HB 36-FOSTER CHILDREN PSYCHIATRIC TREATMENT  [SCS HB 36(HSS) was before the Senate.] 2:20:17 PM CHAIR CLAMAN reconvened the meeting and announced the consideration of HOUSE BILL NO. 36 "An Act relating to the placement of foster children in psychiatric hospitals; relating to the care of children in state custody placed in residential facilities outside the state; and amending Rule 12.1(b), Alaska Child in Need of Aid Rules of Procedure." CHAIR CLAMAN said this is the first hearing of HB 36 in the Senate Judiciary Committee. The intention is to consider a Senate committee substitute (SCS), version W, as the working document. 2:20:30 PM CHAIR CLAMAN solicited a motion. 2:20:34 PM SENATOR KIEHL moved to adopt the Senate committee substitute (SCS) for HB 36, work order 34-LS0358\W, as the working document. 2:20:51 PM CHAIR CLAMAN objected for purposes of discussion. He invited his staff to present the summary of changes. 2:20:58 PM BREANNA KAKARUK, Staff, Senator Matt Claman, Alaska State Legislature, Juneau, Alaska, presented the explanation of changes for HB 36 from version [L] to version W. [Original punctuation provided.] House Bill 36  Explanation of Changes  Version L to Version W  Version W defines treatment foster homes and allows regulations for treatment foster homes licenses. These changes are seen in Sections 1-2, 5-7, and 9-13. Version W changes language in section 4 about "admissions" and "admit" to "seek services for" and "placement". Section 4 amends the standards for placement in a hospital in (a)(1) and (a)(2). Version W deletes Section 2(a)(3) of Version L. Version W updates requirements and language for the Department of Family and Community Service's annual report to the legislature on employee recruitment and retention. Version W includes a title change and conforming changes. 2:22:10 PM CHAIR CLAMAN removed his objection and SCS HB 36, version W, was adopted as the working document. 2:22:24 PM CHAIR CLAMAN invited Ms. Vogeley from the Department of Family and Community Services (DFCS) to discuss the changes in HB 36 related to treatment foster homes. 2:22:51 PM CHRISSY VOGELEY, Senior Policy Advisor, Department of Family and Community Services, Juneau, Alaska, delivered a presentation, "Treatment Foster Home License." She explained the impetus for the change to HB 36. She said that Executive Order 121, issued in 2022, reorganized the Department of Health and Social Services into the Department of Health (DOH) and the Department of Family and Community Services (DFCS). She stated that the reorganization allowed each department to focus on their respective responsibilities and better assess the needs of the state. The DFCS has operated as an independent department for nearly three years. She said it has implemented new processes, analyzed needs, and identified gaps in services. One gap DFCS seeks to address is the lack of appropriately licensed settings for services needed by the state's youth. 2:24:00 PM MS. VOGELEY moved to slide 2 and offered a narration of the following points: [Original punctuation provided.] What is Treatment Foster Care?  • States have a defined treatment/therapeutic foster care program that includes: • Enhanced/intensive case management services • Caregivers who are active in the treatment team • Clinical services provided by community or agency providers • Alaska is the only state that does not have a defined treatment foster care program • Most states create licenses via regulation not statute • Behavioral Health Roadmap identified expansion of treatment foster care as an action item for the state 2:24:05 PM MS. VOGELEY explained that the traditional foster care system is designed for children who have been removed from their families due to abuse or neglect and require temporary care in a safe and stable environment. She stated that this differs from treatment foster care, which is the focus of the proposal. MS. VOGELEY stated that treatment foster care is an exciting idea that addresses gaps and provides more services to children. Treatment foster care is designed for family-based placement for children with serious behavioral, emotional, or medical needs. The program aims to serve these children in the community, with intensive support from agencies specializing in such services. MS. VOGELEY stated that treatment foster care programs are specialized and include enhanced or intensive case management services. The caregivers, who are also foster parents, are highly trained and participate as members of the treatment team. Community or agency providers deliver clinical services to the children. 