SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE 1:30 p.m. February 17, 1999 MEMBERS PRESENT Senator Mike Miller, Chairman Senator Pete Kelly, Vice-Chairman Senator Gary Wilken Senator Kim Elton MEMBERS ABSENT Senator Drue Pearce COMMITTEE CALENDAR Briefing by the Mental Health Trust Authority relating to SB 31 PREVIOUS SENATE COMMITTEE ACTION No previous action to report WITNESS REGISTER Mr. Nelson Page, Chair Board of Trustees Alaska Mental Health Trust Authority 810 N Street PO Box 91977 Anchorage, AK 99509 Mr. Jeff Jesse, Executive Director Alaska Mental Health Authority 550 West 7th Avenue, Ste. 1820 Anchorage, AK 99501 Ms. Kay Burrows, Director Division of Senior Services Department of Administration 3601 C St., Ste. 310 Anchorage, AK 99503-5984 Ms. Jane Demmert, Executive Director Alaska Commission on Aging PO Box 110209 Juneau, AK 99811-0209 Mr. Karl Brimner, Director Division of Mental Health & Developmental Disabilities PO Box 110620 Juneau, AK 99811-0620 Ms. Kathy Carssow, Project Manager API 2000/The Community Mental Health Project Anchorage, AK Mr. Walter Majoros, Executive Director Alaska Mental Health Board 431 N. Franklin St., Ste. 101 Juneau, AK 99801-1121 Ms. Cristy Willer Tilden Governor's Advisory Board on Alcoholism and Drug Abuse Dillingham Ms. Caren Robinson, Trustee Alaska Mental Health Trust Authority 211 4th St., Ste. 108 Juneau, AK 99801 ACTION NARRATIVE TAPE 99-05, SIDE A Number 001 CHAIRMAN MILLER called the Senate Health, Education and Social Services (HESS) Committee to order at 1:30 p.m. and announced that the Mental Health Trust Authority (MHTA) would present an overview for the committee. Number 013 MR. NELSON PAGE, Chair of the Board of Trustees, MHTA, stated that the objective of today's overview is to discuss the recommendations for FY 00, both in terms of the budget and in terms of programs. He said that for each topic on the agenda, he would ask members of the boards and commissions to come up and provide the committee with information. He introduced two of the trustees present at the hearing, Caren Robinson and Phil Younker. Number 063 MR. JEFF JESSE, the Executive Director of the MHTA, spoke on behalf of the Governor's Council on Disabilities & Special Education who had a conflicting meeting outside of Juneau. He stated the council has focused on outcomes for beneficiaries. Employment continues to be a major focus because it benefits the individual beneficiaries, the community and the budget. Many beneficiaries are excellent employees who are very reliable and appreciative of their independence and ability to make a living. One employment issue of concern is the continuation of health care coverage for persons with disabilities in low-wage jobs. He asked the committee's help on this issue, and said that having to give up health care coverage for significant medical needs may make employment not feasible for many beneficiaries. Initiatives in SB 31 use trust receipts for trust employment. The council took those funds and leveraged them to obtain a $2.1 million federal grant. The grant will look at strategies over the next 3 years to get people with disabilities back to work. Creating businesses for people with disabilities is no longer the emphasis. Now, the focus is on getting people in the worksite, with job coaches to support the employers, and on teaching them the real job to ensure their success over the long run. Data will be collected on how many beneficiaries still have their jobs at 6, 12 or 36 months, to see if the employment programs are working. MR. JESSE stated the council's second issue relates to institutional prevention. The basic rate of pay for employees in foster homes and group homes is not much higher than entry level at McDonald's or Burger King. Grantees are having a harder time maintaining their workforce on a direct care level. There is no job security or career track, resulting in a lot of turnover in those positions. He asserted that the quality of that care will suffer over the long term. MR. JESSE brought up the council's third issue, substance abuse treatment for people with multiple diagnoses. The MHTA has influenced the various boards' awareness of how their population intersects with other populations. Many beneficiaries have more than one issue. One effective program deals with the dual diagnosis of mental retardation and substance abuse, the ARC dually diagnosed program in Anchorage. It originally started with HUD funds that were not renewed except for emergency funding to get them through this fiscal year. The program is currently at risk. The trustees want to salvage this program, and feel that more of these programs are needed. The ARCS program has kept a significant number of people out of the correctional system. Judges will often place people if they know there is a secure system of support. Number 173 SENATOR WILKEN asked him the name, and MR. JESSE replied the ARC of Anchorage. It used to be the Association of Retarded Citizens, but