Legislature(2023 - 2024)ANCH LIO DENALI Rm
11/17/2023 10:30 AM Senate JUDICIARY
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| Audio | Topic |
|---|---|
| Start | |
| Presentation: Hb 172 Psychiatric Patient Rights Report to Legislature | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
SENATE JUDICIARY STANDING COMMITTEE
November 17, 2023
10:31 a.m.
MEMBERS PRESENT
Senator Matt Claman, Chair
Senator Jesse Kiehl, Vice Chair
Senator James Kaufman
Senator Cathy Giessel
Senator Löki Tobin
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
PRESENTATION: HB 172 PSYCHIATRIC PATIENT RIGHTS REPORT TO
LEGISLATURE
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
CLINTON LASLEY, Deputy Commissioner
Department of Family and Community Services (DFCS)
Juneau, Alaska
POSITION STATEMENT: Co-presented the presentation on House Bill
172 Psychiatric Patient Rights Report to Legislature.
THEA AGNEW BEMBEM, Consultant
Agnew Beck Consulting, LLC
Anchorage, Alaska
POSITION STATEMENT: Co-presented the presentation on House Bill
172 Psychiatric Patient Rights Report to Legislature.
EMILY RICCI, Deputy Commissioner
Alaska Department of Health (DOH)
Juneau, Alaska
POSITION STATEMENT: Co-presented the presentation on House Bill
172 Psychiatric Patient Rights Report to Legislature.
STEVE WILLIAMS, CEO
Alaska Mental Health Trust Authority
Anchorage, Alaska
POSITION STATEMENT: Co-presented the presentation on House Bill
172 Psychiatric Patient Rights Report to Legislature.
ACTION NARRATIVE
10:31:18 AM
CHAIR MATT CLAMAN called the Senate Judiciary Standing Committee
meeting to order at 10:31 a.m. Present at the call to order were
Senators Giessel, Kaufman, Tobin, Kiehl, and Chair Claman.
^Presentation: HB 172 Psychiatric Patient Rights Report to
Legislature
PRESENTATION:
HB 172 PSYCHIATRIC PATIENT RIGHTS REPORT TO LEGISLATURE
10:31:18 AM
CHAIR CLAMAN announced the consideration of a presentation on HB
172 Psychiatric Patient Rights in Alaska, offered by the
Department of Family and Community Services (DFCS), the Alaska
Mental Health Trust Authority, Agnew-Beck Consulting LLC, and
the Alaska Department of Health (DOH).
10:32:53 AM
CLINTON LASLEY, Deputy Commissioner, Department of Family and
Community Services (DFCS), Juneau, Alaska, stated that the need
for behavioral health services is outpacing available services.
There is a need for a more robust behavioral care system and an
expansion of existing resources to build on the continuum of
care in order to ease stresses on first responders, public
safety officers, and hospitals. These steps would prevent
individuals from being held at higher, more restrictive levels
of care. The State of Alaska, the Alaska Mental Health Trust
Authority, community partners, and others have been exploring
behavioral health care system development. House Bill 172 was
passed in 2022, and has since created an opportunity to
transform the way individuals are assisted amidst acute mental
health crises. The system outlined in House Bill 172, referred
to as the "No Wrong Door" approach, has proved successful in
other states. The bill allows law enforcement and mobile crisis
teams to deliver voluntarily and involuntarily care to
individuals in a least restrictive setting.
10:34:29 AM
MR. LASLEY said that House Bill 172 added an intermediate
subacute level of care to divert individuals in behavioral
health crises from institutional settings, allows examination
under a notice of emergency detention and evaluation, and
permits a civil commitment at a subacute mental health facility
when appropriate. Concerns regarding preexisting challenges with
patient rights and protections were voiced by constituents and
mental health advocates. As a result, House Bill 172 set a
requirement that a joint report be delivered to the legislature
by October 2023.
10:35:43 AM
STEVE WILLIAMS, CEO, Alaska Mental Health Trust Authority,
Anchorage, Alaska, referred to slide 3 and said that House Bill
172 played a critical role in laying the foundation for the "No
Wrong Door" model of providing services to those experiencing a
behavioral health crisis. There is an opportunity to transform
the current system by using lower levels of care, ensuring
timely transportation, and relieving hospital emergency rooms,
staff, law enforcement, and jails from the default crisis
response. Providers seeking to establish a 23-hour crisis
stabilization center or a 7-day crisis residential center could
accept voluntary and involuntary admissions under House Bill
172. He said that stakeholders took a holistic approach to
strengthening patient rights and described the process. The
contract for the report was awarded to Agnew Beck Consulting,
LLC. He encouraged members to read the report.
Mr. Williams advanced to slide 3 and spoke to the following:
[Original punctuation provided.]
