Legislature(2019 - 2020)GRUENBERG 120

03/06/2020 01:00 PM House JUDICIARY

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Heard & Held
-- Public Testimony --
+ Bills Previously Heard/Scheduled TELECONFERENCED
Moved HB 148 Out of Committee
                    ALASKA STATE LEGISLATURE                                                                                  
               HOUSE JUDICIARY STANDING COMMITTEE                                                                             
                         March 6, 2020                                                                                          
                           1:03 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Representative Matt Claman, Chair                                                                                               
Representative Harriet Drummond                                                                                                 
Representative Gabrielle LeDoux                                                                                                 
Representative Laddie Shaw                                                                                                      
Representative Sarah Vance                                                                                                      
MEMBERS ABSENT                                                                                                                
Representative Chuck Kopp                                                                                                       
Representative Louise Stutes                                                                                                    
COMMITTEE CALENDAR                                                                                                            
HOUSE BILL NO. 148                                                                                                              
"An Act relating to solemnization of marriage."                                                                                 
     - MOVED HB 148 OUT OF COMMITTEE                                                                                            
HOUSE BILL NO. 290                                                                                                              
"An  Act  establishing an  alternative  to  arrest procedure  for                                                               
persons  in  acute  episodes  of   mental  illness;  relating  to                                                               
emergency detention  for mental  health evaluation;  and relating                                                               
to licensure of crisis stabilization centers."                                                                                  
     - HEARD & HELD                                                                                                             
PREVIOUS COMMITTEE ACTION                                                                                                     
BILL: HB 148                                                                                                                  
SHORT TITLE: MARRIAGE WITNESSES                                                                                                 
SPONSOR(s): REPRESENTATIVE(s) CLAMAN                                                                                            
04/29/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
04/29/19       (H)       STA, JUD                                                                                               
02/20/20       (H)       STA AT 3:00 PM GRUENBERG 120                                                                           
02/20/20       (H)       Heard & Held                                                                                           
02/20/20       (H)       MINUTE(STA)                                                                                            
02/27/20       (H)       STA AT 3:00 PM GRUENBERG 120                                                                           
02/27/20       (H)       Moved HB 148 Out of Committee                                                                          
02/27/20       (H)       MINUTE(STA)                                                                                            
02/28/20       (H)       STA RPT 5DP 1DNP                                                                                       
02/28/20       (H)       DP: HOPKINS, THOMPSON, STORY, FIELDS,                                                                  
02/28/20       (H)       DNP: VANCE                                                                                             
03/02/20       (H)       JUD AT 1:00 PM GRUENBERG 120                                                                           
03/02/20       (H)       Scheduled but Not Heard                                                                                
03/04/20       (H)       JUD AT 1:00 PM GRUENBERG 120                                                                           
03/04/20       (H)       Heard & Held                                                                                           
03/04/20       (H)       MINUTE(JUD)                                                                                            
03/06/20       (H)       JUD AT 1:00 PM GRUENBERG 120                                                                           
BILL: HB 290                                                                                                                  
SHORT TITLE: ALTERNATIVE TO ARREST: MENTAL HEALTH CTR.                                                                          
SPONSOR(s): REPRESENTATIVE(s) CLAMAN                                                                                            
02/24/20       (H)       READ THE FIRST TIME - REFERRALS                                                                        
02/24/20       (H)       JUD, FIN                                                                                               
03/06/20       (H)       JUD AT 1:00 PM GRUENBERG 120                                                                           
WITNESS REGISTER                                                                                                              
SOPHIE JONAS, Staff                                                                                                             
Representative Matt Claman                                                                                                      
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Explained the Sectional Analysis for HB 290                                                              
on behalf of Representative Claman, prime sponsor.                                                                              
STEVE WILLIAMS, Chief Operating Officer                                                                                         
Alaska Mental Health Trust Authority                                                                                            
Department of Revenue                                                                                                           
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Offered a PowerPoint presentation on the                                                                 
Crisis Now Model.                                                                                                               
ALBERT WALL, Deputy Commissioner                                                                                                
Office of the Commissioner                                                                                                      
Department of Health and Social Services                                                                                        
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Offered an explanation on the 1115                                                                       
Behavioral Health Waiver, pertaining to HB 290.                                                                                 
TIMOTHY QUIGLEY PETERSON, MD                                                                                                    
Bartlett Regional Hospital                                                                                                      
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Offered testimony in support of HB 290.                                                                  
RAY MICHAELSON, Program Officer                                                                                                 
Healthy Minds Focus Area                                                                                                        
Mat-Su Health Foundation                                                                                                        
Wasilla, Alaska                                                                                                                 
POSITION STATEMENT:  Offered testimony in support of HB 290.                                                                  
GENNIFER MOREAU-JOHNSON, Director                                                                                               
Division of Behavioral Health                                                                                                   
Department of Health and Social Services                                                                                        
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Offered testimony in support of HB 290 and                                                               
answered questions pertaining to the proposed legislation.                                                                      
ACTION NARRATIVE                                                                                                              
1:03:02 PM                                                                                                                    
CHAIR MATT CLAMAN called the House Judiciary Standing Committee                                                               
meeting to order at 1:03 p.m.  Representatives Claman, Drummond,                                                                
LeDoux, Shaw, and Vance were present at the call to order.                                                                      
                   HB 148-MARRIAGE WITNESSES                                                                                
1:03:41 PM                                                                                                                    
CHAIR CLAMAN announced that the first order of business would be                                                                
HOUSE BILL NO. 148, "An Act relating to solemnization of                                                                        
1:04:10 PM                                                                                                                    
REPRESENTATIVE DRUMMOND moved  to report HB 148  out of committee                                                               
with  individual  recommendations  and  the  accompanying  fiscal                                                               
notes.   There being no objection,  HB 148 was reported  from the                                                               
House Judiciary Standing Committee.                                                                                             
        HB 290-ALTERNATIVE TO ARREST: MENTAL HEALTH CTR.                                                                    
[Contains discussion of HB 86 and HB 181.]                                                                                      
1:04:37 PM                                                                                                                    
CHAIR CLAMAN announced that the  final order of business would be                                                               
HOUSE  BILL  NO. 290,  "An  Act  establishing an  alternative  to                                                               
arrest  procedure  for  persons   in  acute  episodes  of  mental                                                               
illness;  relating  to  emergency  detention  for  mental  health                                                               
evaluation;  and relating  to licensure  of crisis  stabilization                                                               
1:05:10 PM                                                                                                                    
CHAIR CLAMAN  noted that  there would  be invited  testimony from                                                               
experts  on the  proposed legislation,  who were  well-suited for                                                               
answering any  questions the committee  might have, and  he asked                                                               
the  committee  to  refrain from  asking  questions  until  after                                                               
invited testimony.                                                                                                              
1:05:34 PM                                                                                                                    
CHAIR CLAMAN passed the gavel to Representative Drummond.                                                                       
1:05:40 PM                                                                                                                    
CHAIR CLAMAN presented HB 290, as  prime sponsor.  He stated that                                                               
people living  with serious mental health  disorders or emotional                                                               
difficulties  are  subject   to  periodic  recurring  psychiatric                                                               
emergencies or  crises that require prompt  medical attention and                                                               
stabilization.   He  said that  factors  such as  lack of  timely                                                               
access  to   essential  services   and  support,   substance  use                                                               
disorders,  unstable   housing  and  homelessness,   and  poverty                                                               
exacerbate these crises.  He said  that in Alaska, and across the                                                               
nation, challenges are faced in  how to address people in crises;                                                               
current treatment  options for those  in crises  are concentrated                                                               
at either  end of the  behavioral health continuum of  care, with                                                               
long-term  outpatient  treatment  options   at  one  end  of  the                                                               
spectrum and  intensive inpatient treatment options  at the other                                                               
CHAIR  CLAMAN expressed  that when  comprehensive community-based                                                               
mental health  services are insufficient,  the burden  of dealing                                                               
with   those   in  crisis   often   falls   on  individuals   and                                                               
organizations whose  primary duties  lie outside  the traditional                                                               
scope  of psychiatric  destabilization.   He  stated that  police                                                               
officers,    hospital    emergency   departments,    correctional                                                               
facilities, and social services providers  are often on the front                                                               
line  of  dealing with  those  experiencing  a behavioral  mental                                                               
health   crisis.     He  stated   that   these  individuals   and                                                               
organizations  are  already at  capacity  in  dealing with  their                                                               
primary  functions in  public safety,  health, and  nonbehavioral                                                               
health services.                                                                                                                
CHAIR  CLAMAN stated  that  HB 290  would be  the  first step  in                                                               
adding  a much-needed  intermediate  treatment  option for  those                                                               
suffering  from  a  mental  health  or  substance  abuse  crisis.                                                               
Created  by  the  National Association  of  State  Mental  Health                                                               
Program Directors (NASMHPD), the  National Council for Behavioral                                                               
Health, RI  International, and suicide prevention  groups make up                                                               
the Crisis  Now Model.   He said that the  Crisis Now Model  is a                                                               
type  of  community-based  intervention  to  better  serve  those                                                               
experiencing  intermediate mental  health crises.   He  explained                                                               
that these  facilities are open  24 hours a  day, 7 days  a week,                                                               
365 days a year, are  staffed by mental health professionals, and                                                               
have  a "no  wrong door"  approach  that is  designed to  provide                                                               
prompt mental health evaluation and  stabilization.  He said that                                                               
crisis  stabilization  centers  have   already  proven  to  be  a                                                               
successful community tool in other  states, including Arizona and                                                               
CHAIR  CLAMAN stated  that he  and several  other people  went to                                                               
Peoria, Arizona, a  suburb of Phoenix, in December  and visited a                                                               
Crisis Now  Center to  see how  the system  works.   He explained                                                               
that he was able to observe  how police officers are able to drop                                                               
people off  at the door,  how the center  is able to  take people                                                               
in, and  how treatment proceeds.   He said that the  centers have                                                               
recliners instead of beds, because no  one can stay for more than                                                               
24  hours.     He  expressed  that  the  Crisis   Now  Model  has                                                               
dramatically improved  public safety  response and  mental health                                                               
access to  treatment.  He  expressed that everyone he  has spoken                                                               
with,  who  has  been  to  Arizona to  observe  the  centers,  is                                                               
uniformly  impressed with  the effectiveness  of the  project and                                                               
how well  it serves the  people in need  of assistance.   He said                                                               
that there are  currently no facilities like this  in Alaska, and                                                               
HB  290  would authorize  the  Department  of Health  and  Social                                                               
Services  (DHSS)  to  write regulations  to  permit  and  license                                                               
crisis stabilization centers in Alaska.                                                                                         
CHAIR CLAMAN  stated that  once regulations are  in place,  it is                                                               
anticipated   that   interested   providers  will   open   crisis                                                               
stabilization centers  in Alaska's  communities.  He  stated that                                                               
Steve Williams,  from the Alaska  Mental Health  Trust Authority,                                                               
would be providing  more information on the Crisis  Now Model and                                                               
