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." 1:37:25 PM Co-Chair Johnston requested a bill introduction from the sponsor and staff. REPRESENTATIVE MATT CLAMAN, SPONSOR, introduced the bill with prepared remarks: Those living with serious mental health disorders are subject to periodic recurrent psychiatric emergencies or crises that require prompt medical attention and stabilization. Factors such as the lack of timely access to essential services and supports, substance abuse disorders, unstable housing and homelessness, and poverty exacerbate these crises. In Alaska and across the nation we face challenges in how we address people in crisis. Current treatment options for those in crisis are largely 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. 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 lay outside the traditional scope of psychiatric stabilization. Police officers, hospital emergency departments, correctional facilities, and social service providers are often on the frontline of dealing with those experiencing a behavioral health crisis. These individuals and organizations are already at capacity in dealing with their primary functions in public safety and health services. House Bill 290 is the first step in adding a much needed intermediate treatment option for those suffering from a mental health crisis. Created by the National Association of State Mental Health Directors, the National Council for Behavioral Health, RI International, and Suicide Prevention Groups and known as the "Crisis Now" model, crisis stabilization centers are community-based interventions to better serve those experiencing intermediate mental health crises. These facilities are open 24 hours a day, 7 days a week, 365 days a year; are staffed by mental health professionals; have a no wrong door approach; and are designed to provide prompt mental health evaluation and stabilization. Crisis stabilization centers have already proved to be a successful community tool in other states including Arizona and Washington. 1:40:27 PM Representative Claman noted that the Alaska Mental Health Trust Authority (AMHTA) paid to bring a number of people to take a tour in Arizona. He acknowledged that Co-Chair Johnston had attended the tour. He shared that he had been in Arizona on other matters and had done a tour himself. He reported that the facility in the Phoenix suburb of Peoria was operated by a private group. He stated it had been inspiring to see how well the facility worked and to hear from police officers about how satisfied they were with the option for dealing with people with a mental health crisis and as an alternative to dealing with people they may have to otherwise arrest. He continued reading from prepared remarks: No facilities currently exist in Alaska. HB 290 authorizes the Department of Health and Social Services to write regulations to permit and license crisis stabilization centers in Alaska. Once the regulations are in place, it is anticipated that interested providers will open crisis stabilization centers in Alaska's communities. House Bill 290 also gives our public safety professionals an essential alternative to improve public safety. It amends 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. Using the crisis stabilization alternative would require the police officer to find that the 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. House Bill 290 ensures that even if a person is taken to a crisis stabilization center, they can still be prosecuted for alleged criminal activity. Representative Claman thanked AMHTA for committing resources to urge getting crisis stabilization centers in Alaska. His office had worked with the Department of Health and Social Services, particularly Deputy Commissioner Al Wall. He reported that a number of changes had been made to the original bill version to address concerns raised by the Department of Law, Criminal and Civil Divisions. His office had long discussions with the Alaska Network on Domestic Violence and Sexual Assault and had made adjustments to the bill in regard to their concerns. Additionally, they had a number of calls with the Anchorage Police Department. He shared that all of the groups were supportive of the bill. He asked his staff to present the sectional analysis. 1:43:04 PM SOPHIE JONAS, STAFF, REPRESENTATIVE MATT CLAMAN, reviewed a sectional analysis (copy on file): Section 1 AS 12.25.030. Grounds For Arrest By Private Person or Peace Officer Without Warrant Amends AS 12.25.030 by adding a new section providing peace officers with an alternative to arrest. An officer may, at their discretion, deliver a person to a crisis stabilization center or evaluation facility instead of arresting them if the officer believes that the person is suffering from an acute episode of mental illness or if the person voluntarily agrees to be taken to a crisis stabilization center or evaluation facility. Taking an individual to a crisis stabilization center or evaluation facility, as provided for in this section, does not bar prosecution of the individual for alleged criminal activity or on charges for the original grounds for arrest. Section 2 AS 18.65.530 Mandatory Arrest For Crimes Involving Domestic Violence, Violation of Protective Orders, and Violation of Conditions of Release. Amends AS 18.65.530(c) 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 has authorization from a prosecuting attorney in the jurisdiction in which the offense under investigation arose to deliver the person to a crisis stabilization center or an evaluation facility as provided in AS 12.25.031(b) because the person is subject to involuntary commitment under AS 47.30.705. Section 3 AS 18.65.530 Adds a new subsection (g) to AS 18.65.530 that requires a peace officer who delivers a person to a crisis stabilization center or evaluation facility to leave their contact information with the crisis stabilization center or evaluation facility and, if notified of a release from crisis stabilization under AS 12.25.031(d), to make reasonable efforts to inform the victim of a crime under (a)(1) and (2) of AS 18.65.530. Section 4 AS 47.30.705 Mental Health Emergency Detention for Evaluation Amends 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. 