ALASKA STATE LEGISLATURE  SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  March 20, 2019 1:30 p.m. MEMBERS PRESENT Senator David Wilson, Chair Senator John Coghill, Vice Chair Senator Gary Stevens Senator Cathy Giessel Senator Tom Begich MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION: OVERVIEW OF THE DEPARTMENT OF HEALTH AND SOCIAL SERVICES BY COMMISSIONER DESIGNEE ADAM CRUM (CONTINUATION OF MARCH 13, 2019 PRESENTATION) - HEARD PRESENTATION: OFFICE OF CHILDREN'S SERVICES CITIZEN'S REVIEW PANEL BY JP OUELLETE, CHAIR - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER ADAM CRUM, Commissioner Designee Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Gave an overview of the Department of Health and Social Services. RENEE GAYHART, Program Manager Tribal Health Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Provided information on DHSS tribal health reclaiming. JP OUELLETE, Chair Alaska Citizen Review Panel (CRP) Anchorage, Alaska POSITION STATEMENT: Presented on the Alaska Citizen Review Panel. ACTION NARRATIVE 1:30:44 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:30 p.m. Present at the call to order were Senators Giessel, Begich, Stevens, and Chair Wilson. ^Presentation: Continuation of Overview of the Department of Health and Social Services Presentation: Continuation of Overview of the Department of  Health and Social Services by Commissioner Designee Adam Crum 1:31:03 PM CHAIR WILSON announced that Commissioner Designee Adam Crum would continue his presentation from March 13, 2019 on the Overview of the Department of Health and Social Services. 1:31:35 PM ADAM CRUM, Commissioner Designee, Department of Health and Social Services (DHSS), Anchorage, Alaska, said that Deb Etheridge is the acting director of the Senior and Disabilities Services (SDS), which has 175 positions. They worked with the Community First Choice 1915(k) program to increase the federal match to 56 percent from 50 percent. The enhanced federal match provides person-centered home and community-based services and supports to help individuals with disabilities live within the community. The 1915(c) Individualized Support Waiver (ISW) is part of the SB 74 refinancing. The new waiver helps with the community development disabilities grant. It allows each ISW participant to access up to $17,000 of buying power in waiver funds per year. They are trying to keep individuals in homes and communities longer, which is more cost effective and therapeutically viable for the individual. COMMISSIONER DESIGNEE CRUM said they are also working on implementing an Electronic Visit Verification (EVV) system to meet federal requirements related to personal care attendants. COMMISSIONER DESIGNEE CRUM said the mission of the Division of Public Health is to protect and promote the health of Alaskans. The director is Mary Carlson. They took an active role with the 7.1 earthquake on November 30, 2018, which activated the emergency response center at DHSS. They had teleconferences within three hours of the earthquake occurring. They worked with hospital partners, providers, and senior living facilities to determine such things as whether the labs were running, what care was needed, and what were transportation issues. It was an involved process and he was proud to be part of the division's work. A few weeks after the earthquake, their partners got a standing ovation for how coordinated the care was and the level of information that was disseminated. They had unique concerns with a lot of the workforce being stranded in the Mat-Su Valley because of the Glenn Highway issues. DHSS and the Department of Commerce worked on temporary licensing so that nurses from Oregon could be part of the response. COMMISSIONER DESIGNEE CRUM added that it was a traumatic event, especially with all the aftershocks. They had serious mental health and behavioral health concerns. Crisis canines are one example of the follow up that the department did to make sure individuals had access to therapeutic resources. 1:36:50 PM SENATOR BEGICH said that he had a conversation with the commissioner of the Department of Military and Veterans Affairs about the earthquake. He asked what coordination took place because that department also has an emergency response. COMMISSIONER DESIGNEE CRUM replied that the statewide emergency operations center is based at JBER (Joint Base Elmendorf- Richardson). It was the incident command center for the state throughout the earthquake and in charge of everything from infrastructure to overall response. DHSS' side was making sure health care infrastructure and vulnerable populations were accounted for. On the SDS side, they worked to make sure they were in touch with personal care attendants and reached out as quickly as possible to see whether anyone was stranded and if there were any issues with items like oxygen and medications. They worked in conjunction with the statewide OCC [Operation Control Center] based on JBER for any concerns such as medevac issues. SENATOR BEGICH asked if he observed anything that could have been done better. He said he didn't expect an answer immediately but asked Commissioner Crum to give it some thought and then provide it to the committee. The commissioner of the Department of Military and Veterans Affair expressed a desire for better coordination. COMMISSIONER DESIGNEE CRUM replied that he could provide a list of possible systems improvements. State commissioners and deputy commissioners have toured the statewide operations center to understand what their role is. They are looking at where they did succeed and where can they improve. 