crisis   stabilization  centers   at  the   conclusion  of   this                                                               
presentation.   He  said that  HB  290 would  give public  safety                                                               
professionals an essential alternative  to improve public safety,                                                               
and  amend  the  code  of  criminal  procedure  to  allow  police                                                               
officers, who  have probable  cause to  arrest an  individual, to                                                               
elect to take  the person to a crisis stabilization  center as an                                                               
alternative  to  jail.    He  explained  that  using  the  crisis                                                               
stabilization center  alternative would require a  police officer                                                               
to  find  that a  person  was  experiencing  a mental  health  or                                                               
substance  abuse   crisis,  and   that  treatment  at   a  crisis                                                               
intervention center  would lead to  a better outcome from  both a                                                               
treatment and public  safety perspective.  He stated  that HB 290                                                               
would  ensure that  even  if  a person  were  taken  to a  crisis                                                               
stabilization center,  he/she could  still be prosecuted  for any                                                               
related criminal activity.                                                                                                      
1:10:24 PM                                                                                                                    
SOPHIE  JONAS, Staff,  Representative Matt  Claman, Alaska  State                                                               
Legislature,  explained  the Sectional  Analysis  for  HB 290  on                                                               
behalf of Representative Claman, prime  sponsor.  She stated that                                                               
Section 1  of HB  290 would  amend AS 12.25.030  by adding  a new                                                               
section providing  peace officers with an  alternative to arrest.                                                               
She  explained  that  an  officer  may,  at  his/her  discretion,                                                               
deliver  a person  to a  crisis stabilization  center instead  of                                                               
arresting the person, if the  officer believes that the person is                                                               
suffering from an acute episode  of mental illness or voluntarily                                                               
agrees to be taken to a  crisis stabilization center.  She stated                                                               
that taking  an individual to  a crisis stabilization  center, as                                                               
provided for  in this section,  would not bar prosecution  of the                                                               
individual for  alleged criminal activity  or on charges  for the                                                               
original grounds of arrest.                                                                                                     
MS.  JONAS  stated that  Section  2  of  HB  290 would  amend  AS                                                               
18.65.530(c),  which already  allows an  officer to  not make  an                                                               
arrest with permission  from a prosecuting attorney,  by adding a                                                               
subsection  providing that  a peace  officer is  not required  to                                                               
make an  arrest under  AS 18.65.530(a),  if the  officer delivers                                                               
the  individual to  a crisis  stabilization center  or evaluation                                                               
facility.   She stated that  Section 3 of  HB 290 would  amend AS                                                               
47.30.705 by clarifying that a  person who is gravely disabled or                                                               
suffering from  mental illness and  poses immediate harm  to self                                                               
or others  may be delivered  to a crisis stabilization  center or                                                               
to an evaluation center, pursuant to AS 47.30.700.                                                                              
MS.  JONAS explained  that Section  4 of  HB 290  would amend  AS                                                               
47.30.710(a)  to   provide  for  an  examination   by  a  medical                                                               
professional  within  three hours  for  those  brought to  crisis                                                               
stabilization  centers.   She stated  that  Section 5  of HB  290                                                               
would  amend  AS  47.32.010(b)   to  allow  licensing  of  crisis                                                               
stabilization  centers under  Chapter 32.   Section  6 of  HB 290                                                               
would amend  AS 47.32 to add  a new section providing  for crisis                                                               
stabilization center licensure standards.   Ms. Jonas stated that                                                               
Section 7  of HB  290 would  amend AS 47.32.900  by adding  a new                                                               
paragraph that defines crisis stabilization centers.                                                                            
1:12:57 PM                                                                                                                    
REPRESENTATIVE DRUMMOND passed the gavel back to Chair Claman.                                                                  
1:13:14 PM                                                                                                                    
CHAIR CLAMAN opened invited testimony on HB 290.                                                                                
1:13:45 PM                                                                                                                    
STEVE  WILLIAMS, Chief  Operating Officer,  Alaska Mental  Health                                                               
Trust Authority  (AMHTA), Department of Revenue  (DOR), offered a                                                               
PowerPoint  presentation   on  the   Crisis  Now   Model,  titled                                                               
"Enhancing Alaska's  Psychiatric Crisis  Continuum of Care."   He                                                               
stated that the work that has  been going into the project is not                                                               
just the work of AMHTA but  includes many partners, such as:  The                                                               
Department of  Health and Social Services  (DHSS), the Department                                                               
of  Public Safety  (DPS), the  Department  of Corrections  (DOC),                                                               
tribal  health  organizations,  community  providers,  behavioral                                                               
health organizations, local hospitals, and many others.                                                                         
MR.   WILLIAMS,   referencing   slide   2   of   the   PowerPoint                                                               
presentation,  stated that  nationally, the  Centers for  Disease                                                               
Control and Prevention (CDC)  estimated that approximately 47,000                                                               
Americans will  die of suicide  this year; in Alaska  that number                                                               
is estimated to  be [185], which is about 25  Alaska suicides per                                                               
100,000 national  suicides.  He expressed  that often individuals                                                               
in  psychiatric  crises  are  often   first  encountered  by  law                                                               
enforcement, which  is not the  most effective approach  for most                                                               
situations.  He  said that the Anchorage  Police Department (APD)                                                               
reports  that 200  of 400  calls it  receives a  month are  for a                                                               
behavioral  health  crisis  of  some   sort  and  result  in  the                                                               
individuals  going to  hospital emergency  rooms.   He said  that                                                               
nationally,  DOC has  become the  default mental  health provider                                                               
for individuals.                                                                                                                
1:15:59 PM                                                                                                                    
MR. WILLIAMS, referencing  slide 3, stated that  the continuum of                                                               
behavioral health  care has  been eroding  in Alaska  for several                                                               
years, despite  efforts to "shore  up" the system.   He expressed                                                               
that this has  resulted in an inability to  provide timely access                                                               
to people in  psychiatric crises or meet them where  they are at,                                                               
whether  that  be   in  their  homes,  shelters,   or  places  of                                                               
employment.  He  said that the erosion of  the community behavior                                                               
health system  has led to  individuals being diverted to  DOC and                                                               
hospital emergency rooms,  and there has been a  reduction in the                                                               
capacity at  the Alaska Psychiatric Institute  (API); ultimately,                                                               
individuals   in  psychiatric   crises   are   not  getting   the                                                               
appropriate  treatment  in  the appropriate  settings  needed  to                                                               
address their issues.                                                                                                           
MR.  WILLIAMS, referencing  slide 4,  asked, "Would  this be  the                                                               
response and care system you  would want, or design, for someone,                                                               
an Alaskan, who experiences a  cardiac arrest?"  He asked whether                                                               
anyone would want a uniformed officer,  with a gun, to show up on                                                               
the street corner to help an  individual in such a situation.  He                                                               
expressed that  mental health conditions are  medical conditions,                                                               
just like  cardiac arrest, kidney  disease, epilepsy,  or asthma.                                                               
He  stated that  the response  should  not be  a law  enforcement                                                               
individual,  it should  be someone  trained in  mental health  or                                                               
with experience related to mental health conditions.                                                                            
1:17:57 PM                                                                                                                    
MR. WILLIAMS,  referencing slide  5, suggested  that transforming                                                               
the psychiatric  crisis response  system in  Alaska has  to start                                                               
with a no wrong  door approach:  there must be  no refusal and no                                                               
eligibility  requirements and,  if  someone  calls, the  response                                                               
must  be handled  in the  appropriate way,  with the  appropriate                                                               
professionals, and the appropriate level of care.                                                                               
1:19:02 PM                                                                                                                    
[MR. WILLIAMS played  a video that was approximately  three and a                                                               
half minutes long, pertaining to the Crisis Now Model.]                                                                         
1:22:41 PM                                                                                                                    
MR.   WILLIAMS,   referencing   slide   7   of   the   PowerPoint                                                               
presentation,  expressed  that  a true  mental  health  emergency                                                               
response system is  integrated across a region,  a community, and                                                               
a state.  He stated that  it utilizes peers and people with lived                                                               
experiences to help a person  in crisis to resolve his/her crisis                                                               
and move  forward.  He reemphasized  that it requires a  no wrong                                                               
door,  24/7, 100  percent acceptance  policy, and  he said  there                                                               
should be strong coordination across all levels of care.                                                                        
1:23:19 PM                                                                                                                    
MR.   WILLIAMS,   referencing   slide   8   of   the   PowerPoint                                                               
presentation,  stated that  the  Crisis Now  Model,  in terms  of                                                               
service   delivery,  partners   closely  with   law  enforcement,                                                               
embraces  recovery,   and  sees  recovery  as   the  outcome  for                                                               
individuals  in crises.   He  stated  that the  Crisis Now  Model                                                               
ensures the safety of the  patients and the professionals working                                                               
in  these  settings  and incorporates  a  significant  number  of                                                               
people with  lived experience as a  part of the recovery  and the                                                               
services that  get delivered.   He explained that the  Crisis Now                                                               
Model  is grounded  in trauma,  informed  care, and  has a  zero-                                                               
tolerance goal for suicides.                                                                                                    
MR.  WILLIAMS, referencing  slide  9, pointed  out agencies  that                                                               
have  endorsed  the  Crisis  Now  Model.    He  stated  that  the                                                               
Substance  Abuse Mental  Health Services  Administration (SAMHSA)                                                               
released its  guidelines in the past  month on how to  respond to                                                               
behavioral health  crises.  He  said that SAMHSA  highlighted the                                                               
Crisis Now  Model in its  guidelines and the three  components of                                                               
that model:   the  crisis call center,  the co-response,  and the                                                               
23-hour crisis  stabilization center.  Referencing  slide 10, Mr.                                                               
Williams  pointed  out that  a  crisis  call center  has  trained                                                               
professionals  who   can  receive   calls  from   individuals  in                                                               
psychiatric  crises and  are able  to resolve  90 percent  of the                                                               
issues  over the  phone.   He  expressed that  for 7  out of  the                                                               
remaining  10 percent  of individuals,  the dispatch  center will                                                               
send  out a  co-response  team, which  includes  a mental  health                                                               
clinician  and a  person  with lived  experience,  and they  will                                                               
resolve  those  issues.    He stated  that  the  remaining  three                                                               
percent of  individuals require more  intensive service  and will                                                               
be dropped off  at a 23-hour crisis stabilization  center so that                                                               
their needs can  be met.  He explained that  the essential crisis                                                               
care  principles  and  practices   are:    zero  suicide,  trauma                                                               
informed care, and patient and staff safety.                                                                                    
1:26:04 PM                                                                                                                    
MR. WILLIAMS,  referencing slide 11,  pointed out a  "cross walk"                                                               
of current systems as they exist  and how they respond to crises.                                                               
He  highlighted that  law enforcement  is currently  used as  the                                                               
default response in  the behavioral health crisis  system, and in                                                               
the Crisis Now Model it would  be mobile crisis teams.  He stated                                                               
that typically  when law enforcement  officers respond,  they end                                                               
up  waiting at  the DOC  or hospital  emergency rooms  for up  to                                                               
several hours for  the person to get care in  those settings.  He                                                               
explained that  with a 23-hour  crisis stabilization  center, law                                                               
enforcement  can drop  someone off,  and in  Maricopa County  the                                                               
wait time is  less than five minutes for a  professional from the                                                               
crisis  stabilization center  to  greet the  individual and  take                                                               
him/her from  the patrol  car to the  stabilization center.   Mr.                                                               
Williams,  referencing   slide  12,  pointed  out   some  of  the                                                               
successes  in  Maricopa County,  which  were  highlighted in  the                                                               