1:45:31 PM Ms. Jonas continued to review the sectional analysis: Section 5 AS 47.30.710 Mental Health Examination Amends AS 47.30.710(a) to provide for an examination by a medical professional within three hours for those brought to crisis stabilization centers. Section 6 AS 47.32.010 Centralized Licensing and Related Administrative Procedures Purpose and Applicability Amends AS 47.32.010(b) to allow licensing of crisis stabilization centers under Chapter 32. Section 7 AS 47.32 Centralized Licensing and Related Administrative Procedures Amends AS 47.32.900 to expand the definition of crisis stabilization centers to include 23-hour crisis stabilization, crisis residential centers, and sub- acute facilities. Section 8 Uncodified Law of the State of Alaska Amends sec. 6 of this act to allow the Department of Health and Social Services, before a crisis stabilization center is licensed under AS 47.32.010(b), to issue a provisional license to or reimbursement to a crisis stabilization center. Ms. Jonas thanked the committee for the opportunity to present. 1:46:31 PM Co-Chair Johnston asked members to hold questions until after hearing from invited testifiers. STEVE WILLIAMS, CHIEF FINANCIAL OFFICER, ALASKA MENTAL HEALTH TRUST AUTHORITY (via teleconference), spoke in support of the bill. He read from a prepared statement: The trust supports HB 290. As you are aware, Alaska's psychiatric continuum of care is not a full continuum. It currently relies on the most expensive level of care, API, and at other times expensive and inappropriate levels of care, hospital emergency rooms and Alaska jails, to address the needs of Alaskans who are in acute psychiatric crisis. This is not the best way to expend the state's limited financial resources or provide care to Alaskans in a medical crisis. Currently, the Department of Health and Social Services, law enforcement agencies, local hospitals and nonprofit behavioral health providers, tribal health organizations and the trust, and many others, are collaborating to develop community-based psychiatric crisis service components. These components are based on the best practice model called Crisis Now and those components include a 24-hour crisis call center, a 24/7 mobile crisis team, and crisis stabilization centers that operate 24 hours per day, 365 days a year, and accept all persons with a no-refusal policy. These crisis stabilization centers provide law enforcement an option to divert someone in a psychiatric crisis to a location with trained professionals and peers who can address their needs rather than having a law enforcement officer wait for hours at an emergency room or have a person handcuffed in the back of their patrol car for hours until treatment services are available or they might end up inappropriately in a jail. Rather, the officer can appropriately and efficiently meet the needs of the individual in psychiatric crisis by taking them to a psychiatric stabilization center, allowing the officer to return to the street to perform more traditional public safety duties and minutes. HB 290 provides some of the critical policy tools for law enforcement and the healthcare system to effectively implement these much needed services to dramatically enhance our psychiatric crisis continuum of care. The trust believes HB 290 will help the State of Alaska move forward with implementation of community solutions to better respond to individuals in a mental health or substance use related crisis to get them to the proper services to receive the appropriate interventions by individuals appropriately trained. If you're interested in learning more about the Crisis Now model, I would encourage members to go to crisisnow.com and on their homepage there's a short two to three minute video that explains the model and how it operates. 1:50:12 PM Representative Sullivan-Leonard referenced the fiscal note. She asked if AMHTA was in a position to financially assist with the endeavor. Mr. Williams answered that AMHTA had historically committed funding and would continue to financially assist in the development and implementation of the model. Trustees had allocated over $2 million to the effort and the trust was committed for the long haul to ensure the services were available in Alaska. Representative Carpenter had questions related to the victim of a crime. Representative Claman requested to hold the constitutional questions until invited testimony was completed. AL WALL, DEPUTY COMMISSIONER, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via teleconference), discussed that the Department of Health and Social Services (DHSS) had put forward an 1115 Medicaid waiver. He detailed that the waiver was in part to fill in the gaps in the continuum of care for behavioral health. The efforts for the 1115 waiver would need the structure of things like crisis stabilization in order for its implementation, which he believed was supported by the legislation. He noted that the department had been happy to work with the bill sponsor. Mr. Wall communicated that crisis stabilization was an essential piece of any continuum of care and it would successfully shift the bulk of the efforts currently underway. He elaborated that behavioral health efforts were generally focused on crisis and acuity. He explained that because there were some gaps in service in the behavioral health continuum of care, they tended to wait until an individual was in absolute crisis and showed up in the back of a squad car or in the emergency room before they received any care. The incident typically resulted in the person being arrested or in need of inpatient psychiatric care. Crisis stabilization centers would be a step toward stabilization in community, which was less expensive to care for individuals and had been proven to be better care. Historically, the more stabilization focused care provided in community for people, the better the outcomes had been. 1:53:59 PM Mr. Wall addressed the department's two fiscal notes. The first note was related to regulatory oversight of a new type of license. He elaborated that any facility that touched Medicaid or had patients, needed oversight for licensure. The department did surveys and investigation of harm if needed, which required personnel that needed to be funded. There was also the implementation of billing codes in the MMIS [Medicaid Management Information System] computer system for the new provider type. He highlighted that significant savings were anticipated through the effort. He explained that the longer the state waited until a person was in absolute need of acute inpatient psychiatric care, the more it cost the state and the individual. He