  a                                                               
challenge for  OCS for a  while, and  the panel has  noticed this                                                               
consistently over several  years.  Most alarmingly  two years ago                                                               
the panel found  that the in-home services workers  in one region                                                               
found the caseload humanly impossible,  and the panel reported it                                                               
last year.  Therefore, the  panel looked into in-home services to                                                               
determine where  the challenges lay,  and the graph on  the slide                                                               
shows the  percentage of in-home  and out-of-home cases  over the                                                               
period 2011-2014 broken down by OCS  region.  Within the last OSC                                                               
five year  plan, it identified a  goal to develop a  model of in-                                                               
home services for  rural areas, and that goal  continued into the                                                               
current  Child and  Family Services  Plan (CFSP).   Although,  he                                                               
said, OCS  has a clear goal  in its plan the  panel noticed there                                                               
were  no  clear outcomes  identified,  thereby,  being unable  to                                                               
assess whether  it made its  goal, or made  satisfactory progress                                                               
on  the goal.    The  panel recommended  that  OCS constitute  an                                                               
internal task  force to  address its  new in-home  services model                                                               
and identify specific measurable clear  outcomes so it can assess                                                               
periodically  on  the progress  being  made.   In  response,  OCS                                                               
indicated it wanted  to persist with the existing  model that its                                                               
(indisc.) new increased opportunities  for stakeholders to play a                                                               
meaningful  role  in  providing  home services.    Currently,  he                                                               
noted, the panel  has seen new developments on  the enrollment of                                                               
tribal  entities  in  providing  in-home  services.    The  panel                                                               
strongly  believes  that  identifying  additional  more  specific                                                               
measurable outcomes is certainly  important regardless of who the                                                               
service provider  is, whether  it is through  a contract,  or OCS                                                               
directly providing the services.                                                                                                
CHAIR SEATON  asked for an  explanation of  what the new  in home                                                               
services model is and what  services those are in relationship to                                                               
3:28:14 PM                                                                                                                    
MS. LAWTON replied  that typically in-home services  is viewed as                                                               
an opportunity to  work with a family less  formally than through                                                               
foster care.   When OCS  is working with  a family and  the child                                                               
remains in-home the  child could be in the  state's legal custody                                                               
but more  often than not  is not  in the state's  custody because                                                               
OCS had investigated and found  some concerns, wherein the parent                                                               
agrees they  are have a problem  but is willing to  work with OCS                                                               
to please  not take  custody of  their child.   In the  event the                                                               
parent is  truly motivated and  genuine in their efforts  and OCS                                                               
believes it  can keep the  child safe  in the home  while working                                                               
with  the parent,  OCS  will try  to open  the  case for  in-home                                                               
services  without having  to file  a  petition and  go to  court.                                                               
Currently, and what  OCS has done for many  years, she explained,                                                               
is that when a case is  opened for in-home services on an ongoing                                                               
basis, it is assigned to a  case worker similar to any other case                                                               
that is transferred  from the investigative worker  to an ongoing                                                               
family  services  worker.   The  struggle  OCS  has had  and  the                                                               
recommendation  from the  panel  over the  years,  is that  OCS's                                                               
model hasn't  been completely  successful, particularly  in rural                                                               
Alaska.   She related that the  challenge has been that  its case                                                               
workers  are trained  to be  more of  the middle  man, organizer,                                                               
coordinator of services, and are  not the direct service provider                                                               
in those  cases.  The case  workers do not provide  the parenting                                                               
classes, therapy for  the parent or child, they  don't go in-home                                                               
and do intensive family based  engagement because OCS trains them                                                               
to connect families  to resources.  In rural  Alaska, where there                                                               
are not many providers, the challenge  has been that OCS does not                                                               
have a mechanism  to train its staff to play  all of those roles.                                                               
It's been  a challenge, and  what OCS  is currently trying  to do                                                               
and what it  addressed in response to the  recommendation, is put                                                               
forth that perhaps OCS is not  the best suited to provide in-home                                                               
services due to the large portion  of crisis driven work that OCS                                                               
2:30:24 PM                                                                                                                    
MS.  LAWTON pointed  out that  typically  in-home services  takes                                                               
place between  the case worker  and the  family when there  is no                                                               
legal  involvement, thereby,  it does  not bring  in the  court's                                                               
oversight, the other  legal parties, and all of  the other people                                                               
that ensure  those cases move  forward.  Those families  often do                                                               
not  receive as  much attention  as  they need  because the  case                                                               
worker is  trying to meet the  demands of all of  the other cases                                                               
of children in  foster care.  The division believes  that some of                                                               
its  non-profit  social  services organizations  and  its  tribal                                                               
entities would be far better suited  to serve these families in a                                                               
less formal  intervention.  Also,  she commented,  those families                                                               