the consumers didn't want to use "retarded" anymore, so it's now the ARC of Anchorage. SENATOR ELTON asked if judicial referral is done the same way they make a referral to 30 days in jail. MR. JESSE replied that many of the crimes are not felonies; they include multiple charges of disturbing the peace, trespassing, defrauding an innkeeper (when you don't pay for your meal in a restaurant and walk out). These often get significant jail time after several charges accumulate. The public defenders and district attorneys want to divert these people from the criminal justice system if they have a placement for them. Jail time won't correct this situation, and the council tries to avoid repeated admissions to the jail. Programs like the ARC are contacted to see if there is a slot. In Anchorage, the trust has funded a Jail Alternative Service (JAS) which picks up misdemeanants at the front end of their justice system contacts, and diverts them into programs like the ARC. MS. KAY BURROWS, Director of the Division of Senior Services, spoke for the Alaska Commission on Aging. She introduced three of the commissioners, Marge Hays from Soldotna, Doris Bacus from Kodiak, and Ella Craig from Anchorage. She said the commission's first issue relates to Assisted Living. The committee did not receive the full fiscal work for the Assisted Living rate study recently released, but she brought those figures along with her today. She said that Assisted Living is the cornerstone that allows seniors and adults with disabilities to stay in their homes and communities. The commission has been successful in expansion, and now has 90 homes and about 700 beds outside of the Pioneer Home system. The reason it's a challenge to build more homes in certain communities involves the rates the State currently spends. The commission is anxious to look at the whole issue of Assisted Living, particularly the rates in relation to the budget. Other recommendations that are a part of the rate study include educational opportunities for the administrators of homes. This is a new part of the business, looking at quality issues as well as budgetary issues. MS. BURROWS brought up the Guardianship Study, conducted by the McDowell Group through the trust and recently released. There is not a budget impact right now, but she said she wants to alert the committee to the fact that the issue has 4 components. These are code changes, and legislative changes coming before the committee relating to current practices and the need for guardianship work. The second part is oversight monitoring and training; the study showed that over 90% of the people with guardianships in the state are beneficiaries of the trust. Seventy-five percent of those are family guardians, and the commission has not been able to do the training and oversight to ensure citizens are getting their guardianship needs met. A summit meeting on guardianship, comprised of people from the court system, other agencies, private and public businesses will take place in the next month. Their findings will be brought before the trust and the committee. MS. JANE DEMMERT, Executive Director for the Commission on Aging, spoke to the third issue of the commission, the mental health needs of the elderly. She referred to page 9 of the commission's Annual Report FY 98 that graphs Alaska's projected senior population growth through the year 2015. Issues of mental health are fundamental to everyone regardless of age. In the past there has not been linkage between supportive services and mental health services to older Alaskans, so it was found that less than 1% of those being served in mental health clinics were older Alaskans. The point is to work together for more efficient use of resources. The incentives and urging of the MHTA have brought about some change. In the trust budget there's a request for the 3rd year project known as the Mental Health needs of the Elderly. It's a joint project bringing together the two systems of care - supportive services and mental health services - for more integration. Now that it's known those services are needed, the question is how to sustain it over time using existing mechanisms for funding. This is in the budget request moving forward now. SENATOR WILKEN expressed that MS. DEMMERT AND MS. BURROWS were integral members of the long-term care task force, and they did an excellent job of advising the lay members on the issues. He said he wanted to thank them publicly for their help. MR. PAGE responded that he read and was impressed by the long-term care task force report, and he thanked Senator Wilken and other legislators for their hard work. He commented that Assisted Living is an issue before the trust authority as a budget recommendation by not just the Commission on Aging, but the Governor's Council, for example. The trust tries to winnow down the budget process before the committee ever sees any budget recommendations. This recommendation resulted from a lot of consideration, in