reported that the care at an instate psychiatric hospital was much more expensive and typically involved an emergency room visit and/or court time, lawyer fees, and jailtime. He reiterated that savings were expected, but he did not have a specific amount to include in the fiscal note. 1:55:35 PM Representative Knopp asked if there were any positions in DHSS funded through AMHTA. He was skeptical of any more unrestricted general funds (UGF) going to any positions. He stated he would be more receptive to the idea if they were funded through AMHTA. He asked if it would be feasible to incorporate the crisis stabilization center on the grounds at the Alaska Psychiatric Institute (API). He asked what the statewide plan would be. He wondered if there would be a crisis center in multiple regions throughout the state. Mr. Wall replied that AMHTA helped fund a number of positions in DHSS related to various issues. He elaborated that typically AMHTA funded half a position, with the other half funded by the state. In regard to the bill topic, the effort was not isolated. He explained that coexisting with a crisis stabilization center there would need to be coordination and communication regarding which patients were going were. The coordination may or may not be directly in the crisis stabilization center, meaning it likely not a person in a specific crisis stabilization center, but there would still need to be someone "directing traffic." Mr. Wall detailed that if a crisis stabilization center had a person who needed to go to inpatient psychiatric care there would have to be a coordinator assisting with the process. He shared that the position was part of the Morse Plan and was partially funded through the trust. He noted that it was not specifically in the bill, but the efforts of crisis stabilization were not isolated - the issue required coordination across DHSS and with the Department of Corrections and the Department of Public Safety as well. Mr. Wall cautioned against thinking the bill would result in a "light switch approach" where on July 1 all of a sudden there would be crisis stabilization centers all over the state and everything would be fixed. He underscored that would not occur. The efforts would be phased in over time with the first efforts focusing on the more populated areas where the highest need existed. He referenced an RI International study focused on Anchorage and Fairbanks and relayed that the initial phase of the work would be on Anchorage. He highlighted that the plan was adaptable to other areas including rural areas. Mr. Wall shared that the trips to Arizona had demonstrated that the approach worked if modified, not only in rural areas, but also with tribal organizations. If the bill passed, the department planned on rolling out the 1115 services beginning with crisis stabilization centers in the state's more populous urban areas. Subsequently, there would be modifications made to accommodate a regional approach. 1:59:38 PM Representative Knopp relayed that earlier in the day the committee had considered legislation related to administering psychotropic drugs. He asked if there was a need for advanced practice registered nurses (APRN) or registered nurses in the crisis intervention centers. He asked if that was the case in the facilities in Arizona. Mr. Wall answered that Arizona and the Crisis Now model (utilized by RI International) used licensed independent practitioners. There were advanced nurse practitioners and physician assistants that worked in the particular field. He explained that the crisis med bill [SB 120] discussed earlier in the day had to do with involuntary commitments and individuals who are administered medications involuntarily. He clarified that the crisis stabilization center setting would be voluntary. 2:01:12 PM Representative Wool thanked the bill sponsor, AMHTA, and DHSS for bringing the legislation forward. He noted that the committee had heard a presentation on the Arizona model from AMHTA earlier in the year. He believed the approach was a step in the right direction. He remarked on the testimony that someone could not be held against their will in one of the centers. He reasoned it was not like being arrested and put in jail while law enforcement figured out where the person should go. He asked for confirmation that a person had to be willing to go stay in one of the facilities even if they needed inpatient psychiatric care. Representative Claman made a correction to Mr. Wall's testimony. He clarified that the provisions of the bill allowed a voluntary placement in the crisis stabilization center, but an officer also had the authority to admit someone subject to involuntary commitment into a crisis stabilization center for a limited time. Representative Wool referenced bill language about a 23-hour crisis observation stabilization center. He asked if the 23 hours reflected the legally allowable timeframe. Representative Claman replied in the affirmative. Representative Wool referenced bill language specifying that only a small number may need long-term services through a subacute residential crisis center or inpatient psychiatric care. He stated that API was the only option available in Alaska. He detailed that the facility had 50 beds and was expensive. He asked if the state had a subacute residential crisis center. Mr. Wall made clarifying remarks pertaining to involuntary medication. He was aware the bill allowed for involuntary commitment to the crisis center. His remarks had pertained to the involuntary administration of medication addressed by other legislation [SB 120]. He moved to Representative Wool's question and confirmed there was a necessary full continuum of care. He highlighted that the RI International model had four pillars including a call center, crisis response teams, crisis stabilization center, and continuum of care. He explained that there was a broader application, the effort was not isolated. He confirmed that subacute care or "step down units" were needed - the availability in the state was extremely limited. Representative Wool spoke to involuntary administering of psychotropic or antipsychotic drugs. He thought it sounded like a physician assistant or APRN could prescribe dosages against a person's will for a limited period of time under a separate piece of legislation [SB 120]. He referenced Mr. Wall's testimony that the practice would not be allowed at the crisis stabilization centers. On the contrary, he thought that it would be a policy call for each center if the other legislation passed. He noted he was not weighing in on whether it was a good or bad idea. He reasoned it may be what was needed. He asked if the issue was addressed in either of the bills [HB 290 or SB 120]. 