SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE March 17, 1999 1:35 p.m. MEMBERS PRESENT Senator Mike Miller, Chairman Senator Gary Wilken MEMBERS ABSENT Senator Pete Kelly, Vice-Chairman Senator Drue Pearce Senator Kim Elton COMMITTEE CALENDAR Overview by Commissioner Karen Perdue, Department of Health and Social Services SENATE BILL NO. 73 "An Act relating to assisted living homes; and providing for an effective date." -HEARD AND HELD PREVIOUS SENATE COMMITTEE ACTION SB 73 - No previous action to report WITNESS REGISTER Senator Mike Miller Alaska State Capitol Juneau, AK 99811-1182 POSITION STATEMENT: Presented SB 73 Ms. Kay Burrows, Director Division of Senior Services Department of Health & Social Services 3601 C St. Suite 310 Anchorage, AK 99503-5984 POSITION STATEMENT: Commented on SB 73 Ms. Montafaye Lane 109 E 5th Avenue North Pole, AK 99705 POSITION STATEMENT: Commented on SB 73 Ms. Lynn Branson PO Box 948 Palmer, AK 99645 POSITION STATEMENT: Commented on SB 73 Ms. Leslee Orebaugh 309 E. 24th Avenue Anchorage, AK 99503 POSITION STATEMENT: Commented on SB 73 Ms. Helen Powell 1913 Jack St. Fairbanks, AK 99709 POSITION STATEMENT: Commented on SB 73 Ms. Debbie Cash 3291 Jefferson Fairbanks, AK 99709 POSITION STATEMENT: Commented on SB 73 Ms. Frances Purdy Long-Term Care Ombudsman 3601 C St., Ste. 260 Anchorage, AK 99503-5984 POSITION STATEMENT: Commented on SB 73 Mr. Les Westling 329 D St. Fairbanks, AK 99701 POSITION STATEMENT: Commented on SB 73 ACTION NARRATIVE TAPE 99-12, SIDE A Number 001 CHAIRMAN MILLER called the Senate Health, Education and Social Services (HESS) Committee to order at 1:35 p.m. and announced that the committee did not have a quorum, with one member having airplane trouble returning to Juneau and another attending the ground-breaking for the new Juneau police station. He said the committee would hear an overview by Commissioner Perdue, and take initial testimony on SB 73 which he sponsored. MS. KAREN PERDUE, Commissioner of the Department of Health & Social Services, highlighted the department's programs for the next year. She discussed Child Protection and said the department has had its first termination case under the new law in effect since September 1998. A new training system has increased the number of calls that can be answered. Challenges include the training and support of workers who do this difficult work, and dealing with the heavy caseload. She urged more funding this session for positions in Fairbanks and Anchorage where the workers carry up to 35 or 40 cases and can't adequately do their jobs. Consequently, public and child safety are impacted in two ways - by not getting out on the calls to investigate the situations; and not ensuring the child's placement in a safe, nurturing foster home or adoptive home. The department is improving the foster care program. Denali Kid Care has been launched with a new, private sector type of approach. The insurance card for a parent signing up a child is good for six months, cutting repeated paperwork. The application is short, and can be accessed on the Internet and faxed or mailed in. There is no walk-in office. Since opening on March 1, 3,000 calls and 900 applications have been taken, and 400 pregnant women have been enrolled in the program. Number 132 SENATOR WILKEN asked if the program is on track for projected enrollment. COMMISSIONER PERDUE replied that it's early to know, but the response has been beyond expectation. COMMISSIONER PERDUE said that valid concerns were expressed in the Legislature last year about people dropping insurance to sign on to the program. The department revised its regulations so that a person or business cannot drop their insurance and be qualified for this program for one year's waiting period between the time the insurance is lost or dropped and enrollment in this program. A hardship section is tightly written, for bankruptcy. The department expects the uninsured to use this program. The financing is mostly federal, with the state paying about $530 per child per year. The sicker children, particularly those with disabilities, are already in the pool. Immunization rates were second to the last in the nation a couple years ago for up to two-year olds. The latest data showed Alaska as 22nd in the Nation and the department expects to be near the top in a couple more years. Nearly every kid in the state was given a shot during the measles outbreak. In revamping the API building and its operations, she said API could be much smaller if communities did more crisis service work at the hospital level, like Fairbanks Hospital has always done. Senator Kelly's bill on designated evaluation and treatment is very important in this regard because it assures the hospitals of a stable source of funding to get into the business of providing emergency psychiatric care. The issues of vulnerable adults and children fit into the work of the Long-Term Care