2:25:16 PM MS. VOGELEY emphasized that Alaska is the only state without a defined treatment foster care program. Treatment foster care is not established in statute or regulation, in part, due to how DFCS was statutorily structured. She explained that under existing licensing statute AS 47.32, DFCS lists the types of licenses it offers. Most other states do that differently; they authorize departments to establish licenses through regulation. She said that, due to the structure of its statutes and the effort required to change them, DFCS has relied on traditional foster home licensing rather than addressing the need for treatment foster home licensing. MS. VOGELEY stated that in recent years, both the Department of Health and DFCS conducted a behavioral health roadmap. The departments engaged with communities across the state to identify their needs. She said that expansion of treatment foster care was identified as an action item. She said that while the roadmap did not specifically call for creation of a new license, DFCS believes establishing a treatment foster care license is a necessary first step to expand the service. 2:26:41 PM MS. VOGELEY moved to slide 3 and provided the following narration: [Original punctuation provided.] What do we have?  AS 47.32.990 (5) "foster home" means a place where the adult head of household provides 24-hour care on a continuing basis to one or more children who are apart from their parents; • Foster home license is the only family-like setting in statute. • Utilized to create settings for children to receive health care services • Therapeutic Treatment Home • Family Habilitation Homes • Regardless of service delivery, all foster homes have the same regulatory requirements • Foster parent qualifications, training, physical environment • Kids can currently stay in a therapeutic treatment home for longer than treatment is necessary 2:26:45 PM MS. VOGELEY referred to the statutory definition of foster home on slide 3. She said the definition is vague and allows for any child, essentially, to be placed in a foster home regardless of custodial status. Foster homes are the only family-like setting listed in statute. As a result, it has been used to create health care settings for children, such as therapeutic treatment homes and family habilitation homes. MS. VOGELEY stated that therapeutic treatment homes utilize a foster care license and are certified by Medicaid to provide therapeutic treatment home services to children with serious behavioral and emotional needs. She explained that family habilitation homes also utilize a foster home license and are certified by Medicaid to provide services to children with complex medical needs or intellectual and developmental disabilities. MS. VOGELEY emphasized that all foster homes are subject to the same regulatory requirements, regardless of the type of services provided or whether the caregiver is a relative. She stated that all foster parents must meet the same qualifications, training requirements, and physical environment standards. MS. VOGELEY stated that DFCS does not have homes that address both behavioral and complex medical needs, describing the system as siloed. It is a challenge to find placements for children with complex needs. She further explained that because therapeutic treatment homes are licensed as foster homes, children may remain in those homes indefinitely after completing treatment services until reunification or another permanency option is available. She stated that this means less beds for kids that need those services. 2:28:52 PM MS. VOGELEY moved to slide 4 and offered a narration of the following points: [Original punctuation provided.] Why Do We Need a Treatment Foster Home License?  • Alaska has a disconnected way of ensuring treatment foster care is provided effectively • OCS oversees traditional foster care license • DBH oversees therapeutic treatment home service certification • SDS oversees family habilitation home service certification • Child Placement Agencies manage these homes • Acuity in children is increasing we can ensure better service provision to children with complex needs • Traditional foster care is not health care 2:28:55 PM MS. VOGELEY explained that DFCS proposed the treatment foster home license to address fragmentation within the system. She stated that multiple agencies are involved in service delivery, including the: • Office of Children's Services (OCS), which oversees traditional foster care licensing, • Division of Behavioral Health, which oversees therapeutic treatment home certification, and • Division of Senior and Disabilities Services, (DOH), which oversees family habilitation home certification. MS. VOGELEY said that child placement agencies, which are community providers, manage all these homes and provide services. However, there is no single framework connecting these components. She expressed her belief that the proposed treatment foster home license would ensure better care coordination across agencies and improve service delivery for children with complex needs. She noted that the severity and complexity of children's needs are increasing and emphasized that the state really needs to do something to ensure better service to these children. 