ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 22, 2011 3:06 p.m. MEMBERS PRESENT Representative Wes Keller, Chair Representative Alan Dick, Vice Chair Representative Bob Herron Representative Paul Seaton Representative Bob Miller Representative Charisse Millett MEMBERS ABSENT  Representative Sharon Cissna COMMITTEE CALENDAR  PRESENTATION(S): COMMISSION ON AGING - HEARD LONG TERM CARE OMBUDSMAN - HEARD COMMUNITY CARE COALITION - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER DENISE DANIELLO, Executive Director Alaska Commission on Aging Division of Senior and Disabilities Services Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Presented a PowerPoint during a presentation by the Alaska Commission on Aging. DIANA WEBER, Ombudsman Long Term Care Ombudsman Alaska Mental Health Trust Authority Department of Revenue (DOR) Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint during discussion of the role of the Office of the Long Term Care Ombudsman. SANDRA HEFFERN, Chair Community Care Coalition POSITION STATEMENT: Testified about long term care in Alaska. PAT HEFLEY, Deputy Commissioner Office of the Commissioner Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Testified during discussion of long term care in Alaska. ACTION NARRATIVE 3:06:13 PM CHAIR WES KELLER called the House Health and Social Services Standing Committee meeting to order at 3:06 p.m. Representatives Keller, Dick, Herron, Millett, and Miller were present at the call to order. Representative Seaton arrived as the meeting was in progress. ^PRESENTATION: Commission on Aging PRESENTATION: Commission on Aging    3:07:00 PM CHAIR KELLER announced that the first order of business would be a presentation by the Alaska Commission on Aging. 3:08:46 PM DENISE DANIELLO, Executive Director, Alaska Commission on Aging, Division of Senior and Disabilities Services, Department of Health and Social Services (DHSS), presented a PowerPoint entitled, "Findings from the Older Alaskans Survey and Elder/Senior Community Forums." She spoke about slide 1, "Our Purpose," and shared that the purpose of the Commission was to plan, educate, and advocate on behalf of all Alaskans, 60 years and older, and ensure that they had meaningful lives, had access to necessary services, and remained in their homes and communities as long as possible. She stated that the commission had to provide information and recommendations about the needs of older Alaskans to the governor and the legislature. She shared that the commission was formed in 1982, and that the 11 board members were comprised of appointed Alaskan seniors, and staff from DHSS, Department of Commerce, Community & Economic Development (DCCED), and the chair of the Pioneer Home advisory board. 3:12:09 PM MS. DANIELLO moved on to slide 2, "Growth of Alaska's Senior Population," and spoke about the growth surge of the senior population in Alaska. She reported that there were about 85,100 Alaska seniors, with the majority having lived here for some time. MS. DANIELLO pointed to slide 3, "Comparison of Age Distribution 1977 and 2009," and compared the changes for age profile distributions as the baby boomers aged. 3:13:41 PM MS. DANIELLO shared slide 4, "The population of Alaskans age 85+ will grow by nearly 500% from 2000 to 2034." She noted how quickly this age group would grow with the arrival of the baby boomers. She reported that it was this group of seniors most in need of health care services, and would have the highest health care costs. MS. DANIELLO reviewed slide 5, "Growth of Alaska's Senior and Youth Populations," and compared that from 2001 to 2009, the number of youth under 18 years of age, had increased by 4 percent, whereas the number of seniors 60 years and older, had increased by 53 percent. Currently, about 12.3 percent of the Alaska population is seniors, and she projected that seniors would comprise 20 percent of the state population in 20 years. 3:14:45 PM MS. DANIELLO furnished slide 6, "Senior Growth Rates Vary by Region," and shared that Southcentral, Anchorage, and the Fairbanks/Interior were the fastest growing regions. She confirmed that every region of the state had a senior growth rate of more than 20 percent in the past 8 years. 3:15:22 PM MS. DANIELLO shifted to slide 7, "There are over 6,000 Alaskans with Alzheimer's disease and related dementias, based on national prevalence rates." She observed that a consequence of an aging population was an increase in Alzheimer's disease and related dementias (ADRD). She estimated there were about 6000 Alaskans, age 65 and older, with ADRD, but that this number could increase to 17,000 in 20 years. She stated that health care costs were three times higher for those with ADRD. 3:16:01 PM MS. DANIELLO offered slide 9, "Needs Assessment Efforts for State Plan Development Process," and reported that this was required for all states using federal funds. She listed these programs to include home and community based services funded by Title III of the Older Americans Act, funds for vocational training for low income seniors, funds for elder protection, and funds for nutrition, transportation, and supportive services for tribal organizations. She presented that the needs assessment would be done at community forums and by statewide survey. 