ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  January 27, 2011 3:03 p.m. MEMBERS PRESENT Representative Wes Keller, Chair Representative Alan Dick, Vice Chair Representative Bob Herron Representative Paul Seaton Representative Sharon Cissna Representative Bob Miller Representative Charisse Millett MEMBERS ABSENT  All members present COMMITTEE CALENDAR  OVERVIEW: DEPARTMENT OF HEALTH AND SOCIAL SERVICES - HEARD PREVIOUS COMMITTEE ACTION  No previous action to report WITNESS REGISTER BILL STREUR, Acting Commissioner Office of the Commissioner Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Presented a power point overview of the Department of Health and Social Services. ALISON ELGEE, Assistant Commissioner Central Office Finance and Management Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Presented a power point overview of the Department of Health and Social Services. DAVE COTE, Director Central Office Division of Alaska Pioneer Homes Juneau, Alaska POSITION STATEMENT: Answered questions during the overview of Department of Health and Social Services. MELISSA WITZLER-STONE, Director Central Office Division of Behavioral Health Anchorage, Alaska POSITION STATEMENT: Answered questions during the overview of Department of Health and Social Services. CHRISTY LAWTON, Acting Director Central Office Office of Children's Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during the overview of Department of Health and Social Services. DR. WARD HURLBURT, Director and Chief Medical Officer Central Office Division of Public Health Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Answered questions during the overview of Department of Health and Social Services. ACTION NARRATIVE 3:03:02 PM CHAIR WES KELLER called the House Health and Social Services Standing Committee meeting to order at 3:03 p.m. Representatives Keller, Dick, Herron, Seaton, Cissna, Miller, and Millett were present at the call to order. ^OVERVIEW: DEPARTMENT OF HEALTH AND SOCIAL SERVICES OVERVIEW: DEPARTMENT OF HEALTH AND SOCIAL SERVICES  3:03:24 PM CHAIR KELLER announced that the only order of business would be an overview by the Department of Health and Social Services (DHSS). 3:04:46 PM BILL STREUR, Acting Commissioner, Office of the Commissioner, Department of Health and Social Services (DHSS), explained that this overview would not delve into budget detail. He referenced the handout entitled, "2011 Priorities' [Included in members' packets.] and relayed that the DHSS mission was to promote and protect the health and well being of Alaskans, and its vision was for all individuals and families to be healthy, safe, and productive. He listed the first DHSS major priority, substance abuse and mental health, and declared that each were significant issues in Alaska. He summarized the major strategies to deal with this: prevention and health promotion, early intervention, treatment services, and recovery. He noted that this was a lifelong process. He directed attention to the second priority, health and wellness, and ascertained its major strategies to include: prevention and health promotion, disease control, access, emergency response and preparedness, and environmental health impacts. He elaborated on the next priority, health care access and delivery, and listed these major strategies to include: technology for sustainable and effective health care delivery, workforce development, and enhanced management of high health needs. He emphasized the need for an electronic health records system. 3:10:56 PM REPRESENTATIVE SEATON observed that providers had concerns for connectivity with the DHSS system. 3:11:31 PM ACTING COMMISSIONER STREUR acknowledged that older systems may need to be updated; however, he pointed out that the Health Information Exchange worked with a variety of systems. He offered his belief that there would be many fewer problems than feared initially. 3:12:13 PM CHAIR KELLER opined that there was still a long way to go, as only 18 percent of providers had signed on. 3:12:47 PM ACTING COMMISSIONER STREUR agreed. He suggested that the first step was to entice providers to convert to electronic health records, and then for the providers to recognize the value of participation with the Health Information Exchange. He directed attention to federal financial support for the state and the providers for conversion. He elaborated on the workforce development advancements around Alaska. 3:14:31 PM REPRESENTATIVE CISSNA asked about the current billing problems with telemedicine. 3:16:19 PM ACTING COMMISSIONER STREUR, in response to Representative Cissna, shared that a change in regulations would resolve this problem. He observed that telemedicine programs lowered transportation costs by 40 percent. 3:17:47 PM ACTING COMMISSIONER STREUR, in response to Chair Keller, said that very little would change for the provider with the Medicaid Management Information System (MMIS) system. He confirmed that more than 78 percent of claims were submitted electronically. 