2:30:07 PM MS. VOGELEY emphasized that traditional foster care is not the same thing as health care. She explained the healthcare provision as it relates to foster care, stating that traditional foster care provides a safe and stable family environment for children temporarily separated from their families. She explained that the healthcare component involves enrolling foster parents in Medicaid and training them to provide services to children. She said legislative approval of the proposed treatment foster care would demonstrate that the state distinguishes between traditional and treatment foster care. She noted that other states and experts make that distinction in terms of the healthcare provision. 2:31:19 PM MS. VOGELEY moved to slide 5, Payment Structure: [Original punctuation provided.] Payment Structure  Children in state custody Children in parental custody Room and board funded Room and board funded through Title IV-E, by parents if eligible Services funded by Medicaid Services funded by Medicaid, private insurance (if services are covered), or self-funded by parents Codifying a treatment foster home license would have zero  fiscal impact on the state since the payment structure  already exists.  2:31:20 PM MS. VOGELEY explained the proposed payment structure for treatment foster homes. She stated: • If a child is in state custody and requires services, room and board would be funded through Title IV-E, consistent with traditional foster care, while Medicaid would fund services. • If a child is in parental custody and requires services, the parents would fund room and board. Medicaid would fund services if the child were enrolled. If the child is covered by private insurance and the policy includes the services, the private insurance would pay, or the cost would be self-funded by the parents. MS. VOGELEY expressed her belief that codifying the program would have zero fiscal impact because the payment structure and the infrastructure within DFCS are already in place. 2:32:08 PM MS. VOGELEY moved to slide 6, Anticipated Effect of Treatment Foster Home License: [Original punctuation provided.] Anticipated effect of Treatment Foster Home license  • Separating the settings to distinguish between traditional and treatment foster care will lead to more services being provided to children in Alaska • Remove the disconnect and ensure service coordination among agencies • Align licensure standards with Medicaid requirements • Increase in the number of treatment foster homes due to streamlining processes • Increase in positive outcomes for children 2:32:11 PM MS. VOGELEY stated that the goal of creating a treatment foster home license is to separate it from traditional foster care. The department believes the separation will lead to more services for children in Alaska. She explained that removing the disconnect between agencies would ensure better service provision to children with complex needs. MS. VOGELEY expressed her belief that aligning licensure standards with Medicaid requirements will streamline the process and increase the number of treatment foster homes. The DFCS would ensure that children who need treatment services are in settings designed to support positive outcomes. She stated that the objective is to ensure that children receive the services they need and achieve successful outcomes. 2:33:09 PM SENATOR MYERS asked whether the proposal could have been implemented through regulation rather than legislation if the Department of Health and Social Services had not been reorganized into the Department of Health (DOH) and the Department of Family and Community Services (DFCS). MS. VOGELEY responded that, regardless of the reorganization, establishing a treatment foster home license is necessary to clearly distinguish it from traditional foster care. She explained that traditional foster care provides a temporary, safe, and stable environment for children in custody, whereas treatment foster care would serve as a separate family-like setting that provides healthcare services. MS. VOGELEY stated that while there may be an avenue to implement such a license through regulation, the distinction is significant enough to warrant creation of a statutory license. 2:34:21 PM SENATOR TOBIN stated that the Senate Health and Social Services Committee would have been a great place to propose this particular license type and discuss related healthcare dynamics. She asked for examples of the types of healthcare services provided under the proposed treatment foster care model. She asked the DFCS senior policy advisor to describe the training required for foster parents, the additional supports DFCS intends to provide, and any associated resource or funding requirements, including Medicaid. 