3:18:09 PM MS. DANIELLO referred to slide 10, "Senior Survey Methodology" and the 2010 Survey of Older Alaskans [Included in members' packets] and explained that the survey had been widely distributed. She shared that 3,222 responses to the survey had been received. She stressed that, as this was not a random, statistically-valid sample of Alaska seniors, precise conclusions could not be drawn from it. She pointed out, however, that the large number of responses and widespread representation did offer valuable information. 3:19:46 PM MS. DANIELLO turned to slide 12, "The great majority of survey responders were seniors (age 60+). We received responses from every senior age group. The oldest respondent was 107." She noted that more women responded, even though the population was equal, and that the ethnicity tracked comparable to the general profile of Alaska. 3:20:46 PM MS. DANIELLO supplied slide 14, "We received survey responses from every region of the state," and slide 15, "The majority of seniors who responded have lived in Alaska for 40 years or more." She shared that 56 percent of the respondents had lived in Alaska for more than 40 years. 3:21:28 PM MS. DANIELLO pointed out the findings of the survey on slide 17, "Alaskan seniors are very happy here. More than 9 out of 10 older Alaskans (94%) would recommend their community as a good place to live for seniors," and on slide 18, "Research shows that social engagement is an important correlate of both mental and physical health for seniors," which indicated that 33 percent got together four or more times each week. 3:22:15 PM MS. DANIELLO directed attention to slide 19, "Senior centers are an important key to senior community involvement. Nearly six in ten seniors visit a local senior center at least occasionally." She reported that only 9 percent reported that there was not a senior center in their community. 3:22:48 PM MS. DANIELLO indicated slide 20, "Many older Alaskans are struggling financially. One in five cannot make ends meet, and another two in five are just getting by." She compared this to the 2005 survey, which had a similar response. 3:23:35 PM MS. DANIELLO move on to slide 21, "More than half of the older Alaskans who responded to the survey indicated that they live in a household with $2,000 or less of monthly income," and she stated that this was 176 percent of the federal poverty guideline for a one person household, or 131 percent for a two person household. 3:24:11 PM MS. DANIELLO indicated slide 22, "Three out of five older Alaskans surveyed have an illness or disability that limits the range of activities they can enjoy." She said that many of these were physical disabilities. 3:24:50 PM MS. DANIELLO summarized slide 23, "Seven out of ten responders live in a home they or a family member own. Two in ten live in a rented home or apartment." 3:25:13 PM MS. DANIELLO commented on slide 24, "One in three seniors say their home needs some sort of modification-such as ramp installation, grab bars, or insulation-in order for them to be safe and comfortable." MS. DANIELLO reviewed slide 25, "Most older Alaskans (69%) are not having trouble finding a primary care doctor. Of those who are, Medicare payment issues are the most often-cited reason." She stated that the majority of seniors having difficulty were in the Anchorage area, but that Fairbanks, the Aleutians, and Southcentral were also areas of difficulty. She pointed out that these seniors with difficulties reflected an increase from the 2005 survey. 3:26:40 PM MS. DANIELLO assessed slide 26, "More seniors rated "health care" and "financial security" as important issues than any other topic. These two issues were also the top concerns listed in our 2005 senior survey." She listed other concerns to be fuel costs, housing, enough food to eat, in-home services, and transportation. 3:27:34 PM MS. DANIELLO spoke about slide 27, "Most seniors have not used any of the available senior services. Of those who have, most are satisfied with the service they received." She noted that only about 33 percent used any of the services, similar to the results of the 2005 survey. The two programs which gathered the highest satisfaction rating were adult day programs and home delivered meals. She opined that the services were only being used when needed, and that they fulfilled the basic needs. 