HB 172-MENTAL HEALTH FACILITIES & MEDS  3:15:11 PM CO-CHAIR ZULKOSKY announced that the only order of business would be HOUSE BILL NO. 172, "An Act relating to admission to and detention at a subacute mental health facility; establishing a definition for 'subacute mental health facility'; establishing a definition for 'crisis residential center'; relating to the definitions for 'crisis stabilization center'; relating to the administration of psychotropic medication in a crisis situation; relating to licensed facilities; and providing for an effective date." [Before the committee was CSHB 172(JUD).] 3:15:28 PM CO-CHAIR ZULKOSKY opened public testimony on CSHB 172(JUD). 3:15:48 PM BRENDA STANFILL, Executive Director, Alaska Network on Domestic Violence and Sexual Assault (ANDVSA), stated that ANDVSA has looked at the mandatory arrest statutes around domestic violence and the alternatives to arrest. She expressed the understanding that [perpetrators of domestic violence] with underlying mental health issues would not benefit from being taken to jail after an assault. She stated that, for the record, ANDVSA is working with the administration "making sure we have the right guardrails when it comes to victim notification." She expressed concern that when [a perpetrator of domestic violence] is not taken to jail but taken to a mental health crisis center, the victim would need to receive adequate notification before the individual in the crisis center is released. She stated that ANDVSA has no desire to stop the bill from passing, but there would need to be assurances. She stated that ANDVSA would be working through regulation, policy, and training with the Department of Law (DOL) and the Department of Health and Social Services (DHSS) to make sure the right safety measures would be in place to protect the victim. 3:18:03 PM CO-CHAIR SNYDER questioned whether ANDVSA supports the use of law enforcement to ensure the victims of domestic violence are notified when the perpetrator is released from a crisis center. She questioned whether statute or regulation should be used to ensure this notification. MS. STANFILL suggested that some small changes to the statute would need to be made. She stated that the victim would need to be notified when [the individual in the crisis stabilization center has been released], and this notification should be mandatory. She recommended there be a requirement that contact information for the attending officer and his/her agency be provided. She expressed the understanding that the legislative language concerning regulation and policy would need "tightening up." The changes in the regulatory language would concern the licensing of the crisis centers. The changes in policy language would concern the determination of whether an individual should be transported to the crisis center or to jail. She offered that this would involve training law enforcement to recognize who would benefit from the crisis center or who should go to jail. She concluded that this could all be done through regulation, policy, and training. 3:20:06 PM REPRESENTATIVE MCCARTY asked if this referenced the difference between criminal and noncriminal proceedings. He stated that when someone commits domestic violence, normally the individual would go to jail for the crime of assault, by definition. He questioned what the deciding factor would be when an individual has mental health issues. MS. STANFILL explained that frequently these types of cases involve an adult child, who lives with his/her parents, and has a behavioral health issue. She provided the example of an adult child with bipolar disorder, who has gone off his/her medication and is aggressive. She added that when this individual is arrested and put in jail, he/she would not be getting the right help. She suggested that, often times, the aggression would be directed towards the mother or father, and, under the definition of domestic violence, this would be a domestic violence crime, which looks different from domestic violence between spouses, for example. In the case of an adult child, it may be beneficial to take him/her to a crisis stabilization center so medication could be monitored. MS. STANFILL, in response to a follow-up question, confirmed that the guidelines in the statute would need to be addressed. She stated that ANDVSA is working with the language to make sure the officer and his/her agency, such as dispatch, are notified, so the abused individual could be informed when the [the perpetrator of domestic violence] has been released from the crisis stabilization center. 3:23:31 PM The committee took an at-ease from 3:23 p.m. to 3:25 p.m. 3:25:57 PM FAITH MYERS, Affiliate, Mental Health Advocates, advised that an amendment needs to be added to the legislation to prevent events such as that which occurred in Alaska 60 years ago, when legislation had been passed which created multiple private psychiatric facilities. The facilities had detained, evaluated, and treated patients. She voiced the opinion that these facilities had been allowed to "keep secrets" from the public and the legislature. The secrets had involved patients' complaints, injuries, and traumatic events. She cautioned that the same mistake could be made again, unless there is a requirement that psychiatric facilities receiving state funding record statistics on the number and types of patient injuries. This would need to include the cause, the complaint, and the resolution. She stated that traumatic events include patients strapped to gurneys, isolated, restrained, and handcuffed during transportation. 