(1) include an assessment of the current state,
federal, and accrediting body requirements;
(2) identify and recommend any additional changes to
state statutes, regulations, or other requirements;
(3) assess and recommend any needed changes to current
processes for data collection and reporting and
(4) identify methods for collecting and making
available to the legislature and the general public
statistics.
10:41:51 AM
THEA AGNEW BEMBEM, Consultant, Agnew Beck Consulting LLC,
Anchorage, Alaska, referred to slide 4 and acknowledged report
contributions from Dr. Cody Chipp of Elevation Consulting, Jeff
Jessee of Paladin Alaska, and True North Recovery, a peer-led
behavioral health organization based in Mat-Su, Alaska, which
also provides services in Fairbanks, Alaska. Four subcommittees
were identified for the advisory team, as required in statute,
to develop the report, including a legal subcommittee, a data
subcommittee, a provider subcommittee, and a lived experience
subcommittee. A project management team represented the two
departments: the Alaska Mental Health Trust Authority and Agnew
Beck Consulting, LLC.
MS. BEMBEM moved to slide 5 and highlighted the following
activities that the advisory team participated in:
• 12 Subject Matter Interviews
• 5 Advisory Team Meetings
• 11 Law Enforcement Interviews
• 14 Lived Experience Contacts
• 12 Facility Visits
• 20 Subcommittee Meetings
MS. BEMBEM moved to slide 7 and provided a breakdown of
facilities serving psychiatric patients in Alaska. Most of the
facilities are not psychiatric hospitals but provide care
through general acute care hospitals and critical access
hospitals. There is one formal Designated Evaluation and
Stabilization (DES) hospital in Ketchikan, which provides
voluntary and involuntary care. The Designated Evaluation and
Treatment (DET) hospitals are located in Fairbanks, Mat-Su, and
Juneau, Alaska, and can provide involuntary treatment for up to
30 days. In addition to Anchorage Psychiatric Hospital (API),
North Star, and Providence, hospitals in Anchorage can service
children as well as adults.
10:46:41 AM
MS. BEMBEM moved to slide 8 and said that the components of the
main report were directly identified in statute and were
addressed by the project. She said there are systemic barriers
that limit access to care, including lengthy delays and extended
periods of detention. Many health care environments have failed
to meet patient needs. Patients, providers, and law enforcement
have maintained different experiences, varying by location. The
assessment found that there's a lack of alignment regarding what
is "done on the ground" and state statute. She implied
difficulty in tracking court forms that are filed under statute
as a result of unpolished law enforcement training. There are a
constrained number of inpatient beds in psychiatric care
settings, resulting in substantial wait times for patient
evaluation and a conflated acuity of need for involuntary
commitments due to limited access to higher levels of care. Some
access to care has been made possible, but the need remains
unmet.
MS. BEMBEM said that without intermediary levels of care,
psychiatric patients have no middle ground prior to involuntary
detention at the Alaska Psychiatric Institute (API). A review of
credential and accreditation requirements in facility interviews
demonstrated that the structures and rules that are in place are
largely being followed, but patients have limited access to
legal counsel and an understanding of the grievance process.
Lived experience interviews found that patients in crises are
not always aware of the availability of these services, which
differs from what facility staff perceive. Despite conflicting
views, patient advocacy is unavailable in most facilities and
patients are held responsible for navigating the grievance
process.
10:55:43 AM
MS. BEMBEM expressed a concern about nuances with data
collecting and reporting given variability in patient
experiences. For example, it can be difficult to obtain
individual patient data from a hospital setting. She suggested
that the starting point is to know what data has been gathered,
coordinate with others, analyze the data, and move forward from
there.
MS. BEMBEM pointed out that there is a data collection issue
during the period between a law enforcement officer bringing an
individual experiencing a psychiatric crisis into emergency
detention and reaching an ex parte determination. It was
mentioned that law enforcement officers delivering individuals
in a psychiatric crisis to emergency detention are required to
fill out court form MC-105. This form serves as notice that an
individual is under emergency detention. However, there is
uncertainty among agencies regarding what to do with this form
if an individual's evaluation reveals unmet criteria for
detention. This systemic issue contributes to the inaccuracy of
knowing the number of people held in emergency detention.
10:59:59 AM
MS. BEMBEM moved to slide 11 and briefly discussed the
supplemental material content of the appendices:
[Original punctuation provided.]