3:18:18 PM CHAIR KELLER asked what steps DHSS was taking to make the work force more attractive. ACTING COMMISSIONER STREUR replied that DHSS was working with the University of Alaska on strategies to entice and retain a skilled workforce. He confirmed that the State of Alaska offered few incentives, such as loan repayment or forgiveness programs. He offered his belief that there was an effort from the Alaska State Legislature to bring an incentive program forward. He stated the importance of a work environment in which the providers wanted to stay. 3:19:34 PM ACTING COMMISSIONER STREUR summarized that "15 percent of the population consumes 75 percent or 85 percent of the health care dollar." He pointed to the necessity for enhanced management of high health needs. He assessed the next major priority to be a sustainable long term care delivery system, and identified its strategies: identify and coordinate health and welfare need, promote a service array that meets the needs of underserved who require long term care services, and develop an integrated and comprehensive model of care. 3:21:29 PM ACTING COMMISSIONER STREUR presented the final priority, vulnerable Alaskans, and the need to provide protective services, which included the promotion of domestic violence and sexual assault programs, and suicide prevention programs. He updated the Bring the Kids Home initiative, sharing that although 90 kids were still out of state, this was down from more than 400 kids. 3:23:20 PM REPRESENTATIVE CISSNA asked if there was a means for the public to track the Bring the Kids Home program. 3:24:34 PM ACTING COMMISSIONER STREUR replied that he would research this, but he did not know of any website to track this. 3:24:49 PM CHAIR KELLER clarified that the goal for the Bring the Kids Home program was not to bring all the kids home, as there were some needs that could not be addressed in Alaska. 3:25:27 PM REPRESENTATIVE HERRON asked if the bed capacity had been increased at the Fairbanks Boys and Girls Home of Alaska. ACTING COMMISSIONER STREUR replied that he would forward that information. 3:26:12 PM ACTING COMMISSIONER STREUR concluded his discussion of major strategies for Vulnerable Alaskans. He reported that expansion of the Family First Initiative would help families leave the public assistance rolls. 3:26:55 PM CHAIR KELLER expressed his appreciation for the emphasis on "individual and family responsibility and engagement, and community engagement." 3:27:47 PM ACTING COMMISSIONER STREUR, referring to the PowerPoint entitled "2011 Alaska Department of Health and Social Services Overview," [Included in members' packets] explained the Alaska Department of Health and Social Services Organization Chart (slide 1). He shared that DHSS was a "super agency at the national level" as it included full health and social services within eight divisions. He reported that DHSS employed 3690 people, and had a budget of $2.445 billion. He continued with slide 2, "Budget Highlights," explained the distribution of the money, and directed attention to Medicaid as the largest recipient, $1.513 billion. 3:29:41 PM REPRESENTATIVE HERRON praised the federal performance bonus that DHSS had received. ACTING COMMISSIONER STREUR confirmed that a $4.4 million performance bonus had been received for the Denali Kid Care program. 3:30:38 PM CHAIR KELLER communicated his appreciation for DHSS. 3:31:10 PM ALISON ELGEE, Assistant Commissioner, Central Office, Finance and Management Services, Department of Health and Social Services, referring to the FY 2012 budget overview documents and the FY 2011 operating grants book, [distributed earlier to the HHSS members] shared that each of these documents contained "a wealth of information." 3:32:41 PM CHAIR KELLER directed attention to the details in the operating grants book which were reflected in just a few lines of the budget. MS. ELGEE relayed that grants accounted for more than $160 million to the division programs. 3:33:16 PM REPRESENTATIVE CISSNA asked if there were any reference to former grant levels, in order to compare to current distributions. MS. ELGEE, in response, said that although that information was not included in this publication, it was possible for a year to year comparison of program areas. She noted that the availability of grant funding had remained "relatively steady." REPRESENTATIVE CISSNA asked for a nationwide comparison. 3:34:59 PM MS. ELGEE, pointing to slide 3, "Alaska Pioneer Homes," recounted that there were 5 Pioneer Homes, with 508 licensed assisted living beds, located in Anchorage, Fairbanks, Juneau, Ketchikan, and Sitka. In addition, there was the Palmer State Veterans and Pioneer Home. She explained the eligibility for admission: 65 years of age and an Alaska resident for the year prior. She recounted that there were both active and inactive wait lists, depending on your immediate need. She confirmed that 500 people were currently on the active wait list for the 508 beds. She listed the range of fees, $2135/month to $6170/month, depending on the level of service. She identified that the Palmer Home had a federal obligation for veteran preference. She disclosed that financial information was not a criterion for admission, and there was aid to look at payment assistance which could include Medicaid waivers, state payment assistance programs, and veterans' assistance. 3:40:19 PM MS. ELGEE shared that in 1995, 63 percent of residents needed the highest level of care, whereas today 88 percent required this same level of care. She explained that a result of progressive dementia could include a period of assaultive behavior. She reported on the financial difficulty for maintaining higher levels of staffing. 