2:35:04 PM MS. VOGELEY replied that agencies in the state already provide similar services, commonly referred to as therapeutic foster care. These programs include counseling and family therapy, and foster parents receive training, including trauma-informed care. She stated that while these services are already provided, each agency has its own program structure and requirements, and each operates differently. There are 15 such agencies, and their practices vary. She stated that the proposed license would establish a regulatory framework to create consistency across agencies. She expressed her belief that DFCS would see positive outcomes with the proposed change. She emphasized that while the agencies already provide strong services, the intent is to standardize practices to support improved outcomes. 2:36:25 PM SENATOR TOBIN expressed her understanding that the state would oversee the proposed license type and direct how programs operate. She asked whether this oversight would extend to municipalities or other entities. MS. VOGELEY replied, yes, the state would provide oversight. She clarified that private agencies, not municipalities, operate the programs. SENATOR TOBIN asked what extra support the department would provide if new requirements were set. MS. VOGELEY deferred to the Department of Health (DOH) for questions related to Medicaid certification, stating she could follow up with DOH and coordinate Medicaid certification responses. MS. VOGELEY addressed the question of extra support. DFCS has already given agencies the authority to conduct foster home studies. Agencies select which homes to bring in and support. She explained that licensing packets are submitted to the Office of Children's Services (OCS), which then issues the licenses. MS. VOGELEY stated that the department does not provide significant extra support; rather, agencies are given flexibility to operate their programs and ensure services are provided to the children who are in their programs. She explained that the DFCS would streamline the licensure and Medicaid certification processes, making it easier for agencies to develop homes and deliver services. MS. VOGELEY asked if that answered the senator's question. SENATOR TOBIN indicated that the response did not fully address her question. 2:38:17 PM SENATOR KIEHL referenced materials that were before the committee, including court case documents, hospital admission standards, and a presentation on "a different type of foster home that may not be foster care." He wondered when the committee would address those topics or if there had been a substantive change made to HB 36. 2:38:47 PM CHAIR CLAMAN responded by explaining that during the development of HB 36 and discussions with the governor's office, treatment foster homes were identified as a recommended component. He stated that treatment foster homes would help address fiscal challenges and provide less restrictive service options, allowing individuals to avoid extended hospital stays or hospitalization altogether. There was a very small fiscal note. CHAIR CLAMAN stated that the behavioral health roadmap for youth recommendations included the provision for treatment foster homes. He explained that while the language and structure are new, the provision is consistent with the overall subject matter of HB 36. 2:39:51 PM SENATOR KIEHL stated that while the explanation was helpful, it was difficult to track the various types of foster homes: the licensed foster homes, therapeutic foster homes, family habilitation foster homes, and treatment foster homes. He asked for clarification on the new treatment foster home category, including the level of service the provider must offer and whether they function as an alternative to hospitalization or as a step below hospital-level care. MS. VOGELEY explained that these types of homes have existed for some time and have been funded through various ways. The [Medicaid Section] 1115 waiver led to the therapeutic treatment home services provision. 2:41:21 PM At ease. 2:41:41 PM CHAIR CLAMAN reconvened the meeting. 2:41:42 PM MS. VOGELEY continued her response, stating that the therapeutic treatment home service provision was intended as a step-down placement from residential psychiatric treatment centers. The idea was that children could transition from a higher level of care into a treatment foster home or move to a more intensive setting. All the while, continuing to receive wraparound support from a treatment team to ensure the child receives appropriate services in the least restrictive setting. MS. VOGELEY stated that treatment foster homes are operated by foster parents who receive specialized training through an agency to provide services to children with serious behavioral, emotional, or medical needs. She explained that individuals serving in this role must also enroll in Medicaid as direct service providers in order to deliver services and receive reimbursement. She said the role of a treatment foster care provider could be filled by individuals who choose to become trained foster parents and service providers. 