video he had shown earlier.                                                                                                     
1:28:12 PM                                                                                                                    
MR. WILLIAMS, referencing  slide 13, asked, "What is  going on in                                                               
Alaska?"   He  stated that  in 2018,  the conversation  about the                                                               
Crisis  Now Model  started when  then division  director, Randall                                                               
Burns, had  just come back from  a conference on the  East Coast,                                                               
had  heard  about  the  model,  and  started  engaging  entities,                                                               
including  AMHTA,  on  how  the model  could  be  implemented  in                                                               
Alaska.   He said  that the current  default response  system is,                                                               
for the  most part,  inappropriate and most  expensive.   He said                                                               
that  another "big  thing" that  happened in  2018 was  that DHSS                                                               
submitted its  application for the 1115  Behavioral Health Waiver                                                               
to  the Centers  for  Medicare and  Medicaid  Services (CMS)  for                                                               
approval.   He explained that  that is important because  many of                                                               
the services  provided by  the Crisis Now  Model are  outlined in                                                               
the  waiver  application.   He  highlighted  the work  that  many                                                               
people at  DHSS had done over  the past few years  in getting the                                                               
application approved and  ensuring that a piece  of the financial                                                               
foundation would be in place to implement the Crisis Now Model.                                                                 
MR. WILLIAMS  stated that  in 2019,  AMHTA worked  in partnership                                                               
with DHSS to  look at what it would take  to implement the Crisis                                                               
Now Model  in Alaska.   He  said that  AMHTA procured  a contract                                                               
with  RI International,  which operates  some of  the Crisis  Now                                                               
Model pieces in Maricopa County, to  come to Alaska and meet with                                                               
three  urban hubs  in Anchorage,  Fairbanks,  and the  Matanuska-                                                               
Susitna ("Mat-Su")  Borough and perform community  assessments of                                                               
the gaps  in needs for  what it would  take to employ  the Crisis                                                               
Now Model.   He explained  that the  consultants spent a  week in                                                               
each community,  met with representatives  for several  days, and                                                               
at the end of the week  there was a debriefing and identification                                                               
of  next steps.   He  said that  the result  of that  work was  a                                                               
consultative  report  released in  December  of  2019 [hard  copy                                                               
included in the  committee packet].  He said  the report outlined                                                               
14 recommendations,  6 of  which are  listed on  slide 14  of the                                                               
PowerPoint presentation.  He said  that AMHTA had just procured a                                                               
contract to  provide project  management for  up to  three years,                                                               
with  each  of  the  three communities  and  their  partners,  to                                                               
identify the steps needed to implement  the Crisis Now Model.  He                                                               
asked whether  the deputy commissioner  would like to  comment on                                                               
the services outlined in the waiver.                                                                                            
1:31:44 PM                                                                                                                    
ALBERT  WALL, Deputy  Commissioner, Office  of the  Commissioner,                                                               
Department of Health and Social  Services, offered an explanation                                                               
on  the  1115  Behavioral  Health  Waiver  ("the  1115  waiver"),                                                               
pertaining to  HB 290.   He stated that the  proposed legislation                                                               
was arriving "at a very  timely fashion," because the first phase                                                               
of the waiver  had been accepted and the  department was "putting                                                               
out" the second phase of the  waiver.  He expressed that up until                                                               
this point  in the history  of Alaska,  there had been  no crisis                                                               
stabilization facility  types, and no  means of payment  for them                                                               
should they  exist.  He  stated that  now, with the  1115 waiver,                                                               
there  was a  way to  pay for  those facilities.   He  referenced                                                               
three  graphs [hard  copies included  in  the committee  packet],                                                               
explaining  that  the  differences  between  them  were  the  age                                                               
differences  at the  top, as  the 1115  waiver is  separated into                                                               
three target groups  by age.  He said that  there are three types                                                               
of  services:   grant-funded,  Medicaid state  plan,  and 23  new                                                               
services offered  under the  1115 waiver.   He explained  that up                                                               
until  the acceptance  and implementation  of  these new  service                                                               
types, there  would not have been  the means to pay  for a crisis                                                               
stabilization  center with  no  partial hospitalization,  23-hour                                                               
holds, and  other things of that  nature.  He explained  that the                                                               
1115  waiver  is   coinciding  in  a  timely   fashion  with  the                                                               
legislation  proposed under  HB  290,  and there  will  now be  a                                                               
payment  mechanism  for  the services  that  would  be  delivered                                                               
through the proposed model.                                                                                                     
1:33:58 PM                                                                                                                    
MR.   WILLIAMS  continued   with  the   PowerPoint  presentation.                                                               
Referencing slide  14,  he  pointed out  6 of the  14 broad-based                                                               
recommendations  from the  Crisis  Now consultative  report.   He                                                               
said that  the elements  required to  fully implement  the Crisis                                                               
Now  Model  were  identified  early   on  in  multiple  community                                                               
conversations, as they  would be great for  urban communities but                                                               
need  continued  conversations  on the  implementation  in  rural                                                               
communities.  He stated that  something AMHTA, the committee, and                                                               
many others  are interested  in is  how to  create accountability                                                               
and what  the performance metrics  are for the Crisis  Now Model.                                                               
Referencing slide  15, he  explained that  AMHTA had  sponsored a                                                               
group of  26 individuals to go  to Maricopa County and  meet with                                                               
the operators of the Crisis Now  Model.  He said that pictured on                                                               
the  slide  was a  subacute  crisis  stabilization center,  which                                                               
would be the  location for someone who was  not stabilized within                                                               
23 hours and needed a more acute level of care.                                                                                 
1:35:26 PM                                                                                                                    
MR. WILLIAMS, referencing slide  16, pointed out several entities                                                               
that  had sent  representatives  on the  site  visit to  Maricopa                                                               
County.   He  explained that  there is  broad-based interest  and                                                               
support moving  forward, and these  entities will be  required to                                                               
lay  out the  plan and  develop and  implement the  services long                                                               
term.   He noted that AMHTA  sponsored this trip, but  many other                                                               
people have  gone on  separate trips  to look  at the  Crisis Now                                                               
Model, including various legislators,  local law enforcement, and                                                               
DHSS  through   the  Milbank  Memorial   fund.     Mr.  Williams,                                                               
referencing  slide  17,  pointed   out  some  of  the  highlights                                                               
reported back from the AMHTA sponsored  site visit.  He said that                                                               
it was important to  be able to see how the  model works, to talk                                                               
to  local  law  enforcement  in  Maricopa  County  to  see  their                                                               
benefits and hear  their support, and to understand  what did not                                                               
work previously  and how well things  work now.  He  said that it                                                               
helped  AMHTA connect  with  what  needs to  happen  in terms  of                                                               
policy regulation  and statute in  Alaska to make the  Crisis Now                                                               
Model effective.                                                                                                                
MR. WILLIAMS,  referencing slide 18,  stated that the  next steps                                                               
moving forward  would involve a  project management  team picking                                                               
up the  work that  has been  started to look  into the  14 broad-                                                               
based recommendations  from the report,  start to develop  a plan                                                               
for how to  implement the Crisis Now Model  in three communities,                                                               
and  continue to  work with  local  health providers  to get  the                                                               
model up and running in Alaska.                                                                                                 
1:37:36 PM                                                                                                                    
MR. WILLIAMS, referencing slide 19,  stated that AMHTA has been a                                                               
partner in  the process and  will continue  to be.   He expressed                                                               
that  AMHTA  will  be  involved   in  consultations  and  project                                                               
management  support.    He  stated  that  the  trustees  recently                                                               
approved  $2.6  million of  new  funding  to help  forward  these                                                               
efforts.   He thanked AMHTA  staff Katie Baldwin,  Senior Program                                                               
Officer; Eric  Boyer, Program Officer; and  Travis Welch, Program                                                               
Officer, who  have all worked  closely with partners to  help the                                                               
Crisis Now Model move forward.                                                                                                  
1:39:09 PM                                                                                                                    
TIMOTHY  QUIGLEY   PETERSON,  MD,  Bartlett   Regional  Hospital,                                                               
offered testimony  in support of HB  290.  He stated  that he has                                                               
been an  emergency physician in Juneau  for 31 years, and  one of                                                               
the things he has seen happen  over that time is that more people                                                               
with anxiety and depression have  been treating those issues with                                                               
drugs  and  alcohol,  which   can  sometimes  unmask  psychiatric                                                               
illnesses, and  as a  result hospitals are  seeing more  cases of                                                               
psychiatric illness.   He stated that the system  as designed, as                                                               
said earlier, is straightforward.   He explained that most people                                                               
with behavioral  health emergencies  are brought to  the Bartlett                                                               
Regional Hospital emergency room  by the Juneau Police Department                                                               
when it  is determined that someone  needs to be "assessed."   He                                                               
said  that this  leads  to  a "whole  gamut"  of  people who  are                                                               
brought to  the hospital.   As an  example, he stated  that there                                                               
will  be times  when a  schizophrenic person  who was  on his/her                                                               
medication(s)   and   feeling   good  will   not   fill   his/her                                                               
prescription, slowly  decompensate, see  a police  officer, freak                                                               
out because  of previous  issues with  law enforcement,  and then                                                               
end up in  the emergency room with a security  guard and a police                                                               
officer  on   each  extremity  while  he/she   is  injected  with                                                               
medicine, just to keep him/her  safe, when all that person really                                                               
needed was a medicine  refill.  He said that he  thinks that is a                                                               
good example  of why the  emergency room is  a bad place  to take                                                               
people "like  this."  He  said that  if someone were  suicidal it                                                               
would be a different scenario.                                                                                                  
DR.  PETERSON  stated that  security  and  nursing staff  end  up                                                               
spending  a  lot  of  time  being diverted  to  help  with  these                                                               
situations and not  doing the jobs that they are  assigned to do.                                                               
He stated that emergency rooms  are noisy and chaotic places, and                                                               
many people  with mental  health issues  do not  do well  in that                                                               
environment.  He  stated that he speaks for  the American College                                                               
of Emergency Physicians (ACEP) in  Alaska, in that it is thankful                                                               
for legislative support to API,  because the bed capacity was "up                                                               
to 50 or something from a year ago."   He said that there will be                                                               
times that someone will  need a bed in Juneau and  have to sit in                                                               
the emergency  room for  a day  or two,  because someone  from up                                                               
North  was sent  down  in a  Medivac, at  great  expense, and  is                                                               
taking up a bed.   He said that these individuals  are "just in a                                                               
bed, on the  floor, get brought a meal, and  someone stands there                                                               
and looks at them."   He said that this is a  big expense for the                                                               
hospital and  the system does not  work very well, which  he said                                                               
he thinks is clearly outlined  by the recent presentation and the                                                               
proposed legislation.                                                                                                           
1:42:23 PM                                                                                                                    
REPRESENTATIVE DRUMMOND remarked that she  is on the House Health                                                               
and Social Services Standing Committee,  which had spoken the day                                                               
before about the  psychiatric beds that are  being made available                                                               
at Bartlett  Regional Hospital, Fairbanks Memorial  Hospital, and                                                               
in Anchorage, and she asked whether those beds are "full."                                                                      
1:42:56 PM                                                                                                                    
DR.  PETERSON answered  that Bartlett  Regional  Hospital has  12                                                               
dedicated psychiatric beds in a  locked unit, and they are almost                                                               