2:06:01 PM Mr. Wall did not believe the topic of involuntary medication was addressed in HB 290, nor did he believe the specific location was addressed in SB 120. He would have to speak with the department's attorney Steven Bookman and follow up with the committee. Representative Wool clarified that he was not taking a position on the issue and reasoned that it may be what was needed in the facilities. Representative Josephson stated that the bill created a definition called a crisis stabilization center and he was confident that Senator Cathy Giessel's bill [SB 120] did not refer to that. However, he wondered if someone in acute crisis taken to a crisis stabilization center could be involuntarily administered a drug. Mr. Wall responded that he would speak to the department's legal team and would follow up. He highlighted the system they had visited in Arizona and detailed that their entire system was built around de-escalation and stabilization. He explained that at the point on the service spectrum where people needed involuntary commitment and involuntary meds, the number of people needing services became a smaller and smaller. Currently, there were two outcomes for individuals taken to an emergency room and given a psychiatric evaluation due to their state of mind. He detailed that either the person was a danger to themselves or others and gravely disabled and they needed to be committed to care or they were not. Mr. Wall explained that the crisis stabilization center instituted another level of care focused on actual de- escalation and stabilization of their crisis in place. He addressed why he had been talking about not isolating the crisis stabilization center from the rest of the system of care. He detailed that the call center in Arizona was the first of the four pillars of the RI International study and it had been found to stabilize the vast majority of calls prior to getting to a crisis stabilization team. Likewise, when a crisis stabilization team was needed, the team stabilized a large percentage of cases before there was a need for going to a crisis stabilization center. Those individuals who went to a crisis stabilization center had an ever reducing percentage need for inpatient care. For example, Arizona had a far larger population than Alaska and it only had one inpatient psychiatric hospital as well with a slightly higher capacity than API. Mr. Wall stressed the effectiveness of the approach of stabilizing individuals in community without needing inpatient psychiatric care. He recognized there would be a percentage of the population that would need inpatient care due to the severity of their illness, but the crisis stabilization center in Arizona had proven extremely effective in reducing the incidence rates of inpatient psychiatric need and stabilizing individuals in community. 2:10:10 PM Representative Josephson asked for a repeat of the four pillars. Mr. Wall replied that the four pillars included a call center, crisis response teams, crisis stabilization center, and continuum of care. He elaborated that the call center acted as an air traffic control center for a region or entire state. The crisis response teams were comprised of a behavioral health technician and a peer or individual who had a behavioral health crisis in their past and had been trained to intervene with other people. The crisis stabilization center was a drop off center with "no wrong door" in terms of admittance. He elaborated that a person could walk in or be brought in by ambulance, police, or relatives. The fourth pillar was a more robust continuum of care that linked into the crisis stabilization center and looked like a handoff - called a "warm handoff" - specifically centered around the needs of the individual being stabilized. Some individuals had a stronger substance abuse need, while others had a stronger mental health need, and some individuals may have a stronger social determinate need. 2:11:51 PM ROBIN MINARD, CHIEF COMMUNICATIONS OFFICER, MAT-SU HEALTH FOUNDATION, WASILLA (via teleconference), testified in strong support of the bill. She read from prepared remarks: Foundation shares ownership in Mat-Su Regional Medical Center and we invest our share of the profits back into the community to promote health and wellness of Alaskans living in Mat-Su. I'm testifying today in strong support of House Bill 290 to change Alaska statute to allow for creation of crisis stabilization services as an alternative to arrest. We support this legislation because it paves the way for some of our most vulnerable residents to receive medical evaluation and care and lower cost settings than hospital emergency departments. This results in better outcomes and tremendous cost savings. As was mentioned earlier by Representative Claman, there's a crisis stabilization in Maricopa County, Arizona, similar to what could be created in Alaska and it's had stunning results over ten years' time. They've seen savings equivalent to 37 full-time law enforcement officers because it's less labor intensive to take people to a crisis stabilization drop off center than to book them into jail. They've had a reduction of 45 cumulative years of psychiatric boarding in hospital emergency departments and that represents a savings of $37 million in cost and they've had a reduction of $260 million in potential state-paid acute care inpatient expenses. Since the prevalence of mental health and substance use problems is increasing in our community and statewide, just think about what savings like that could mean to Alaska. 