HB 172-MENTAL HEALTH FACILITIES & MEDS  1:03:19 PM CHAIR CLAMAN 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, adopted as a working document on 2/16/22, was the proposed committee substitute (CS) for HB 172, 32-GH1730\W, Foote, 2/16/22 ("Version W").] 1:04:28 PM MARK REGAN, Legal Director, Disability Law Center of Alaska, provided invited testimony during the hearing on HB 172, Version W. He explained that the Disability Law Center was the plaintiff in a lawsuit against the Department of Health and Social Services (DHSS) regarding the system of involuntary evaluation and treatment of patients. The lawsuit was based on people "stacking up" in [police] custody and emergency rooms. The lawsuit was settled based on the recommendation that the state implement the Crisis Now model, which would provide for short-term treatment. He expressed the opinion that Version W would aid individuals with two major improvements on the original bill. He stated that the first improvement would be when an individual is taken into custody on an involuntary basis, it would provide for an ex parte order to appoint an attorney for the individual. He stated that the second improvement would be that when an individual is being held for more than three days, the individual would have a right to an attorney and a judicial hearing. He concluded that Version W would remedy previously held concerns. He expressed support for the proposed legislation on behalf of the Disability Law Center. 1:08:47 PM MR. REGAN, in response to a question from Representative Eastman, stated that the lawsuit had been settled in 2020. He added that one of the terms of the settlement is the state would introduce legislation to implement the Crisis Now model of care. CHAIR CLAMAN pointed to a letter from the Disability Law Center [included in the committee packet] entitled, "HB 172 Supporting Document - Disability Law Center Letter 2.21.2022.pdf" which contains additional information on the lawsuit. REPRESENTATIVE EASTMAN asked whether there existed any exceptions to the 72-hour rule, such as inclement weather events in rural communities. 1:11:57 PM STEVEN BOOKMAN, Senior Assistant Attorney General, Civil Division (Anchorage), Human Services Section, Department of Law, answered questions during the hearing on HB 172, Version W. In reference to Representative Eastman's question, he stated that the 72-hour timeframe would begin upon arrival at a crisis stabilization center or a crisis residential center. He reminded the committee that an individual would have an attorney appointed. Responding to a follow-up question, he stated that a weather delay could increase the amount of time an individual was in custody, beyond the 72-hour limit. He added that the 72- hour period would be based on actual clinical time. CHAIR CLAMAN questioned whether the proposed legislation would create changes to how or when guardians would be contacted. MR. BOOKMAN offered that there exists a statute which requires notice to be given to guardians. He referred to his experience in dealing with civil commitments at the Alaska Psychiatric Institute (API) and pointed out, if the API had knowledge of the existence of a guardian, efforts would be made to contact this person. He characterized the process as an informal one. He expressed the opinion that Version W would improve the quality of notification requirements by the court of a scheduled hearing. CHAIR CLAMAN added that the court system had provided an updated fiscal note. 1:17:09 PM HEATHER CARPENTER, Senior Policy Advisor, Department of Health and Social Services, answered questions during the hearing on HB 172, Version W. She stated that current statute does not formally mandate the contact of a guardian, while Version W would codify this requirement. CHAIR CLAMAN invited the court system to answer questions regarding guardian contact and the fiscal note. 1:18:23 PM NANCY MEADE, General Counsel, Office of the Administrative Director, Alaska Court System, answered questions during the hearing on HB 172, Version W. She stated that the court system had conducted research in CourtView to ascertain how many guardians are private versus those provided by the Office of Public Advocacy (OPA). The conclusion had been that most known guardians are private. She added the caveat that the data source for guardians is not ordinarily tracked for this; nevertheless, she expressed her opinion this was useful. MS. MEADE, responding to Chair Claman's request for information regarding the fiscal note, stated that there is not a current statutory requirement for the court system to notify guardians in the case of an involuntary commitment proceeding. She noted that, per page 6, line 3 of the proposed legislation, the court would be obligated to notify the guardian when the individual in crisis is admitted to a crisis residential center, and again, on page 9, line 28, the court would be obligated to notify the guardian when an involuntary mental commitment is ordered. She noted that CourtView is a confidential source of information for parties to the case, so other entities would likely not have complete information. She stated that the fiscal note includes 2, range 12, clerk positions. These positions would be responsible for the increased notification requirement to the court. Because the probate office is currently very busy, she explained that the court is not able to absorb the responsibilities with its current resources. She added that mental commitment cases are likely to be filed with the court after [business] hours, and currently no staff are available during this time. CHAIR CLAMAN asked whether Crisis Now would be accessible to minor children. MS. CARPENTER answered that the proposed crisis stabilization process would be available to minors in the same way intervention services are currently available for minors and adults. She noted that some providers are currently providing such services to minors via the [1115 Behavioral Health Medicaid Waiver]. She noted that, currently, when there are involuntary commitment proceedings against a minor, a guardian must be notified. 