order to maintain the integrity of the Assisted Living system, and to move forward. SENATOR WILKEN asked Mr. Page if he is aware of CHAIRMAN MILLER'S bill to address Assisted Living. MR. PAGE responded that he's aware of it and wanted to stress the importance. MR. CARL BRIMNER, Director of the Division of Mental Health & Developmental Disabilities introduced Ms. Kathy Carssow, Project Manager coordinating the replacement of API. He will discuss one issue regarding the statutory change, and Ms. Carssow will talk about the services and implementation. Number 327 MR. BRIMNER stated they are trying to create a new system in the Anchorage bowl area replacing the aging API and downsizing the hospital from its present 79 beds to 54 beds. Many partners have been involved in this process, including the division, the trust authority, the Alaska Mental Health Board, and the Division of Alcohol and Substance Abuse. He referred to the handout listing their three objectives: the replacement of the building; the development of community services to assist with the reduction in number of beds, including private treatment alternatives to hospitalization; and to make statutory changes in designated evaluation and treatment (DET). DET is for those people needing services in a private hospital setting for in-patient psychiatric services. MR. BRIMNER emphasized the goal is to build a better emergency mental health system, and to improve the response to substance abuse and mental health crises. Number 360 MS. CARSSOW referred to their report titled The Community Mental Health Project/API 2000, and stated that API is 35 years old and has been functionally obsolete for over a decade. It has asbestos problems and less than five years of service life remaining. It would not be economical to renovate it. Two other reasons why this project needs to happen now include the one-time federal funding secured by Senator Stevens for the project; and the decrease in federal participation and support of API starting in FY 2001 because of the Federal Reapportionment Act. The state has two choices: make up the difference of $4.8 million by 2003 in order to continue the operation of API in the present facility at the present level of service; or develop private community-based services eligible for other funding sources like Medicaid, and downsize API. MS. CARSSOW said that a recurring question is why Anchorage is the focus of the project. Eighty-five percent of those admitted to API live in Southcentral Alaska. Unless the new and expanded services are in place to serve Anchorage residents with mental health emergencies, the need for API beds won't be reduced. They wouldn't be able to downsize by 25 fewer beds. The new smaller building would benefit all Alaskans requiring hospitalization by providing an improved facility in a more therapeutic setting. Currently emergency services are available in Anchorage, but a clearly defined way for people in crisis to get help is lacking. MS. CARSSOW described the single point of entry to mental health services. It would give the individual in crisis access to enhanced crisis respite care, preventing hospitalization. In respite care, people are stabilized and assisted in transitioning back into community outpatient follow-up care. The individual would also have access to enhanced detoxification and dual diagnosis treatment, other alternatives to hospitalization at API. These programs reduce future hospitalizations by getting people into treatment following crisis. The single point of entry would also be the doorway to access designated evaluation and treatment (DET) services. Other Alaska regions as well as Anchorage residents would have access to private hospitals for DET. It also would be the doorway to API, a new facility providing quality treatment, safety and privacy in a therapeutic environment. MS. CARSSOW stated that it would also create new alternatives, and enhance existing private alternatives to using API for extended care for the chronically mentally ill. API now provides residential care to people who need long-term treatment because they're difficult to place outside of a very restrictive environment. She said their objective is to reduce the demand for 7 long-term care beds by improving the capability of private providers to care for these individuals. Target dates focus on the year 2000: April 1, 2000 for the new single point of entry system and the downsizing of API. Number 418 MR. BRIMNER reiterated their 3 goals listed on the last page of the report. He explained the third goal deals with statutory changes to the DET program. The current statute needs a change to clarify when the state can pay and will not pay in situations where someone is eligible for services and we're the payer of last resort. Under the current statutes, individuals receiving in-patient services that the state can pay for, enter on an involuntary basis. It's both administratively and clinically responsible to allow those people