may be  more likely to engage  with them than with  an OCS worker                                                               
to  begin with.   She  advised she  is looking  at sending  out a                                                               
letter of  interest to explore this  idea, and that OCS  has been                                                               
talking with  its tribal  entities as  well.   Many of  them have                                                               
been  working for  a  number of  years to  create  and build  the                                                               
infrastructure  to provide  in-home  services  to these  families                                                               
that are at  risk.  She stressed that OCS  has so many challenges                                                               
to work on within its agency, it  would like to find a way to get                                                               
services to these families via  other entities that may be better                                                               
equipped than OCS.                                                                                                              
3:31:38 PM                                                                                                                    
CHAIR  SEATON   referred  to  slide  16,   and  Dr.  Hirschfeld's                                                               
presentation  regarding  the  Help  Me  Grow  program,  and  that                                                               
appears to  be a  family functioning  tool with  case management.                                                               
He  asked whether  the department  has looked  into these  models                                                               
that  would be  similar  to telehealth  and  the coordination  of                                                               
services,  especially  in  rural  Alaska where  there  is  little                                                               
access to services.                                                                                                             
MS. LAWTON  answered that she was  unaware whether OCS has  a lot                                                               
of that going on and that she  is not familiar with Help Me Grow,                                                               
although it  is on her list  to speak with Dr.  Hirschfeld.  Many                                                               
of  the  rural families  are  connected  to their  tribal  health                                                               
organizations that can  provide some of those services.   Most of                                                               
the  department's standard-type  services that  the families  OCS                                                               
sees are needs around parenting,  around substance abuse, and she                                                               
opined  there was  not  much availability  in  terms of  creative                                                               
access.  Although,  she noted, currently there  is effort through                                                               
behavioral  health,  and  with Medicaid  expansion  that  she  is                                                               
hopeful  there will  be far  more opportunities  for access  that                                                               
doesn't look  like the standard  urban setting access,  but there                                                               
is an area for growth there.                                                                                                    
CHAIR SEATON  noted that within  the telehealth  presentation, it                                                               
found that there was a  far better compliance rate with substance                                                               
abuse, counseling and such because  people just could not make it                                                               
to the appointments.  Possibly OCS  could do that through some of                                                               
the telehealth  data the  committee received,  and he  offered to                                                               
steer Ms. Lawton to the  telehealth presentation.  He pointed out                                                               
that whether the  issue was behavioral health  or compliance with                                                               
a substance  abuse program, the telehealth  compliance rates were                                                               
approximately  80 percent  higher,  which  included urban  Alaska                                                               
because people can miss the bus or whatever.                                                                                    
3:34:27 PM                                                                                                                    
REPRESENTATIVE WOOL  noted that certain aspects  of treatment had                                                               
a  stigma and  possibly  people  didn't want  to  go  in and  see                                                               
certain kinds  of providers, but  if they  are in the  comfort of                                                               
their  own  home  they  do  not  have  to  interact  with  anyone                                                               
CHAIR SEATON added that most of  it was visual through a computer                                                               
or iPad  or similar.   He noted his surprise  at the data  on the                                                               
compliance  rates, and  that  it appears  the  state keeps  going                                                               
through  these  cycles  because  it  has  problems  with  getting                                                               
compliance throughout a full program.                                                                                           
3:35:21 PM                                                                                                                    
DR.  VADAPALLI returned  to  slide 9,  and  drew the  committee's                                                               
attention  to  the  last  bullet   point  which  read,  "Identify                                                               
additional, more specific measurable  outcomes."  He advised that                                                               
the  panel had  several discussions  with OCS  regarding applying                                                               
measurable outcomes to access programs  as they move along trying                                                               
to do  the work it  is mandated  to do.   He added that  that has                                                               
been a problem with the  in-home services and a recommendation is                                                               
that any new  models must have an accompanying  set of measurable                                                               
CHAIR  SEATON   asked  whether  the  department   felt  this  was                                                               
meaningful and doable moving forward in designing the program.                                                                  
MS.  LAWTON said  that certainly  if OCS  is putting  dollars out                                                               
through  grants or  contracts, by  some  means it  will build  in                                                               
measures  of   accountability.    Certainly,  she   related,  Dr.                                                               
Vadapalli  brings  much expertise  to  this  area and  OCS  would                                                               
appreciate his crafting assistance when OCS gets to that point.                                                                 
3:36:48 PM                                                                                                                    
DR. VADAPALLI turned to slide  10, "Recommendation 3: IA Backlog"                                                               
and  said  that  Initial  Assessment  (IA)  backlog  has  been  a                                                               
challenge for several  years and it is the second  step of a case                                                               
after the initial screen-in.   The process, he explained, is that                                                               
a reporter  calls in and  the report is screened-in  or screened-                                                               
out, in the  event the report is screened-in there  is an initial                                                               
assessment  conducted  by an  IA  worker.    He noted  there  are                                                               