1:24:27 PM REPRESENTATIVE SNYDER asked whether currently an attempt would be made to contact a guardian. MS. CARPENTER answered yes. She noted a "guardian ad litem" is appointed in such cases, and an attorney is appointed to both the youth and the guardian. MR. BOOKMAN added that existing law would permit a minor to provide consent to services in case the guardian cannot be contacted. He stated that parents and guardians are likely the individuals who would bring minors to facilities for treatment. MR. BOOKMAN, in response to a question from Representative Snyder, stated that should API have knowledge of a guardian for an adult, it will attempt to make contact. He pointed out AS 7.25 directs that a guardian shall be notified of a respondent's rights; however, in AS 7.15 there is no mention of guardian notification. He pointed out Version W would address this inconsistency. 1:28:41 PM STEVE WILLIAMS, Chief Executive Officer, Alaska Mental Health Trust Authority, in response to Representative Eastman, answered that the intention of Version W would be to transform the current system, along with the new components developed and implemented. He noted that first, a crisis call center would be contacted, and there would be an attempt to resolve the crisis with de-escalation and no additional intervention. He explained that, should the call center determine additional intervention is necessary, a mobile crisis intervention team, consisting of a medical professional and a peer, would be dispatched to assess the situation and make decisions regarding the need for any additional intervention. He noted that this is the current practice in Anchorage and Fairbanks. He explained that, should the crisis intervention team determine the situation cannot be resolved, the individual would be transported to a crisis stabilization facility in the community. He further explained that, should the individual [remain unstable for] more than 23 hours, 59 minutes, the individual would be referred for 7 days at a crisis residential center. He added that not every community would have the ability to implement all the components as described, such as in rural Alaska. He stated that Version W would allow for each of the components to be implemented according to resources available in each community. REPRESENTATIVE EASTMAN asked whether the scenario described would apply in a case where someone other than the patient should call the crisis center. MR. WILLIAMS cautioned that he did not have direct experience as an emergency dispatcher and offered that trained professionals would receive and assess the initial call for assistance. In response to a follow-up question, he stated that a peace officer or law enforcement officer could refer an individual [to an escalated level of care]. He continued that Version W would not remove the authority of law enforcement or other first responders to respond to an emergency; rather, the intent would be to deter this level of intervention unless it is deemed necessary. He offered that health care professionals are trained and equipped to deal with mental health crises. He noted that a uniformed responder, or the potential for flashing lights, may unintentionally escalate a [mental health crisis] situation. 1:34:46 PM CHAIR CLAMAN, in response to Representative Eastman, offered to clarify his question into two parts. He stated that the first question is whether an individual may be brought to a crisis center by law enforcement, and second, how soon would a medical professional evaluate the individual. In other words, how long until a diagnosis is made. REPRESENTATIVE EASTMAN clarified that his line of questioning concerns when the individual could elect to leave. MR. WILLIAMS answered that, when a person is brought to a crisis stabilization center or to a crisis residential center, an evaluation would take place within three hours. MS. CARPENTER explained that, once at the crisis center, an individual would receive an evaluation within three hours, then a determination would be made as soon as possible regarding the resolution of the crisis. However, she stated that she would not offer the DHSS's judgment in lieu of professional clinical judgment, as each case would be based on individual circumstances. She stated that the current law permits a patient to be held involuntarily, while the proposed legislation would direct a 72-hour timeframe within which a clinical determination could be made. She added that clinical considerations, such as the administration of medication, would need to be considered by a professional. She added that, should no treatment be required, the individual may not be held involuntarily. 