always  full.     In  response  to  a   follow-up  question  from                                                               
Representative Drummond, he  stated that the program  has been in                                                               
place for  15 or  18 years,  and was designed  to be  regional so                                                               
that  people  from  all over  the  region,  including  Ketchikan,                                                               
Petersburg, Angoon, and many others  could receive care closer to                                                               
home.  He said that as  it works currently, though, there will be                                                               
times  where there  are  Juneau residents  up  North, and  Mat-Su                                                               
residents  down  South.    In   response  to  another  follow  up                                                               
question, he  explained that  the patient is  put wherever  a bed                                                               
happens to be.   He said that there is a ranking  list at API for                                                               
patients  trying to  be admitted.   There  was a  teenage boy  in                                                               
Kodiak who  was in the  hospital waiting for a  bed for 10  or 11                                                               
days,  and his  position on  the list  kept changing  and no  one                                                               
could figure  out what was happening.   He said that  those kinds                                                               
of people  will probably get  their medicine  if they are  in the                                                               
hospital, but they  will not receive any therapy  or resources to                                                               
help them  adapt back as a  functioning member of the  world.  He                                                               
said that by the time these  individuals get to the mental health                                                               
unit,  their mental  health conditions  may have  stabilized, but                                                               
their abilities  to cope  and function  have not.   He  said that                                                               
this  results in  shorter admissions  for  those patients,  which                                                               
makes them more  likely to "bounce back" and  creates a revolving                                                               
door of  the same  people back  for treatment  four to  six weeks                                                               
1:44:37 PM                                                                                                                    
CHAIR  CLAMAN   asked  whether  Juneau   had  created   a  crisis                                                               
intervention  unit, and  whether  it was  currently operating  at                                                               
Bartlett Regional Hospital.                                                                                                     
DR. PETERSON replied that there is  not currently a unit like the                                                               
Crisis Now Model.  He  explained that currently Bartlett Regional                                                               
Hospital  has an  on-call mental  health  practitioner, who  will                                                               
come  to the  emergency room  three to  five times  in a  12-hour                                                               
shift to assess someone who comes  in with a mental health issue.                                                               
He  said  often the  people  admitted  are depressed,  off  their                                                               
medications, or "back in town  after a bad divorce elsewhere, and                                                               
they don't  even know  where to  turn."  He  said that  often the                                                               
staff  at the  emergency room  are  not qualified  to help  these                                                               
people, although they try their best,  and the hospital is set up                                                               
to take care of heart attacks and strokes, among other things.                                                                  
1:46:08 PM                                                                                                                    
RAY MICHAELSON,  Program Officer, Healthy Minds  Focus Area, Mat-                                                               
Su Health  Foundation, offered  testimony in  support of  HB 290.                                                               
He  stated that  he oversees  all  projects that  are related  to                                                               
behavioral health.   He  said that  the Mat-Su  Health Foundation                                                               
shares co-ownership with the Mat-Su  Regional Medical Center, and                                                               
it invests a  portion of the profits from the  hospital back into                                                               
the  community in  order to  improve the  health and  wellness of                                                               
Alaskans living  in the Mat-Su  area.   He said that  he supports                                                               
the proposed  legislation to change  Alaska statute to  allow for                                                               
the creation  of crisis stabilization services  as an alternative                                                               
to  arrest for  people suffering  behavioral health  crises.   He                                                               
expressed  that   the  Mat-Su  Health  Foundation   supports  the                                                               
proposed legislation, because  it would pave the way  for some of                                                               
Alaska's most vulnerable residents  to receive medical evaluation                                                               
and  care   in  lower-cost   settings  than   hospital  emergency                                                               
departments,   which  would   result  in   better  outcomes   and                                                               
tremendous cost savings.                                                                                                        
MR.  MICHAELSON  stated that  he  appreciated  hearing about  the                                                               
trips  to Maricopa  County,  as  he was  fortunate  enough to  be                                                               
included  on one  of those  trips.   He expressed  that the  cost                                                               
savings over time  were impressive, as well as the  number of law                                                               
enforcement hours saved  with the psychiatric boarding.   He said                                                               
that the  potential to  divert inpatient  stays for  acute mental                                                               
health would  be quite impactful on  a financial basis.   He said                                                               
that  the  prevalence  of  mental   health  and  substance  abuse                                                               
problems  is  increasing in  Alaska,  and  the savings  could  be                                                               
significant  for  the  state by  having  a  crisis  stabilization                                                               
option for  law enforcement.   He stated that the  average annual                                                               
growth  rate for  visits to  the Mat-Su  Regional Medical  Center                                                               
Emergency  Department,  by  patients  with  a  behavioral  health                                                               
diagnosis, grew 20 percent from 2015  to 2017, due in part to the                                                               
opioid epidemic and  the shortage of outpatient access.   He said                                                               
that  from  2014   to  2017  the  number   of  behavioral  health                                                               
assessments required  for patients in  a crisis in  the emergency                                                               
department grew from 349 annually to more than 1,000.                                                                           
MR. MICHAELSON stated that HB  290 would allow police officers to                                                               
bring  patients  to  a crisis  stabilization  center  in  Mat-Su,                                                               
instead of  to the Mat-Su  Regional Medical Center or  the Mat-Su                                                               
Pre-Trial Facility.  He said  that in 2013, the "Mat-Su Community                                                               
Health"  needs assessment  allowed Mat-Su  residents to  rank the                                                               
health issues  that they were  most concerned about, and  the top                                                               
five  issues were  all  related to  mental  health and  substance                                                               
abuse.   He  said that  as a  follow up  to the  community health                                                               
needs   assessment,  there   was  a   Mat-Su  Behavioral   Health                                                               
environmental scan, in  which policies were looked  at that could                                                               
address barriers  to access  to care  and improve  the behavioral                                                               
health  systems.   He stated  that one  recommendation from  that                                                               
report  was  to   add  a  crisis  stabilization   center  to  the                                                               
behavioral  health continuum  of  care;  however, current  Alaska                                                               
statute  does not  allow for  that to  happen, and  HB 290  would                                                               
change that.  He said  that additional recommendations out of the                                                               
behavioral  health environmental  scan included  the crisis  line                                                               
and mobile crisis  services.  He summarized  that system changes,                                                               
such  as the  proposed legislation  would allow,  would alleviate                                                               
suffering  for   people  in   behavioral  health   crises,  while                                                               
delivering  significant  cost  savings, especially  for  Alaska's                                                               
Medicaid  program.     He  reiterated  that   the  Mat-Su  Health                                                               
Foundation is in  strong support of HB 290 and  urges the passage                                                               
of the proposed legislation.                                                                                                    
1:50:21 PM                                                                                                                    
CHAIR CLAMAN closed invited testimony on HB 290.                                                                                
1:50:40 PM                                                                                                                    
REPRESENTATIVE  LEDOUX asked  whether  anyone  other than  police                                                               
officers   would   be  allowed   to   take   people  to   "crisis                                                               
intervention" centers, under the proposed legislation.                                                                          
1:51:04 PM                                                                                                                    
MR. WILLIAMS  replied that anyone  would be served  and admitted,                                                               
by various  sources, to a  crisis stabilization center.   He said                                                               
that if  he were in  a mental health  crisis, then he  could seek                                                               
services  there himself,  a  family member  could  assist him  in                                                               
getting there  for services, or Emergency  Medical Services (EMS)                                                               
could drop him off; it would not be limited to law enforcement.                                                                 
REPRESENTATIVE LEDOUX asked  whether crisis stabilization centers                                                               
exist  currently  in Alaska,  whether  the  current law  requires                                                               
another law  to allow  police officers to  take people  to crisis                                                               
stabilization centers, or whether they exist at all.                                                                            
1:52:01 PM                                                                                                                    
CHAIR CLAMAN remarked that they do not exist - "period."                                                                        
1:52:07 PM                                                                                                                    
MR. WILLIAMS  clarified that there is  the Providence Psychiatric                                                               
Emergency Department,  in Anchorage,  which was constructed  as a                                                               
piece of the new  API and was supposed to be  the single point of                                                               
entry.  He explained that it  has eight beds in Anchorage, and it                                                               
tries to stabilize people within  23 hours, but it is inadequate.                                                               
He added  that while the  service is  critical, it is  a slightly                                                               
different model from  what is being operated  in Maricopa County,                                                               
specifically  around the  use  of  peers as  a  key component  of                                                               
1:52:54 PM                                                                                                                    
REPRESENTATIVE  LEDOUX asked  whether the  Providence Psychiatric                                                               
Emergency Department  is a lock-down  facility and  remarked that                                                               
she didn't  think it was a  place to which someone  could just go                                                               
for 24 hours.                                                                                                                   
MR.  WILLIAMS replied  that  he was  not going  to  get into  the                                                               
specifics of  whether it  is a lock-down  facility, but  he knows                                                               
that the  model is based on  trying to stabilize someone  in less                                                               
than  24 hours  and, if  not, make  a recommendation  for someone                                                               
going to API or a higher level of care in other communities.                                                                    
1:53:42 PM                                                                                                                    
REPRESENTATIVE DRUMMOND remarked  that Mr. Williams' presentation                                                               
resulted  in bringing  questions to  mind.   She stated  that she                                                               
serves on  two other committees,  in which  she is hearing  of an                                                               
overwhelming need for mental health  services.  She said that the                                                               
proposed crisis  stabilization center seems  to be at  the center                                                               
of a  continuum of care issue  that Alaska has.   She stated that                                                               
the day before  in the House Health and  Social Services Standing                                                               
Committee, testimony  had been heard  regarding HB  86, regarding                                                               
mental health  and contract  bids.   She said  that in  the House                                                               
Special  Committee  on Education,  they  were  talking about  the                                                               
Department   of  Education   and  Early   Development's  (DEED's)                                                               
approach to  teaching children  who come  to school  with Adverse                                                               
Childhood  Experiences (ACES),  with  trauma informed  awareness.                                                               
She  stated that  high school  students are  asking for  a mental                                                               
health curriculum,  and that is  being addressed through  HB 181.                                                               
She said that former Governor  Bill Walker's administration had a                                                               
"cross-department  summit" in  Anchorage in  Fall 2018,  where it                                                               
was  acknowledged that  quite  a few  State  of Alaska  employees                                                               
suffered  or  acquired secondary  trauma  through  their work  as                                                               
public safety  officers, working  with dysfunctional  families in                                                               
the  Office  of  Children's  Services   (OCS),  or  working  with                                                               
suicidal people in all kinds of situations.                                                                                     
REPRESENTATIVE  DRUMMOND  asked  who  would be  tying  all  these                                                               
topics together.   She remarked that it  "can't be up to  me as a                                                               
legislator, who just happens to  be on the right three committees                                                               
to  pull this  together."   She  stated that  she  had just  been                                                               
assigned to  the House Judiciary  Standing Committee, as  well as                                                               
Representative Vance, and this was  opening her eyes to the needs                                                               
across the state.   She expressed that the  biggest issue missing                                                               
from  the  presentation  Mr.  Williams  had  given  pertained  to                                                               
education,  and  she  asked,  "What about  the  children?"    She                                                               
remarked that  there were  people from  the University  of Alaska                                                               
who were  on the trip to  Maricopa County, but there  was nothing                                                               
about DEED or school districts  included in the presentation, and                                                               
she  asked how  children would  be addressed  under the  proposed                                                               
1:56:42 PM                                                                                                                    