several different types  of scenarios where an IA  can quickly be                                                               
concluded,  or can  be delayed  over time.   Given  how busy  OCS                                                               
frontline workers  are, and how  much they have on  their plates,                                                               
it's not uncommon that some of  these are overdue.  Anything that                                                               
needs  to be  addressed  right  away are  addressed  to the  best                                                               
possible extent,  but there are  several that just sit  there and                                                               
don't get  closed in time.   Obviously,  he pointed out  there is                                                               
concern about what is happening  with these children while a case                                                               
is open  but nothing is moving.   However, the number  of backlog                                                               
IAs  ran up  to  approximately  4,000 statewide  in  2012.   This                                                               
happens approximately every  4 years because OCS puts  all of its                                                               
resources to  quickly close all  pending IAs once every  4 years,                                                               
and 2016 is  that 4 year cycle and the  numbers were creeping up.                                                               
The panel recommended that OCS  have a structured plan to address                                                               
this and dig into the nature  of the IA cases that are backlogged                                                               
by 30, 60, 90,  or 120 days.  The division came  up with a system                                                               
internally  and it  included mostly  trying to  keep up  with the                                                               
regional  managers and  unit supervisors  to make  sure that  the                                                               
cases  are closed  on  time.   Although,  that  is obviously  not                                                               
working as they  hoped.  The recommendation is to  come up with a                                                               
system that  is a structural  solution to this and  to understand                                                               
it better and get a solution, he said.                                                                                          
3:39:42 PM                                                                                                                    
CHAIR  SEATON asked  whether there  is an  explanation for  the 4                                                               
year cycle.                                                                                                                     
MS. LAWTON  replied that  in terms  of root  cause, she  does not                                                               
think  there is  any mystery,  and  to be  clear when  discussing                                                               
backlog, the backlog is in  the completion of the final paperwork                                                               
and  writing up  the summary  of  what happened  and issuing  the                                                               
final letter  that goes to the  family.  She expressed  that this                                                               
is  the  key   issue  OCS  feels  badly   about  because  parents                                                               
absolutely  are entitled  to receive  notification that  the case                                                               
has  been closed  and the  ultimate finding.   However,  when the                                                               
work load  is such that staff  are getting too many  reports than                                                               
they can  possibly keep  up with, the  paperwork always  moves to                                                               
the bottom  of the list because  the workers are going  to go out                                                               
and  see the  people in  person and  assess each  child's safety.                                                               
She  related that  [there  may  be backlog]  until  OCS has  more                                                               
balance  in terms  of  the  work load  and  the  number of  staff                                                               
available  to address  the  issue and  giving  worker more  tools                                                               
because  currently all  of the  staff have  to basically  perform                                                               
duplication of documentation in almost everything they do.                                                                      
3:40:45 PM                                                                                                                    
MS. LAWTON  continued that the  workers go  out in the  field and                                                               
talk to  the family and  write on a  tablet, they then  come back                                                               
and have to document it.   She described this as a duplication of                                                               
efforts that  OCS simply does  not have the  time for them  to be                                                               
doing.   Unfortunately, the financial aspects  of getting laptops                                                               
and the  security issues  from an IT  perspective, it's  just not                                                               
something OCS  has in the  cards for  probably a number  of years                                                               
until OCS  will have the  funding to do  that.  Until  that time,                                                               
the  cycle is  just  that when  OCS diverts  all  attention to  a                                                               
problem, generally,  it makes headway  and some  improvement, but                                                               
typically OCS  has more problems at  any given time than  it does                                                               
resources to focus on all of them.   She opined that the cycle is                                                               
more   reflective  that   the  numbers   grow  and   OCS  decides                                                               
"everything is going to this until  we get this settled," it then                                                               
goes back to  trying to address everything else,  and the numbers                                                               
creep  again.   Particularly,  she  noted,  with IA  workers  and                                                               
investigators because  they are almost  always the newest  to the                                                               
agency,  and  the  greenest  to working  in  child  welfare,  and                                                               
typically are  the employees  quickly trying  to move  from their                                                               
jobs to family services which tends  to be a more predictable day                                                               
schedule and  work load.   She remarked  that they are  the least                                                               
skilled and the  least trained employees dealing  with the crisis                                                               
in your face child maltreatment issues every day.                                                                               
3:42:23 PM                                                                                                                    
REPRESENTATIVE SEATON  surmised that  OCS hasn't gotten  to using                                                               
Siri  to type  out the  reports yet.   He  referred to  2012 when                                                               
extra workers were added, and said  in looking at the budget each                                                               
time there is  a vacancy the legislature takes  the positions and                                                               
doesn't  refill them.   He  asked  whether that  is happening  as                                                               
MS. LAWTON offered that the  legislature has been very supportive                                                               
of OCS over the years in  getting it new positions, but it hasn't                                                               
kept up  with the pace,  and OCS  continues to struggle  with the                                                               