2:43:02 PM SENATOR KIEHL stated that he was reticent to do Health and Social Services committee work in the Judiciary Committee. He asked about the length and intensity of training required for treatment foster care providers. He expressed concern that subacute mental health care would require more than minimal training and asked her to elaborate on that. MS. VOGELEY replied that there are currently no statutory or regulatory standards specifying training requirements for treatment foster parents. She explained that training varies by agency, though many use evidence-based models, such as Pressley Ridge which provides the training. Training may range from 30 to 60 hours and is tailored to the needs of the child. She stated that establishing a treatment foster home license would allow the department to set minimum training standards through regulation that agencies would be required to meet or exceed. 2:44:24 PM SENATOR KIEHL asked who would provide subacute mental health care services and whether an outpatient provider would deliver those services in conjunction with the treatment foster home. MS. VOGELEY responded that subacute mental health facilities are distinct from treatment foster homes. She explained that in treatment foster homes, foster parents are trained to provide certain services. Agencies that offer other services would support foster parents. Such support would include clinicians, who provide counseling and support. Most programs include 24- hour crisis care support, which DFCS would require as well. She explained that agencies can provide immediate assistance through internal staff or through contracted providers to deliver services such as counseling and other intensive supports. 2:45:42 PM SENATOR KIEHL asked about access to treatment foster care services and whether availability would be limited to hub communities or include telehealth providers. MS. VOGELEY responded that telehealth could be incorporated into the model. She stated that agencies are primarily located in hub communities, but that DFCS would like to expand them. She noted the potential for kinship treatment foster homes, including training relatives in rural communities to provide services. MS. VOGELEY stated that, unlike many states that limit services to children in custody, DFCS intends to make treatment foster care available to all children, regardless of custodial status. She explained that Alaska needs to expand access to mental health services for children with complex needs. It does not matter whose custody they are in if they need the services. 2:47:02 PM SENATOR MYERS asked whether the proposal would allow a parent or parents to obtain a license to provide treatment services to their own child. MS. VOGELEY replied that is not necessarily how it would work. She explained that parents usually approach an agency when a child has significant needs. The agency would conduct an intake evaluation to determine whether services can be provided in the home or if the child should be placed in a treatment foster home. She stated that treatment foster care providers would typically not be the child's biological or adoptive parents, but would include other individuals, such as relatives, depending on the structure of the program. 2:48:05 PM SENATOR TOBIN asked how the proposed legislation would intersect with the Indian Child Welfare Act (ICWA) and referenced a comment made by the senior policy advisor. She referred to a scenario mentioned by the advisor involving a parent requesting placement of a child who identified as a different gender and had severe behavioral issues. She said the comment raised a personal red flag and asked whether HB 36 would allow parents to make such decisions. MS. VOGELEY expressed her belief that DFCS would need to establish a regulatory framework, potentially informed by Medicaid certification, to determine when it could accept a child for these services. She expressed uncertainty about whether that would use a DMS-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition] to identify what would be considered a disorder for mental and emotional health. She stated that she might need to follow up on how to set that up. SENATOR TOBIN requested further explanation about ICWA. MS. VOGELEY responded that ICWA would still apply, and that DFCS would like to see more ICWA treatment foster homes. She emphasized the importance of cultural connections. She said the intention of treatment foster care is as a service rather than a long-term, permanent placement. She noted that cultural competency training could be incorporated into the regulatory framework. She stated that DFCS hopes and anticipates having treatment foster homes aligned with ICWA. 2:50:05 PM SENATOR TOBIN asked about the number of foster care families in Alaska, whether there is sufficient capacity, and how the proposed license type might affect that dynamic. MS. VOGELEY sought clarification, asking whether the question pertained to all foster homes in general or only to the proposed type. SENATOR TOBIN replied, all. MS. VOGELEY responded that there are about 1,000 licensed foster homes statewide, with about 29 providing therapeutic treatment or family habilitation services. She stated that separating treatment foster care from general foster home licensing could allow for regulatory adjustments that better meet the needs of Alaskans and potentially increase the number of general foster homes. There is a clear need for more treatment foster homes, and she noted that agencies expressed a strong demand for expanding this type of service. 