1:39:11 PM SENATOR STEVENS noted the concerns about vaccinations with the national measles outbreak. He asked if the Division of Public Health does vaccinations for measles and other diseases. COMMISSIONER DESIGNEE CRUM answered that the Division of Public Health has epidemiology and public health nurses and the Alaska Vaccine Assessment Program (AVAP), the reauthorization of which is working its way through the Senate. AVAP increases the state's purchasing power to get vaccines at a cheaper rate and distribute them to health clinics. They monitor outbreaks and issue health notices. They share information with the public as the issues arise. Public health, epidemiology, and the public information team in the commissioner's office work to address issues. 1:40:31 PM SENATOR STEVENS asked what they can do about irresponsible parenting that sends kids to school who infect the whole school with measles. He mentioned he had had measles as a child. It is quite damaging and dangerous. He asked what their responsibility is for dealing with irresponsibility in parents and do they have a responsibility. COMMISSIONER DESIGNEE CRUM replied that they try to measure and put together the data. Their chief medical officer has been attending conferences, such as for the Association of State and Territorial Health Officials and members of the Academy of Pediatrics. Medical and science professionals are discussing these issues and policy concerns. They are just trying to present the data and what they know about these issues. SENATOR STEVENS asked Commissioner Crum to keep them up to date of what is going on and how they can keep Alaska from having a major outbreak. COMMISSIONER DESIGNEE CRUM presented on the department's efforts with the ongoing opioid epidemic. Since the disaster declaration in 2017, the state of Alaska has secured over $35 million in federal grants. This is an on-going process of working with federal partners to address this issue. Next month he will be attending a national conference on this for health secretaries about how to address the epidemic. They are trying to find best practices. It cannot just come from the state level. They need grassroots, local task forces to move forward with this. The preliminary numbers show that in 2018 they did see a 26 percent decrease in drug overdoses compared to 2017. In 2018 there was a 67 percent decrease in fentanyl overdoses compared to 2017. That is a massive achievement. It involved DHSS education efforts and NARCAN kits and working with Public Safety and the Department of Transportation. They do attribute reductions across the board for all drug overdoses to distribute of naloxone. 1:43:57 PM SENATOR GIESSEL said she has been in contact with Andy Jones, Director of the Office of Substance Misuse and Addiction Prevention. She noted that the state includes veterinarians in the prescription drug monitoring program (PDMP) because they occasionally prescribe opioids. She is hearing from veterinarians about the question of whose name to enter in the database, the animal's or the human with the animal. It gets very complicated. She has heard that several states have waived the requirement for veterinarians. She knew this was really down in the weeds, but it might be something he could ask about at the national conference. The state veterinarians are in a quandary about how to manage being part of the opioid- prescribing community because they hardly ever do it. COMMISSIONER DESIGNEE CRUM said they will look into that. It does help bring to light that this is not a complex issue. People don't think about it very often. The White House refers to this as the crisis next door. People think about unfortunate individuals on the street, but this could be someone's neighbor who was overprescribed and became addicted. Another simple point they are trying to educate people about is what to do with unused prescription drugs. Drug disposal bags are charcoal- activated and can make drugs biodegradable. Drugs are not safe just to dump in the sink or toilet. They are trying to educate people on issues like that. CHAIR WILSON asked if the prescription-monitoring database is with Department of Commerce, Community and Economic Development (DCCED). COMMISSIONER DESIGNEE CRUM replied that it is with Commerce. CHAIR WILSON asked if he could provide to the committee the impact of the prescription drug monitoring database with the decrease of opioids and morphine provided to the hospitals from the database. He knew there was a decrease of about five percent of the injectable drugs like morphine during the first six months after the database went into effect and about an 11 percent decrease of pills prescribed. COMMISSIONER DESIGNEE CRUM said the PDMP has 6,580 registered users. That is a four-fold increase over the past two years. The efficacy is increasing as more people are enrolled in that program. 