ALASKA STATE LEGISLATURE  HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE  February 1, 2005 3:02 p.m. MEMBERS PRESENT Representative Peggy Wilson, Chair Representative Tom Anderson Representative Vic Kohring Representative Lesil McGuire Representative Paul Seaton Representative Sharon Cissna Representative Berta Gardner MEMBERS ABSENT  All members present COMMITTEE CALENDAR    OVERVIEW: DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES - HEARD PREVIOUS COMMITTEE ACTION    No previous action to record WITNESS REGISTER    BILL HOGAN, Director Division of Behavioral Health Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Presented an Overview of the Division of Behavioral Health. PATRICIA SENNER, Family Nurse Practitioner Covenant House Alaska Anchorage, Alaska POSITION STATEMENT: Described the problems with caring for youth with mental and substance abuse issues, and suggested being a part of the new Bring the Kids Home initiative. KARA NYQUIST, Attorney Covenant House Alaska Representative, Alaska Association of Homes for Children (AAHC) Anchorage, Alaska POSITION STATEMENT: Testified in support of the Bring the Kids Home initiative and made suggestions. ACTION NARRATIVE CHAIR PEGGY WILSON called the House Health, Education, and Social Services Standing Committee meeting to order at 3:02:03 PM. Representatives Seaton, Wilson, and Kohring were present at the call to order. Representatives Cissna, Gardner, Anderson, and McGuire arrived as the meeting was in progress. ^OVERVIEW: DIVISION OF BEHAVIORAL HEALTH CHAIR WILSON announced that the only order of business would be an overview of the Division of Behavioral Health. 3:03:31 PM BILL HOGAN, Director, Division of Behavioral Health, Department of Health and Social Services (DHSS), presented an overview of the division. Mr. Hogan pointed out that the Division of Behavioral Health has been working with federal, regional, and community partners to transform the way health care and substance abuse services are provided in Alaska. He reminded the committee that on July 1, 2003, DHSS formed the new Division of Behavioral Health by integrating the Division of Mental Health, the Division of Alcohol and Drug Abuse; the Office of Fetal Alcohol Syndrome; and various staff of the Divisions of Public Health and Medicaid. 3:04:19 PM MR. HOGAN noted that the division has responsibility for developing, implementing, and managing a "welcoming, accessible, continuous, comprehensive, and integrated behavioral health services system based on sound policies, effective practices, and partnerships." He said that the division wants to do a better job for people with both a mental health and a substance abuse disorder. 3:05:20 PM MR. HOGAN stated that the division supports an array of services, including prevention, treatment, rehabilitation, and aftercare. The structure of the division includes a steering committee made up of various entities and two task forces: an external one which includes other agencies and an internal one made up of senior management. MR. HOGAN discussed the new focus on providing help for individuals with co-occurring disorders. Between 50 and 75 percent of clients have both mental health and substance abuse disorders, and he said the goal is to create an integrated system. He said the state has separate statutes for mental health and substance abuse. Currently the system is financed through grants and fee-for-service Medicaid, and Mr. Hogan thinks there is a better way to fund it. He said that Alaska is one of seven states that received a co-occurring disorder grant from the federal Substance Abuse and Mental Health Services Administration. 3:11:02 PM MR. HOGAN informed the committee that the division is working with the University of Alaska and the Alaska Mental Health Trust to determine what kind of work force the state will need for the new integrated system. The division is providing technical assistance in the communities of Tok, Wrangell, Kodiak, Unalaska, Palmer/Wasilla, and Nenana. Mr. Hogan said the division wants to move toward an efficient service-delivery system that focuses on what the communities, individuals, and families need by promoting shared services. 3:13:10 PM MR. HOGAN spoke of the new web-based Alaska Automated Information Management System. Health care providers use it to obtain medical records and as a billing system. The system has allowed the division to analyze the "outcomes" of individuals being served by its mental health and substance abuse programs "between intake and discharge." He summarized the analysis as follows: Based on 4,000 clients, 60 percent reported an increase in productive activities; 70 percent reported a reduction in physical health problems; 70 percent reported a reduction in not having the ability to pay for basic needs, such as food and clothing; and 21 percent reported a reduction in homelessness. 3:19:17 PM MR. HOGAN introduced the Bring the Kids Home initiative. He said there are "a number of kids in out-of-state residential psychiatric treatment placements, and we want to not only bring those kids home to Alaska to stay with their own families and be in their own communities, but we also want to keep kids from going out of state." 