2:51:23 PM SENATOR KIEHL said what remains unclear is the nature of treatment foster homes. He said they appear to function as a step below mental health hospitalization and wondered whether such placements involve a mental health provider. He said they provide a residential home setting but are not intended as a long-term placement. He noted that OCS could order a placement or a parent could initiate one. He wondered whether a court could also order a child placed there. MS. VOGELEY responded that courts could potentially have the authority to place a child in such a setting if the child were involved with the Division of Juvenile Justice. However, this has not occurred in recent years. She explained that treatment foster homes are family-based settings where foster parents are trained to provide behavioral and mental health services and are enrolled in Medicaid as direct service providers. She expressed her belief that foster parents are enrolled as behavioral health associates or similar roles due to the training they receive. MS. VOGELEY stated that treatment foster homes are a step-down or less restrictive alternative to residential psychiatric treatment centers or psychiatric hospitals. She said the upcoming invited testimony could elaborate on what these homes look like, which might help clarify what they will look like in the future. She said that similar models already exist and that the purpose of the proposed legislation is to codify and provide greater oversight of these homes to ensure better outcomes for the children receiving services. SENATOR KIEHL stated that he looked forward to the upcoming testimony. 2:53:40 PM CHAIR CLAMAN expressed his belief that, in child-in-need-of-aid cases, DFCS or the involved parties typically propose placements. The court approves rather than initiates placements independently. He noted that the fiscal note decreased from $18,000 to $0. He asked how the changes in Senate committee substitute (SCS), version W, fiscally affected the department. MS. VOGELEY replied that version W includes language allowing a hearing to be vacated if all parties agree on the course of treatment. This aligns with the existing OCS team's decision- making process in which stakeholders determine appropriate services for a child. She stated that this provision would reduce or eliminate additional costs, resulting in a zero fiscal note. 2:55:39 PM CHAIR CLAMAN announced invited testimony on HB 36. CHAIR CLAMAN invited Ms. Malchick to identify herself for the record and speak to the SCS, version W. 2:55:57 PM BARBARA MALCHICK, Member, Board of Directors, Facing Foster Care in Alaska (FFCA), Anchorage, Alaska, testified by invitation in support of HB 36, version W, with remarks as paraphrased: Mostly, my comments are going to be directed to Section 4 of the bill, which is the short-term psychiatric hospitalization on pages 6 and 7 of version W that I'm looking at. A little bit about me. I've been involved with FFCA since it began over 20 years ago, and I've been on its board of directors since it became a nonprofit in 2012. Prior to that, I was a guardian ad litem supervising attorney with the Office of Public Advocacy (OPA) beginning in 1984. I retired from OPA and stopped practicing law in 2010, and then worked part-time for the court system, developing training criteria for all the parties involved in child-in- need-of-aid custody cases. In my past role as a guardian ad litem (GAL) and attorney, and my current role as an FFCA board member, I have represented and come into contact with hundreds and most probably thousands of children and youth in the foster care system, many of whom have spent time in emergency psychiatric hospital settings. Sadly, those stories have not changed all that much in the past 40 years. Youth have been told that they were only admitted to the hospital because there was no other place they could go, like a foster home, or they were not told at all why they were admitted. I'm thinking that a lot of you in the committee hearing today have talked with FFCA youth during their retreats in Juneau, and they've talked about their experiences in these hospitalizations. 