1:47:34 PM SENATOR BEGICH said those are great numbers. When Dr. Butler [former DHSS acting commissioner and chief medical officer] was before them, he said he would aggressively pursue the opioid epidemic. It looks successful from these numbers, so he commends the department. Some pharmacy groups came to his office recently and had a graph to show the success of an effort to reduce the number of pills prescribed per prescription. He asked if the department has a formal process to engage with prescribers to encourage them to reduce the number of pills prescribed. COMMISSIONER DESIGNEE CRUM replied that he would get back to him on that. SENATOR GIESSEL said she could answer the question. They passed a bill that limited a prescription to seven days for prescribers (and optometrists are limited to five days), and that could have had an impact on the decrease in volume. SENATOR STEVENS said the fewer deaths from one year to the next is remarkable. He asked if Commissioner Crum attributes that to naloxone and he wondered how many times it had been used in Alaska. He knows policemen and communities have it. COMMISSIONER DESIGNEE CRUM replied that he is not an expert on it, but they work with public safety, the state drug enforcement unit, and local municipalities and police force to educate them on this process so they can carry that as well. They work with local health communities and aides and urgent clinics. They have worked with the local task forces to educate them and pass out kits. They have educated individuals operating in a first- response role. He does not have hard data, but he will look to see what data they have on how many times it has been deployed. SENATOR STEVENS asked if naloxone is readily available. COMMISSIONER DESIGNEE CRUM replied that they have grant funds for the kits. He will find out how much money they have left. He mentioned that he had just been informed that the kits had been used more than 250 times. 1:51:15 PM CHAIR WILSON said the kits were funded with a federal grant. He asked what the department plan is for the naloxone program after the two years of grant funding ends. COMMISSIONER DESIGNEE CRUM said anecdotally, it does seem to be a successful program. They will continue to evaluate it. At the conference next month, they will learn about other things that can be done as they update their comprehensive, long-term plan. CHAIR WILSON said he heard that the Office of Substance Misuse and Addiction Prevention has been changed and a new position was created in the governor's office. COMMISSIONER DESIGNEE CRUM said an official order has not been released yet. Because of the priority of public safety, the administration is considering something along the lines of an Office of Drug Control Policy. That would allow the individual to work interdepartmentally and have access to data and work across departments and statewide. CHAIR WILSON said that it would be a more integrated approach. COMMISSIONER DESIGNEE CRUM answered yes. COMMISSIONER DESIGNEE CRUM said that tribal Medicaid beneficiary claims have been reimbursed at a 100 percent federal match for services provided by or through a tribal health facility. The State Health Official Letter requires care coordination agreement, referrals, and exchange of records. 1:53:55 PM RENEE GAYHART, Program Manager, Tribal Health, Department of Health and Social Services (DHSS), Juneau, Alaska, said that tribal health reclaiming came about in February of 2016. SB 74 gave them targets to meet for FY 17 through FY 22. They had to work with tribal health organizations, so the previous administration scheduled two week-long meetings with the tribes. The department needed their help with care coordination agreements, which have to be between the tribal and non-tribal organizations. The state is not part of the care coordination agreement. The tribal organizations have to assist with the referrals and exchange of records. MS. GAYHART said the state worked with tribes to enhance the partnership. The tribes had three projects they wanted the department's assistance with. One was to reimburse community health aides, levels 1-4 and practitioner, and the behavioral health aides at an encounter rate. There are about 450 providers around the state. They came up with a set rate that assisted with the tribe's revenue generation to maintain that infrastructure and the staffing patterns of community health aides in the most outlying areas. The department also assisted with reimbursing for lodging. Tribes own 500 pre-maternal homes or hotel beds. They now reimburse those at the federal per diem rate rather than the state rate. The third project was to let tribes take over travel arranging. They took over all the air and ground transport arrangements for their Medicaid beneficiaries, which is about 1,000 travels a week. That also assists with the reclaiming effort. That was the first piece to work out on partnering in exchange for assistance with the three elements the department needs to meet in the State Health Official Letter. MS. GAYHART shared the three-year snapshot of efforts: SFY17: Look at high dollar/low volume claims to meet target: • Transportation (air and ground ambulance, travel broker services) • Hospital inpatient/outpatient, case managed complex kids • Accurate IHS Coding in MMIS SFY18: Continue to add care coordination agreements and strategize • Continue with services from SFY17 plus: • Pharmacy, Long-Term Care, Out of State Residential Psychiatric Treatment Facilities • Tribal Providers in Non-Tribal Facilities • Non-IHS Mothers with IHS Newborns SFY19 • Continue with services from SFY17 and SFY18 plus: • Waiver Services • Service Authorizations with date spans on travel itineraries • Optical Services MS. GAYHART said they had to strategize about how they were going to get to those dollars. They looked at the high dollar claims with low volume. Those are transportation claims, hospital inpatient/outpatient, both in-state and out-of-state facilities. There are many kids around the state who need things such as neonatal help, transplants, brain surgery, and heart surgery. They looked at accurate coding in MMIS [Medicaid Management Information System]. Race is an optional code. When anyone applies for Medicaid, they can claim a race, if they wish. When claims are paid when a race is absent, they don't get the appropriate match. They worked with Indian Health Services'(IHS) central office in