SB 72-DESIGNATED CAREGIVERS FOR PATIENTS  3:04:21 PM CHAIR SEATON announced that the first order of business would be CS FOR SENATE BILL NO. 72(L&C), "An Act relating to the discharge of patients from hospitals and to caregivers of patients after discharge from a hospital; and providing for an effective date." 3:04:52 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature was available to offer the sectional and answer questions. EMMY VAN WHY, Intern, Senator Cathy Giessel, Alaska State Legislature, paraphrased the sponsor statement, as follows: Senate Bill 72, the caregiver advise, record, and enable act, or the Care Act is not about hospitals, it's not really even about patients, it's about caregivers. And it's important to reduce health care costs and improve the health of Alaska citizens. This bill seeks to improve post-discharge health outcomes for patients by improving coordination with designated caregivers, providing training to caregivers on discharge tasks, enabling older or disabled Alaskans to stay safely in their homes longer, and decreasing the likelihood of hospital readmissions. At any given time, around 128,000 Alaskans are providing some type of caregiving services and support to a loved one, friend, or neighbor. This assistance is crucial and helps patients remain healthy in their homes as long as possible. This is also a better alternative than costly long-term care facilities like nursing homes. And it is estimated to save approximately $1 billion that would otherwise be spent by the state. Alaska caregivers are increasingly being asked to perform complex nursing and medical tasks, such as dispensing countless medications, administering injections and providing wound care often with little or no training. Many family caregivers report that they received little or no training to perform these tasks and ended up stressed and with a lack of confidence. Lack of adequate preparation to perform post-discharge tasks jeopardizes the patient's recovery, as well as often puts the caregiver at risk for their own injury and burnout. Most of all, SB 72 will help Alaskans to live independently at home and will support the family caregivers who make this possible. Many states, 20 so far, have passed the Care Act or similar legislation and several other states are in the process. And, SB 72 contains these important provisions: it allows the patient to name a lay caregiver with his or her consent to provide after-care following discharge from the hospital; the designated caregiver is notified of the patient's discharge or transfer to another facility; the hospital consults with the designated caregiver and offers training to the caregiver for aftercare medical or nursing tasks, either in person or through video instruction; and the hospital will adopt and maintain written policies. And, we'd be happy to walk through the sectional, Mr. Chairman, if you'd like. CHAIR SEATON asked Ms. Conway to go through the sectional. 3:07:59 PM MS. CONWAY paraphrased from the Sectional Overview [included in members' packets], which read, [original punctuation provided]: Section 1. AS 18.20 adds new sections:  Sec. 18.20.500: Requires hospital, before discharge, assess the patient, provide patient opportunity to designate a caregiver, who consents/agrees to provide patient with aftercare Sec. 18.20.510: Requires a hospital to provide opportunity for a designated caregiver to participate in the discharge planning of the patient; and that the hospital provide training and/or instruction to the designated caregiver on how to perform medical and nursing aftercare prior to patient's discharge Sec. 18.20.520: Requires a hospital to notify the designated caregiver of the patient's discharge or transfer Sec. 18.20.530: Directs the hospital to adopt and maintain written discharge policies. The policies must comply with this chapter. The written policy must specify requirements for naming of the designated caregiver and those policies may incorporate best practices for hospital discharge planning, such as those outlined in Center for Medicaid and Medicare Services (CMS) …and that the discharge plan is appropriate for the patient's condition. The discharge plan may not delay a discharge or transfer of a patient or oblige hospital to divulge patient's health information to the designated caregiver without patient's consent Sec. 18.20.540: The hospital and its contractors are protected from lawsuit in regard to the discharge planning of a patient Sec. 18.20.550: This chapter many (sic) not interfere with or supersede the powers/duties of an agent or legal guardian acting upon a health care directive Sec. 18.20.590: Provides definitions Section 2: effective date of January 1, 2017. 3:10:46 PM CHAIR SEATON asked whether this was for all patients after discharge, and noted there were no age requirements or condition requirements. He opined that this allows them to designate but does not require that it be done. MS. CONWAY said correct. 3:11:21 PM REPRESENTATIVE TARR offered that she understands why the fiscal note from the state would be zero, and asked for the response from health care providers and possible increase in costs for hospitals. MS. CONWAY replied that the sponsor's office has worked closely with the Alaska State Hospital and Nursing Home Association (ASHNHA), the American Association of Retired Persons (AARP), and the Alaska Nurses Association. She explained that SB 72 maps out policies that they strive to do, and that most hospitals actually do have fairly good discharge planning policies, but not all. This legislation would bring all hospitals in alignment with each other, which has been an active cooperation between those three entities and the sponsor's office, she said. CHAIR SEATON opened public testimony. 