App A: Resource Inventory
App B: Stakeholder Vision and Access to Treatment,
Stabilization, and Discharge
MS. BEMBEM added that Appendix B speaks to appropriate and
timely behavioral care access. This section provides
insight into what the experience is like for an Alaskan
resident during a crisis, including the process for
seeking, receiving, and discharging from care. When the
advisory team process was started, a question was raised
about what the criteria includes. Stakeholders articulated
a vision that goes beyond the scope of what is contained in
statute.
App C: Psychiatric Advanced Directives
MS. BEMBEM added that the interviews conducted provide
insight on what other states do.
App D: Previously Proposed Legislation
MS. BEMBEM said that this legislation concerns the
grievance process and has come before the legislature a
handful of times.
App E: Comparison of Grievance Processes in Other
States
App F: Recommendations: Full list
MS. BEMBEM noted that over 90 recommendations organized by
topic can be found in this section.
App G: Public Comment and Response
11:02:41 AM
MS. BEMBEM moved to slide 12 and said that the graphic depicts
stakeholders' vision for a comprehensive behavioral health
continuum of care.
MS. BEMBEM moved to slide 13 and shared a summary of
departmental recommendations:
[Original punctuation provided.]
Legislative fixes
• Amend AS 47.30.709
• Law enforcement officers training
• Define "impartial body" as it is used in Sec.
47.30.847: Patients' grievance procedures.
• Enact a psychiatric patient care Ombudsman's office
in statute.
• Review and update of the civil commitment and
related statutes.
Recommendations for Departments
Court forms
• Guidance and standardized training that defines
entity roles and patient rights in specific settings.
• Review what additional data and tracking can be
completed and how it will be shared.
Supplemental recommendations:
• 90 recommendations recorded, including those outside
of scope or without consensus
MS. BEMBEM urged departments to review statute and court forms
to ensure consistency, define entity roles, and review the
process for data tracking. Per lived experience interviews,
advocacy team members report that patients in crises are not
always informed or aware of opportunities available for legal
counsel and grievances. She concluded that amping up efforts to
track court form MC-105, appropriately training officers, and
clearly defining roles would ensure consistent reporting of
emergency detentions.
11:05:45 AM
EMILY RICCI, Deputy Commissioner, Alaska Department of Health
(DOH), Juneau, Alaska, thanked patients and advocates for
sharing their lived experiences, noting that it requires a
tremendous amount of courage. She said that measuring systemic
success is evidenced by patient experiences and referenced the
report that highlights ways in which the system can be improved.
There are over 90 recommendations in the report consisting of
several branches of government and multiple perspectives. She
mentioned the complexity of the patient's experience as well as
challenges presented in the development of patient's rights.
There is an opportunity for all to contribute to ensure patient
rights are clearly understood, including everyone from emergency
responders to direct care staff. She expressed appreciation to
the various stakeholders who worked on the report. DOH remains
committed to coordinating with other agencies and the
legislature on psychiatric patient rights.
11:08:43 AM
CHAIR CLAMAN noted that before House Bill 172, Senate Bill 120,
sponsored by Senator Giessel, was passed to uphold crisis
stabilization centers during the COVID-19 pandemic.
11:09:21 AM
SENATOR KAUFMAN noted that there are many complexities and
prerequisites to achieving the desired outcomes of House Bill
172. He asked whether a comprehensive improvement plan had been
established through change sequencing and other management
processes.
11:10:30 AM
MS. RICCI responded that there are many different branches
involved. Now that the data has been collected, the next step
entails a discussion on implementation.
11:11:09 AM
SENATOR KAUFMAN suggested a master schedule to help manage
multiple tasks and complex components to allow a smooth
transition forward and work in sequencing.
11:11:48 AM
SENATOR TOBIN referenced the 'impartial body' bullet on slide 9
and asked if there were any significant conclusions in the
report concerning the legislature's role in supporting the state
grievance process.
11:12:47 AM
CHAIR CLAMAN rephrased the question by asking whether the work
established a definition for 'impartial body.'
11:13:11 AM
MS. BEMBEM replied no. However, the appointment of an ombudsman
for individuals receiving psychiatric care was a point on which
the advisory teams reached consensus. She acknowledged that many
of the 90 recommendations provided in the report are low-hanging
fruit that the state could readily address. She stated that
although there was no clear consensus on a statewide grievance
process, similarities exist in accreditation requirements
thereby offering some consistency.
The Health Facility Licensing and Certification Office receives
and responds to reports on certain levels of mental health and
injury grievances, establishing a direct connection with Centers
for Medicare and Medicaid. However, many individuals believe
that this does not adequately address the issue of transparency
in reporting.