Baltimore to get the Indian Health Services' beneficiary list. Then they could compare what they had in MMIS to get the appropriate race codes. For FY 18 they continued with those efforts and moved on to the other items in the bulleted list. They also worked with the feds on something that many other states were doing, but Alaska wasn't. A non-IHS mother with a Native baby can be claimed as IHS from prenatal to 60 days postpartum. That includes all their claims, including behavioral health, dental, optometry, etc. In FY 19, they continued with previous efforts and added the items in the bulleted list. MS. GAYHART said that all the reclaiming efforts are just guidance from the feds. They don't have to get approval for what they do, but they must have criteria and justification as to why they are claiming on certain referrals or certain episodes of care each quarter. Whenever there is a service authorization from someone to travel from one location to another, they include all the claims within that travel span. MS. GAYHART showed in slide 26 that they exceeded their target in FY 17 and FY 18. They are on path to meet their target for FY 19. CHAIR WILSON said that his office has heard concerns about tribal compacting. He asked if the department has a timeframe for deciding about whether to continue tribal compacting. COMMISSIONER DESIGNEE CRUM clarified that Chair Wilson was referring to child tribal compacting and said the next negotiation is scheduled for May. This is an ongoing discussion between the department and their partners. MS. GAYHART added that the compacting is with the social services of the tribes and she works with tribal health organizations. They go hand-in-hand in the communities, but when they look at tribal health reclaiming, it is separate from the social services organizations. SENATOR BEGICH asked if they are still supporting efforts for tribal compacting. COMMISSIONER DESIGNEE CRUM replied that yes, they are working with them and talking about that process, as well as what increased services may be available. CHAIR WILSON asked if the commissioner had any last words. COMMISSIONER DESIGNEE CRUM said that he had explained last week that they had a goal of gaining efficiencies--how to provide service better. They are increasing efforts for customer service. They are dealing with vulnerable populations. They want to address them with care and speed. They will continue to look at how to maximize relationships with community-based partners and work with them to make sure they are providing the most care possible. 2:03:12 PM At ease ^Presentation: Office of Children's Services Citizen's Review Panel by JP Ouellete, Chair Presentation: Office of Children's Services Citizen's Review  Panel by JP Ouellete, Chair  2:05:33 PM CHAIR WILSON announced the presentation on the Office of Children's Services Citizen's Review Panel by JP Ouellete, Chair. He noted this is the third year in row the panel has briefed the committee. 2:06:01 PM JP OUELLETE, Chair, Alaska Citizen Review Panel (CRP), Anchorage, Alaska, began by thanking Diwakar Vadapalli [former chair of the Citizen Review Panel] for legitimizing what they do. MR. OUELLETE gave the presentation outline: • Introduction to the role and purpose of the Citizen Review Panel • Goals and recommendations from 2017-2018 • Goals for 2018-2019 • Improvements in CRP-OCS collaboration • Way forward MR. OUELLETE reviewed the central purpose of the CRP: • Congress created CRPs to help child protection systems be more responsive to community needs. A CRP is a mechanism for public participation in child protection. • It should facilitate robust and meaningful participation by citizens 1. In diverse roles in child and family welfare 2. Representing all five regions 3. With a shared interest in promoting a healthy and collaborative CPS system MR. OUELLETE said they have really tried to target people with diverse roles in child and family welfare so that the panel has that expertise. In the past, CRP has taken anyone with an ax to grind. That is helpful in voicing some things that need to be highlighted, but they want to create something that is empowering the child protection system to do its best and be the best. They are recruiting someone from Southeast Alaska so that all five regions will be represented on the panel. MR. OUELLETE reviewed the federal mandate and state mandate. Federal Mandate (42 U.S.C. ? 5106a.(c)): • Examine the policies, procedures, and practices of state and local child protection agencies and evaluate the extent to which these agencies are effectively discharging their child protection responsibilities • Conduct public outreach both to assess the impact of current policies and procedures, and to solicit public comment on the panel's recommendations. State Mandate (AS 47.14.205): "The CRP shall examine the policies, procedures, and practices of State and local agencies and where appropriate, specific cases, to evaluate the extent to which State and local child protection system agencies are effectively discharging their protection responsibilities." MR. OUELLETE reviewed the primary functions of the CRP: Review/Evaluate (from statute): • States' CAPTA Plan • Child protection standards • And any other criteria that the Panel considers important Conduct public outreach (from statute): • Assess the impact of OCS policies, procedures, and practices on children and families • This assessment should inform its review function Advocate for (from congressional record): • Relevant changes based on its review MR. OUELLETE said the panel develops its criteria as it visits each region throughout the year. They advocate for a healthy, effective child protection system (CPS), not one agency over another. MR. OUELLETE reviewed what CRP does not do: • Comment on proposed or pending legislation • Get involved in individual cases, contract, or situations • Micromanage OCS operations • Program evaluation • Lobby MR. OUELLETE said that when they visit regions, they provide feedback specific to that region, but this year they made it clear that their feedback is not official but rather talking points about collaboration. 