3:42:00 PM REPRESENTATIVE HERRON asked if the staffing ratio was one employee per resident. MS. ELGEE agreed that this ratio reflected total staffing, but she clarified that this was not possible for a 24 hour day/ 7 day week (24/7) coverage. REPRESENTATIVE HERRON asked about the schedule for patient transfers between facilities in order to maintain their level of care. 3:43:06 PM CHAIR KELLER asked about the availability of nursing beds throughout Alaska. MS. ELGEE, in response, said that 700 nursing home beds were available in assisted living homes. She confirmed that 3500 patients had long term care waivers, though some of these patients were still in their homes. CHAIR KELLER asked about the coordination of care between nursing homes and the Pioneer Homes. 3:44:26 PM DAVE COTE, Director, Central Office, Division of Alaska Pioneer Homes, in response to a question by Representative Herron, said that should Pioneer Home patients need nursing home care, it became necessary for them to move to a nursing home. He acknowledged that the Pioneer Home level of care only went to Level 3. CHAIR KELLER asked to define the levels of care. MR. COTE explained that level 3 patients needed 24 hour care, and that the Pioneer Homes were not licensed as a nursing home. REPRESENTATIVE HERRON asked if the medication error rate in Pioneer Homes had decreased, and if the Medicaid administered rate had increased over the prior year. MR. COTE replied that the medication error rate was stable, and that the volume of medication was about 550,000 doses quarterly. 3:46:39 PM REPRESENTATIVE SEATON asked if the issue surrounding veterans' medication packaging had been resolved. MR. COTE replied that the Veterans Administration (VA) medications were being directly administered by nurses. 3:47:38 PM MS. ELGEE addressed slide 4, "Behavioral Health," and reported that the Division of Behavioral Health had 334 full time employees. She noted that 240 of the staff worked at Alaska Psychiatric Institute (API) in a 24/7 operating environment. She relayed that the majority of its work was done in partnership with communities and non-profit agencies throughout Alaska, and it had served almost 19,000 people in 2010. She established that program performance standards were built into the grant review process. She reported that the Alaska Mental Health Board, the Alcohol and Substance Abuse Advisory Board, and the Suicide Prevention Council were all administered by the Division of Behavioral Health. She pointed out that patients were often referred to API, where alternative treatments at the community level would be more appropriate. 3:51:27 PM REPRESENTATIVE SEATON asked if the earlier problems with mandatory overtime and staffing at API had been resolved. MS. ELGEE replied that reports regarding the use of mandatory overtime were being prepared, and would include both API and the Pioneer Homes. She stressed that the department worked hard to avoid mandatory overtime, or unplanned overtime. She pointed out the difference with scheduled overtime, noting that the employees participated in the scheduling. REPRESENTATIVE SEATON expressed his concern for patient safety, regardless of the type of overtime. MS. ELGEE agreed that nurses should not work more than 14 hours each day. 3:54:32 PM REPRESENTATIVE CISSNA expressed appreciation for the ongoing efforts from the Division of Behavioral Health. She asked about the availability of community health care jobs for recent graduates. MELISSA WITZLER-STONE, Director, Central Office, Division of Behavioral Health, in response to an earlier question by Representative Herron, said that the Fairbanks Boys and Girls Home had 60 beds, of which 56 were currently occupied. She added that 44 of the patients were Level 5 and 16 were Level 3. 3:57:38 PM CHAIR KELLER asked if API care was both in-patient and out- patient. MS. STONE replied that there was only in-patient care, and there were 80 beds. 3:58:09 PM REPRESENTATIVE DICK questioned whether expansion to 120 beds would also result in full occupancy. MS. STONE replied that it was most important to maintain appropriate admission decisions, and that before expansion, it was necessary to ensure that the system was working as efficiently and effectively as possible. REPRESENTATIVE DICK reflected that ten years ago, people needed service that was not available. 3:59:42 PM REPRESENTATIVE SEATON asked about a program for intermediate stays. MS. STONE clarified that Representative Seaton had referred to the designated emergency stabilization and treatment option. She pointed out that there was a recent focus to keep people at the local community care level, and there was now a statewide effort to make it work effectively. 4:01:23 PM MS. ELGEE referred to slide 5, "Office of Children's Services," and introduced its Acting Director, Christy Lawton. She stated that Office of Children's Services (OCS) had 499 full time staff, organized in 5 regions with 26 field offices. She announced that the primary purpose of OCS was to provide protective services to children at risk of harm. She pointed out that OCS also managed the grants for the Infant Learning Program. These grants provide early childhood special education services to children with developmental delays. She observed that OCS provided grant funding to 9 child advocacy centers. She said that "the division provides a multitude of family support and family preservation services to improve the success of families in caring for children who otherwise might be at risk of removal." Its first effort was to maintain intact families, where at all possible, and provide direct family services to enable this. She affirmed that OCS was subject to periodic review by its federal partners, as measured against federal statistics for performance and improvement standards. She shared that the biggest challenge was to maintain an experienced staff, as this was a high stress environment. She pointed to an earlier survey of OCS staff which indicated that 60 percent of frontline social workers were in position for less than 2 years. She reported on the realignment of OCS resources to create the Western Region, a result of suggestions from the Citizens Advisory Review Panel, the court system, and the legislative delegation. She acknowledged that the Wasilla office for the Southcentral region had experienced an increased caseload, so this separate region allowed for a more direct management. She noted that the rural offices still experienced difficulty in hiring experienced staff. 