MR. WALL answered  that the behavioral health system  of care has                                                               
been  in disarray  in Alaska  for quite  some time,  and DHSS  is                                                               
aware of that.   He stated that it has  traditionally been funded                                                               
through a  blend of grants  through non-profit  organizations and                                                               
Medicaid  services in  a limited  fashion.   He advised  that the                                                               
behavioral  health system  was  designed years  ago  and has  not                                                               
evolved with the  current situation in health care,  and it needs                                                               
to do so.  He stated that there  is a broad discussion and a plan                                                               
for changing that system, and  crisis stabilization is a piece of                                                               
that change.   He said that Representative  Drummond was correct,                                                               
there are  many elements to  the system.   He said that  DHSS has                                                               
had  conversations  with EED  recently  at  a summit  in  Mat-Su,                                                               
around  school-based  services  and  education,  and  is  looking                                                               
specifically  at opportunities  in that  area.   He related  that                                                               
Mat-Su has a behavioral health  program in its school system that                                                               
is running very  well.  He stated that Senator  von Imhof brought                                                               
that group together, and DHSS is glad to be a part of it.                                                                       
MR.  WALL stated  that  there is  a  very broad-based  discussion                                                               
around the implementation of care.   He explained that SAMHSA has                                                               
a continuum of care that has  been developed over time, which has                                                               
tremendous amounts  of research  and clinical thought  behind it,                                                               
and  when a  state looks  at  what its  behavioral health  system                                                               
should look  like, it  compares its system  to that  continuum of                                                               
care.  He  stated that it is evident where  gaps in service exist                                                               
in Alaska,  and DHSS is actively  looking to fill them.   He said                                                               
Alaska's service of  care has been driven for a  long time on the                                                               
end  of "expense  of  acuity," as  shown in  the  video clip  and                                                               
explained by  Mr. Williams previously.   He said that there  is a                                                               
tendency to  hold on to  a behavioral health problem  until there                                                               
is  an  absolute  emergency,  and  deal  with  it  in  either  an                                                               
emergency room or acute psychiatric setting.                                                                                    
1:59:38 PM                                                                                                                    
GENNIFER   MOREAU-JOHNSON,  Director,   Division  of   Behavioral                                                               
Health,  Department  of  Health   and  Social  Services,  offered                                                               
testimony in support of HB  290 and answered questions pertaining                                                               
to  the proposed  legislation.   She  addressed  a question  from                                                               
Representative   Drummond   pertaining   to   adverse   childhood                                                               
experiences.   She explained that the  three graphics, referenced                                                               
earlier by Mr.  Wall, show the three populations  targeted by the                                                               
1115 waiver:   the substance use disorder  population, the mental                                                               
health population, and  the at-risk families.  She  said that the                                                               
idea of  the 1115 waiver  is to drive down  the cost of  care and                                                               
provide appropriate care  where needed.  She  stated that at-risk                                                               
families are  in the section in  which multi-generational returns                                                               
on services provided are being  investigated.  She explained that                                                               
the  point   of  entry  for   at-risk  families  at   the  early-                                                               
intervention end  of the continuum  is entirely based  on adverse                                                               
childhood   experiences;  the   data   comes   from  the   Alaska                                                               
Longitudinal Child Abuse and Neglect  Linkage Project, which came                                                               
out of the Division of Public Health (DPH).                                                                                     
MS. MOREAU-JOHNSON  said that  Jared Parrish,  an epidemiologist,                                                               
established "stressors" - indicators  that would likely result in                                                               
child  abuse and  neglect -  which are  the criteria  for at-risk                                                               
families.   He worked  with [the  department] to  "crosswalk" the                                                               
indicators from  his study  to diagnostic codes.   She  said that                                                               
there  are 17  criteria, including:   homelessness,  incarcerated                                                               
parents, substance  use, and atypical parenting  situations.  She                                                               
said  that  the  services  available  through  home-based  family                                                               
therapy  are  specifically  targeted  as  protective  factors  to                                                               
ameliorate  the impact  of adverse  childhood  experiences.   She                                                               
stated  that  the federal  government  approved  this, because  a                                                               
study from the  Alaska Mental Health Board  demonstrated that the                                                               
number  of adverse  childhood experiences  have a  correlation to                                                               
Medicaid expenditure, and it saves  money to reduce the impact of                                                               
2:01:47 PM                                                                                                                    
REPRESENTATIVE DRUMMOND  asked for  clarification on  what SAMHSA                                                               
2:02:06 PM                                                                                                                    
MR.  WALL answered  that  SAMHSA is  the  Substance Abuse  Mental                                                               
Health  Services  [Administration],  which  is a  branch  of  the                                                               
federal government.   He said that  he could provide a  link to a                                                               
good modern continuum of care.                                                                                                  
2:02:28 PM                                                                                                                    
REPRESENTATIVE  VANCE remarked  that the  Medicaid expansion  has                                                               
increased the obligation  Alaska has in its  "portion of carrying                                                               
that burden," which has affected the  budget.  She asked what the                                                               
1115 looks like "in comparison to  that," and how it would affect                                                               
future  growth.   She expressed  that the  visible mental  health                                                               
issues  are  only  "the  tip  of  the  iceberg,"  and  asked  for                                                               
explanation on the services that might be needed.                                                                               
2:04:02 PM                                                                                                                    
MR.  WALL  answered that  DHSS  would  be  happy to  make  itself                                                               
available  to  answer  specific   questions  by  members  of  the                                                               
committee at any time.  He  stated that the history of behavioral                                                               
health in the state is  funded primarily through a combination of                                                               
behavioral health grants, which are  generally funded and have no                                                               
federal match attached  to them, and the  Medicaid portion, which                                                               
is  limited,  administratively burdensome,  and  costly.   As  an                                                               
example,  he  said  that traditionally  services  provided  under                                                               
clinic  services  and  rehabilitation  ("rehab")  for  behavioral                                                               
health are billed  in small increments of time,  which requires a                                                               
great   deal  of   paperwork  and   has  a   limited  amount   of                                                               
reimbursement with  a lot  of administrative  overhead.   He said                                                               
that the 1115 waiver pays for  services in a different way, which                                                               
is  in a  bundled  fashion, requires  a  lot less  administrative                                                               
overhead, and allows  DHSS to access the federal match  for it as                                                               
MR. WALL  explained that the plan  for a move to  the 1115 waiver                                                               
has been around since Senate Bill  74 was passed [in 2016, during                                                               
the Twenty-Ninth Alaska State Legislature].   He said that grants                                                               
have been reduced  over time, so the general fund  has gone down,                                                               
and the Medicaid  pieces have been used to fill  in where needed.                                                               
He  said  that  overall,  healthcare   is  costly  and  tends  to                                                               
increase.   He explained  that DHSS is  actively engaged  in cost                                                               
containment  and  has  addressed  the 1115  waiver  from  a  cost                                                               
containment point of view.                                                                                                      
2:06:18 PM                                                                                                                    
MS.  MOREAU-JOHNSON  pointed  out   that  her  department  is  in                                                               
contract with  an actuarial firm  and is working very  closely to                                                               
do analysis around  expenditures and, as Mr.  Wall had described,                                                               
the actuaries  are monitoring the  situation with the  idea being                                                               
that if  there is an uptick  in the consumers of  these services,                                                               
it will be at the lower end of the cost of care.                                                                                
2:06:47 PM                                                                                                                    
REPRESENTATIVE VANCE  asked whether  the type of  additional care                                                               
that would be needed for 30  percent of patients, as described by                                                               
Mr. Wall  previously, would  be "API type  of care,"  and whether                                                               
there are preparations in place for an increase in volume.                                                                      
2:07:21 PM                                                                                                                    
MR.  WALL answered  that the  numbers  being used  came from  the                                                               
crisis intervention  stabilization model  out of Arizona  and are                                                               
specific  to Maricopa  County and  reflect  how many  stabilizing                                                               
interventions were made during a specific  time.  He said that as                                                               
mentioned  previously, 90  out of  100  of those  cases would  be                                                               
stabilized  over the  phone.   He said  that the  remaining cases                                                               
would not necessarily require an  API level of care, meaning they                                                               
would  end  up  in  a  stabilization  center,  but  that  is  not                                                               
precluding  an inpatient  level  of care  because  some of  those                                                               
cases  "do go,  but those  were not  included in  that number  of                                                               
three."   He explained that the  three sets of numbers  used were                                                               
for those that were stabilized in  a call center, those that were                                                               
stabilized by mobile  behavioral health teams, and  those that go                                                               
to a stabilization center.                                                                                                      
2:08:17 PM                                                                                                                    
CHAIR  CLAMAN  remarked  that  this means  that  90  percent  are                                                               
stabilized  on the  phone,  7 percent  are  stabilized by  mobile                                                               
teams, and  3 percent  are stabilized  in a  crisis stabilization                                                               
center.    He  said  that  within the  3  percent  is  a  smaller                                                               
percentage  that will  go  to  what would  be  called  an API  in                                                               
Alaska,  to an  involuntary  commitment setting  for longer  care                                                               
treatment than can be received in a 23-hour window.                                                                             
MR. WALL  replied that that  is potentially correct.   He pointed                                                               
out that  solving a problem  on the phone is  astronomically less                                                               
expensive than doing it in an emergency room.                                                                                   
2:09:00 PM                                                                                                                    
REPRESENTATIVE VANCE  asked how  many central locations  DHSS was                                                               
looking into, given how large Alaska  is and the rural areas that                                                               
are in the state.                                                                                                               
2:09:23 PM                                                                                                                    
MR. WALL answered  that the process would be phased  in over time                                                               
and there is  a rural application, which DHSS is  working on with                                                               
tribal  partners.   He  expressed that  an  exciting thing  about                                                               
going to Maricopa County was  that a tribal liaison was available                                                               
to answer questions.  He said  that while Arizona is not the same                                                               
as Alaska,  there are remote areas,  such as a tribal  village at                                                               
the  bottom of  the Grand  Canyon,  that are  only accessible  by                                                               
mule.  He stated some of the  ways that this model was adapted to                                                               
Arizona could  potentially be  adapted for  the model  in Alaska.                                                               
He said  that there  are different ways  to handle  mobile teams,                                                               
like in the village mentioned before.   He explained that all the                                                               
adults were trained,  and the phone was traded amongst  them.  He                                                               
said that there are interesting  applications that can be applied                                                               
in Alaska,  and he mentioned  that Arizona has  Medicaid approved                                                               
transportation for horses.   He added that he  was not suggesting                                                               
that would  be applied in  Alaska.   He explained that  there are                                                               
different ways to adapt for rural  areas as needed, and DHSS will                                                               
be working towards  that.  He said that the  initial push will be                                                               
for urban  areas, as they have  the highest volume of  cases, and                                                               
DHSS will be looking to put  up a full system that is sustainable                                                               
in those areas and then work with other areas.                                                                                  
2:10:56 PM                                                                                                                    
MS.  MOREAU-JOHNSON remarked  that  the 1115  waiver is  designed                                                               
around  regions, and  the idea  is to  develop capacity  in every                                                               
region.   She  said that  there will  be monitoring  across every                                                               