Task Force. The department is very supportive of several task force recommendations. SB 73 addresses an issue of safety by paying providers a decent wage to ensure continuity and professionalism, and to attract more people into the business. Regarding developmental disabilities, the department has asked for funding this year to raise the wages of care givers. Because the care givers are paid $6 to $8 an hour, the turnover in one program is 133% "which is incredibly distressing on the clients, and not good for the quality of care," COMMISSIONER PERDUE said. The youth corrections system is gradually expanding with an addition of 80 beds. The juvenile facilities have operated at 170% over capacity. At the local Johnson Center dedication, there were 30 kids in the 8-bed facility. By next year, if things go as planned, the department will have reduced the overcrowding. Youth courts are very successful in the communities that have invested in them and inexpensive for the department to start up. If kids receive consequences as first-time offenders, it makes a big difference in the direction they head in life. DHSS is also working with tribal organizations to start elder courts, using the same concept as youth courts but with elders making decisions. The Native community often reports kids running around and something needs to be done before the situation escalates to serious law enforcement intervention. Regarding welfare reform, Alaska is in the second year of a 5-year lifetime limit and seeing a 27% drop in the caseload using the system. With the help of day care and job training, about 40% of the people on welfare are also working. The department is starting the first Native organization public assistance program with Tanana Chiefs Conference (TCC) in Fairbanks. It will reduce dependency on welfare more than anything the State can do in the villages. It's a challenge to help people work in villages where there are no jobs, through community work service or seasonal work. TCC has other job training and economic opportunities to bring to this effort, and it's the largest program in the country. Number 267 COMMISSIONER PERDUE explained to Senator Wilken that it's located in the TCC building, with workers in each of the communities. She asked if the bill authorizing this program will come through HESS, and CHAIRMAN MILLER said although he hasn't seen it, it should. She said the department needs that legislation to clarify the respective roles in the TCC public assistance program. COMMISSIONER PERDUE mentioned the law that passed last year helping people with disabilities join the workforce without losing their medical benefits, and said the department needs to do more policy work on it. Even relatively disabled people are willing to work as long as they don't lose their benefits; loss of their prescriptions alone would keep them from working. The department is helping people make choices on planned pregnancies. The teen pregnancy rate has declined by 25% over the last three or four years- the greatest of any state in the nation. If the department can prevent a young girl from having a child if she's not ready to support it, COMMISSIONER PERDUE said "it's about the best thing the state can do for the future of a young person." She said everything seems to relate to substance abuse, with 70-80% of the cases in Child Protection going back to it. In the work on FAS prevention, pregnancy is a time when a lot of healthy behavior can begin because women are highly motivated to make a change for their children. COMMISSIONER PERDUE, now into her fifth year as commissioner, said it has been a real privilege to be in the job, and there are some solid accomplishments that the department can look to. SENATOR WILKEN remarked that she has done a good job in a tough spot. He informed her that Chairman Miller has been supportive of the long-term care legislation which is being pushed along and received pretty well. COMMISSIONER PERDUE said she's very pleased about that. She served on the task force and it recognized all the work that had gone before it, a phenomenal amount of work in this state. She said there are "pockets of excellence," and if Alaska can strengthen community care, which fits with the state philosophy, "it will be one of the best places in the nation to be a senior or a person with disabilities. That will be a real accomplishment for everyone." SENATOR WILKEN and CHAIRMAN MILLER thanked the Commissioner. Number 334 CHAIRMAN MILLER brought up SB 73, a bill he also introduced last year. He explained that SB 73 would essentially raise the rates the state is currently paying to the "Mom and Pop" providers in assisted living homes, from about $30 in Anchorage and $34.50 in Fairbanks, to $70 a day. The Alaska Rate Study Report of December 1998 put $70 right on target. CHAIRMAN MILLER said it's kind of funny because they considered a lot of numbers and didn't have