4:05:54 PM REPRESENTATIVE HERRON asked if the Citizens Advisory Review Panel would be making a presentation to the House Health and Social Services Standing Committee. CHAIR KELLER, referring to the DHSS organization chart, declared that it would allow for the committee to better understand the relationship of each division and committee. In response to Representative Herron, he said that the panel would make a presentation on a still to be determined date. REPRESENTATIVE CISSNA reflected on the need for foster care, as it was an "ongoing chronic problem." She observed that the safest place for a child was in their own home. She requested regular updates on the foster care program to help ensure "that these kids are getting the kind of care that gives them a better future." 4:12:30 PM CHRISTY LAWTON, Acting Director, Central Office, Office of Children's Services, Department of Health and Social Services, in response to Representative Cissna, offered to provide data on a regular basis. She agreed that kids should be in their own home, and that the OCS emphasis was to do so, whenever it was safe. 4:13:37 PM MS. ELGEE, directing attention to slide 6, "Public Health," declared that there were 507 full time staff. She listed the various operations to include public health nursing, vital statistics, public health labs, infectious disease information, licensing for health facilities, and the State Medical Examiner's office. She added that the division administered the statewide emergency services programs. 4:15:55 PM REPRESENTATIVE HERRON summarized an incident in Bethel with the office of the State Medical Examiner, and he asked to discuss the possibility of a policy change for rural Alaska. DR. WARD HURLBURT, Director and Chief Medical Officer, Central Office, Division of Public Health, Department of Health and Social Services, agreed to work on that. He discussed the reasons for the policy, and he opined that during these times of grief there could be miscommunications. REPRESENTATIVE HERRON emphasized that this was an important issue for his constituency. 4:19:50 PM REPRESENTATIVE SEATON asked if the state's decision to no longer offer flu shots for adults indicated a shift away from preventative health. DR. HURLBURT explained that efforts by the late Senator Ted Stevens had resulted in Alaska consistently receiving extra federal funding for immunizations. He pointed out that Alaska now received less funding, but still maintained vaccinations for children. He indicated that there was still an effort to maintain vaccinations for people over 65 years of age. 4:22:26 PM REPRESENTATIVE SEATON reported on his research about Vitamin D, and stated his desire to work with DHSS on the use of Vitamin D for preventative health. CHAIR KELLER pointed out that Dr. Hurlburt was also Chair of the Alaska Health Commission, which would present an annual report to HHSS. He stated his respect and appreciation for the expertise and leadership skills of Dr. Hurlburt. 4:25:01 PM REPRESENTATIVE CISSNA, referencing the Alaska State Constitution, said that "the legislature shall provide promotion and protection of public health." She pointed out that the Division of Public Health was responsible for fulfilling this constitutional mandate. She asked Dr. Hurlburt to elaborate on the preventative aspect. 4:26:19 PM DR. HURLBURT agreed that public health and prevention efforts were important. He affirmed that all Alaskans were patients of the Division of Public Health, and although it did not receive the glamour "of the high tech stuff," prevention was important. He detailed that although some infectious diseases were still a problem, the chronic diseases, especially tobacco, were the problem now. He pointed to the progress being made for all age groups toward cessation of tobacco use. He credited Governor Parnell, who as a legislator had been instrumental in using the tobacco settlement money for tobacco education. He referenced the Center for Disease Control and Prevention (CDC) report which stated that Alaska was the number one state in funding for anti tobacco efforts. He offered his belief that now the biggest public health challenge was the complications from obesity and overweight, as this was approaching the same number of premature deaths as tobacco. He referred to a CDC study which estimated that 33 percent of the kids born in the last decade were at high risk of developing diabetes, compared to a current rate of 6 - 8 percent of adults. He stressed that the economic impact would be "unfathomable" and he emphasized the importance for a change to the culture. 4:30:08 PM The committee took a brief at-ease. 4:31:30 PM CHAIR KELLER reported that the overview would continue at the next HHSS meeting. 4:32:24 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:32 p.m.