1:39:35 PM MS. CARPENTER, in response to a question from Representative Eastman, stated that a mental health professional, as defined in AS 47.39.15, in cooperation with the individual in charge, would determine when a patient no longer meets the involuntary detention criteria. REPRESENTATIVE EASTMAN questioned that, if there is a delay for crisis intervention, and an enforcement officer is on the scene, could the officer offer professional judgment on whether the individual may no longer require crisis care. MS. CARPENTER offered that, per the terms of the settlement of the lawsuit brought by the Disability Law Center, the state would be required to enact a re-evaluation after 48 hours to ensure an individual is not held without cause. CHAIR CLAMAN interjected that the information Ms. Carpenter provided is not a component of Version W. REPRESENTATIVE EASTMAN asked whether the 48-hour re-evaluation could occur over the phone or by other remote technologies. MS. CARPENTER answered that the re-evaluations could occur via telehealth and offered to follow up with the committee after consulting with the contractor who conducts the evaluations. 1:43:06 PM REPRESENTATIVE VANCE asked what percentage of individuals experiencing a crisis are self-reporting. She expressed the understanding that the intent of the proposed bill would be to limit the role of law enforcement in mental health crisis intervention. MR. WILLIAMS answered that the percentage of patients self- reporting is not readily available. He explained that, for the communities where the system has been implemented, national data reflects 90 percent of cases are resolved during the initial phone call and, of the remaining 10 cases, 7 are resolved by the mobile crisis intervention team. He noted that for the remaining 3 unresolved cases, the patient would be transported to a crisis intervention center or a crisis residential center for 5 to 7 days. REPRESENTATIVE VANCE referred to the definitions listed on page 11 of the bill and asked what the scope of the authority of a health officer. MR. BOOKMAN answered that the current definition of a peace officer includes professionals such as a public health nurse. He stated that Version W would define "health officer" consistently to draw a distinction between a health officer and a peace officer. He noted that a health officer would include a paramedic or a firefighter. He stated that, should HB 172 pass, a peace officer or health officer would be the one authorized to initiate a formal involuntary hold process. REPRESENTATIVE VANCE questioned the health officers' training which would enable them to make these decisions. MR. BOOKMAN answered that Version W would not create a change to any required training; however, it would add firefighters and paramedics who would have professional licensing. He added that the health or peace officer would transport an individual in crisis to a center for an evaluation by a medical professional. 1:48:52 PM REPRESENTATIVE KURKA questioned the provision in the proposed legislation which gives the criteria to hold an individual against the individual's will. MR. BOOKMAN answered that the criteria would be that probable cause exists when an individual is likely to cause harm to self or others, or is gravely disabled, as defined in current law. In response to a series of follow-up questions, he answered that the definition of "likely to cause harm" and "gravely disabled" is in AS 47.30.915. He explained that a peace officer or a health officer would have the authority to transport an individual to a crisis center and a mental health professional would have the authority to keep the individual in custody. He stated that mental health professionals include a licensed clinical social worker, a professional counselor, a psychiatrist, or an advanced nurse practitioner. He answered that, once an individual has been taken to a crisis center, the same criteria would apply to determine whether the individual stays. He added that a mental health professional would be required to petition the court and attest to the need for the recommended treatment. CHAIR CLAMAN, for a list of definitions, referred to the committee packet item, titled "Version W Additional Document - Definitions for Alaska Involuntary Commitment Statutes (AS 47.30.915) 2.21.2022.pdf." 1:54:52 PM REPRESENTATIVE VANCE questioned the required evidence for probable cause. MR. BOOKMAN answered that an application would be made to the court for an involuntary hold, and an explanation of the events leading to the professional's conclusion would be required. In relation to the individual in crisis, he stated that considerations may be made based on the ability to communicate logically, personal hygiene or wound care, and actions, including catatonia or involuntary movements. REPRESENTATIVE VANCE asked whether a mobile crisis team, health officer, or first responder would be required to provide proof for the reason for detention. MR. BOOKMAN answered that an emergency 24-hour hold may be determined necessary by a police officer or medical professional without judicial review based on professional judgment. He stated that a mobile crisis team would be required to keep records for Medicaid waivers and case management, which are subject to review by regulatory bodies but not subject to judicial review. CHAIR CLAMAN pointed out the current practice where a police officer may complete an ex parte order for a 72-hour hold based on the officer's professionally trained judgment, and this is subject to judicial review. REPRESENTATIVE VANCE expressed concern that the proposed legislation would expand authority for health officers and peace officers to initiate an involuntary hold. CHAIR CLAMAN offered that, in current practice, individuals may be subject to ex parte orders despite not being in custody. He deferred to Mr. Bookman. MR. BOOKMAN offered clarification that the "health officer" reference would not be an expansion of additional authority; moreover, it would be a clarification of the definition. He