turnover.  She noted that if  OCS could solve the worker turnover                                                               
issue,  which is  largely driven  by the  work load,  it wouldn't                                                               
need more staff and  it could do a far more  effective job.  This                                                               
is a  challenge every  state in  the country  is facing  with the                                                               
backlog and that  those paperwork functions tend to  always be at                                                               
the bottom of the list.   The division has actually been asked to                                                               
present in  some states about how  Alaska has been able  to, with                                                               
some frequency,  get the backlog  fixed.  Unfortunately,  OCS has                                                               
not been able to devise a sustainable effort, she said.                                                                         
3:43:55 PM                                                                                                                    
DR.  VADAPALLI  turned to  slide  11,  "Recommendation 4:  Foster                                                               
Care" and advised  that previously the panel had  not looked into                                                               
foster care issues, and since it is  a huge area of OCS's work it                                                               
looked into how the recruitment  and retention efforts for foster                                                               
families were going.  The  panel noticed that recruitment efforts                                                               
were  not uniform  across the  state  and there  were no  outcome                                                               
measures; therefore,  he related, there  was no clear  message on                                                               
what the  need was,  how many foster  families were  needed, what                                                               
the target  of recruitment  is, and  when will  OCS know  when it                                                               
gets there.   The recommendation was to  clearly identify outcome                                                               
measures  with appropriate  channels  for  communicating a  clear                                                               
message with the approximate number  of resource families needed.                                                               
The division  responded that  it is working  with the  Center for                                                               
Resource Families  that provides training for  foster families to                                                               
make  progress  on  identifying   measures  and  giving  a  clear                                                               
message.    The  Center  for Resource  Families  understands  the                                                               
challenge OCS  has in trying  to identify  the exact need  at any                                                               
point in time because children are  always coming in or out.  The                                                               
panel  believes  that  an approximate  number  can  certainly  be                                                               
identified, he remarked.                                                                                                        
3:46:08 PM                                                                                                                    
CHAIR SEATON referred  to the outcome measures  and asked whether                                                               
he meant the  chart [on the slide] and what  the outcome measures                                                               
the panel is looking for are.                                                                                                   
DR. VADAPALLI responded  that essentially OCS put a  lot of plans                                                               
together  at  a  reasonable  level in  terms  of  recruiting  and                                                               
retaining  foster families.   Although,  many of  those sub-goals                                                               
within the  plan did not have  any sort of outcome  measures, and                                                               
it was not clearly identified when  OCS will know it had attained                                                               
success, what  is the goal here,  and when it will  know the goal                                                               
has been achieved.                                                                                                              
3:47:45 PM                                                                                                                    
DR.  VADAPALLI turned  to slide  12, "Recommendation  5: Employee                                                               
Survey" and  said this is an  example of something that  comes up                                                               
during the year  but is not necessarily a part  of the work plan.                                                               
He pointed  out that there is  an annual employee survey  and the                                                               
survey results  are summarized and  passed across the  agency for                                                               
supervisors to  use to  make revisions on  various things.   Two-                                                               
three years  ago when the  panel started looking into  the survey                                                               
it noticed that the results were  not summarized in a manner that                                                               
supervisors  could make  decisions.   Ms.  Lawton disagreed  with                                                               
him, he said, and  she advised that OCS is using  it and that the                                                               
summarized results  are useful.   Two years  later the  panel had                                                               
the same challenge and asked for  data and the data was (indisc.)                                                               
for the  last two  years.   Last year  the survey  instrument was                                                               
passed on  to the panel for  comment and it provided  feedback on                                                               
how questions  could be changed  and the panel's list  of changes                                                               
did  not  make it  into  the  instrument  before the  survey  was                                                               
conducted.    He  explained  that  the  recommendation  is  about                                                               
restructuring the  OCS employee  survey and  the way  the surveys                                                               
are summarized  which is important  due to the total  turnover of                                                               
32 percent over the last decade  among the frontline workers.  It                                                               
is important  to know how  the workers feel about  certain things                                                               
and  the  published  document  on  line  does  not  separate  out                                                               
responses from those frontline workers.   This year OCS asked the                                                               
panel to assist  and because he is a professor  at UAA, his class                                                               
is conducting the survey in collaboration with OCS this year.                                                                   
3:50:46 PM                                                                                                                    
CHAIR  SEATON  asked  whether the  survey  results  are  internal                                                               
DR. VADAPALLI replied  that this is an internal  staff survey but                                                               
the results are  summarized for the public's purposes  and are on                                                               
the  OCS  website for  the  entire  state.    He opined  that  by                                                               
grouping  all  of  the  frontline  workers  into  one  group  and                                                               
examining  just  their responses  will  help  OCS in  identifying                                                               
specific  reasons for  this high  turnover and  possibly identify                                                               