that meet the involuntary statute criteria, but who wish to stay in the hospital on a voluntary basis, to do so. One of the administrative reasons is that an individual who meets the criteria, but is not allowed to have a choice to be there on a voluntary basis, must go through the justice system, involving attorneys and the court system. This may not be necessary if an individual is willing to stay there on a voluntary basis when they meet the criteria. It would not expand services in any way, and it would reduce costs related to the legal system. He stated the hope that legislation will be introduced soon, and will be looking for support for it. Number 445 CHAIRMAN MILLER asked if the Administration or an individual legislator will be introducing it. MR. BRIMNER replied it will be a legislator. SENATOR ELTON asked about 85% of the client population being in Anchorage. Are they in Anchorage because that's currently where the best services are, creating a magnet that pulls them out of their own communities? MS. CARSSOW responded no. Half the population of the state lives in Anchorage. The residents have become reliant on API and alternative services like DET haven't been developed, except in Juneau, Sitka and Fairbanks by private hospitals. SENATOR ELTON asked if single point of entry means Anchorage. MS. CARSSOW replied yes. It will direct people to the most appropriate and cost efficient service as opposed to direct access to API. The demand for API is affected by not having a clear route to alternatives. SENATOR ELTON asked if Mr. Brimner's division would be the gatekeeper for checking out the alternative services and their costs. MR. BRIMNER answered that the single point of entry could be the state, or a contract or grant to a provider in the Anchorage area. The utilization review process would look at all the individuals going through the system to see that they received the appropriate service. The inappropriate situations would be corrected. The state would be the reviewer on an on-going basis. DET services will be expanded to other communities outside of Anchorage, allowing maintenance of people closer to their homes. Number 484 MR. PAGE interjected that API will be a "Catch-22" situation for the state if it does nothing: the state will incur additional costs because the federal disproportionate share funds are going away. The trust feels it's appropriate to take affirmative steps now with the new hospital and the new system better oriented to serve the beneficiaries. Number 500 MR. WALTER MAJOROS, Executive Director of the Alaska Mental Health Board, gave members a printed copy of his remarks. By statute the board has specific responsibilities for planning and advocacy, including mental health parity, which is parity in insurance coverage for people with mental illnesses vs. people with physical illnesses. Senator Wilken helped establish the Mental Health Parity Task Force (MHPTF)last year. It was funded by the trust authority and its completed report will be distributed soon. The board is also mandated to do program review of individual mental health programs as well as API. The board is helping develop an integrated quality assurance system. Another statutory duty is to make budgetary recommendations to the trust. The rigorous process includes input from many mental health consumers and focus groups. Over 50% of the board is composed of consumers and family members. Seven of its thirteen members are consumers, and four of those are direct primary mental health consumers. The board believes in consumer leadership in all aspects of the system. The board's responsibility is to people who are mentally ill or seriously emotionally disturbed, including children and adults. Prevalence estimates indicate 14,700 children and youth with serious emotional disabilities (10% of the population of that age group); 25,600 adults (6.3% of the state's population in that age group); and 4,200 people who would either be institutionalized or homeless. The total is 44,500 individuals. Those receiving public mental health services are estimated at 50% of those adults, and 1/3 of the children and youth. MR. MAJOROS reviewed 4 areas of priority concern for the board for the last 2 years that drive its planning and budgeting process. These include support for a smaller API, and outcomes and quality assurance, including development of one unified set of indicators and performance measures funded by the trust authority. An integrated quality assurance system developed for community-based programs is currently in place, and will eventually include API and all state-funded mental health programs and DET facilities. The criminalization of mental illness is a tremendously important issue. Last year there were 1,800 inmates with a serious mental illness at the Department of Corrections, compared to 1,200 admissions at API. The single biggest mental health provider in the state is the Department of Corrections. He stated that is an embarrassment