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 a shortage of outpatient treatment access. Additionally, from 2014 to 2017, the number of behavioral health assessments required for patients in crisis in the ED grew from 349 to more than 1,000. HB 290 will allow police to bring patients to a crisis stabilization center instead of a hospital emergency room or jail and will result in more humane treatment and great cost savings. In 2013, with our Mat-Su community health needs assessment, Mat-Su residents ranked health issues they were concerned about. The top five were all related to mental health and substance use. As a follow up to that assessment, we conducted a behavioral health environmental scan where we looked at policies that could address barriers to care and improve the behavioral health system challenges we're facing. One recommendation from that report was to add a crisis stabilization center to the behavioral health continuum of care; however, current state statute does not allow this to happen. HB 290 will change that. 2:14:51 PM Ms. Minard continued to read from a prepared statement: System change, such as what this legislation allows, will alleviate suffering for people experiencing behavioral health crisis while delivering significant cost savings, especially under Alaska's Medicaid program. The Mat-Su Health Foundation is in strong support and we urge you to pass this important legislation. Ms. Minard thanked the committee for its time. Representative Sullivan-Leonard thought the Mat-Su Regional Hospital ER had a triage system to evaluate patients in crisis mode. She mentioned the expansion of the hospital's third floor for behavioral health. She asked if there was a system in place where patients were triaged and then moved on to inpatient or outpatient behavioral health services at the hospital. Ms. Minard answered, "Sort of." She elaborated that the 16 behavioral health beds were open; however, there was no outpatient care or crisis center. She explained that a person could come in, but they were trying to avoid costly inpatient treatment. She detailed that if there was a crisis stabilization center where a person could go for 24 hours to be assessed, it may be determined the person did not need inpatient care versus immediately putting them into that costly limited setting. 2:16:30 PM Representative Sullivan-Leonard asked if there was a backlog of patients in the emergency room as they were triaged and possibly held for inpatient admittance or referral to another facility. Ms. Minard replied she could follow up with the information. She confirmed there were times when the emergency department was overwhelmed by people with behavioral health and other needs. The bill would allow the backlog to be alleviated somewhat. Representative LeBon thanked Ms. Minard for her testimony. He asked if the Mat-Su Health Foundation would be ready, willing, and able to assist in covering financial costs for a crisis stabilization center. Ms. Minard could not currently commit to covering future operating costs. She shared that the subject was a high priority for the foundation, and it had already committed financial resources to get the project to its current point. Co-Chair Johnston believed Mr. Wall had an answer to an earlier question. Mr. Wall communicated that he had spoken with the DHSS legal team and followed up on questions by Representative Wool and Representative Josephson about whether a crisis stabilization center would be able to administer crisis involuntary medication under SB 120, which had been discussed earlier in the day. He explained that it depended on the designation of the crisis stabilization center. He elaborated that could be administered at a designated evaluation and treatment center or a designated evaluation and stabilization center. The centers were regulated by the state with very specific psychiatric credentials and training. He expounded that if a crisis stabilization center went the extra step to become a designated evaluation and treatment center it would be possible to administer involuntary medication at the location. 2:19:00 PM Representative Wool thought it sounded like the crisis stabilization centers were not really set up for different levels of care and intervention. He believed a considerable amount of staff would be needed to involuntarily administer medication. He thought a person may be taken to a psychiatric facility if the situation escalated to that level. He surmised it would depend on a facility's certification level. Mr. Wall agreed. He detailed that crisis stabilization centers were focused on de-escalation and stabilization to the greatest extent possible. There was a small percentage of the population whose severity of illness would require them to receive inpatient psychiatric care. Crisis stabilization centers would be able to refer and follow the proper procedure to get their patients into inpatient care if needed. He explained that because the stabilization centers would be keeping so many patients out of inpatient psychiatric care, it would take the pressure off the system of designated evaluation and treatment centers including API and would give more flexibility and availability of beds. The long-term goal of the crisis stabilization centers was to take the pressure off the inpatient psychiatric system (as proven in other states). The conversation would stop being about the lack of beds and become one of stabilization and community. The department believed the best route would be to relieve pressure from inpatient psychiatric hospitals. Representative Wool referenced the language highlighted by the bill sponsor that the centers would provide an alternative to arrest. He stated his understanding that being taken to a center by the police was not the only way a person could end up there. Additionally, a person could walk in or be brought in by a family member. He asked for verification it would be like going to the emergency room or an urgent care clinic, but the center would be for psychiatric evaluation. Mr. Wall agreed. He added that if done properly the crisis centers, as evidenced in Arizona, had a more significant impact on the substance abuse population. There was no wrong door, regardless of a person's issue, ability to pay, or how they arrive at a facility. 