solutions.   This year CRP  restructured the survey quite  a bit,                                                               
although  it  did  not  change  the  questions  or  add  any  new                                                               
questions because this  is the first time that OCS,  CRP, and the                                                               
graduate class  from UAA are  collaborating so  that is a  lot of                                                               
change in the way the survey  was administered in the past.  They                                                               
agreed not  to add any  new questions  and maybe get  the process                                                               
right  so  next  year  additional   questions  may  be  added  or                                                               
different questions  asked.  The report  will be a CRP  report so                                                               
it will be a public report  and all members of the committee will                                                               
receive a copy, he said.                                                                                                        
3:52:31 PM                                                                                                                    
CHAIR SEATON asked whether the  collaboration was working well in                                                               
trying to get at the survey of the initial intake workers.                                                                      
MS. LAWTON said  she would wait to see the  results of the survey                                                               
and the  overall response rate  because there certainly  could be                                                               
value  in  some  of  the   restructure,  and  the  questions  are                                                               
fundamentally all  the same.   The division obviously  sees value                                                               
in gathering information  from its staff population  in total and                                                               
it hadn't been particularly narrowing  in on those frontline case                                                               
workers when looking at how to  deal with the turnover.  She said                                                               
it will be interesting to see  what the results will say and what                                                               
that means for future years.                                                                                                    
3:53:24 PM                                                                                                                    
DR. VADAPALLI  turned to slide  13, "Recommendation  6: Workload"                                                               
and noted that  a consistent message from the  frontlines was the                                                               
challenge  of  workload  management.    In  2006  and  2012,  two                                                               
workload studies  recommended that OCS measure  workers' workload                                                               
on  a regular  basis and  that its  workload balancing  tool only                                                               
allowed  senior managers  to allocate  resources and  assign work                                                               
between  offices.   The  workload balancing  tool  did not  allow                                                               
workload  assessment as  recommended  by either  of the  workload                                                               
studies.   He advised that the  agency can make some  progress if                                                               
there is  a clear tool  to assess  workload on an  ongoing basis.                                                               
In response,  OCS reported that  it is working with  the National                                                               
Child  Welfare  Workforce  Institute  to  examine  caseloads  and                                                               
workloads,  and is  also working  with a  national consultant  in                                                               
examining  prior  workload studies  to  determine  what the  next                                                               
steps could be.                                                                                                                 
3:55:02 PM                                                                                                                    
REPRESENTATIVE TARR  asked whether  other opportunities  had been                                                               
looked into.  For example,  the Rasmuson Foundation has a program                                                               
that  offers sabbaticals  for  non-profits, executive  directors,                                                               
with  the  thinking regarding  retention  is  to give  someone  a                                                               
period of  time to refresh.   She  asked whether there  are other                                                               
supportive things  the legislature should be  considering or have                                                               
been done elsewhere that may help reduce the turnover.                                                                          
MS.  LAWTON  responded  that  OCS  is  always  looking  to  those                                                               
opportunities and  she is on  a number of national  lists serves,                                                               
and probably every week a  state inquires, "who's doing something                                                               
that's working"  in this  area.  Currently,  the State  of Alaska                                                               
together with the  University of Alaska Anchorage is part  of a 5                                                               
year  grant  it  received  in working  with  the  National  Child                                                               
Welfare Workforce Institute, and that  there is a lot of dialogue                                                               
happening there.   She  opined there are  not any  magic bullets,                                                               
and OCS periodically meets with  human resources and personnel to                                                               
go back over questions previously  asked before because sometimes                                                               
the questions change  over time in state government.   During the                                                               
meetings   they  try   to  determine   whether  there   could  be                                                               
flexibility with "this," or whether  they could do something that                                                               
the state hasn't  done.  For example, OCS has  seen success in an                                                               
office  that,  historically,   had  significant  difficulties  in                                                               
recruiting  at  St.  Mary's  in the  western  region  outside  of                                                               
Bethel.  The  division has employed an  alternative work schedule                                                               
such that the  employees work one week  on and one week  off.  It                                                               
is not  exactly the same  as the  Alaska State Troopers,  but the                                                               
workers at  St. Mary's have  stayed for approximately  two years.                                                               
Although, one  worker recently turned  over but the  other worker                                                               
is  still  there.   A  thought  for  Bethel,  with the  four  new                                                               
positions  the   division  recently   received,  is   basing  the                                                               
employees out of Anchorage and  then being deployed to Bethel one                                                               
week  on and  one week  off.   Although, she  noted, that  is not                                                               
ideal from a  community perspective, if the workers  stay as long                                                               
as what is being seen with  the folks at St. Mary's they actually                                                               
will become just as familiar as  though they were living in those                                                               
communities  and  there  won't  be the  current  turnover.    The                                                               