3:28:18 PM RENEE RAFFERTY, Regional Director of Behavioral Health, Providence Health and Services, stated that she has worked closely with many stakeholders over the last three years in an effort to support the transformation of Alaska's behavioral health crisis system. She described that it is currently a fractured system of services, and many individuals are unsure where to go when in a crisis. These individuals often end up in the prison system or in a hospital emergency room. She stated that the proposed legislation would provide a "No wrong door" approach for anyone experiencing a mental health or substance abuse crisis. She expressed the opinion that stakeholder engagement, including emergency medical services (EMS), law enforcement, and health care providers, is crucial. She offered her support for the Crisis Now model, which extends the timeframe for patient stabilization, voluntary and involuntary. She mentioned that the model has been replicated all over the nation, and statistics show that individuals treated in this model stabilize faster. She shared that she has worked in the mental health field for 30 years and has never experienced this type of collaborative effort. She listed multiple involved organizations. 3:32:03 PM BRENT JOHNSON, representing self, spoke in support of HB 172. He shared that over the past seven years he has been a law enforcement officer. He stated that he has had a "front row seat" to the "explosion" of citizens suffering from mental health crises. He described the rise in crises as the result of controlled substance abuse and the lack of mental health treatment facilities. He stated that he has been involved with the collaborative process, traveling outside of Alaska to see the systems in other areas. He said the behavioral health system in Alaska "is broken," describing it as "a revolving door" that does not help anyone. He argued that, while put in the position of attempting to stabilize individuals who need professional care, valuable first-responder time is taken away. He stated that crisis stabilization centers would allow a "No wrong door" approach. He stated that, after seeing implementation in other states and agencies, he firmly believes this would be the best path forward. 3:34:07 PM MICHELLE BAKER, Acting Vice-President, Behavioral Services, Southcentral Foundation (SCF), testified in support of HB 172. She shared that the SCF provides services throughout Southcentral Alaska, serving over 65,000 people. She informed the committee that SCF plans on opening an adult crisis stabilization center on the campus of the Alaska Native Medical Center. Using the Crisis Now model, she said, rather than relying on the emergency department, individuals would be treated with trained behavioral health staff in a more appropriate and therapeutic environment. She indicated that the Crisis Now model has strong support from behavioral health providers, law enforcement, and the community. She expressed the opinion that using the "No wrong door" approach offers better care for individuals in behavioral health emergencies. While most individuals come for help voluntarily, she stated there are a small number who are involuntary. She emphasized that this small number of individuals would need to be evaluated promptly and receive care in a crisis stabilization center. She stated that while SCF is planning for the development of these programs, the legal framework in HB 172 would be necessary for successful implementation and operation. She cautioned that if the legislation does not pass, the program design would be greatly impacted, and individuals would be referred back to the emergency rooms, and health care costs and the system would be affected. She stated that SCF strongly supports the passage of the legislation to meet the needs of those in crisis by giving providers, law enforcement, and EMS the flexibility and options to deliver care. She urged that HB 172 pass in the current legislative session. 3:36:54 PM JARED KOSIN, President and CEO, Alaska State Hospital and Nursing Home Association, stated that the association supports HB 172. He emphasized and reiterated that the behavioral health crisis care system is "broken," and hospitals see the effects of this every day. He stated that, with nowhere else to turn, Alaskans in behavioral health crises go to emergency rooms looking for help, which is not the best environment. Individuals are forced to wait in emergency rooms for days or weeks for a bed to open in a specialty psychiatric hospital. He stated that addressing these struggles will take time and action, and the formal implementation of crisis stabilization centers would be a critical step for advancing system change. He thanked all the stakeholders for their work. 3:38:28 PM JOSH NOLDER, Captain, Anchorage Police Department, shared that he had the opportunity to travel to Phoenix, Arizona, where he witnessed the Crisis Now model in action. He stated that the model and the comprehensive system were impressive. He suggested that law enforcement was able to focus on crimes, as opposed to being thrust into the gaps of the mental health system. He stated that, more importantly, the [Crisis Now model] shows a higher level of care for citizens, with better outcomes. He said in Alaska the system is "a revolving door, where ... too many citizens suffering from mental illness are back into the community ... and often times back on the streets, suffering from homelessness." 