2:22:10 PM Representative Josephson referenced the testimony that the facilities could be allowed to administer drugs if they were designated evaluation and treatment centers. He thought it sounded like a term of art. He reasoned a facility could do so if it achieved the status in accordance with some regulation or statutory definition. He was trying to keep track of who was administering drugs. He asked if his understanding was accurate. Mr. Wall responded that the bill previously heard by the committee, SB 120, related to the involuntary administering of medications in crisis allowed at a designated evaluation and treatment center or designated evaluation and stabilization center. The designation was given by DHSS to hospitals it had an agreement with that had specific psychiatric professional capability and oversight. Hospitals included Fairbanks Memorial Hospital, Bartlett Regional Hospital, API, and more. There was a designated evaluation and stabilization designation for a couple of beds in PeaceHealth Medical Center in Ketchikan and a couple of beds in the Yukon-Kuskokwim Health Corporation in Bethel. The department had the designated evaluation and treatment center or designated evaluation and stabilization center oversight agreements with specific facilities. He explained that if a crisis stabilization center went the extra step to get the professional oversight and capacity needed to become a designated evaluation and treatment center, the facility could enter into an agreement with the state to do so. 2:24:23 PM Co-Chair Johnston requested a review of the fiscal notes beginning with DOL. KACY SCHROEDER, ASSISTANT ATTORNEY GENERAL, CRIMINAL DIVISION, DEPARTMENT OF LAW (via teleconference), shared that the fiscal note from the DOL Criminal Division was zero. The division did not anticipate an increased caseload as a result of the legislation. She noted that the legislation may actually result in some caseload diversions. 2:25:15 PM CORNELIUS SIMMS, LIEUTENANT, ALASKA STATE TROOPERS, DEPARTMENT OF PUBLIC SAFETY (via teleconference), addressed the Department of Public Safety's indeterminate fiscal note. He explained that because the centers did not currently exist, the Alaska State Troopers did not know the cost of potentially having to transport someone from rural Alaska to one of the centers. He highlighted the mindset of treating all Alaskans equally regardless of where they lived; individuals should be given the same opportunities for alternative to arrest. Representative Josephson asked if the committee had the specific fiscal note. Co-Chair Johnston responded in the affirmative. Representative Tilton remarked that the fiscal note referred to a provision in the bill allowing alternatives to arrest for a person a peace officer believed in good faith was suffering from an acute episode of mental illness. She asked for the definition of the term. Mr. Simms deferred the question to the bill sponsor. Co-Chair Johnston would hold the question until the fiscal note review was complete. 2:27:27 PM GENNIFER MOREAU, DIRECTOR, DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via teleconference), was available for questions. The fiscal note associated with the services was part of the Medicaid projection because the services as described through the 1115 waiver would be funded by Medicaid. Therefore, the fiscal note did not include the Medicaid services. 2:28:23 PM Representative Josephson referenced earlier testimony that that the bill was not a light switch. He noted he did not expect it to be. He asked if the bill would require a serious capital budget at some point. Representative Claman replied that it was his understanding that AMHTA was supportive of providing funding for the capital side. He noted that he did not speak for AMHTA. He relayed that existing facilities may provide some of the space. For example, the Fairbanks hospital group had suggested they may not need to construct a new building, but they may dedicate a certain amount of square footage in their existing facilities. He spoke to the fiscal side of the cost. He highlighted that in Arizona, the cost was associated with fees for services that could be billed to insurance and Medicaid. He reported that providers had found that the model paid for itself. Representative Josephson asked if the facility would be staffed with public or private workers. Representative Claman replied that the expectation was for the centers to be staffed with private workers. Representative Josephson asked if it [the employment of private workers] reflected the typical Arizona model. Representative Claman replied that Arizona centers were staffed with private workers. He elaborated that the Arizona building housed a crisis stabilization center and two sub-acute facilities. There was initially only one sub- acute facility, but due to the volume of incoming clients, a second sub-acute area had been built. He added that the cost was all paid with fee for services. 2:30:38 PM Representative Carpenter highlighted constitutional considerations. He provided a scenario where an individual experiencing an episode committed a crime and law enforcement got to decide whether to make an arrest or, with the individual's consent, take them to a crisis stabilization center. He asked how the victim's constitutional rights that required due process were considered. He listed the constitutional provisions of condemnation, rights of a victim, and restitution, all of which had to go before a judge to adjudicate or decide. Representative Claman replied that the question applied to three areas of the law. At present, an officer had discretion to arrest or not arrest. He provided a scenario where a person committed a felony level assault and an officer believed the individual was gravely disabled. An officer was trained to make the determination and commit someone under Title 47 and had the discretion to bring the individual to the psychiatric hospital or jail. The victim notification requirements came into play after charges were filed. He detailed that in the same sense that a prosecutor would contact a victim if they were going to decline prosecution, there was not further notice required to a victim. The primary victim notification provisions came into play once a charge was in place and there were criminal charges going forward. None of the statute would limit the prosecution's ability to charge somebody even if they went to crisis stabilization. He noted that two different places in the legislation referred specifically to the issue. Representative Claman continued that the third area involved domestic violence protective situations under Title 18. He detailed that a domestic violence call to a police officer was one of the only areas with a mandatory arrest in statute. Currently, when a police officer went to a house with a domestic violence complaint, the officer could get permission from the prosecutor to not arrest if the officer did not believe they had probable cause. He explained it was the reason there were on-call prosecutors available to receive the calls. He recommended speaking to Ms. Schroeder [with the DOL Criminal Division) to learn how frequently the calls occurred. Under current statute, if a