much basis for that number at the time, other than it doubled the rate in Fairbanks. CHAIRMAN MILLER related that his father was in a private-pay home in North Pole where he observed the level of care. He said "quite frankly, it was a very good level of care for a very inexpensive amount." Charts show that if the rate increased to $100 a day, it would be less than half what the state pays in hospitals and facilities around the state like the Denali Center. In his opinion, older residents are getting a very good deal for what is being paid, and he's afraid if the rate stays low the state will begin to lose providers. As the population continues to age, Alaska cannot lose its providers. CHAIRMAN MILLER said his goal is to pass the rate increase this year, in order to keep the current assisted living providers and attract new providers to the market. Fortunately, fellow legislators are supportive of the concept but the problem will be to find it in the budget. He said he will work hard to find it in the budget. CHAIRMAN MILLER thanked the department for their support of the concept and their help in coming forward with different numbers. MS. KAY BURROWS, Director of the Division of Senior Services, stated SB 73 would help Alaskans assist vulnerable adults in having a place to live with dignity, hope and care. The Alaskans who care for other Alaskans need this living wage. The rate study was funded by the Mental Health Trust Authority and conducted by the Assisted Living Training Institute out of Connecticut. She cited statistics for the FY 98 caseload on which the rate study was based, noting 68% fell under the Mental Health Trust beneficiary, and an additional 32% were either physically disabled or vulnerable adults. Most of the caseload receive general relief funding for one year or less in assisted living. The rate study asked 33 homes to provide detailed private financial information, and resulting data showed that if the rate were adjusted just for inflation over the 15 years it has not been adjusted, it would be $68. The study looked at the actual financial costs to a home for 15 people or less, which came to about $73 per day. More severely ill people are in the homes and may need an augmented rate of between $3 and $22, mostly for added staffing. MS. BURROWS concluded the rate study showed a rate of $70 per day is appropriate for the kind of care being offered. The department will be looking at the assisted living home regulations through the Long-Term Care Task Force, and a number of the task force recommendations. The recommendations include increased training and education requirements for assisted living administration and staff, and separate standards for homes caring for fifteen people and less, and homes caring for sixteen people and more. MS. BURROWS said she and Dwight Becker, Supervisor for Adult Protective Services, would stay on-line to answer questions. Number 426 CHAIRMAN MILLER remarked that Mr. Becker did the fiscal note and could explain the numbers. Mr. Becker responded that he didn't have anything to add to the discussion at this point. CHAIRMAN MILLER said he would begin with the Fairbanks providers waiting on-line to testify, and requested that people limit their remarks to 5 minutes. He publicly thanked Ms. Montafaye Lane for the care she provided for his father in North Pole when he had Alzheimers. Chairman Miller said he is acutely aware of the current situation with assisted living homes because of Ms. Lane. Number 438 MS. MONTAFAYE LANE, Assisted Living Home provider, thanked the division and the committee, and stated the private assisted living home administrators work very hard at their own expense to provide a high standard of care for vulnerable people at a very reasonable cost to the public. The homes are the grass-roots place that families, agencies and guardians bring people in emergency need for nurturing and basic care. The providers welcome people, often with no guarantee of pay, and share their home with no idea of the impact the resident will have on it and the people in it. The provider accepts people when they arrive, and worries about the pay later. MS. LANE admitted that from a practical standpoint, adopting that philosophy is probably a mistake but it is the nature of their business to care for the vulnerable ones. She said that the current stipend is not only unrealistically low, it often takes three months to receive the reimbursement covering someone who couldn't make it through the door of a larger, more profitable facility. The homes cannot continue to adequately care for these people at $1.44 an hour with the minimum wage at $5.62. Qualified helpers demand at least $10 per hour, a wage they can get at a facility taking in the $3000 per month resident. If the bill does not pass, MS. LANE said the providers have no hope of financial relief and many will have to look to their own survival at a great emotional