region  in   the  state,  and   there  is  a  contract   with  an                                                               
administrative   services  organization   tasked  with   building                                                               
capacity  and doing  continual gap  analyses  where services  are                                                               
missing.    She said  that  the  idea is  not  just  to build  up                                                               
services in Anchorage,  Fairbanks, and Mat-Su and  fly people in,                                                               
but  to serve  people within  their  hub communities  as much  as                                                               
possible.  She said that  AMHTA helped fund an infrastructure gap                                                               
analysis, which  should be released  by March 15, 2020,  in which                                                               
it went  to every  regional hub and  visited 75  providers across                                                               
the state to talk about services.                                                                                               
2:11:56 PM                                                                                                                    
REPRESENTATIVE VANCE  remarked that  she noticed that  the fiscal                                                               
notes  included   health  facilities,   licensing  certification,                                                               
Medicaid services, and trooper detachments,  but did not have any                                                               
information  regarding  facilities  and the  "RTC,"  or  response                                                               
team.   She  asked  whether  someone could  talk  more about  the                                                               
fiscal notes for these things.                                                                                                  
2:12:45 PM                                                                                                                    
MR.  WALL  answered that  all  those  things  have not  yet  been                                                               
determined.  He said that DHSS  is in the process of working with                                                               
the  bill  sponsor   and  is  happy  to  work   on  the  proposed                                                               
legislation  as it  develops.    He stated  that  there are  some                                                               
service  lines within  the  Crisis Now  Model  that will  require                                                               
licensure,  while others  will not.   He  said that  some of  the                                                               
service lines could be handled  through regulation, some could be                                                               
handled by a service provider "standing  it up and doing it," and                                                               
others would have to be put into statute.                                                                                       
2:13:19 PM                                                                                                                    
CHAIR  CLAMAN   remarked  that  his   understanding  of   the  RI                                                               
International  model  and  experiences in  Phoenix,  Arizona,  in                                                               
terms  of funding  the crisis  intervention center,  is that  the                                                               
organization  that runs  it is  able to  fund operations  through                                                               
"billables,"  although there  may  be some  capital expense  when                                                               
getting  started.   He suggested  that Mr.  Wall or  Mr. Williams                                                               
might  be able  to give  more information  on who  would build  a                                                               
crisis center once permission is in place.                                                                                      
2:13:54 PM                                                                                                                    
MR. WALL replied  that that is true, the model  is designed to be                                                               
a billable service.   He said that there are  different levels of                                                               
service and the call center,  mobile crisis teams, and the crisis                                                               
stabilization centers  are three separate  lines of service.   He                                                               
said that in  Maricopa County each line of service  is handled by                                                               
a different type  of organization, and they are all  handled in a                                                               
slightly  different manner.   He  added that  in Maricopa  County                                                               
services  are  run under  managed  care,  and  it is  a  slightly                                                               
different model from what would be seen in Alaska.                                                                              
2:14:36 PM                                                                                                                    
MR.  WILLIAMS remarked  that he  thinks it  is important  for the                                                               
committee  and anyone  watching  the meeting  to understand  that                                                               
these are  the beginning phases of  looking at what it  will take                                                               
to implement  the Crisis  Now Model in  one to  four communities,                                                               
which is why there is  project management under contract to start                                                               
working  and  do  the  proformas  for  the  costs  that  will  be                                                               
associated with capital  facility costs and operations.   He said                                                               
that as work is done to  identify how to implement the Crisis Now                                                               
Model to  meet the needs  of local communities,  that information                                                               
will  become clearer  and  will  be readily  available  as it  is                                                               
2:15:30 PM                                                                                                                    
REPRESENTATIVE  LEDOUX asked  for clarification  on what  an 1115                                                               
waiver is.                                                                                                                      
2:15:48 PM                                                                                                                    
MR. WALL answered  that there is standard  Medicaid under federal                                                               
statute, and  there are different  ways that requirements  can be                                                               
waived  for  standard Medicaid,  which  are  applied for  through                                                               
several different types of waivers.   He said that Alaska already                                                               
has some waivers  in the state, and that  Senior and Disabilities                                                               
Services (SDS) operates under a  complex 1915(c) waiver.  He said                                                               
that the  1115 waiver  is a  section in federal  law that  can be                                                               
applied to in order to get  certain requirements waived.  He said                                                               
that there  are basically two types  of waivers:  one  waives how                                                               
to become  eligible, and the  other waives the types  of services                                                               
involved and  how to pay for  those services.  He  expressed that                                                               
it is a complex system.                                                                                                         
2:17:02 PM                                                                                                                    
CHAIR CLAMAN remarked  that a large measure of what  is seen with                                                               
an 1115 waiver is that  primarily federal funds pay for treatment                                                               
services,  whether that  be for  substance  abuse, mental  health                                                               
disorders, or  psychiatric issues.   He said  that there  is more                                                               
than one type  of waiver in terms of what  treatment is provided,                                                               
but largely  federal funds are  used, because it is  an expansion                                                               
of Medicaid,  and the  people who  are eligible  for that  do not                                                               
typically have insurance; a waiver  allows them to get treatment.                                                               
He expressed  that if he  explained that incorrectly,  then there                                                               
were two people present who could offer a correction.                                                                           
MR.  WALL  remarked that  the  1115  waiver  is not  a  "standard                                                               
package."  He explained that many  states have an 1115 waiver and                                                               
they all look vastly different,  and sometimes the waivers do not                                                               
even pertain to  mental health.  He said that  the reason Arizona                                                               
has been  talked about so  much, and  people went there  to study                                                               
the model,  is because  the waiver  there is  the closest  of any                                                               
state to the waiver in  Alaska, although they are still different                                                               
from one  another.  He  expressed that Ms. Moreau-Johnson  is the                                                               
DHSS's expert on waivers, and she could explain in more detail.                                                                 
2:18:19 PM                                                                                                                    
MS. MOREAU-JOHNSON remarked that Mr.  Wall had described the 1115                                                               
waiver correctly.  She said that the  way she likes to look at it                                                               
is that  the 1915(c) waiver, which  SDS has purview over,  is for                                                               
individuals waiving a level of  care; individuals waive the level                                                               
of care they would otherwise receive  in a nursing facility.  She                                                               
said the 1115 waiver is  the federal government allowing, through                                                               
the section  of Title 19  that Mr.  Wall had described,  to waive                                                               
the rules  of the  program; therefore,  instead of  an individual                                                               
waiving  something,  it  is  the program  rules  that  are  being                                                               
waived.   She  said that  to  Chair Claman's  point, many  people                                                               
served  by [the  Division of]  Behavioral  Health fit  in to  the                                                               
expansion  population, which  is "round  numbers of  90/10 match,                                                               
the 90 percent  federal, 10 percent state match."   She said that                                                               
Chair Claman  was correct in  saying that any population  can fit                                                               
into that,  and when looking  at the populations,  "the different                                                               
people being  served will have  varying federal  matches attached                                                               
to their eligibility."                                                                                                          
2:19:28 PM                                                                                                                    
REPRESENTATIVE LEDOUX asked, "What rules are getting waived?"                                                                   
2:19:36 PM                                                                                                                    
MS. MOREAU-JOHNSON  answered that  there are several  rules being                                                               
waived.  She  said that Representative LeDoux's  question is like                                                               
the  question that  led  to  how the  design  of  the waiver  was                                                               
approached, and she asked,  What do  we want to waive?   She said                                                               
that one  of the primary rules  that was waived was  the  rule of                                                               
comparability  in Medicaid.    She  said  that under  traditional                                                               
Medicaid  through the  state plan,  any service  that is  offered                                                               
must  be  available  to  any   Medicaid  eligible  person.    She                                                               
expressed that  her department wanted  to target  populations, so                                                               
the comparability rule was waived,  and populations were designed                                                               
around data  that showed who  tend to  be  high consumers.    She                                                               
explained  that  one of  the  cost-containment  strategies is  to                                                               
target the  populations that tend to  be at the high  end of care                                                               
and design services to keep them.                                                                                               
REPRESENTATIVE LEDOUX  expressed that her understanding  was that                                                               
anyone could be  accepted to a crisis  stabilization center under                                                               
the proposed  legislation, and  she said  she found  it confusing                                                               
that  Ms. Moreau-Johnson  was  now saying  it  would be  targeted                                                               
towards certain populations.                                                                                                    
MS.  MOREAU-JOHNSON  answered   that  Representative  Ledoux  was                                                               
 right  to be  confused  and  said that  the populations  she was                                                               
explaining  are the  populations that  are eligible  for Medicaid                                                               
coverage.   She  explained  that the  difference  is between  the                                                               
model and  the services being proposed  in the 1115 waiver.   She                                                               
said that  services will  be covered when  a claim  comes through                                                               
and  will  be  paid  for  through Medicaid,  for  anyone  who  is                                                               
Medicaid eligible  and meets the  qualifications.  She  said that                                                               
the Crisis Now  Model has 100 percent acceptance,  and the  phone                                                               
doesnt  get  answered with the  question,  What is  your Medicaid                                                               
ID number?  The phone gets answered with, What do you need?                                                                     
2:21:37 PM                                                                                                                    
MR. WALL commented  that it is important to  separate what crisis                                                               
stabilization is  from the  1115 waiver.   He explained  that the                                                               
1115 would be used as a  vehicle to provide payment for a certain                                                               
group of people.  He said that  this does not meant that the 1115                                                               
waiver  is  crisis  stabilization,  as  they  are  two  different                                                               
things.   He  said there  are  people with  regular Medicaid  and                                                               
people  with no  payment capacity  whatsoever, and  all kinds  of                                                               
people will  be able to go  to a crisis stabilization  center and                                                               
be served.   He said that the  mechanism that was used  to set it                                                               
all up  in the first  place was the  1115 waiver.   He summarized                                                               
that it is somewhat complex, and the two are separate entities.                                                                 
2:22:31 PM                                                                                                                    
REPRESENTATIVE  DRUMMOND, referencing  the three  charts provided                                                               
by DHSS, remarked that the  blue  stuff  is the 1115 waiver.  She                                                               
asked for  clarification on  what are  we getting and what  is it                                                               
costing?    She mentioned  grant funding  and asked  whether this                                                               
was  how behavioral  health used  to be  administered.   She said                                                               
that she  had heard someone  mention earlier that  the  patchwork                                                               
is  not working,  so were   fixing it.    She  asked whether  the                                                               
Medicaid  state  plan is  general  fund  dollars, and  the  other                                                               
services federal dollars.                                                                                                       
MR.  WALL  answered  that  Ms.  Moreau-Johnson  has  been  giving                                                               
presentations on that  very topic to the DHSSs   partners in many                                                               
legislative  settings   for  the  past  year,   and  offered  his                                                               
understanding that  she would be  happy to give  the presentation                                                               
to Representative  Drummond.   He said  that the  presentation is                                                               
approximately an  hour and it  might be better  to  do it  on the                                                               