prosecutor gave authorization, the officer would not be required to make an arrest. Representative Claman furthered that Title 18 had notice provisions related to domestic violence that were different than the criminal code. Under the bill, with regard to Title 18 domestic violence circumstances, two areas had been identified with real potential where there could be a call in a domestic violence setting. The first was with an Alzheimer's and dementia type population where a family called the police because they were having trouble controlling a family member. Under the circumstances, the family may say the individual needed help and did not need to go to jail. He explained that the ability to take the individual to a crisis stabilization center could be what the family was looking for. Representative Claman detailed that the second environment involved an individual under long-term psychiatric treatment who may have fallen off their medication and may be having an acute episode. He provided a scenario where a twenty to thirtysomething was having an episode while living at home with their parents. He elaborated that the family had tried everything and had called the police, but with the desire to send the individual to a crisis center because jail would only exacerbate the crisis. He explained that the police officer would have the authority to arrest to take them to the crisis stabilization center. Under the legislation, the officer would be required to get permission from the prosecutor to take the individual to the stabilization center. He relayed that if an individual was taken under Title 18 domestic violence circumstances, the officer was required to have the crisis stabilization center provide notice to the officer. He added that it was limited in Title 18 to involuntary commitment circumstances. 2:36:19 PM Representative Carpenter had a question about the concept of a crime being committed but not arrested for. He thought Representative Claman was saying that when a crime was committed and no arrest was made, it meant there was no follow up with the victim because there was no arrest. He thought it meant there were no victim rights and they were technically not the victim because there was no arrest. Representative Claman did not believe the statement was accurate. He clarified that what triggered the victim notification was the filing of charges. He stated that arrest was not required. For example, an individual could be involved in a bar fight and could be issued a summons by the police officer to come to court in a week. There were a number of crimes where there was never an arrest because officers knew there was no bail requirement or if an individual could post $200 on the spot they were not arrested. He reiterated it was not the arrest that triggered the victim rights, it was the filing of charges. 2:37:50 PM Representative Carpenter asked for verification the bill did not preclude a request for filing of charges at some point in time by the victim. Representative Claman answered that only a prosecutor had the right to file charges because the charges were on behalf of the state. He added that, unrelated to the bill, in a domestic violence scenario, a person could be arrested and brought to jail and a prosecutor could decline to prosecute for some reason. Under the scenario, the victim had the right to go to court to obtain a domestic violence restraining order, which was a civil order. Representative Carpenter asked if the bill set aside involuntary commitment under Title 47 and was not included as part of the legislation. Representative Claman pointed to Section 1(b) of the legislation pertaining to involuntary commitment authority. He detailed that an officer had the ability to enter into a voluntary agreement and not arrest. Additionally, an officer had the ability to require an individual go to crisis stabilization under the officer's power to hold someone for involuntary commitment. Representative Carpenter stated that Title 47 required the involuntary commitment to involve a judge. Representative Claman agreed. He elaborated that an involuntary commitment was sometimes referred to as a 72-hour hold. He detailed that if a person was deemed to be a danger to themselves or others, a police officer could take them in to be placed in a 72-hour hold for evaluation. He explained that if an officer took the individual to a crisis stabilization center first, there would be an examination in the first 24 hours. He expounded it was quite possible the person would be stabilized during the first 24 hours and would not require holding for the remaining 48 hours. 2:40:24 PM Representative Carpenter asked if the evaluation [in a crisis stabilization center] would be medical. Representative Claman highlighted the important distinction between an examination and an evaluation. The evaluation was a psychiatric evaluation performed by a psychologist or psychiatrist. The examination done in the first three hours at a crisis stabilization center would be performed by a nurse for an initial determination. The examination would not be the psychiatric finding that would allow the state to hold an individual on involuntary commitment past the 72 hours. Representative Carpenter explained that he was trying to understand the due process component. He stated that the judicial branch was supposed to look out for individuals' due process. He stated that currently in statute there was a requirement for a judge to be involved if a person was taken involuntarily. He did not see that in the bill. He believed the bill allowed a person to be put involuntarily in a crisis stabilization center without a judge's order. Representative Claman answered that it was not included in the bill because there was no change to that specific structure. He provided a scenario where a Mr. Smith was having an acute psychiatric episode and was a danger to himself or others - possibly off his medication. Currently, an officer in Anchorage would take the individual to API and there would be hearings within a 72-hour period where a judge would hear testimony and determine whether there was probable cause to hold the person for a period. He explained that taking an individual to API triggered the process where a hearing took place within a three-day period. The bill enabled an initial placement at a crisis stabilization center for the first 23-hour period. He explained that if a person was brought in on an involuntary basis, they would have the same statutory rights for the 72-hour evaluation and examination by a judge. He detailed it was quite possible the person may stabilize soon enough to negate the need for future hearings. By the time the court was ready to convene the individual may feel much better and the treatment staff may communicate there was no longer a basis to hold the individual longer. The bill did not change the current 72-hour cycle. The bill provided an alternative for the first 23 hours where someone was held. He detailed that if a person was not stabilized within that timeframe they would have to go to a facility that could hold them longer - API in Anchorage and potentially a subacute facility in Arizona for a longer hold that was not as extensive as API. Alaska did not have the subacute option. 