to him, and the board wants to change it. Rural and urban services show tremendous disparities, with the need for more equitable distribution of resources. Two hundred villages have no mental health services, and 60 villages have just one part-time person providing all mental health and substance abuse services. The board finds this an unacceptable situation. Children and youth services lack the capacity of adult services because they were developed later. He brought up the tremendous increase of children in custody with serious mental health needs, and emphasized that with the passage of last year's child abuse law, the number of kids in custody will increase. The system of placements for children is very fragmented right now. Funding priorities include the consumer affairs position, who would be in a senior management position in DHSS, Division of Mental Health & Developmental Disabilities. The position would help increase the consumer voice in state policy making. The board also participates in the Comprehensive Integrated Mental Health Plan. The board was active in advocating for the women's psychiatric unit, funded in partnership between the trust authority and the state. The jail alternative services was promoted initially by the board, and takes misdemeanants who have been convicted and diverts them from the 6th Avenue jail into community-based mental health services. The board also endorsed funding for the Department of Corrections planner to develop and implement a coordinated plan for the trust beneficiaries. The board has advocated an expanded rural human services program, which the trust has funded. TAPE 99-05,SIDE B Number 587 MR. MAJOROS continued discussing funding priorities for rural services. A program would place paraprofessionals in villages throughout the state to address both mental health and substance abuse issues in an integrated, dual-diagnosis way. A new project this year that is funded through the trust trains people to provide counseling to deaf and hearing impaired people in rural areas. The board feels enhanced DET services are needed in the Anchorage area to downsize API, and in rural areas as well. Relating to the children and youth services issue, the board has advocated and the trust is funding community residential alternatives like therapeutic foster care, the treatment of kids in custody; and secure residential care. Now many children and youth are being sent out of state because there are no facilities here to meet their intensive needs. $300.0 is targeted for FAS and related disorders to do increased diagnostic work, transitional living for women who come out of alcohol treatment, and to assist school districts and local communities in screening and assessing high- risk women. MR. MAJOROS said the childrens' care coordination model looks like it is not going to work. The project attempted to develop a new way of delivering services and blending funding sources. The project's success was in helping to fund a children's mental health coordinator position that recently completed a 18-month plan for children's services. Future funding priorities will be very clear as they relate to that plan. The board believes in prevention, and endorses funding for the control group study that will show if the Healthy Families Control Group approach is effective. Number 562 SENATOR WILKEN asked Mr. Majoros how mental health is defined, and how the total of 1,800 people annually in the Department of Corrections was arrived at. MR. MAJOROS replied the trust authority funded a study to find out the numbers of trust beneficiaries, in all four groups, in the Department of Corrections. The study profiled every facility on a given day. Some have serious mental illnesses (clinically known as Access I disorders) and others have personality disorders (Access II disorders); both are included in the total. SENATOR WILKEN asked if the 1,800 figure is therefore an extrapolation based on a snapshot study. MR. MAJOROS said that is correct, but it was also verified by the clinicians that it is not an anomaly. Number 546 SENATOR ELTON asked what services are provided. MR. MAJOROS answered there is at least one mental health clinician at each facility throughout the state, full-time. There are also intensive care units. Until recently there was just one unit, at Cook Inlet Pretrial Facility in Anchorage, for men who have decompensated, have medication that is not working right, or have acute mental health needs. Until last year there was no similar facility for women. Now through the partnership of the trust and the state, that service also exists for women. There is largely a full continuum in Corrections, but the department and the board both feel that many of these people would be better served in the community, to normalize and live successfully within it, not in an incarceration setting. MR. PAGE remarked on the prior treatment of locking up in solitary confinement the very seriously mentally ill who pose a