3:12:54 PM KATHLEEN TODD, M.D., asked whether this only applies to inpatient admissions, overnight outpatient observation, or is it to every emergency room visit which actually would be a costly and difficult thing to do. Also, she opined that according to the Nursing Practice Act from a few years ago, nurses are not allowed by their rules to teach anyone who is not a nurse and is not a family member to do things that usually are only done by nurses. They are not to teach aides or persons hired to get the patient in and out of bed and into their wheelchair, those people cannot do things that are deemed to be nursing acts. This bill would probably be a step in the right direction if it is, in fact, counter mandating that and saying that the paid caregiver can be taught, who is not a family member, how to take care of a burn as opposed to having to either assign an RN or find a family member. She is hopeful this is a step in the right direction and that it doesn't apply to every single emergency room visit, she related. MS. CONWAY answered that the bill is for hospital admissions only, not emergency rooms. She deferred to Jeannie Monk for the answer to Dr. Todd's second question. CHAIR SEATON clarified that the second question related to the ability to train or teach care to non-family members. 3:15:44 PM JEANNIE MONK, Senior Program Officer, Alaska State Hospital and Nursing Home Association (ASHNHA), in response to the second question opined that the bill is focused on unpaid family caregivers. These unpaid family caregivers provide a wide range of care at home, although, some of it could be nursing level if the patient was in a facility. She explained that family members are asked to give medication, wound care, and a variety of care that would require a nurse if they were in a nursing home, and when the patient is in their own home it is up to the family members. She said she is unaware of anything that precludes hospital staff training family caregivers in how to care for their loved ones once they go home. She pointed out that this is something that happens every day already, and no change is being proposed in what is already happening. CHAIR SEATON related that the bill will be up for another hearing on Tuesday, and suggested that possibly she could address that issue and get back to the committee. MS. MONK said she would leave it to the sponsor to contact the Nurses Association or someone with the answer. 3:17:08 PM REPRESENTATIVE TARR asked whether this was a billable service, how much time would be spent on this particular component, and how is it reimbursed to the hospital. MS. MONK responded that ASHNHA has been working with the sponsor's office and AARP for more than one year. The original version was prescriptive with specific timelines with concerns of adding extra work with modifications of electronic health records, they feel fine about Version Y. She related that it will add some additional work but for the most part hospitals already have discharge policies and this legislation forces them to strengthen their discharge policies in a helpful manner. A large problem hospitals face is when there is not a family caregiver. The best possible scenario is when a person is willing to be designated as the patient's caregiver and willing to be trained. Hospitals want to be sure those caregivers have the skills they need to take care of their family member at home and this will require hospitals to modify their discharge policies. There is a national CMS rule very similar to this, she pointed out. 3:18:44 PM REPRESENTATIVE TARR asked whether this was a billable service. MS. MONK replied that she would not say yes or no because hospital billing is complicated. Discharge planning is part of the billable services that hospitals do, and she said she was unsure whether it was a standalone billable code. 3:21:16 PM REPRESENTATIVE VAZQUEZ said that this bill is needed and she appreciates its intent; however, the chapter dealing with the definition of hospital is broad. She referred to AS 18.20.210(5), which read as follows: (5) "hospital" includes a public health center and general, tuberculosis, mental, chronic disease, and other type of hospital, and related facilities, including laboratory, outpatient department, nurses' homes, and training facilities, and central services facilities operated in connection with a hospital, but does not include a hospital furnishing primarily domiciliary care; REPRESENTATIVE VAZQUEZ reiterated that it is a broad definition. CHAIR SEATON asked whether she was reading the definition in AS 18.21.130. REPRESENTATIVE VAZQUEZ responded no, there is another definition presently in the statutes, and she did not see where this was totally replacing that definition. MS. MONK offered that this legislation does not change any of the definitions, it is referencing the definition of hospital and no changes are proposed to change any definitions. 3:23:26 PM REPRESENTATIVE VAZQUEZ pointed out that she was reading the definition AS 18.20.210, in the chapter dealing with "hospitals." She referred to Article 02. Alaska Hospital and Medical Facilities Survey and Construction Act, AS 18.20.140 - 18.20.220, and she said she was wondering whether something needed to be reconciled. CHAIR SEATON suggested asking the sponsor to address the definition of hospitals. REPRESENTATIVE VAZQUEZ noted that it is not impossible to fix and that she was bringing up the possible unintended consequences. MS. MONK said it was important to the drafters that this not apply to hospitals treating mental disorders, that it be limited to hospitals providing "traditional hospital services." 