2:43:42 PM Representative Tilton asked about the definition for acute episode of mental illness. She believed substance abuse could be different from having an acute mental illness episode. Representative Claman answered that acute behavioral health crisis in the bill title was one of the changes his office had worked through with the DOL Civil Division. The language had been used because it was already defined in statute and/or regulations. It was his understanding was the language encompassed both. He deferred to DOL for additional detail. Ms. Schroeder deferred to the question to the department's Civil Division. Representative Claman relayed that he would coordinate a response with the department. Representative Josephson asked if law enforcement could file a charge and take a person to a crisis stabilization center. Representative Claman answered in the affirmative. He anticipated the sequence would be dropping a person off at the center first, followed by filing charges. Representative Josephson thought the system would lend itself to a mature, intelligent, sophisticated officer thinking about defenses to crimes under Title 11 and looking at the facts. He asked if an officer could chart a person "all day long," but they could be found not guilty for one reason or another. 2:46:16 PM Representative Claman supposed everything was possible at some level. Based on his conversations with Anchorage police about their interest in crisis stabilization, it was his understanding that there was a certain group of individuals seen with some frequency who commit crimes including shoplifting, non-felony assault behavior, and various property crimes. He elaborated that the officers knew some repeat offenders who they knew to be people with significant substance and mental health issues. He believed it was more likely that an officer would look at the individuals and consider that it may be better to take them to a crisis stabilization center to get into a better health position rather than taking them to jail where they would likely continue the cycle of being picked up by officers in the future. He continued that a prosecutor may choose not to prosecute, or the person may do well at crisis stabilization and the officer may be comfortable not prosecuting. Additionally, the victim may be comfortable not prosecuting because they had seen the people before as well. He thought it was the more likely scenario where repeat offenders going round and round without improvement, could benefit from the stabilization centers. 2:47:49 PM Representative Wool asked about a scenario where a person had not committed any crime, but they were at a bus stop talking to themselves and making people feel uncomfortable. He reasoned it may be a scenario where someone called the cops and the person obviously needed some help. He asked if it would be a situation where the cops could tell the person they did not want to arrest them or take them to the emergency room, but they could suggest going to the crisis stabilization center to potentially get on the road toward getting some medication and so forth. Representative Claman replied it was a circumstance. He clarified that it would not be an alternative to arrest because at some level the officer would need probable cause to arrest before the alternative to arrest came into play, but the officer would have the ability to give a person a ride to the crisis stabilization center. He added the option would be available for de-escalating the bus stop scenario [provided by Representative Wool] where people were nervous about a person's behavior. He added that the option would be available to firefighters as well. He believed that in the crisis stabilization model described by Mr. Williams and Mr. Wall, the first call would be to the crisis hotline. He detailed that a mobile crisis team may be sent if the call did not de-escalate the situation. He explained that the crisis team was sent prior to a police officer being called and the team may be able to de- escalate the situation without a trip to the crisis stabilization center. The team could take the individual to the center if they were unable to de-escalate the situation. Representative Wool considered the rule where a person could be held involuntarily for up to 23 hours. He asked how long a person could remain in a center voluntarily prior to getting moved to the next stage. He asked if the same timeframe pertained to voluntary stays as well. Representative Claman replied that the time limit was 23 hours, which pertained partly to how services were billed with insurance and Medicaid. He stated that one of the hallmarks of the facilities was there were no beds, only recliners. 2:50:18 PM Representative Knopp asked for verification a person could not be held against their will at one of the facilities for any period of time. Representative Claman responded that under Section 1(a) of the bill, placement was voluntary as an alternative to arrest. He clarified that Section 1(b) pertained to involuntary commitment where a person could be prevented from walking away. For example, if an officer delivered an individual to a crisis stabilization center and would fill in the required paperwork specifying the commitment was involuntary, the person would not have the ability to walk away. He added that police officers had communicated that for the idea to work they would need the ability to place individuals in centers both voluntarily and involuntarily. Co-Chair Johnston set an amendment deadline for the following day at noon. HB 290 was HEARD and HELD in committee for further consideration. 2:51:44 PM AT EASE 2:54:54 PM RECONVENED