3:40:15 PM MARK SIMON, M.D., representing self, shared that he works as an emergency physician and in addiction treatment. He also shared that he went to Phoenix to review the Crisis Now model. He said, "It just makes sense." He stated that there is not a system for psychiatric care in Alaska, and the proposed legislation would provide an opportunity to create one. He reasoned that creating something new would be much easier than changing an existing system. He referenced three important pieces of the Crisis Now model: ambiance, results, and focus on care. He stated that the ambiance in emergency rooms and hospitals is stark and rigid, and people who are in crisis do not need this. He stated that for better results some of the personnel in the Crisis Now model would be peers. Peers with lived experiences would engage individuals in crisis to help put them at ease; individuals would less likely escalate and need medication or restraint. He stated that focus on care would enable the individuals in crisis to move home as safely as possible. He stated that in the medical system there is little time to gather resources. With a lack of information, the safest option often is to retain individuals in the hospital. 3:42:25 PM REPRESENTATIVE PRAX confirmed that Dr. Simon works at Fairbanks Memorial Hospital. He noted that this hospital was not on DHSS's crisis center list. DR. SIMON stated that he does not know whether Fairbanks Memorial Hospital would be active in the program. He explained that he is not testifying on behalf of the hospital but from a personal standpoint. CO-CHAIR ZULKOSKY reminded Representative Prax that locations for crisis stabilization providers have not yet been identified, as this would require statutory passage and then approval by DHSS. She questioned Heather Carpenter on this point. 3:44:24 PM HEATHER CARPENTER, Healthcare Policy Advisor, Department of Health and Social Services, in response, stated that the first step for providers would be voluntary participation through the Section 1115 Medicaid waiver ("1115 waiver"). She stated that, as of now, DHSS and the Alaska Mental Health Trust Authority (AMHTA) have engaged with Fairbanks Memorial Hospital to ensure its services would work under the model. She stated that the hospital operates a designated evaluation and treatment center, but there are other providers in Fairbanks already starting to provide [Crisis Now] services. She pointed out that a crisis stabilization center recently opened in downtown Fairbanks, and a mobile crisis team has started operations. She added that these services are not being run by the hospital. 3:45:32 PM KATHLEEN WEDEMEYER, Deputy Director, Citizens Commission on Human Rights, Alaska and Washington Chapters, shared that the Citizens Commission on Human Rights is a psychiatric watchdog group. She expressed the opinion that HB 172 has multiple issues which need addressing. She pointed out that the 72-hour timeframe in the Crisis Now model would work only if an individual was picked up on a Monday or Tuesday, otherwise the hold period would average closer to five or six days. She suggested that this would need to be remedied to be a legitimate 72 hours. She referenced that minors are mentioned in the legislation, but specific protocols have not been worked out regarding parental notification, provisions for treatment, and psychotropic medication, particularly in the seven-day facility. She added that a parent or guardian would be more familiar with the adolescent's history of trauma, behavioral health triggers, and adverse reactions to drugs. She added that there needs to be protection for minors, as well as parents and guardians, on the process and notifications specific to this legislation. She stated that the push for an increase in involuntary treatment is completely opposite to advances in human rights. She cited that a noncoercive approach has been outlined in a report by the World Health Organization on community mental health services. MS. WEDEMEYER stated that the proposed legislation lacks accountability and oversight from legislators and system managers. She said all facilities should be required to report actual hold times to DHSS and the legislature. She continued that, instead of focusing on system utilization, the legislation should focus on health outcomes and tracking. She argued that the increased use of involuntary commitment facilities represents focus on the system and not on individual health. She insisted that the bill has not been designed to address the "real world needs" of the individuals who are the targets of the legislation. MS. WEDEMEYER offered that this version of HB 172 represents an expansion of the public mental health system, which would increase the use of forced detention and psychiatric drug treatments. She argued that, for those admitted to treatment centers, there should be a requirement for a physical examination in order to diagnose any symptoms or ailments which might mimic psychiatric disorders. She offered a quote from the World Psychiatric Association, which she read: A fundamental shift within the mental health field is required, in order to end this current situation. This means rethinking policies, laws, systems, services, and practices across the different sectors which negatively affect people with mental health conditions and psychosocial disabilities, ensuring that human rights underpin all actions in the field of mental health. In the mental health service context specifically, this means a move towards more balanced, person-centered, holistic, and recovery-oriented practices that consider people in the context of their whole lives, respecting their will and preferences in treatment, implementing alternatives to coercion, and promoting people's right to participation and community inclusion. MS. WEDEMEYER concluded that individuals experiencing emotional crises can represent harm to themselves or others; she argued that the legislature must work out a system to safeguard the public while working out safeguards for these individuals. 