3:28:43 PM MS. DANIELLO discussed slide 28, "Many seniors included open- ended comments on a wide range of topics." She reported that more than 1,300 comments had been received, which included thoughts on the increase in rental and fuel costs, problems with health care, senior housing and transportation, and home care. 3:29:31 PM MS. DANIELLO summarized slide 30, "Findings from the ACoA's elder/senior community forums held in Anchorage, Fairbanks, Juneau, Kotzebue, Bethel, and with the Alaska Native Tribal Health Consortium Elders Committee highlighted similar concerns:" She said that each forum was conducted in the same format, with the same questions focusing on health care and long term supports, financial security and housing, and healthy lifestyles and social wellbeing. She listed participants to include elders, seniors, family care givers, and senior providers. She stated that the issues raised at the forums were similar to the senior survey, and included: access to primary care and geriatric specialists, and the need for increased long term support services. She shared that the rural forums stated a need for the same services as in the urban areas. She cited a need for hospice service and family care giver training in rural communities. She reported that transportation, senior housing, and culturally appropriate living facilities were issues at all of the forums. She declared a need for a "one-stop shop" for information and referral services. 3:35:15 PM MS. DANIELLO concluded the PowerPoint with slide 32, "Future priorities for addressing senior needs and concerns include:" She stated the highest priority to be resolution of the primary health care access for Medicare recipients. 3:36:01 PM REPRESENTATIVE HERRON asked for some strategies to provide this necessary access. 3:36:43 PM MS. DANIELLO, in response, said that two new senior facilities in Anchorage would provide services to Medicare beneficiaries. She pointed to legislation regarding financial incentives for health care personnel to accept Medicare patients. She declared that a too small health care workforce was a big issue. She advocated legislation for both loan repayment and forgiveness, and recruitment for health care providers to Alaska. 3:37:45 PM REPRESENTATIVE HERRON asked for details of the administration's strategy to create opportunities for providers to interact with customers. In response to Chair Keller, he explained that he had hoped that Ms. Daniello, as a professional, "had the magic wand." He agreed that Medicare was a challenge for seniors. 3:40:06 PM MS. DANIELLO, returning attention to slide 32, emphasized the need for a statewide long term health care plan, which would guide the development of quality senior care. She stated the need for a well-trained workforce, more quality senior housing with supportive services on site, expanded transportation service, a senior friendly environment, and financial assistance programs for seniors. 3:43:28 PM CHAIR KELLER asked about senior centers and transportation services in the members' communities. He opined that there was more federal funding than state grants. 3:44:38 PM MS. DANIELLO, in response, said that the state did receive federal funding for transportation services, as well as spending state general funds for senior services. CHAIR KELLER suggested that efficiencies were a necessary part of the long term care program. 3:45:37 PM REPRESENTATIVE SEATON explained that Homer and Cooper Landing had a senior van, with plans for the development of a small private bus system. He noted that a voucher system, contracted with the local taxi companies, had been another senior transportation solution. MS. DANIELLO pointed out that seniors contributed more than $1.7 billion to the state. 3:47:25 PM REPRESENTATIVE SEATON, reflecting on an earlier presentation to HHSS on prevention and disease, suggested working with the senior community on these issues. 3:48:17 PM CHAIR KELLER reflected that he had read that one dollar spent on health prevention saved three dollars. 3:48:37 PM The committee took an at-ease from 3:48 p.m. to 3:50 p.m. ^Long Term Care Ombudsman Long Term Care Ombudsman    3:50:36 PM CHAIR KELLER announced that the next order of business would be a presentation from the long term care ombudsman. DIANA WEBER, Ombudsman, Long Term Care Ombudsman, Alaska Mental Health Trust Authority, presented a PowerPoint entitled "Office of the Long Term Care Ombudsman," [Included in the members' packets]. She explained that the Office of the Long Term Care Ombudsman (OLTCO) was a small program with a small budget and a big mission. She referred to slide 1, "Authority" and explained that the federal Older Americans Act of 1965 gave the office its authority. She reported that the job was "to investigate and resolve complaints on behalf of seniors in long term care," with the idea of protecting elders who were not able to speak for themselves. She directed attention to AS 47.62.015, which authorized OLTCO to investigate and resolve complaints made by or on behalf of older Alaskans in long term care, if the complaint relates to a decision, action or failure to act by a provider or by a public agency or social services agency that may adversely affect the health, safety, welfare, or rights of an older Alaskan. She explained that, as her office investigated complaints in all agencies, it could not be administered in Department of Health and Social Services. 