2:23:49 PM                                                                                                                    
MS.  MOREAU-JOHNSON   remarked  that   Representative  Drummonds                                                                
question pertains  to funding across  the three  different colors                                                               
on the charts.  She said  that the grant lines are funded through                                                               
some federal grants and some  state funded grants.  She explained                                                               
that the  orange bars on the  chart are the Medicaid  state plan,                                                               
which is the match mentioned  earlier; the federal match is drawn                                                               
down in varying amounts depending  on the eligibility group being                                                               
served.   She expressed that the  problem with the state  plan is                                                               
that  the  services  allowed  come  straight  out  of  Title  19,                                                               
referred to  earlier by  Mr. Wall,  which is  a list  of services                                                               
that is  very limited  in nature, and  behavioral health  has not                                                               
traditionally  fit into  that  list  very well.    She said  that                                                               
another  rule that  was waived  through this  process was  to get                                                               
away  from the  medical model,  which allowed  for the  design of                                                               
more services that people will be  willing to engage with and are                                                               
more appropriate in the behavioral health world.                                                                                
MS. MOREAU-JOHNSON  stated that  all the  services in  the orange                                                               
and blue  on the charts are  Medicaid dollars, which fit  in as a                                                               
revenue  source for  the  people providing  a  service in  crisis                                                               
stabilization when provided to someone  who is Medicaid eligible.                                                               
She said  that she  does not  want the 1115  to be  a distraction                                                               
from HB 290, but said that  the reason it is important is because                                                               
it  will   be  a   primary  funding   source  for   the  proposed                                                               
legislation.   She said  that she thinks  approximately 80  to 85                                                               
percent of the costs in Arizona were covered by Medicaid.                                                                       
2:25:36 PM                                                                                                                    
REPRESENTATIVE  VANCE  asked  for clarification  on  whether  the                                                               
intent for  HB 290 is just  to establish a procedure  so that the                                                               
process of setting up mechanisms  in Alaska for an alternative to                                                               
arrest can  begin and  would not directly  impact setting  up the                                                               
crisis stabilization centers.                                                                                                   
2:26:17 PM                                                                                                                    
CHAIR  CLAMAN answered  that Representative  Vance was  partially                                                               
correct and HB  290 would do two things.   First, in the criminal                                                               
code  it  would  provide  an alternative  to  arrest  option  for                                                               
officers.  Second, it would give  DHSS the authority to write the                                                               
regulations  that would  allow for  it to  start standing  up the                                                               
process.  He  said that the timeframe he foresees  is that if the                                                               
proposed  legislation were  to pass  in the  current session,  it                                                               
would take DHSS  6 to 12 months to get  the regulations in place,                                                               
and the  goal would be  to have regulations  in place so  that by                                                               
the next fiscal year, meaning the  beginning of 2022, one or more                                                               
of these  facilities could be  started in one of  the communities                                                               
that  have been  described.   He  stated that  the finer  details                                                               
would be  left to regulations,  and without the  statutory change                                                               
that specifically  allows for DHSS  to have  crisis stabilization                                                               
centers  within  its  range  of  care  options,  the  process  of                                                               
drafting the regulations to make that possible cannot begin.                                                                    
2:27:46 PM                                                                                                                    
REPRESENTATIVE  VANCE asked  how  much  training police  officers                                                               
have,  regarding   mental  illness,  to   be  able  to   make  an                                                               
identification, and she asked whether  DHSS thinks it is adequate                                                               
given the high number of mental crises in Alaska.                                                                               
2:28:09 PM                                                                                                                    
CHAIR CLAMAN responded  that he did not want to  speak for police                                                               
officers, although  he said  he has been  in contact  with public                                                               
safety and local police departments  in the state, and the answer                                                               
he  has heard  is that  police  officers do  receive training  in                                                               
dealing  with  mental health  and  substance  abuse crises.    He                                                               
stated that  the reality is  that the population  police officers                                                               
see every day is people  having mental health and substance abuse                                                               
issues.   He said  that the  police officers  are not  trained as                                                               
psychologists,  but they  must make  these decisions  as part  of                                                               
their work daily, as that is what they are dealing with.                                                                        
2:29:10 PM                                                                                                                    
MR.  WILLIAMS  commented that  the  training  academies do  cover                                                               
mental  health issues  in a  very  small piece  of their  overall                                                               
training,   and   there   are  communities   that   have   crisis                                                               
intervention team training.   He said that AMHTA  has worked with                                                               
communities in Anchorage, Fairbanks, and  Juneau.  He stated that                                                               
the  Mat-Su Health  Foundation  and AMHTA  have  worked with  the                                                               
troopers in the Palmer and  Wasilla police departments to provide                                                               
a more  intensive 40-hour crisis intervention  team training, for                                                               
which officers  and other first  responders voluntarily  agree to                                                               
apply.  He  explained that the intent is never  to train a police                                                               
officer to be  a clinician but to be able  to recognize whether a                                                               
situation requires more  work and questions of  the individual or                                                               
those around him/her.                                                                                                           
2:30:13 PM                                                                                                                    
REPRESENTATIVE VANCE stated that she had  met a man that day from                                                               
a rural village in a region  that has the highest rate of suicide                                                               
in Alaska.   She asked  whether there  was a partnership  to work                                                               
with  the  Village  Public  Officer  Safety  Program  (VPSO)  and                                                               
whether it  was possible to  have that  community as part  of the                                                               
first regional model,  as it currently has the  greatest need for                                                               
2:30:56 PM                                                                                                                    
MR. WALL replied that DHSS  works with every region, particularly                                                               
around  behavioral   health  emergencies   and  crises,   and  he                                                               
reiterated that this model would first  be rolled out in an urban                                                               
setting, because the infrastructure  necessary to run it requires                                                               
that.  He explained that it  would then be adapted to each region                                                               
and work would be done to  put the model in place, including with                                                               
the VPSO structure.                                                                                                             
2:31:27 PM                                                                                                                    
REPRESENTATIVE LEDOUX  asked whether  anything is  anticipated to                                                               
be   between the  crisis stabilization  center and  API,  meaning                                                               
something that could  take care of people for a  few days instead                                                               
of committing them to API indefinitely.                                                                                         
2:32:04 PM                                                                                                                    
MR.  WILLIAMS  answered that  the  model  in Arizona,  its  three                                                               
components having been discussed  earlier, has a fourth component                                                               
that had not yet been discussed.   He said that this component is                                                               
a subacute  unit, and if  someone cannot  be stabilized in  a 24-                                                               
hour period and needs a higher  level of care, then he/she can be                                                               
referred there or to other services like API, if required.                                                                      
2:32:39 PM                                                                                                                    
CHAIR CLAMAN remarked that for  the short term in Alaska, because                                                               
the state  is trying crisis  stabilization first, someone  who is                                                               
not stabilized in the first 23  hours would likely be sent to API                                                               
or an  equivalent.  He  expressed that in  the long term,  a goal                                                               
would be to have the next level of care in place.                                                                               
2:32:57 PM                                                                                                                    
REPRESENTATIVE LEDOUX asked  Mr. Williams what the  role of AMHTA                                                               
would be in paying for the proposed facilities.                                                                                 
2:33:25 PM                                                                                                                    
MR. WILLIAMS answered  that over the past 25 years  AMHTA has had                                                               
the role  of helping to identify  and invest in a  model that can                                                               
enhance the  system of  care and  improve outcomes  for Alaskans.                                                               
He said that  AMHTA provides funding to explore  that and acquire                                                               
continued  project management  and  consultation.   He  expressed                                                               
that as  the pieces of  standing up and operating  the components                                                               
of the proposed model come  into play, he anticipates AMHTA would                                                               
be playing a role in that as well.                                                                                              
2:34:21 PM                                                                                                                    
REPRESENTATIVE  DRUMMOND,   referencing  Representative  Ledouxs                                                                
question  about what  happens  between  crisis stabilization  and                                                               
API, asked where  the subacute treatment fits on  the chart, with                                                               
acute  being  the third  column,  outpatient  services being  the                                                               
second  column, and  residential  and inpatient  being the  third                                                               
column.   She asked  whether subacute would  be before  acute, or                                                               
2:34:43 PM                                                                                                                    
MR. WALL answered that  it could be a bit of both.   He said that                                                               
traditionally there  is something  in behavioral health,  or even                                                               
in  respite services  for  surgeries and  such,  that are  called                                                               
 step-down  units.    He said  that someone  can either  be in  a                                                               
step-down unit prior  to going to a higher level  of acuity or be                                                               
in one after he/she is discharged  from a higher level of acuity.                                                               
He said that  it is a level  of service that needs  to be further                                                               
developed in  Alaska.  The  situation is evolving as  things move                                                               
forward,  and  the plan  is  to  eventually put  everything  into                                                               
2:35:25 PM                                                                                                                    
REPRESENTATIVE DRUMMOND  commented that  it did not  surprise her                                                               
to  see all  the  costs related  to mental  health  issues.   She                                                               
remarked  that private  health insurance  has not  covered mental                                                               
health costs  for years.   She said that  the program DHSS  is in                                                               
might provide  a few  sessions of  counseling, but  certainly not                                                               
inpatient  mental health  services.   She expressed  that she  is                                                               
glad to  see society  waking up  to the fact  that  there are all                                                               
kinds of issues,  particularly that ACES result  in medical costs                                                               
later in  life.  She  said that Dr.  Vincent Felitti had  been in                                                               
Alaska  several  years ago  and  introduced  ACES, which  he  had                                                               
discovered accidentally in a long-term  nutritional study that he                                                               
had done  with Kaiser Permanente  on thousands of patients.   She                                                               
said that is  when DEED started talking about  how to incorporate                                                               
ACES into its understanding of how children learn.                                                                              
2:36:52 PM                                                                                                                    
REPRESENTATIVE  LEDOUX,  referencing  fiscal notes  [hard  copies                                                               
included in the committee packet],  remarked that the fiscal note                                                               
from healthcare  services says that crisis  stabilization centers                                                               
will   require  state   licensure,  periodic   surveys,  ad   hoc                                                               
inspections,  and will  require  two  full-time registered  nurse                                                               
positions to fulfill these requirements.   She asked whether this                                                               
was normal,  in respect to licensing.   As an example,  she asked                                                               
whether  nurses would  be sent  as  par  for the  course  if  the                                                               
Providence   Psychiatric  Emergency   Department   or  API   were                                                               
2:37:59 PM                                                                                                                    
MR. WALL answered  that there are a variety  of different surveys                                                               
and  inspections  that are  done  on  facilities.   Some  require                                                               
clinical review, and those that  do will have clinical personnel,                                                               
like a  nurse, to  perform them.   He said  that there  are other                                                               
types of surveys  that do not require clinical  review, but those                                                               