division  is  always  scanning nationally  to  determine  whether                                                               
anyone  has anything  going on  that  is new  or innovative,  but                                                               
there's not many magic bullets out there on this.                                                                               
3:58:07 PM                                                                                                                    
REPRESENTATIVE TARR asked whether there  was the ability to offer                                                               
loan  forgiveness or  bonuses for  individuals if  they, after  a                                                               
five  year  period  ...  she  opined that  the  goal  is  not  to                                                               
incentivize someone to stay just  because they are looking to get                                                               
extra dollars  and not doing a  good job.  She  asked whether any                                                               
of those come up on those lists serves.                                                                                         
3:58:37 PM                                                                                                                    
MS. LAWTON  opined that  they have come  up and  nationally there                                                               
was an  initiative for  social workers that  was more  focused on                                                               
licensed clinical  social workers  working in  rural areas  or in                                                               
Indian health  organizations where  there were  opportunities for                                                               
loan  forgiveness.   There  hasn't been  such  an opportunity  in                                                               
Alaska with  state child  welfare workers, and  she said  she has                                                               
talked  with the  personnel folks  and  asked that  in the  event                                                               
there  was money  in the  budget  whether OCS  could offer  small                                                               
bonuses  for  staying another  year.    She  has also  looked  at                                                               
whether the salary rate could  be increased for those workers who                                                               
perform  investigations  and  initial  assessments  because,  she                                                               
reiterated,  those  tend  to  be the  greenest  workers  with  no                                                               
experience.    The  division actually  needs  the  most  seasoned                                                               
people performing  those jobs because  there are less  eyes, less                                                               
oversight,  less collaboration,  and they  are entirely  on their                                                               
own.  At this point, OCS has not  been able to find an avenue for                                                               
that in Alaska with its current structure or budget.                                                                            
3:59:46 PM                                                                                                                    
DR. VADAPALLI  added that attention on  recruitment and retention                                                               
is important and  those are considerable challenges  for OCS, but                                                               
this  recommendation  is really  about  the  tools available  for                                                               
managers,  supervisors, and  workers  to  manage their  workload.                                                               
Also, for managers to assess  the workload at an individual level                                                               
on  a  regular continuing  basis.    The frontline  workers  have                                                               
consistently said there is too much  to do, no way to prioritize,                                                               
and there is no way to take a break, basically, he related.                                                                     
DR. VADAPALLI turned  to slide 14, "Additional  Work" and offered                                                               
that the  panel conducted three  site visits  and a copy  of each                                                               
visit report was submitted to the  committee.  A survey report of                                                               
all select ICWA  personnel from various tribal  entities has been                                                               
conducted  annually  for the  last  three  years regarding  their                                                               
relationship  with OCS  on the  frontlines.   The  2015 and  2016                                                               
survey reports found that they  rate their local child protection                                                               
at 6  out of 10, with  10 being the best.   He described it  as a                                                               
subjective assessment but still useful  information to know.  The                                                               
panel attended  the National Citizen Review  Panel Conference and                                                               
came back  "pretty proud" of  Alaska's CRP and the  structure and                                                               
support it receives, the report was submitted to the committee                                                                  
4:03:03 PM                                                                                                                    
DR. VADAPALLI turned to slide  15, "National Conference 2017" and                                                               
advised that  the panel will  be attending the 2016  National CRP                                                               
Conference  in  Phoenix.   The  panel  committed to  hosting  the                                                               
National Conference 2017 in Alaska  and OCS intends to support it                                                               
but is skeptical about the  level it can meaningfully support the                                                               
CRP's  efforts in  hosting the  conference.   He opined  that the                                                               
conference  would  be  useful  to Alaska  because  it  brings  in                                                               
national expertise and experience to  weigh in on Alaska's shoes.                                                               
Every  time there  is a  national  conference in  any state,  the                                                               
local CRPs  receive a lot  of focus  and expertise is  offered by                                                               
the  national experts.    He  further opined  that  this will  be                                                               
useful for the  state in making progress  on community engagement                                                               
and social child protection.                                                                                                    
DR. VADAPALLI  turned to slide  16, "Goals  for 2015 -  2016" and                                                               
offered the ongoing goal of  focusing on OCS components, and this                                                               
year the  panel took  a critical  look at  its own  operations to                                                               
refine how things  have been structured and operating.   The goal                                                               
being to  make it easier for  the public to participate  and more                                                               
meaningful  for OCS  to  utilize  as a  tool  for information  to                                                               
inform its policies and practices, he said.                                                                                     
DR. VADAPALLI turned to slide  17, "Changes in CRP operation" and                                                               
explained the slide depicts changes  in the panel's operation and                                                               
it adopted an  official set of guidelines the panel  did not have                                                               
in the  past.  Currently, when  the panel meets at  the beginning                                                               
of the year, which is in  August or September, it puts together a                                                               