stated that firefighters and paramedics would be included in the definition as well. He stated that in Anchorage the fire department is the designated mobile crisis team. 2:01:59 PM REPRESENTATIVE EASTMAN questioned whether, following the initial assessment and prior to transport to a crisis center, would a [mobile crisis team] have the discretion to stop the process. MR. BOOKMAN offered that Version W is not intended to limit the discretion of law enforcement. He stated that there may exist a scenario when a law enforcement officer determines an individual may need to be transported to jail, an emergency room, or mental health facility. He stated that the proposed legislation would expand the officer's options, while maintaining the discretion to reassess the situation according to police standards. CHAIR CLAMAN offered the example of an individual with known mental health issues who lives with his mother. The individual became convinced the mother left the country, when she had only left for the store, and then this person experiences a mental health crisis because of this belief. He explained that a law enforcement officer with no prior knowledge of the person's mental health situation could transport the person to a crisis center. Once the crisis center becomes involved, the mother would be contacted, and the crisis averted. He offered that, if the officer had been familiar with the individual, the officer could contact the mother instead of transporting the person to a crisis center. 2:05:48 PM REPRESENTATIVE EASTMAN asked whether a police officer could offer a crisis center as an alternative to arrest. MR. WILLIAMS stated that law enforcement has the first discretion to assess for safety and risk assessment and whether a crime has been committed. He added that Version W would establish a system wherein a police officer or other first responder may determine whether an individual requires mental health care rather than solely placing the respondent under arrest. He referred to the example offered by Chair Claman and characterized it as a good example of the extent of coordination between law enforcement, first responders, and mental health professionals to determine the best course of action. He noted that the role of law enforcement is not to act as a social worker but to facilitate care and resume law enforcement duties. 2:09:17 PM REPRESENTATIVE EASTMAN asked what safeguards exist to prevent the abuse of the process, including the [unjustified] threat of arrest. MS. CARPENTER answered that there exist patient rights, including the right to counsel. She added that the Medicare and Medicaid offices have oversight of hospitals, which have crisis care facilities. She stated that DHSS has licensing and review staff to ensure the treatment plans and grievance procedures are compliant. She noted that each facility should also have a grievance procedure. She added that the Alaska State Ombudsman and the Police Standards Council could handle complaints. MR. BOOKMAN stated that mental health professionals have expressed a preference to avoid involuntary commitments because it leads to better patient outcomes, and law enforcement professionals have expressed a preference that individuals receive necessary care so officers can focus on law enforcement duties. 2:13:15 PM REPRESENTATIVE EASTMAN suggested that the proposed legislation would create a third alternative to either arrest or involuntary commitment and asked what safeguards exist to prevent coercion. MS. CARPENTER offered to clarify that no new process would be created, and this pertains to individuals who have not committed any crime. She stated that an involuntary commitment would occur when an individual meets the definition of gravely disabled or a danger to self or others. She stated that crisis centers are necessary to prevent individuals from sitting in an emergency room under observation only, or in protective custody at a community jail. CHAIR CLAMAN added that a civil commitment may be either court ordered, involuntary, or voluntary, and the proposed legislation would allow an individual to be held at a crisis residential center for a period of less than 30 days. REPRESENTATIVE EASTMAN asked what safeguards exist to prevent abuse of the proposed process. MS. CARPENTER restated that patient rights exist and added that professionals, such as emergency medical technicians and firefighters, are required to be professionally licensed and overseen by the State Licensing Board. CHAIR CLAMAN added that an essential protection would be the proposed judicial hearings prior to a 72-hour hold. Another protection would be the appointed attorney who may advocate for a patient's release. 2:18:42 PM REPRESENTATIVE EASTMAN noted that the definition of peace officer would include Village Public Safety Officers (VPSOs) and others. He questioned the protections to safeguard first responders concerning individuals who are taken into custody and not vaccinated. MS. CARPENTER answered that VPSOs have oversight via their licensure. She added that the settlement in the lawsuit with the Disability Law Center included a provision that DHSS shall offer training to law enforcement to recognize when an individual may be experiencing a mental health crisis, and the appropriate action which should be taken. She stated that there had been a previously proposed bill which would have allowed for a voluntary designation of a disability on the driver's license of a mentally disabled person. 