are  compliance surveys  that pertain  to physical  structure and                                                               
procedure.  He said that in  the case of the proposed legislation                                                               
there would be a need for clinical review.                                                                                      
REPRESENTATIVE  LEDOUX remarked  that the  zero-fiscal note  from                                                               
the Office  of the Commissioner  stated in its analysis  that DPS                                                               
will   need  funding   support  to   train  officers   in  crisis                                                               
intervention and mental  health first aid, and  she asked whether                                                               
that is something that DPS does already.                                                                                        
MR. WALL replied  that the fiscal note is from  the Department of                                                               
Public Safety,  thus he  would defer questions  about it  to that                                                               
department.   He said that there  are a couple of  different ways                                                               
to  handle the  licensure and  certification process,  that would                                                               
affect a fiscal note.                                                                                                           
2:39:32 PM                                                                                                                    
REPRESENTATIVE LEDOUX remarked that she  was curious as to why it                                                               
would  take different  training to  refer someone  to one  of the                                                               
centers under the proposed legislation  when officers are already                                                               
taking people to API.                                                                                                           
2:39:46 PM                                                                                                                    
MR. WILLIAMS answered  that he did not think that  there would be                                                               
training required to  take someone to one of  the proposed crisis                                                               
stabilization  centers,  but  there  would  be  basic  one-on-one                                                               
training  as to  what  could  be presenting  as  a mental  health                                                               
situation, which allows  an officer to have  more recognition and                                                               
tools to assess  a situation and respond appropriately.   He said                                                               
that  it would  not  be  about a  clinical  diagnosis or  whether                                                               
training  is  needed to  identify  that  the deputy  commissioner                                                               
needs to  go to a  crisis stabilization center  or not.   He said                                                               
that if an officer were to  see that as the appropriate approach,                                                               
with  or without  training, he/she  should be  able to  make that                                                               
call on the street.                                                                                                             
2:40:38 PM                                                                                                                    
REPRESENTATIVE SHAW,  referencing Representative  LeDouxs  point,                                                               
remarked that  he taught at  the Public Safety  Training Academy,                                                               
and over  a 400-hour training  session for a trooper  the academy                                                               
will adjust the  curriculum accordingly to increase  the level of                                                               
training that  might be needed in  a certain area.   He said that                                                               
currently  were  looking at a  totally different scenario  in the                                                               
training because of behavioral health  issues.  He expressed that                                                               
he  thinks there  is a  lot more  sociological and  psychological                                                               
training that  needs to be  established.   He said that  this was                                                               
highlighted  in  the  VPSO  program  the  other  day,  as  it  is                                                               
currently  being worked  on to  increase  the value  of the  VPSO                                                               
program  in rural  communities.   He mentioned   one trooper  one                                                               
riot,  saying that  one trooper covers ten  villages, and without                                                               
the VPSO  interaction the value  of law  enforcements  behavioral                                                               
health support is lost without training.   He said that trying to                                                               
build the  curriculum for  the trooper and  VPSO program  to deal                                                               
with behavioral  health issues is   huge.   He expressed  that it                                                               
must  either be  added to  the training,  or some  other type  of                                                               
training will  have to be removed.   As an example,  he said that                                                               
constitutional law is  taught at the academy, and  he suggested a                                                               
few hours of that  be cut.  He expressed that  it is difficult to                                                               
add a week  or two to law enforcement training,  because there is                                                               
a  desire to  get the  police  officers out  on the  street.   He                                                               
stated,  Get them into a  field training program, then, after the                                                               
fact,   if  training   becomes  available,   additional  training                                                               
relative to  behavioral health, then they  can actually volunteer                                                               
to do that.                                                                                                                     
2:42:26 PM                                                                                                                    
REPRESENTATIVE VANCE  remarked that  the analysis  on one  of the                                                               
fiscal  notes  says  that crisis  stabilization  centers  require                                                               
state  licensure, and  she said  that essentially  this would  be                                                               
paying   for   two   full-time  Health   Facility   Surveyors   I                                                               
[positions].   She asked why  this would  be needed at  this time                                                               
for HB  290, considering  that it was  outlined earlier  that the                                                               
purpose  of the  proposed legislation  was to  allow officers  an                                                               
alternative to arrest, and allow  DHSS to adopt regulations.  She                                                               
expressed  that it  seems  like that  is a  step  ahead of  where                                                               
things need to be.                                                                                                              
2:43:15 PM                                                                                                                    
MR.  WALL  answered  that  there  is  some  oversight  regulatory                                                               
control that  CMS requires of  things that are licensed  and paid                                                               
for under Medicaid.   He said that surveying  a facility, whether                                                               
it  be a  hospital, API,  or  a crisis  stabilization center,  is                                                               
required  by CMS  to ensure  that the  facility is  in compliance                                                               
with the  regulations that CMS has  over them.  He  said that the                                                               
federal government  requires any facility that   touches Medicaid                                                               
money   to   be  surveyed  by  health   care  facility  licensing                                                               
inspectors  on  a  periodic  basis  and be  able  to  respond  to                                                               
complaints from  people in  that center.   He explained  that the                                                               
positions that would be asked  for in the licensure process would                                                               
be doing that line of work.                                                                                                     
2:44:50 PM                                                                                                                    
MR.  MICHAELSON, in  response to  a  request from  Representative                                                               
Drummond,  restated  the  statistics  he  had  previously  shared                                                               
regarding the  20 percent  increase in  numbers of  patients with                                                               
behavioral health crises accepted  by the Mat-Su Regional Medical                                                               
Center  Emergency  Department  between  2015  and  2017  and  the                                                               
increase  in the  number of  behavioral  health assessments  that                                                               
were  required  in  the  emergency  department  as  a  result  of                                                               
behavioral  health emergencies,  which was  from 349  in 2014  to                                                               
more than 1,000 in 2017.                                                                                                        
REPRESENTATIVE  DRUMMOND   remarked  that  it  looked   like  the                                                               
behavioral  health assessments  due  to  emergencies jumped  from                                                               
approximately one  a day, to  around three  a day in  that three-                                                               
year period.                                                                                                                    
2:47:32 PM                                                                                                                    
MR. MICHAELSON answered that is correct.                                                                                        
2:47:40 PM                                                                                                                    
MR. WILLIAMS commented that he wanted  to follow up on a question                                                               
Representative  Drummond  had  raised  at the  beginning  of  the                                                               
questions and  answers session, inquiring how  the proposed model                                                               
would relate to  intervening with youths and  adolescents who are                                                               
in psychiatric crises.   He expressed that he would  like to make                                                               
it clear  that two of  the three components discussed  during the                                                               
meeting would address  youths who are in psychiatric  crises.  He                                                               
said that a youth or adult  could call the crisis call center and                                                               
a situation  could possibly  be deescalated over  the phone.   He                                                               
said that  the mobile co-response  teams could respond  to youths                                                               
in  the  community, and  in  Maricopa  County those  teams  often                                                               
respond and intervene  at schools, which was learned  on the site                                                               
visit to Arizona.   He said that the  crisis stabilization center                                                               
is  currently  targeted  towards   adults,  but  that  would  not                                                               
necessarily need  to be  a limitation  going down  the line.   He                                                               
explained that ways  could be investigated to adapt  the model or                                                               
create different approaches for that level of care.                                                                             
2:49:00 PM                                                                                                                    
REPRESENTATIVE DRUMMOND  commented that  20 years ago  there were                                                               
no  long-term  psychiatric beds  in  the  state  for a  youth  in                                                               
crisis.   She  said that  since  then the  North Star  Behavioral                                                               
Health System has expanded significantly  so that youth in crisis                                                               
can be hospitalized in state, rather  than being  sent to Utah or                                                               
Texas.    She said that  progress has  been made, but  she thinks                                                               
those  are  partially  locked  facilities.   She  said  that  the                                                               
Anchorage school  district sends teachers  to North Star  to make                                                               
sure  the  youths  are  keeping  up  with  their  academics,  and                                                               
regardless how long they are  there, they receive those services.                                                               
She  asked  what an  intermediate  service  might look  like  for                                                               
people younger than the age of 21.                                                                                              
MR. WILLIAMS answered  that he did not know that  he could answer                                                               
that question at that time, but he could follow up.                                                                             
2:50:20 PM                                                                                                                    
MR.  WALL remarked  that there  are  currently several  different                                                               
levels of  care that are available  for youths in the  state that                                                               
fall  under  that  category,   such  as  residential  psychiatric                                                               
treatment centers.   He said  that typically when a  young person                                                               
is  sent  out of  state,  he/she  is  not sent  specifically  for                                                               
psychiatric care,  but for complex behavioral  health and medical                                                               
issues,  and  he/she  would  go   to  a  residential  psychiatric                                                               
treatment  center.   He stated  that  depending on  the level  of                                                               
licensure in the laws of that  state, the facility may or may not                                                               
be  a locked  facility.   He explained  that Alaska  has suffered                                                               
from a  lack of  continuum of care  and bed  availability issues,                                                               
but there  are residential  psychiatric treatment  centers across                                                               
the state and other children services  as well.  He said there is                                                               
a  good network  of partners  to work  with, and  the association                                                               
that works with  all of those is the Alaska  Association of Homes                                                               
for  Children,  which  might  be   a  good  asset  for  answering                                                               
questions as well.                                                                                                              
2:51:32 PM                                                                                                                    
CHAIR  CLAMAN  announced that  HB  290  would  be held  over  for                                                               
further review.                                                                                                                 
2:52:16 PM                                                                                                                    
There being no  further business before the  committee, the House                                                               
Judiciary Standing Committee meeting was adjourned at 2:52 p.m.                                                                 

Document Name Date/Time Subjects
HB 148 v. M 4.29.2019.PDF HJUD 3/2/2020 1:00:00 PM
HJUD 3/4/2020 1:00:00 PM
HJUD 3/6/2020 1:00:00 PM
HB 148
HB 148 Sponsor Statement 2.28.2020.pdf HJUD 3/2/2020 1:00:00 PM
HJUD 3/4/2020 1:00:00 PM
HJUD 3/6/2020 1:00:00 PM
HB 148
HB 148 Sectional Analysis 2.11.2020.pdf HJUD 3/2/2020 1:00:00 PM
HJUD 3/4/2020 1:00:00 PM
HJUD 3/6/2020 1:00:00 PM
HSTA 2/20/2020 3:00:00 PM
HSTA 2/27/2020 3:00:00 PM
HB 148
HB 148 Supporting Document - Holland America Princess Letter 2.18.2020.pdf HJUD 3/2/2020 1:00:00 PM
HJUD 3/4/2020 1:00:00 PM
HJUD 3/6/2020 1:00:00 PM
HB 148
HB 148 Fiscal Note DHSS-BVS 2.28.2020.pdf HJUD 3/2/2020 1:00:00 PM
HJUD 3/4/2020 1:00:00 PM
HJUD 3/6/2020 1:00:00 PM
HB 148
HB 290 ver. S 2.24.2020.PDF HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Sponsor Statement v. S 3.6.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Sectional Analysis v. S 3.6.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Supporting Document - Mat-Su Health Foundation Letter 3.5.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Supporting Document - Crisis Now Alaska Consultation Report 12.13.2019.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Additional Document - DHSS Mental Health Continuum of Care (Individuals 18 Years and Older) 3.6.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Additional Document - DHSS Substance Use Disorder Continuum of Care (Individuals 12 Years and Older) 3.6.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Additional Document - DHSS Mental Health Continuum of Care (At-Risk Children & Adolescents Ages 0-21) 3.6.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Fiscal Note DHSS-HFLC 2.28.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Fiscal Note DHSS-MS 2.28.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Fiscal Note DPS-AST 2.28.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 Fiscal Note LAW-CRIM 2.28.2020.pdf HJUD 3/6/2020 1:00:00 PM
HJUD 3/11/2020 1:00:00 PM
HJUD 3/13/2020 1:00:00 PM
HB 290
HB 290 PowerPoint Presentation on Crisis Now 3.6.2020.pdf HJUD 3/6/2020 1:00:00 PM
HB 290