3:50:03 PM ANN RINGSTAD, Executive Director, National Alliance on Mental Health (NAMI) Alaska, testified in support of HB 172. She shared NAMI is the nation's largest grassroots organization. She cited that mental illness affects more than 1 in 5 adults, or 50 million people in the nation. She offered that this translates in Alaska to over 108,000 individuals. She stated that emergency rooms and jails are not the appropriate "holding rooms" to assist individuals who need professional evaluation and treatment. She stated that a crisis response system is needed which "offers help, not handcuffs." She argued that crisis stabilization centers offer prompt support and evaluation. The centers would more easily address an individual's symptoms, evaluate the needed resources, and move forward with resolution. She offered NAMI's support to the work of AMHTA, along with the other collaborative efforts of stakeholders. She concluded that there is still work to be done, and the proposed legislation is an important step. She stated that NAMI supports a future in Alaska where this type of behavioral health system is in place. 3:52:43 PM ED MERCER, Chief of Police, Juneau Police Department (JPD), stated that in real-life situations law enforcement deals daily with a high percentage of individuals with mental health issues. He said law enforcement is aware that an individual in a mental health crisis could commit a crime, and the proposed legislation would provide an alternative to taking this individual to jail. If an individual is taken to the hospital, the attending police officer may be required to wait for hours; ultimately, the individual could be released back out into the public. He explained that this creates two issues: the individual is not getting the assistance he/she needs, and the individual is at risk of having another contact with law enforcement. He said the Juneau community has been working with stakeholders to adopt the Crisis Now model. He added that being able to bring an individual to a stabilization center for "a cool-off period" and treatment would be "a good thing." He expressed the opinion that law enforcement would rather use violent-voluntary compliance than "forcibly make somebody do something," as the current system causes a "revolving door." He offered support for the proposed legislation so the system could move towards the [Crisis Now] model. He stated this would help law enforcement deal with an issue that "is not going to go away." He stated that JPD supports HB 172. 3:55:58 PM REPRESENTATIVE PRAX questioned the amount of time saved by law enforcement if the proposed legislation were to pass. MR. MERCER responded that when an individual is brought to the hospital, law enforcement could spend four to six hours until a determination has been made that the individual could leave or be retained. He stated that if the individual leaves the hospital, then a mental health follow-up would happen. MR. MERCER, in response to a follow-up question, explained that law enforcement deals with this scenario "more often than one would think." He stated that law enforcement sees some of the same individuals in mental health crises on a daily basis. Law enforcement tries to assist, but this could happen two or three times a week for a single individual. He offered the understanding that, when an individual is having a mental health crisis, the "time is now" to try to help them. He stated that, if an individual is released back into the public, an officer would most likely be sent back to the residence [to address a similar issue]. 3:58:16 PM REPRESENTATIVE MCCARTY offered that he was impressed by the program in Phoenix. He mentioned that because of the communication mechanism, authorities knew in advance the details of the person in transport to the crisis center. He added that the handoff was "very fast." He questioned Mr. Mercer's impression of the procedure in Phoenix and the model proposed by the legislation. MR. MERCER voiced the opinion that the model would expedite law enforcement's ability to create a rapport with the crisis staff. He explained that it would be like triage; law enforcement would arrive at the center, speak with the providers, and hand over the individual. He stated that in Juneau there is open communication with [law enforcement], the hospital, and the Juneau Area Mental Health Initiative (JAMHI). He envisioned that the legislation would only be "a good thing," giving all involved more ability to help, and jail would not be the only option. 4:00:57 PM SHAYNE LACROIX, Police Commander, Palmer Police Department, offered his support and the support of the Palmer Police Department for HB 172. He stated that, as already testified, there are an inordinate number of calls to law enforcement concerning individuals who are experiencing a mental health crisis. He said that the solutions currently available to law enforcement are not in the best interest of "the public we serve or the individual in crisis." He shared that he had been in Phoenix to view the facilities, and the Matanuska-Susitna Valley is working on a Crisis Now program. He stated that the proposed legislation would create an opportunity for individuals in crisis to get care immediately, and potentially long term. 4:02:31 PM CO-CHAIR ZULKOSKY, after ascertaining there was no one else who wished to testify, closed public testimony on CSHB 172(JUD). 4:03:12 PM REPRESENTATIVE PRAX remarked that several testifiers were skeptical of the legislation. He questioned whether these testifiers were "in the loop" with the Division of [Behavioral] Health and other organizations. 4:03:46 PM MS. CARPENTER invited Steve Williams to join in supplying an answer to the question. She responded that she and Mr. Williams have worked closely with shareholders over the last several years. She stated that the work began when the 1115 waiver was implemented, before the Crisis Now model had been introduced. She said DHSS has provided outreach all around the state. She stated that a "need gap analysis" for the 1115 waiver included the building blocks for the Crisis Now model. 