work plan  as a set  of goals and a  clear annual calendar.   The                                                               
plan is then  submitted to OCS to note on  its calendars when the                                                               
panel  plans to  produce the  product  during the  year.   Public                                                               
comments are accepted  at the panel's website,  and documents and                                                               
information are available online  except for the panel's meetings                                                               
with  OCS leadership.    The  panel's intention  is  to create  a                                                               
Public  Outreach  Plan  in  the  near  future  and  offer  a  new                                                               
recruitment  and  orientation  packet  to  each  new  member,  he                                                               
4:06:17 PM                                                                                                                    
REPRESENTATIVE  TARR   pointed  out   that  there  is   no  legal                                                               
requirement the  legislature must  provide funding  or additional                                                               
resources to  accomplish a CRP recommendation,  and asked whether                                                               
Alaska is  in line  with other states  and their  experiences and                                                               
challenges  where they  want  to  do more  but  do  not have  the                                                               
DR.   VADAPALLI  responded   that  her   question  is   the  most                                                               
challenging question  all CRPs have  been asking  themselves, how                                                               
to do what they  are expected to do.  He  offered that a national                                                               
model  has not  been suggested  by  the federal  agencies or  any                                                               
technical consultants  that they hired for  technical assistance.                                                               
Each  panel evolved  in whatever  way it  saw fit  for its  local                                                               
needs.  For example, Alaska has  one panel and the panel appoints                                                               
its  own members  through a  formal  recruitment and  appointment                                                               
process, but  many states follow  a different template  and there                                                               
is no national accepted template.   Most challenging, he related,                                                               
is that  there is no model  stating the principles of  the CRP or                                                               
what is  expected to be  done at the  very least, and  other than                                                               
the  federal mandate  there is  nothing helping  CRPs figure  out                                                               
what they  should be doing.   Over  the last three  years, Alaska                                                               
CRP has  consistently examined its  own work and it  now follows,                                                               
what the panel calls, a  participatory evaluation approach due to                                                               
reading through  several legislative documents  and Congressional                                                               
hearings  documents and  what  the panel  now  understands, as  a                                                               
purpose  of CRPs,  is  that it  is  to be  a  conduit for  public                                                               
participation  in child  protection.   He explained  that at  the                                                               
federal level, the legislation gave  the CRPs two specific tools,                                                               
to evaluate,  and to collect  public opinion or  public outreach.                                                               
He  described that  as a  challenge; however,  at the  moment the                                                               
Alaska CRP  stands high on  the rank of  the other states  on the                                                               
efficiency  and effectiveness  scale  because it  reaches out  to                                                               
many  stakeholders across  the state.    Most of  the Alaska  CRP                                                               
funding  goes to  traveling  across the  state  and meeting  with                                                               
people   as  it   conducts  approximately   100  interviews   and                                                               
approximately 10 focus groups every year through site visits.                                                                   
4:10:48 PM                                                                                                                    
The Alaska CRP  is the only CRP with such  a supportive and clear                                                               
relationship  with  its  state  legislature  and  many  CRPs  are                                                               
surprised  the  panel actually  presents  to  this committee,  he                                                               
continued that the supportive relationship  with OCS is among the                                                               
best across  the nation.   He  opined that if  the panel  makes a                                                               
recommendation that is tangible,  meaningful, and measureable for                                                               
OCS to  do something about,  then certainly  it will take  it on.                                                               
Although,  if  the  recommendation  is  vague  or  too  broad  or                                                               
requires a  lot of funding then  it is challenging for  OCS to do                                                               
anything  with  it.   He  reiterated  that  budget cuts  are  not                                                               
pleasant for anyone and it was  a surprise that $18,000 was taken                                                               
away from  the amount allocated for  the CRP this year,  so it is                                                               
cutting back on  the number of members going on  site visits, and                                                               
today he had to testify telephonically.                                                                                         
4:12:41 PM                                                                                                                    
REPRESENTATIVE WOOL  asked whether there  is a concern  that with                                                               
the  caseload and  workload the  frontline workers  have and  the                                                               
turnover,  that the  number of  recommendations may  increase the                                                               
cause  of the  workload.   Although, recommendations  need to  be                                                               
made  and  followed, it  may  be  that  added reports  and  added                                                               
surveys exacerbates the problem, he said.                                                                                       
DR.  VADAPALLI  opined that  anything  that  cannot be  measured,                                                               
cannot be  changed.   Therefore, if a  project is  not constantly                                                               
assessed, it is  unknown where the project is, or  the way to go,                                                               
or how  far it's gone  in achieving the  desired result.   In the                                                               
event  the director  believes a  recommendation will  add to  the                                                               
workload, the  panel is open  to changing its  recommendations to                                                               
make  it more  meaningful to  the agency.   He  noted that  those                                                               
questions happen  constantly every month with  the OCS leadership                                                               
and this  is a process that  helps both OCS derived  benefit from                                                               
CRP and  it assists the panel  in refining its methods  and means                                                               