2:21:38 PM REPRESENTATIVE DRUMMOND asked how many beds in the state are available for treatment in a subacute mental health care facility. MS. CARPENTER answered that the facilities which currently meet the criteria to qualify as a designated treatment and evaluation facility are the API; Fairbanks Memorial Hospital, which has 20 beds; Mat-Su Regional Medical Center, which has 16 beds; and Bartlett Regional Hospital, which has 12 beds. In response to a series of follow-up questions, she answered that API is currently at its maximum capacity of 80 beds, 10 of which are for forensic care for those deemed incompetent to stand trial in a criminal case. She answered that the facilities are maxed out and waitlists exist, which are reviewed by DHSS daily. She responded, per the proposed legislation, the 48 beds at the listed facilities are where respondents would receive treatment. She continued that Version W would allow for crisis residential centers to provide care, including 72-hour holds, which is the shortest effective treatment period. She advised that the current system does not meet current needs. 2:25:51 PM REPRESENTATIVE DRUMMOND asked whether there exist sufficient beds in residential centers in addition to those at the API and the other hospitals. MS. CARPENTER offered to follow up to the committee with a list of facilities which have requested the [1115 Behavioral Health Medicaid Waiver]. She estimated that 15 facilities had requested such waivers. CHAIR CLAMAN offered that Version W would provide the licensing structure for additional residential facilities. He noted that previous legislation had permitted crisis stabilization centers; however, these were limited to 23-hour treatments. 2:28:50 PM MR. REGAN, in response to Representative Eastman's earlier question regarding the existence of any legal protections for a potential mistake, or worse. He recalled Representative Eastman's suggestion that a peace officer may determine an unvaccinated individual posed a danger to self or others. He stated that training exists which would ensure intervention is based on the existence of mental illness and not based on a difference of opinion. He stated that, should an individual be brought for emergency evaluation, the health officer would seek evidence of mental illness. If it is determined there is no evidence, the individual will be released. REPRESENTATIVE VANCE asked for an explanation of the fiscal notes concerning the Alaska Mental Health Trust Authority's (AMHTA's) funding and general funding. She drew attention to the fiscal note from the Department of Family and Community Services, which would begin with a smaller increment, and then this increment would dramatically increase over the next five years. MS. CARPENTER answered that the reason for the growth depicted in the fiscal note is because of the estimated growth in the number of facilities. She added that, if no alternate funding exists, a statutory requirement determines the state is obligated to cover the costs for an individual who is involuntarily committed. She explained that Disproportionate Share Hospital (DSH) funds within the federal Medicaid program are available only to hospitals and not to tribal hospitals. She noted that several DSH qualifying facilities may be paid with federal and general matching funds. 2:34:42 PM MR. WILLIAMS offered that a partnership exists between AMHTA, community partners, and DHSS. He stated that in fiscal year (FY) 2023 AMHTA had approved $4.5 million of AMHTA funds to coordinate with communities and the department to develop and implement the components of the proposed model. He added that in FY 22 and FY 21, AMHTA invested roughly the same amount. He stated that the role of AMHTA is to effect positive changes to the behavioral crisis care system. REPRESENTATIVE VANCE asked whether the state and tribal health organizations are partnering to leverage additional federal resources to meet the needs in rural parts of the state. MS. CARPENTER answered that the Division of Behavioral Health is in communication with tribal partners weekly. She stated that partners providing these services include Maniilaq Health Services, Norton Sound Health Corporation, and Yukon-Kuskokwim Health Corporation. She stated that, when a tribal provider uses the [1115 Behavioral Health Medicaid Waiver] when serving a tribal beneficiary, the state can obtain 100 percent federal Medicaid funding. She noted that tribal providers are the only providers in certain areas in rural Alaska locations, such as Kotzebue, Nome, and Bethel. 2:38:45 PM REPRESENTATIVE EASTMAN asked whether detention, evaluation, and treatment (DET) facilities would be subject to local ordinances or policies. CHAIR CLAMAN asked the pertinence of the question to crisis residential centers. REPRESENTATIVE EASTMAN stated he was inquiring on which entities would prescribe policies, such as mandatory masking. CHAIR CLAMAN asked Representative Eastman to explain the relevance of his line of questioning. REPRESENTATIVE EASTMAN stated that he was inquiring to learn about the authority responsible for running the facilities. 2:39:58 PM MS. CARPENTER answered that each hospital operating DET has a unique ownership structure. She noted that hospitals with Medicaid and Medicare programs are subject to case management system rules, the Joint Commission, and oversight with health care facility licensing by the state. She explained that Fairbanks Memorial Hospital is a community foundation-owned facility, Mat-Su Regional Medical Center is jointly owned by the Mat-Su Health Foundation and its co-operator, and Bartlett Regional Hospital is owned by the City and Borough of Juneau. 2:41:32 PM CHAIR CLAMAN announced that HB 172 was held over.