2:58:00 PM MS. MALCHICK continued testifying by invitation on HB 36, version W, with remarks as paraphrased: Speaking [as] a former GAL, we never got notified when youth were placed in the hospital until long after the fact. There were no court hearings. There was no attorney appointed for the youth. Youth languished in these places for 30 days or even longer, many times. The youth suffered, being stigmatized, being traumatized from being in the hospital for a long time, where they may be overmedicated. It is pretty chaotic. Their school studies suffered. We believe that HB 36 is long overdue. It's a very important bill and a very necessary bill. About a year ago, the Alaska Supreme Court issued a decision in the "Quinhagak" case, where they addressed the situation of children in hospitals for psychiatric reasons and held that they have a constitutional right to a hearing as soon as reasonably possible after being placed in a hospital for mental health reasons. 2:59:12 PM MS. MALCHICK continued testifying by invitation on HB 36, version W, with remarks as paraphrased: There is currently no statute that addresses this situation. There is a statute, AS 47.10.087, which actually was set forth on page 5 of this bill, and that talks about situations where OCS is required to get prior court authorization in order to place the youth in a long-term residential psychiatric hospital. But there's never been a statute that addresses the situation of a child who is in crisis, an emergency situation where they need to go to the hospital, and there is no time to get prior court authorization to do that. FFCA supports the bill for a number of reasons. In subsection (a) of the bill, it recognizes that OCS has the authority to make emergency placements for youth without prior court authorization. There is a necessary standard there to make sure it is an actual emergency: the child is in crisis, you have a mental health issue that they may harm themselves or somebody else, and also there is no less restrictive setting for the youth. 3:00:25 PM MS. MALCHICK continued testifying by invitation on HB 36, version W, with remarks as paraphrased: Subsection (b) provides that notice must be given immediately, within 24 hours, to all the parties involved in the child-in-need-of-aid case, the child, the guardian ad litem, the parents, the tribes, if there is a tribe, any party, and anybody who has been accepted as a legal party to the case would get notification. I think the really important part of subsection (b) is that OCS needs to start looking as soon as possible, promptly, for less restrictive settings. So, we do not get in a situation where the child is ready to be released, but OCS has not taken the opportunity to look for other placements. Another section of the bill, which is way later on page 13, would amend the child-in-need-of-aid court rule that would require the appointment of an attorney for a youth involved in this situation, which we support. 3:01:41 PM MS. MALCHICK continued testifying by invitation on HB 36, version W, with remarks as paraphrased: Subsection (c) of the bill, I guess, is the key provision, which talks about the time for a hearing. Although FFCA would have preferred a shorter time frame for the hearing, we are okay with the 7 days after the hospitalization. At that point, we should be able to weed out the youth who do not belong there, who did not belong there initially, or who are stabilized enough to be released at that point. It is also an important time to get the parties all together to get the ball rolling on finding a less restrictive setting. As the previous testifier mentioned, there are team meetings where everyone gets together and tries to figure out the best next placement. If that results in agreement with everybody, including the child, after talking with their attorney, then the court hearing can be vacated. I guess that is about all that I had to address. I am happy to answer any questions. We appreciate all the hard work that Senator Claman and Representative Gray have done, and I think it's been kind of a collaborative effort to come up with the bill the way it looks right now. 3:03:25 PM COREY GOHEEN, Chapter Chair, Family Focused Treatment Association (FFTA), Ketchikan, Alaska, testified by invitation in support of HB 36. She provided a brief overview of her background, stating that she has served for the past 14 years in the therapeutic foster care field and has 13 years of experience as a licenser. She said her team reviewed the proposed changes to HB 36 and believes the bill would remove certain licensing barriers. She emphasized the importance of differentiating between traditional OCS foster care homes and treatment foster care homes. MS. GOHEEN discussed training expectations that differ from traditional foster homes, including best practices and ongoing monitoring. She explained that monitoring allows the therapeutic clinical team to make recommendations to families to better support youth in their homes. She said training includes plan development, the Pressley Ridge curriculum, medication management, and medical training for medically fragile youth, describing the training as specialized. MS. GOHEEN stated that the Pressley Ridge curriculum requires approximately 40 hours to complete. She said accreditors require additional annual measures. She expressed her understanding that, as a result of [Section] 1115 [of the Social Security Act,] agencies are required to be accredited. She explained that different accreditation bodies establish standards that require a higher level of care than traditional foster care. She said the expectation is that services are delivered as a team, including 24-hour crisis support and coordination of services across home, school, and other settings to support youth with complex needs. MS. GOHEEN expressed her belief that HB 36 would remove barriers and streamline the licensing process. 