3:20:58 PM MR. HOGAN said the division is proposing four substance abuse prevention initiatives: 1) Reach Out Now, a community and school-based program which works with 11- and 12-year olds, 2) Leadership Initiative, designed to fight underage drinking, 3) Local Options Campaign, which will work with villages in efforts to go dry or damp, and 4) Multimedia Education Campaign, which will be state wide. 3:23:03 PM MR. HOGAN reported that the division is actively involved in disaster response to take care of the emotional needs of victims of natural and man-made disasters. He also highlighted the division's vision of partnering with state, federal, faith- based, and volunteer organizations to promote healthy communities. 3:24:36 PM REPRESENTATIVE GARDNER asked about Mr. Hogan's comment on disaster response. MR. HOGAN responded that it is important to be available for people after disasters because an increase in drug and alcohol abuse often follows. 3:27:01 PM REPRESENTATIVE CISSNA expressed her support for the Bring the Kids Home initiative. She asked about a new facility for youth and wondered if the home is the best place for children, not "large warehousing of kids." 3:28:15 PM MR. HOGAN said the intent is to build the full continuum of care. Families are important, so even in large facilities he feels that there is a need to have a home-like environment. 3:29:24 PM CHAIR WILSON asked Mr. Hogan to explain the program in the six communities he mentioned. MR. HOGAN said the division chose a diverse array of communities where a contractor conducts meetings and helps each community explore the process of integrating services for people with co- occurring disorders. Wrangell has already merged mental health with substance abuse care and has thereby increased its service capacity by 200 percent. Mr. Hogan said such administrative efficiency will allow money to be redirected to serve more people. 3:31:46 PM REPRESENTATIVE GARDNER asked what the legislature can do to promote the division's work, "aside from the funding." MR. HOGAN said he did not want to start at the statutory level; the division will start with standards, build up through regulations, and then assess the need for statutes. 3:32:54 PM REPRESENTATIVE SEATON asked if the newly reorganized human resources program in the Department of Administration is helping the division's efficiency level. 3:33:30 PM MR. HOGAN said the division does not generally provide direct services, instead it directs 300 grants to 135 grantees, which are mostly private, non-profit groups, and so the organizational change in the state's human resources program has had no impact. REPRESENTATIVE SEATON asked if those groups could partner with the state's human resources program. MR. HOGAN responded that he thinks private non-profits have two missions: business efficiency and providing services. He is familiar with the reorganization of the human resources program but would have to explore Representative Seaton's suggestion. 3:35:43 PM CHAIR WILSON said that the work force for health care will see a huge need in the near future, and in Alaska "we don't have the people to do it." She requested that Mr. Hogan expound on the discussion of what the University of Alaska is doing. MR. HOGAN said there are various endeavors, but it will take several years before an impact is seen. Health care will have many needs at the entry level, as well as people with masters and PhD degrees. In conjunction with the university, the state envisions starting a program in psychology. He expressed his hope that these trained psychologists will be directed to work in community settings and not enter private practice. 3:37:39 PM MR. HOGAN stated that the intent is to expand bachelors and master's degree programs in social work. There is preliminary planning for a training academy for rural behavioral health. He said there is a need for orientation for workers moving to Alaska from elsewhere, but he also thinks there is good potential "to grow our own" behavioral health experts. 3:39:02 PM CHAIR WILSON asked about incentives for workers to stay in Alaska. MR. HOGAN responded that the division has talked about stipends, scholarships, and loan forgiveness programs, but the current proposal does not include such incentives. CHAIR WILSON expressed her belief that the need for these workers is "phenomenal." She said that by 2010 the state will need 4,000 more nurses. "We definitely need the training," she said. 3:40:21 PM MR. HOGAN told the committee that he has an analysis of those predicted shortages. REPRESENTATIVE CISSNA said she has been working with the Anchorage School District to develop career ladders in secondary schools. She added her understanding that by the fourth grade, students have already de-selected careers. She suggested statewide curricula that allows students to look at health careers as "viable things that will keep them in their community and give them good, sustainable jobs." 3:42:09 PM MR. HOGAN said Representative Cissna was correct; people who already have headed toward the health care field aren't enough. 3:42:45 PM REPRESENTATIVE SEATON questioned how the state could get people trained for community service and not have them move to private practice. 3:43:42 PM MR. HOGAN believed the state has to create an incentive not a mandate, and he is not sure how it can be done, especially since the money is better in private practice. 3:44:59 PM REPRESENTATIVE MCGUIRE expressed that the incentives within the Public Health Service program are good models. She brought up the topic of traumatic brain injury (TBI), a physical injury that leads to mental disorders, and asked how TBI services fall into the new integrated health model. 3:46:01 PM MR. HOGAN responded that the division received a grant from the Health Resources Services Administration for TBI. The money is helping to create a TBI advisory board. He thinks TBI service should not be completely separate. Since July 2004, all grantees track all individuals regarding TBI, fetal alcohol, substance abuse, and mental health problem. 