3:54:41 PM MS. WEBER, referring to slide 2, "OLTCO Enforcement Authority," clarified that her office was not a regulatory agency, and did not have enforcement authority. She declared that the OLTCO had broad powers to investigate, but did not take away licenses or enforce changes. She added that the Older Americans Act (OAA) offered a broader mandate which allowed for the monitoring of conditions in long term care facilities. She reflected on the difficulty of monitoring all of the long term care facilities in Alaska on a regular basis. 3:56:51 PM MS. WEBER referred to slide 3, "OAA Mandate to OLTCO" and stated its charge of advocating for vulnerable seniors, which could include legislative advocacy, and the raising of public awareness to the needs of elders. She pointed out that Alaska included OLTCO to be responsible for investigating long term abuse and neglect in long term care facilities. 3:57:08 PM MS. WEBER addressed slide 4, "Administration," and explained that the OLTCO was a part of the Alaska Mental Health Trust Authority operations, and was represented in court by the state Attorney General. 3:57:55 PM REPRESENTATIVE HERRON asked if the Attorney General always came to its defense. MS. WEBER replied that although the Attorney General was the lawyer for the OLTCO it was her responsibility to ensure that the Attorney General had reviewed the policies and procedures, and that OLTCO was not going beyond its mandate. 3:58:42 PM MS. WEBER returned attention to slide 4, explained the sources of funding, and stated that the OLTCO funding was not increasing. 3:59:14 PM MS. WEBER, summarizing slide 5, "Staff and Volunteers," conveyed that the five OLTCO staff were responsible for unannounced "friendly visits" to monitor facilities, consultation with the public, and training for providers and volunteers. She reported that there were 12 volunteer ombudsmen in 23 facilities. 4:00:38 PM CHAIR KELLER asked for more information about the provider training. 4:00:52 PM MS. WEBER, in response to Chair Keller, said that the assisted living provider training was supplied under the OAA mandate. 4:01:59 PM MS. WEBER reported that the OLTCO was busier, as the average number of complaints had increased, as shown on slide 6, "Complaints and Cases." She clarified that these could be multiple complaints about the same incident. She pointed to the increase in average number of cases opened each month as a better indicator of the number of people served. 4:02:59 PM CHAIR KELLER asked if the complaints typically came from the family. MS. WEBER replied that the complaints were received from every possible source. 4:03:30 PM REPRESENTATIVE HERRON reflected that this report indicated that the ombudsman was doing their job. 4:04:05 PM MS. WEBER shared that complaints to OLTCO had dropped in other states, and she attributed this to a larger number of volunteer ombudsman. 4:04:42 PM MS. WEBER referenced slide 7, "Complaints FY 2011," and stated that 90 percent of the complaints were about assisted living facilities, and the top three complaints were: poor medication management practices; falls and improper handling of residents; and shortage of staff. 4:05:50 PM MS. WEBER directed attention to slide 8, "Resolution of Complaints July 1, 2010-January 31, 2011," and stated that outcome data was important to review. She stated that OLTCO had resolved 67 percent of the complaints to the satisfaction of the resident or the complainant. She noted that OAA had mandated that resolution be to the satisfaction of the senior. REPRESENTATIVE HERRON asked to clarify how many of the complaints were just a need for attention. MS. WEBER replied that these were real complaints, and that she was impressed that the elder generation did not ask for more than they needed. Returning to the resolution of complaints, she reported that 23 percent of the complaints were referred to another agency for resolution, while only 1 percent were not resolved to the satisfaction of the residents or complainants. 4:08:41 PM REPRESENTATIVE SEATON asked for a distinction between cases and complaints. 4:09:07 PM MS. WEBER, in response, said that the cases opened referred to the people served, and could include many people experiencing the same problem. She explained that the computation of cases and complaints was determined by the OAA. She agreed that this was complicated. She replied that many people could have the same complaint, or one individual could have many complaints. She clarified that the number of cases reflected the number of people making complaints. 