3:08:38 PM CHAIR CLAMAN opened public testimony on HB 36. 3:09:00 PM LEON JAIMES, representing self, Anchorage, Alaska, testified in support of HB 36. He stated that he recently served as a juror in a homicide case and said the experience highlighted systemic gaps in social support systems. He explained that the individuals involved in the case, including the victim, the defendant, and many of the witnesses reflected missed opportunities for intervention during childhood. MR. JAIMES stated that the impacts of the case were significant for the victim's family, friends, and community, and noted that the defendant would face long-term incarceration at state expense. He expressed the view that the outcome was avoidable. MR. JAIMES stated that a family member at sentencing urged the state to address systemic failures that did not meet the defendant's needs during childhood. He said it seemed to him that psychiatric care appeared to have been used inappropriately as an intervention. MR. JAIMES stated that HB 36 represents a step toward addressing those systemic issues and encouraged the committee to advance the bill. 3:10:42 PM CHAIR CLAMAN closed public testimony on HB 36. CHAIR CLAMAN invited the bill sponsor to provide comments on HB 36. 3:10:54 PM REPRESENTATIVE ANDREW GRAY, District 20, Alaska State Legislature, Juneau, Alaska, sponsor of HB 36, stated that foster children are extraordinarily vulnerable to being hospitalized in short-term psychiatric facilities and often remain there longer than other children. They are held there too long in a way that other children are not. He explained that this is mainly because history has shown that OCS does not advocate as a parent would for their own child. These short-term psychiatric facilities often end up serving as a placement. REPRESENTATIVE GRAY said he shares Senator Tobin's concerns about the potential for unintended consequences of creating a new license. He noted that new licensure language was added that day and that he is still reviewing it. REPRESENTATIVE GRAY addressed Senator Kiehl's concerns regarding provider type. It is important to discuss what often happens with foster kids when they end up at a short-term psychiatric facility. He explained that foster children placed in short-term psychiatric facilities often have experienced trauma that led to their removal from home and that the removal itself is traumatic. He said behavioral issues are common and that children may act out in their placements. He stated that in some cases, when a child is out of control, foster parents have limited options. He said a child may threaten suicide, prompting transport to an emergency department. He explained that a doctor, acting out of an abundance of caution, may diagnose suicidal ideation and recommend a hold, resulting in placement in an acute psychiatric facility. That foster parent is not going to be taking the child back. The child ends up there and is held for long periods. 3:13:06 PM REPRESENTATIVE GRAY continued making comments on HB 36: REPRESENTATIVE GRAY said he has worked on the bill for a long time. He explained that in discussions with the commissioner and the Department of Family and Community Services, he identified a gap in Alaska's system between therapeutic foster homes and psychiatric facilities. He said therapeutic foster homes function as a step above traditional foster homes and often serve youth with more severe behavioral issues. He stated that even in therapeutic foster homes, behaviors can become unmanageable, including property damage and injuries to other children in the home. He said in those situations it is not safe for the therapeutic foster parent to continue the placement, and the child often ends up in a psychiatric facility. REPRESENTATIVE GRAY said some states have developed models that provide an intermediate option. He expressed his belief that this is the intent of the new licensure language. He stated that many of these children are traumatized rather than mentally ill and do not necessarily require antipsychotic medication. He agreed with Senator Tobin that the legislature must carefully consider the potential consequences of creating a new license. He said the motivation for the license is the lack of an option between a therapeutic foster home and a psychiatric facility. He emphasized that finding that middle ground is important and relevant to the bill. 3:15:10 PM CHAIR CLAMAN held HB 36 in committee.