cost to their residents, and a great financial cost to the state. She urged doing away with the co-pay for elders, and raising the personal needs spending of the residents to $100-150 per month because many of them smoke cigarettes. Number 510 MS. LYNN BRANSON, Consumer and Assisted Living Home professional, Mat-Su, asked for provisions to monitor the assisted living homes and stricter hiring practices for employees working in the homes. She was concerned that the system is set up for abuse with little monitoring of some of the homes. MS. LESLEE OREBAUGH, assistant at Parkside in Anchorage, discussed the added expenses the assisted living homes have incurred since the new licensing regulations went into effect. Now there is a per-bed fee for licensing, new insurance policies required for professional liability, and new fire and safety equipment expenses. She asked members to take these added expenses into consideration when raising the rate to $70 per day. MS. HELEN POWELL, owner of an assisted living home in Fairbanks and treasurer of Alaska Care Givers Association, said she agreed with Montafaye Lane's comments. She suggested taking $10 from the Permanent Fund Dividend. She said if the homes don't get a higher rate, she could no longer accept general relief clients in her home. "At $70 dollars a day, we're still the best quality of care and the cheapest rent you'll ever get." MS. DEBBIE CASH, Fairbanks provider, discussed fuel cost increases over 3 years, and costs for insurance. She received $99 per day for one client who was paralyzed and totally bedridden, while the same person at Denali Center would have cost $320 per day. MS. CASH said she could no longer keep her doors open at the $34.50 per day rate. She discussed the wear and tear on the home, with nurses, caseworkers, family and friends coming in and out. MS. FRANCES PURDY, Long-Term Care Ombudsman, supported the comments of the Division of Senior Services, and the providers. The potential rate increase would provide clients with the services they need when they first enter an assisted living home, or while waiting for Medicaid waiver programs to be approved. She echoed the fear that many good providers will leave the business because they are constantly overextending themselves to provide services they're not being paid for. The funds are desperately needed to keep the continuum of care for all residents in long-term care services. TAPE 99-12, SIDE B Number 595 MR. LES WESTLING, Assisted Living Home provider in Fairbanks, thanked Ms. Purdy for her testimony and urged passage of the rate increase this session. He recommended building teams of community agencies and assisted living homes around each elder to solve the difficulties in each town. He said training is very necessary to raise the standards of administrators, and workers like CNAs because assisted living homes are a more homelike environment than nursing homes or hospitals. A worker may know how to change a bedpan but that doesn't mean he will know how to sit down and communicate, play a game of cards, or work on memory skills and other ways to increase awareness. On the issue of monitoring abuse, MR. WESTLING said he can't afford a secretary and his paperwork for 10 staff "runs him over" sometimes because he's keeping on top of his staff to ensure there is no abuse. He monitors if workers are not dealing with someone properly due to lack of training, and he urged funding for training. When he started the home, Mr. Westling would take in clients on no notice and without funding and he almost put himself into bankruptcy doing that. Problem clients need placement in the assisted living homes until their funding sources come together. Increasing the daily rate should provide the leeway to make that possible again. He also urged increasing the personal spending of the clients to more than $75 per month, which provides only about two cartons of cigarettes to smokers. Number 545 CHAIRMAN MILLER said there still wasn't a quorum but he intends to work on SB 73 and bring it back before the committee next week. There is a lot of support in the Legislature for this measure but he questioned how to fund it. SENATOR WILKEN questioned if one approach might be to "take this a bite at a time." CHAIRMAN MILLER said that's essentially what he's been looking at, but he hasn't run it by the service providers. The concept would be to "ratchet it up to $50 the first year, to $75 the second year, and up to $100 the third and final year." It would be smaller "bites," but in the long run the providers would actually be ahead. Mr. Becker in Anchorage would do the number crunching for the committee. It would start the rate increase in the right direction. SENATOR WILKEN said he agreed, and he hoped to get it started this year. CHAIRMAN MILLER concurred that it must get started this year. With no further business before the committee, it adjourned at 2:30 p.m.