4:11:41 PM MS. WEBER moved on to slide 9, "Improving the System of Care." She explained that volunteer ombudsmen received about 20 hours of training and practicum, and were assigned between two and five homes. She noted that they visited residents once or twice each month in order to identify problems and resolve them before someone was hurt. She listed some of the problems that volunteers resolved: home too cold, medications not managed properly, meals not adequate, and dirty bathrooms. 4:13:21 PM MS. WEBER considered slide 11, "Collaboration," and informed the committee that OLTCO was reaching out to the Filipino American ALH Provider Association for mutual problem-solving. MS. WEBER indicated slide 12, "FY 2012 Budget," and explained that the OLTCO operating budget was in the Department of Revenue (DOR), and in the Mental Health bill, also under DOR. She requested a continuance of funding for an existing investigator position, which would allow OLTCO to pursue its statutory mandate. 4:15:24 PM REPRESENTATIVE MILLETT asked about the length of tenure for the volunteers. MS. WEBER replied that the tenure had not been longer than one year, possibly because there was not enough support. She established that she had reorganized to add more support and supervision for the volunteers. 4:16:10 PM REPRESENTATIVE HERRON, referring to the OLTCO website, asked about the catalyst for "Watch Your Language." MS. WEBER explained that this was a gentle reminder to respect the seniors' dignity. 4:16:55 PM REPRESENTATIVE HERRON offered his opinion that "Watch Your Language" implied that staff in the assisted living homes spoke languages other than English. 4:17:24 PM MS. WEBER, in response, said that "Watch Your Language" was developed prior to her arrival, and she did not know the reason for its creation. She acknowledged an ongoing concern that staff did not speak English well enough to respond in an emergency, and she pointed to the necessity of understanding the elders and being able to respond. REPRESENTATIVE HERRON asked to clarify that this referred to the caregivers. MS. WEBER confirmed that it was a licensing regulation for caregivers to have the [language] ability to make a coherent emergency report. ^Community Care Coalition Community Care Coalition    4:18:44 PM CHAIR KELLER announced that the next order of business would be a presentation by the Community Care Coalition. SANDRA HEFFERN, Chair, explained that the Community Care Coalition was a newly formed coalition of trade associations, which included: Alaska Association on Developmental Disabilities, AGENET, and Personal Care Assistant Provider's Association. She summarized that the common issues for these organizations allowed for the efficiency of collective representation. She identified the primary problem to be the need for long term care plan, as it was a complex fragmented system which needed to become comprehensive and viable. She pointed out that the highest single cost for providing health and human services was labor. She reflected on the need for additional labor support as the Alaska population aged. She reported that the retirement industry brought $1.7 billion to the state economy. She opined that the infrastructure of an efficient long term care system was necessary for people to stay in the state. She offered her belief that enough studies had been done and she reflected on the history of human services in Alaska. She spoke about the waiver system for individuals, normally going into a nursing home, to choose a community based setting. She pointed out that the cost was less to serve people living in the community. 4:26:44 PM MS. HEFFERN endorsed the jobs provided by community based services and personal care assistant services for people with disabilities. She referred to page 3 of the handout "Brief Overview of the Long Term Care System in Alaska: We need a Plan" [Included in members' packets]. She listed the groups which comprised the current long term care system to include: home and community based grantees, Medicaid home and community based providers, private pay provider companies, Veteran's Administration, and mental health providers. She also pointed out the boards and commissions, which included the Alaska Mental Health Trust Authority and the Alaska Commission on Aging. 4:31:01 PM MS. HEFFERN offered her belief that all of these groups needed to be coordinated. She directed attention to the recent studies, page 4 of the handout, and elaborated on the Lewin Group: Long Term Forecast of Medicaid Enrollment and Spending in Alaska: 2005-2025; and the Public Consulting Group-Alaska Long Term Care and Cost Study February 2006. She declared that long term care was not only about aging people, but included patients with dementia, traumatic brain injuries, physical disabilities, and developmental disabilities. She ascertained that none of the reports offered a vision of direction: "where it is that we are going, so that we can actually get there. What is it that we want, what is it that the system needs to have and then have a road map for how we're going to actually get there." 