3:25:21 PM MARIE DARLIN, AARP, agreed that there has been a lot of work on this legislation to make it acceptable to all stakeholders. She pointed out that a lot of the information the committee has been provided in support of this legislation speaks to the fact there are approximately 8,500 people providing unpaid care. This legislation does not address paid caregivers, this is for the unpaid family caregiver who takes care of the patient after they leave the hospital. A concern of AARP is that there are thousands and thousands of people doing this job that need this kind of information to help them when taking the patient home. MS. DARLIN pointed out that this legislation is not intended to cover a lot of other things, even the definition of hospital. It has been reviewed so that everyone is in agreement, some hospitals are already doing it and doing a good job of it. This also places responsibility so that there is an assigned caregiver because too many people go home from the hospital with no caregiver, or no one actually assigned the responsibility to take care of that patient. By having an assigned caregiver possibly the patient will not end up back in the hospital again because they didn't receive the proper care at home. 3:28:13 PM JAYNE ANDREEN, AARP, said she supports the testimony of Marie Darlin in that this bill does a great job of recognizing the role that caretakers have to provide, how important that is in keeping people out of readmission to the hospital, and keeping health care costs down. She offered that she has provided aftercare for a loved one and it can be confusing, especially when discussing wounds, treatment, bandaging, and various medications. She said that a caregiver has the ability to obtain the information they need. CHAIR SEATON asked whether her understanding of the bill is also that this allows a patient to designate a caregiver, but it's not assigning a caregiver. MS. ANDREEN agreed that is her understanding. 3:29:29 PM KEN HELANDER, Advocacy Director, AARP, pointed out that the bill is not about hospitals or even patients, it's about caregivers. A study performed by the AARP Public Policy Institute a few years ago found that approximately 46 percent of family caregivers were faced with providing these complex medical tasks when a family member was discharged. This would include anything from medications or special diets to wound care, and/or operating specialized medical equipment. He asked the committee to consider someone going in for a hip replacement and at discharge the caregiver is not prepared and does not understand how to transfer that person, or assist in their mobility, and that the risk of injury for the patient and the caregiver is enormous. This bill was drafted as model legislation, he explained, that has been passed in 22 states, to support family caregivers with the idea that no family member, no lay caregiver, should have to face these kinds of stresses and perform these kinds of tasks at home alone because it increases stress, the risk of injury, and certainly of hospital readmission. He reminded the committee that readmission is costly for hospitals. During these budget times in Alaska, the idea of having a readmission, or a burned out family member caregiver, and having to place the patient in paid care somewhere, ultimately, will have an impact on the state budget. He put forth that there are approximately 88,000 family caregivers in the State of Alaska at any given time, and over the course of a year it is approximately 128,000. When doing the math, he said, with the cost of a nursing home approximately $27,000 a month, it's easy to see how supporting family caregivers is the way to go, and this bill is about supporting family, friends, or neighbor caregivers. 3:32:45 PM CHAIR SEATON, after ascertaining no one further wished to testify, closed public testimony. CHAIR SEATON asked the sponsor's staff to address the two previous questions: looking at the ability for nurses to teach non-family members the levels of care necessary, and the definition of hospital. MS. CONWAY said she would research the answers and appear before the committee next week. 3:35:00 PM REPRESENTATIVE VAZQUEZ clarified that the whole section adds additional provisions to Article 04. Overtime limitations for nurses. She related that the definition is confusing because it is plugging that section in here when perhaps it should be inserted under Article 01. Regulation of hospitals, where there is another hospital definition cited. It may be more appropriate to have the entire bill inserted under the regulation of hospitals versus overtime limitations for nurses. CHAIR SEATON noted that Ms. Conway understands the question and will research it and come back to the committee. 3:36:02 PM REPRESENTATIVE VAZQUEZ asked why this legislation exempts mental hospitals. MS. CONWAY opined that a discharge plan for mentally disabled could be far different and more complicated than a regular hospital discharge, and the drafters stayed with medical. REPRESENTATIVE VAZQUEZ said she understood why it would simplify the matter, but it has been her personal experience that this requirement would be needed in a mental health setting. Perhaps, even more critically, and it may be something down the road in dealing with the different stakeholders, she said. CHAIR SEATON asked Ms. Conway to discuss the issue and advise the committee. 3:37:37 PM MS. CONWAY referred to the National Care Act, the Caregiver Advise, Report, and Enable Act, and said it was a national model legislation and basically all of the states implementing this type of legislation deal with the medical side. When the sponsor was approached by AARP about legislation it was about medical discharge planning. REPRESENTATIVE VAZQUEZ said it is a step in the right direction and Rome wasn't built in a day. [SB 72 was held over.]