4:04:51 PM STEVE WILLIAMS, Chief Executive Officer, Alaska Mental Health Trust Authority, Department of Revenue, emphasized that the process of getting to the point of [introducing this legislation] has been ongoing since 2018. He referenced the many statewide organizations and individuals that have been a part of the dialogue. He stated that there has been an effort to reach out to organizations and individuals to engage those who can help inform the transformation, so it can be done the best way possible. He referenced that AMHTA has tried to listen and work with Ms. Myers and address her concerns. He stated that Section 26 in the current version of the legislation represents the Division of Behavioral Health and AMHTA's demonstrated effort to address concerns in a collaborative way which would obtain information from various perspectives to identify potential improvements. 4:06:43 PM REPRESENTATIVE PRAX voiced his understanding that Ms. Wedemyer has concerns. He expressed the belief that the legislation would be an incomplete solution to the entirety of mental health challenges. He expressed the concern that the focus on stabilizing people in crisis and returning them to society would lead to the over reliance on medication, rather than some other approaches. MS. CARPENTER responded that Representative Prax made a good point. She continued that, out of respect, she would have to "agree to disagree" with [Ms. Wedemyer]. She explained that the proposed legislation's focus would be on the highest level of crisis situations, as this is what Title 47 addresses. She stated that most individuals in Alaska who pursue mental health care do so voluntarily. If an individual is taking medication, he/she is doing this under a practitioner's care. She offered that the proposed legislation would not address or change this; rather, the legislation proposes to take the current statutory authority, which would entail short-term crisis medication, and apply this to stabilizing an immediate crisis - a crisis which could possibly cause danger to the individual or others. She stated that medication would be a last resort intervention, authorized by an attending physician, nurse practitioner, or physician assistant. She stated that medication would be administered only when the other alternative is physical restraint. She stated that providers have had to "do extreme things," and studies have shown restraint would be far more traumatic for the patient. She concluded that the ability to administer medication would offer stabilization centers a last resort tool. 4:10:05 PM REPRESENTATIVE MCCARTY expressed excitement concerning the proposed legislation. He stated that technological advances would provide better assessment than in the past. He suggested that some individuals may not be taking their medication and questioned whether an individual's current medication level could be verified, for example with lab work. He questioned whether individual rights would be infringed if the individual was tested for medication levels. MS. CARPENTER responded that this is a good question, and she would need time to supply an answer. She stated that the proposed legislation would address only crisis medication, and if an individual has not taken regularly scheduled medication, he/she could not be forced to do so in an involuntary commitment situation. She offered that, with patient flow, as individuals leave [the crisis center], it would be helpful to work with their regular providers. REPRESENTATIVE MCCARTY, in follow up, expressed concern that patients should be taken care of appropriately. He mentioned the "Thorazine shuffle" and Haldol treatments in the early 1980s. He argued that this would not be "something we want to go back to." He stated that, at the same time, the pendulum should not move so far that staff and employees would be in harm's way because of a patient's [behavioral crisis]. He stated that there have been situations resulting in workers' compensation payments or disability. He deduced that to put staff in a harmful situation would not be fair. MR. WILLIAMS commented that this is a good point. He stated that the centers would be staffed with medical professionals, mental health professionals, and people with lived experience. He stated that this staff would cover some of the issues mentioned. He added that medications would also be covered in the legislation. 4:14:31 PM REPRESENTATIVE KURKA requested a follow-up question on Ms. Carpenter's statement concerning percentages of individuals in a behavioral health crisis who voluntarily seek help. He questioned the percentage of involuntary commitment patients in the state's system. MS. CARPENTER responded that she would work with Nancy Meade of the Alaska Court System for updated, specific numbers on nonvoluntary commitment in the state. She offered that Ms. Meade recently testified in the Senate hearing on the proposed legislation, and she would have the best numbers on court filings. 4:15:44 PM CO-CHAIR SNYDER requested a follow-up question on the topic of utilizing [crisis] medications as a last resort. She questioned Ms. Carpenter on an estimate of the frequency of use of "last resort" medication. MS. CARPENTER responded that she could not give an immediate answer. She offered to look into the Alaska statistics but suggested it may be more helpful to work with AMHTA and other experts that could supply statistics from the [Criss Now model] in Phoenix. 4:16:52 PM REPRESENTATIVE MCCARTY voiced concerns about the suggested friendly amendments. He stated that he would address those at another time. 4:17:42 PM CO-CHAIR ZULKOSKY announced that CSHB 172(JUD) was held over.