3:48:41 PM REPRESENTATIVE MCGUIRE said the state has a high rate of TBI, and she feels that there needs to be more focus on it. 3:49:35 PM REPRESENTATIVE ANDERSON reported that he was visited by advocates from the Alaska Medical Association asking him to sponsor legislation to enhance the ability of foreign physicians to work in Alaska because of shortages in the state. 3:50:13 PM MR. HOGAN agreed there is a shortage of psychiatric doctors, especially child psychiatrists, but one caveat is that psychiatry is practiced in a cultural context which might hamper the proficiency of foreign specialists. 3:51:25 PM REPRESENTATIVE CISSNA expressed how different everyone's needs are and that there are various specialists that can zero in on particular problems, so she asked how the division can meet diverse needs while integrating services. 3:52:39 PM MR. HOGAN said he envisioned a continuum of services, with some basic services at the village level and a broader array of services in Anchorage where there would be more specialists. He added that the division's next big step is integrating primary care with behavioral care. 3:53:50 PM PATRICIA SENNER, Family Nurse Practitioner, Covenant House Alaska, told the committee that her responsibility is to evaluate the roughly 500 youth a year that come through the Covenant House crisis center residential program for physical and mental health problems. She stated that she was acutely aware of the mental health needs of Alaska's youth. The key risk factor for these youth is [substance abuse] by parents; approximately 80 to 90 percent of them have been either physically or sexually abused, and most have been prenatally exposed to alcohol or drugs. Most of these youths have had interactions with the mental health system, and a few of them suffer from mild mental retardation and schizophrenia, and many suffer from depression, attention deficit and hyperactivity disorder, poor anger management, post traumatic stress disorder, and sleep disorders. She said that there needs to be a paradigm shift for youth services because many of them have a disability that can't be cured, and she gave an example of people with fetal alcohol spectrum disorder (FASD) who have "poor executive functioning, they have extreme difficulties planning and connecting causes with effect, they live in the here-and-now and have difficulties planning for the future. They have very poor impulse control." Adolescence is particularly difficult for FASD patients, and they often end up in residential programs because of lack of sound judgment. Research has shown that 80 percent of youth with FASD end up in supervised settings. 3:57:42 PM MS. SENNER said that the current approach of sending youths to residential mental health facilities is expensive and ineffective. She said the Covenant House regularly gets youth recently discharged from an out-of-state residential facility without long term discharge plans and only a couple weeks worth of medication. It often takes months to obtain their records, she reported. MS. SENNER stressed that "we need to give thought to how we are going to provide care to these youths with a lifetime developmental disability." She stated that their mental health issues can be handled on an out-patient basis, but "what is desperately needed is better [indecipherable} for dealing with their poor decision impulsivity which in many cases is caused by brain damage." 3:59:04 PM MS. SENNER said that providers have put an emphasis in getting these kids out of bad home environments. Often the foster or adoptive parents can't handle the problems and then the kids end up in facilities. She stated the Covenant House wants to be part of the Bring the Kids Home initiative. 4:00:18 PM KARA NYQUIST, Attorney, Covenant House Alaska; Representative, Alaska Association of Homes for Children (AAHC), Anchorage. She said AAHC is made up of non-profit, community-based residential programs for homeless and runaway youth. She added that AAHC has been meeting for about 18 years, and the last three years they have focused on bringing children home, so they are happy with the new initiative. 4:01:38 PM MS. NYQUIST noted that the division's Bring the Kids Home plan places an emphasis on "gate keeping," which she supports. She said that many of the youth are in inappropriate levels of care outside of the state, and they could have been helped locally with better success. She pointed out that last year the state spent about $40 million to serve a few hundred kids in out-of- state care. Looking at programs in AAHS, a similar budget served over 10,000 kids. Twenty-five percent of their budget comes from the state through grants, and the rest comes from fundraising, corporate donations, and federal and private grants. MS. NYQUIST said institutional care is not the answer for many of these youths, and "we do not think there is a large need for more than one institution in the state." She stated that community-based programs can serve these kids. She added that there needs to be a lifespan plan for them. When they don't have a plan for aftercare they end up in the court system, and she also noted that Alaska ranks 50th in the nation for teen violent suicide deaths. 4:05:29 PM ADJOURNMENT  There being no further business before the committee, the House Health, Education and Social Services Standing Committee meeting was adjourned at 4:05 p.m.