in the  recommendations it makes.   He reiterated that this  is a                                                               
useful process  and the recommendations  are not  burdensome, and                                                               
if they are they should be discussed.                                                                                           
4:14:25 PM                                                                                                                    
CHAIR SEATON  referred to  Online Resources  for the  Children of                                                               
Alaska (ORCA) and  noted problems such that everything  had to be                                                               
double entered,  or the information  had to  be typed in,  and he                                                               
asked  what progress  had been  made  with ORCA  becoming a  more                                                               
useable tool.                                                                                                                   
MS. LAWTON  opined that  OSC has  come a long  way with  ORCA and                                                               
every year enhancements are made to  it to make is user friendly,                                                               
as  well as  access to  the ORCA  help team  with any  questions.                                                               
Features  have been  changed to  reduce  the number  of things  a                                                               
worker has  to type in  and some  of those are  auto populations.                                                               
Currently, there  is a  lot of duplication  because OCS  does not                                                               
have laptops available for a worker  to access ORCA when they are                                                               
working  in the  field and  everything must  be written  by hand.                                                               
Court orders will now be directly  linked to OCS and entered into                                                               
ORCA, and  OCS will have the  capacity in ORCA, which  is a money                                                               
issue, to  increase space  and have the  capability to  scan more                                                               
documents,  such as  original evaluations  reports received  from                                                               
second parties  into ORCA.  The  department is also working  on a                                                               
shared initiative such  that there would be a  vault where secure                                                               
information could be scanned.                                                                                                   
CHAIR SEATON related  that he was happy to hear  that because not                                                               
long ago it was the bane of  the entire department due to so much                                                               
time  being spent  re-entering  the  same data,  or  it would  be                                                               
entered  and then  there would  be a  long span  of time  between                                                               
transmission such  that the worker had  to go do another  job and                                                               
then come back and  enter a few more lines.   He asked whether it                                                               
was at a point that a person  can complete a full report and send                                                               
MS. LAWTON answered yes, absolutely,  and she said the reality is                                                               
that ORCA  is now becoming  an antiquated system  nationally, and                                                               
the division  has been working with  CGI that is the  provider of                                                               
contract services  for the division  on ORCA.   Soon, nationally,                                                               
there  will be  new data  management models  out there  that will                                                               
provide  opportunities  for  states.    She  explained  that  the                                                               
division  bought  the  whole  package  from  another  state  and,                                                               
consequently, had to  take it as is with as  license and couldn't                                                               
make it their own.  She  further explained that there will be new                                                               
off-the-shelf  opportunities  where  the division  can  pick  and                                                               
choose components to  create its own system down the  road.  With                                                               
technology  advancing at  its current  rate  it may  not be  ORCA                                                               
again but the next time the  division starts a new system it will                                                               
be light years from where the division is now, she said.                                                                        
CHAIR SEATON related that it might  be one of those big helps for                                                               
intake workers, reports, or whatever.   He expressed appreciation                                                               
to panel  for its work  and volunteer  hours, and that  the panel                                                               
and  division   is  working  together   so  well   to  coordinate                                                               
improvement to systems.                                                                                                         
The Citizen Review Panel presentation was concluded.                                                                            
4:19:27 PM                                                                                                                    
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at 4:19 p.m.                                                                                                          

Document Name Date/Time Subjects
Dr. Hirschfield_ACES-April 2, 2016.pdf HHSS 4/2/2016 12:15:00 PM
HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
HCR 21 - Support Jorgensen.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Hirschfeld.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Hummel.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support JSPC Hummel.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Kate Burkhart.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Nakamura.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Pastorino.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Roberts Jr..pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support S.Trivette.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Sealaska.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Woodard.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Storrs.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 Sponsor Statement.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 Version A.PDF HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Background_ Reverse Alchemy in Childhood.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Background_CDC-injury prevention and control.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Letter of Support- AECAG.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Fuller.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Douglas.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support G.Trivette.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
Citizen Review Panel_HSS Presentation 03292016.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
CRP-2015-Annual-Report-Appendices.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
Citizen Review Panel_Letter to the House HSS Committee_03282016.pdf HHSS 4/2/2016 1:30:00 PM
Presentation- HHSS
CRP 2015 Annual Report.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
Alaska CRP 2016 ICWA report.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
HCR 21 - Support Abbe Hensley.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Support Gail AK Association for Infant .pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 - Background_The Origins of Addiction.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
BIA-Providers-Conference-Survey-Results-Final-Report.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
HCR 21 Background- ACEs-Accumulation-AAPP.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
HCR 21 Presentation Adverse Childhood Experiences March 2016.pdf HHSS 4/2/2016 1:30:00 PM
HCR 21
ACE'sToxicStress_Patrick Anderson.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS
ACE'sToxicStress2_Patrick Anderson.pdf HHSS 4/2/2016 1:30:00 PM
Presentation - HHSS