danger to themselves and others. He feels it was a medieval way of dealing with mental illness. It was not until the first womens' mental health unit opened that the trust could say it had services available to every category of the population in the Department of Corrections. The planner position funded over the last few years has enhanced the trust's ability to do that work. MR. PAGE stressed that the 1,800 figure for Corrections is "probably some of the hardest data we have in terms of accuracy" about what's going on in that population. Number 520 SENATOR ELTON asked if there were additional resources, would the judicial system divert these people from the correctional facilities and into the community programs. MR. MAJOROS replied absolutely. These people also need living arrangements, employment, education to be successful within the community. MS. CRISTY WILLER TILDEN,Bristol Bay Area Health Corporation, Dillingham, stated she represents the State Advisory Board on Alcoholism % Drug Abuse. She introduced several board members including Alice Johnstone from Sitka, Ann Kitner from Juneau, CJoe DiMatteo from Anchorage, acting Director Ann Schultz and past Director Don Dapcevich. She referred to the report on their 14- month strategic planning process addressing the board's priorities relative to trust authority funding. The board's biggest priority is to impact the negative influence of alcoholism and drug abuse on Alaskans. The indicators in the plan relate to per capita consumption, DUI convictions, criminal convictions on alcohol-related charges, alcohol-related injuries requiring hospitalization, protective custody holds, binge and chronic drinking rates. There are excellent data for all of these indicators and a baseline to show the curve that she hopes will be downward. The board arrived at 18 strategies, with only a few relating to the work of the trust authority. The board has a statutory obligation to speak to the trust about the board's interest in chronic alcoholics with psychosis. Strategy 12 addresses the need for a continuum of care for chronic alcoholics with psychosis, focusing on long-term care and follow-up on life domain like housing, finance and health concerns. Another strategy relates to assisting communities in efforts to coordinate use of involuntary commitment procedures because they usually involve someone who's reached the point of chronic alcoholism. One strategy regards serving currently underserved populations including the dually diagnosed. MS. TILDEN concluded by saying those target populations and strategies in the plan speak to the board's need for continued funding through the Mental Health Trust Authority. MS. CAREN ROBINSON in summary remarks for Mr. Page and the Mental Health Trust Authority, expressed pride in the volunteer boards. During her two years on the trust board, she has been impressed with the boards' volunteerism and the staff they are able to hire. She introduced two staff members of the trust authority: Bill Herman, a planner who is an expert in budget issues and works with the Alaska Office on Aging and the Alcohol board; and Mary Elizabeth Rider, a planner with the department who focuses on the Governor's Council and the Mental Health Board. MS. ROBINSON announced that Thursday and Friday the trust authority is meeting at the Juneau Assembly Chambers. Thursday night at 6:00 the trust will take public testimony and invites all citizens and consumers to come. She remarked on the successful collaboration of all the boards with the Department of Corrections and recognizing the need for a planner because so many beneficiaries are in Corrections. In the future the trust authority will need to work with the Department of Education because many beneficiaries go through the public education system without getting the kind of help they need. She said the trust authority would like to update the committee on the API plan later on. Tom Hawkins, a trustee member and Phil Younker are resident experts in asset management and the trust lands. MS. ROBINSON said the trust would also like to return to discuss the land trades and land development for the committee. CHAIRMAN MILLER told Ms. Robinson that the committee will schedule that update in the future. For the information of the committee, CHAIRMAN MILLER said next Monday's agenda will include Carl Rose, Association of Alaska School Boards, speaking on the impact of the new Foundation Formula passed last year, and Senator Leman's SB 27 relating to access to driving school records of a child. On Wednesday, Commissioner Perdue is tentatively scheduled to give a brief overview of the Department of Health & Social Services. The following week the committee will take up as a package SB 56, SB 57, SB 58 and SB 59 -- the bills resulting from the long-term care task force. He stated he wants to begin working on them and move them on to Finance. There being no further business before the committee, CHAIRMAN MILLER adjourned at 2:35 p.m.