MS. BEMBEM mentioned that beyond the existing measures, there is
no consensus on what a consistent process should entail. She
expressed her belief that people would support the appointment
of an ombudsman. She opined that there was no consensus
concerning an 'impartial body,' except that many people on the
advisory teams believe that the head of a facility is not
necessarily impartial.
11:16:05 AM
SENATOR TOBIN asked about culturally responsive care and whether
feedback has been provided by stakeholders on this issue.
11:16:32 AM
MS. BEMBEM replied that interview participants highlighted that
the location and distance to psychiatric facilities is the most
important factor to achieving culturally relevant care. Sharing
food, language, and receiving care from those who share similar
characteristics plays a significant role in effective
therapeutic healing and wellbeing. She opined that the
experience of being handcuffed by law enforcement and taken to a
foreign setting is traumatic. The supplemental report entails a
stakeholder vision that encourages care in voluntary settings,
regional crisis centers, and empowering the community in crises
to mitigate the need for involuntary detention.
11:18:21 AM
SENATOR KIEHL inquired about the insights that additional data
would provide beyond what is contained in the stakeholder vision
on slide 12. He expressed his belief that additional data would
not impact the top ten items already identified. He asked if
beginning work now would be more effective than waiting to
gather more data.
11:20:09 AM
MS. BEMBEM relayed that both approaches are crucial. While
Alaska has accumulated a substantial amount of data, it has not
been processed to specific conclusions. She recommended
reviewing the data currently available and highlighted the
difficulty in pinpointing wait times for inpatient psychiatric
beds as an example. A multi-pronged approach involving several
entities is required to comprehend and apply the data. She
concluded that coordinating the data to tell a story would
highlight needed improvements.
11:22:33 AM
SENATOR GIESSEL acknowledged the coherence of the report and
stated that she comes from the framework of community care. The
advocacy group's focus is on an institution versus partial
hospitalization, which is less expensive and potentially creates
better outcomes. She acknowledged Alaska's schools as a critical
access point for youth and asked about the depth of this focus.
She wondered whether a review of legal and statute changes is
mandated and inquired about the age of consent.
11:23:54 AM
MS. BEMBEM replied that the report does not delve into the age
of consent issue. Children in psychiatric crises, including in a
school setting, often end up in emergency departments and remain
there longer than adults. Medicaid recipients also have limited
inpatient access. She reiterated Senator Giessel's point
conveying that this project focuses more on the institutional
component and recommended expanding on the community piece to
circumvent institutional-level care.
11:25:43 AM
SEN. GIESSEL stated that access to care requires reimbursement
for providers and is a huge problem.
11:25:57 AM
CHAIR CLAMAN acknowledged the work of the report and emphasized
Appendix B on slide 11, then asked about youth mental health
treatment, out-of-state transfers, and the lack of in-state
resources. He inquired about the start date for adolescent unit
health operations at the Alaska Psychiatric Institute (API).
11:27:15 AM
MR. LASLEY said that the adolescent unit at API has operated in
some capacity for the past two years and at full capacity since
May 2022.
11:28:02 AM
CHAIR CLAMAN said that although the committee had heard about
the Justice Department investigation, it did not know API had
resumed service for children. He acknowledged the substantial
number of recommendations in the report and noted that the
inpatient process is less of a concern for the Justice
Department than before and after care. He emphasized identifying
what the state can accomplish in the next two years and said
that this issue has risen to the top of the legislative agenda.
11:29:36 AM
MR. WILLIAMS said regarding project management, those involved
must maintain accuracy to avoid systemic impacts on individuals
and their experience with services. As components of the Crisis
Now model are implemented, accurate information must be
gathered. Obtaining critical information is important to
achieving early health care access and preventing future need,
which then provides the opportunity to address the service
structures necessary to assist patients with higher levels of
need. This reduces the impact on law enforcement, hospital
emergency rooms, and jails. Currently, care protocol is treat,
stabilize, and release.
He concluded that it's important for prompt intervention to
ensure health care access is available early on, a direct impact
on the structure of higher-level care.
11:34:29 AM
There being no further business to come before the committee,
Chair Claman adjourned the Senate Judiciary Standing Committee
meeting at 11:34 a.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 172 Report_10-16-2023_FINAL.pdf |
SJUD 11/17/2023 10:30:00 AM |
HB 172 |
| HB172_SUPP_10-16-2023_FINAL.pdf |
SJUD 11/17/2023 10:30:00 AM |
HB 172 |
| Presentation on HB 172 Psychiatric Patient Rights Report to Legislature 11.17.23.pdf |
SJUD 11/17/2023 10:30:00 AM |
HB 172 |