4:34:30 PM REPRESENTATIVE DICK asked for a definition of the government role and the individual role and he reflected on personal responsibility. 4:35:47 PM MS. HEFFERN agreed that the acceptance of personal responsibility was important. She reflected on long term care insurance as one piece of the system that needed to be redesigned. 4:37:37 PM MS. HEFFERN referred to the HCBS Strategies: Recommendations for the Alaska Long Term Care Plan, 2008 Report. She indicated that the study had good recommendations and guidance, and she pointed out the necessity of "knowing who you're serving, who is it that belongs to the long term care system." She suggested a review of this study as a start for a comprehensive long term care plan. She expressed her concern that none of the studies contained a vision statement for "what the system needs to look like." She directed attention to page 8 and page 9 of the handout, and spoke about the current considerations in the long term care industry. She spoke about the Department of Labor & Workforce Development Alaska Economic Trends report, which declared that health care and social assistance was expected to experience the largest amount of growth of any industry, 26.5 percent or 9,400 jobs, through 2018. She reviewed another analysis by the Department of Commerce, Community & Economic Development, which identified community and social assistance as an economic driver, and a key area for additional attention. 4:41:03 PM MS. HEFFERN summarized that the Alaska Health Workforce Development Plan, Health Workforce Coalition, May 2010 reported that health care was one of the largest and most dynamic industries in Alaska, with a payroll of more than $1.4 billion in 2008. She noted that the Health Care Commission was also exploring long term care, and that the Medicaid task force was reviewing cost containment for long term care. 4:42:20 PM MS. HEFFERN, referring to page 10 of the handout, issued a challenge from the Community Care Coalition to the Department of Health and Social Services, Department of Commerce, Community & Economic Development, Department of Labor & Workforce Development, Department of Education and Early Development, and the Administration to work in concert for a long term care plan to "address a vision for quality, accessible, available, and sustainable services." She opined that a long term plan would include cost containment, as it would be a more efficient system. 4:44:37 PM MS. HEFFERN, in response to Representative Herron, said that two weeks prior she had met with the governor's office, and presented this challenge to them, as well. 4:45:00 PM CHAIR KELLER asked what percentage of long term care was Medicaid. 4:45:47 PM MS. HEFFERN replied that 30 percent of the Medicaid budget was for long term care. 4:46:18 PM CHAIR KELLER asked how this cost would project in the next five to ten years. He declared that it was necessary to define who was being served. 4:47:04 PM MS. HEFFERN agreed that it was necessary to define who was being served in the long term care system. 4:47:32 PM CHAIR KELLER announced that the final order of business would be a response from the Department of Health and Social Services. PAT HEFLEY, Deputy Commissioner, Office of the Commissioner, Department of Health and Social Services, said that there was not a magic wand to increase access to primary health care, and he stated that Alaska was not the only state with this problem. He detailed the need for a skilled work force, a balanced demand for providers, and more community health centers. He stated the need to resolve the financial issues around the Medicaid budget. He stated that DHSS was ready to address a long term health care plan, and he agreed with the suggestion to review the existing plans for recommendations. 4:53:44 PM REPRESENTATIVE DICK asked why the health care costs were rising. 4:55:25 PM CHAIR KELLER asked if the earlier description to the make up of the long term health care system was comprehensive. 4:56:42 PM MR. HEFLEY agreed that the existing studies would offer the "backbone to start from." 4:56:53 PM CHAIR KELLER asked for a defined break down of all the providers in the current long term care system, and the related costs. He opined of the difficulty for making decisions without knowing who each was affecting. MR. HEFLEY replied that he would get those provider costs. He reflected on the difficulty of recognizing the impacts of budget cuts. 4:58:47 PM MR. HEFLEY, in response to an earlier question from Representative Dick, explained that until a financial cap was put on the insurance industry, the provider system, or the customer base then costs would continue to rise. 4:59:47 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:59 p.m.