2:11:09 PM MR. OUELLETE presented a visual on how the CPS works. The needs of children and families drive what they do. The needs are shown as the big wheel. They look at three questions: What is supposed to be done? What is actually done? What is needed? Traditionally the CRP has given feedback on the first two questions. The CRP is starting to take a more in-depth look at why things are not being done and what can be done to solicit the support so those things can be done. MR. OUELLETE reviewed changes in CRP operation to become more collaborative with the Office of Children's Services: Reorientation of CRP as a public participation mechanism • Discussions began early fall 2017 • A tentative three-year timeline • Elements will include o Participatory evaluation o A systems focus o Robust recruitment and retention strategy o Data-driven review and outreach o Collaborative and constructive MR. OUELLETE said they have worked to make their OCS goals and recommendations align with the momentum to make OCS better and healthier. He has results to share later in the presentation. MR. OUELLETE reviewed the goals for 2017-2018. He noted they developed the goals in collaboration with OCS: GOAL 1: Examine the effectiveness of the current administrative review process and whether the changes made in 2015 have improved the system. GOAL 2: Examine if 'family reunification' is prioritized as a goal for children in out-of-home care placement, and OCS' efforts in pursuit of 'family reunification'. GOAL 3: Examine OCS' efforts in finding relatives for placement of children in foster care. MR. OUELLETE said the administrative review process became more efficient but accomplished less, so it was about redefining what the administrative review process was supposed to accomplish. In the past, it was an opportunity for everyone to collaborate on the case plan. The administrative review was changed to make it faster. People who were involved with the administrative review process in the past had discomfort because there was not enough time to work with families in the meeting. Now there seems to be a better understanding of what the administrative review is for and efforts are being made to look at the case continuum and identify other areas besides the administrative review to accomplish certain things. MR. OUELLETE said the prioritization of family reunification depended on the region. In policy it always is a priority, but depending on the worker investment in community, it was not always an overt practice. CRP looked at ways to help strengthen some of the things that undergird that sense of why family reunification is a priority. MR. OUELLETE said OCS has been doing well with Goal 3, finding relatives for placement of children in foster care. OCS is collaborating with tribal partners in finding placements and the tribes have incredible databases. 2:17:24 PM SENATOR BEGICH asked if the increase in foster care workers had any impact on Goal 3. MR. OUELLETE replied that in some regions it made an impact. Later in the presentation he would talk about how worker wellness and quality of life undergirds all these priorities and helps those to happen. Where there has been an increase in workers, it has had a dramatic improvement in the quality of life of the workers. He hears from the workers that they have more time to work the case plans with the families. SENATOR BEGICH said anecdotally, he has heard those things about the Mat-Su office. He asked if any measurements of worker satisfaction are made or is it just observed. MR. OUELLETE said they did propose that CRP be part of satisfaction surveys. He worked closely with OCS leadership on developing a section of the survey that focuses on wellness. The Anchorage office has been very cooperative about incorporating the wellness initiatives and getting that staff feedback. The staff feedback he has received has been that feedback or surveys doesn't matter because no one cares what they say. So this year they worked together to try to develop a survey that acknowledges that they heard what the workers said last year and x, y, and z changes are because of the feedback from last year and they look forward to doing x, y, and z this year based on staff feedback. They are wording surveys in ways to encourage participation and reinforce that what they say matters. They are coming to see the CRP as an entity that garners that voice for them. SENATOR BEGICH replied that it is to let them know they are listening. The committee is paying attention thanks to the work Mr. Ouellete is doing. 2:20:15 PM SENATOR STEVENS said last year the legislature was visited by children in foster care. They heard repeatedly that little effort was being done to find relatives. He was glad to hear that it is improving, but it would have had to improve in one year because they heard so many complaints last year from the kids in foster care. To him, their work seemed akin to accreditation in terms of making recommendations. He asked if CRP has any power. He asked in the end, what is the impact of CRP. MR. OUELLETE replied that Diwakar Vadapalli fought that for a long time. CRP has no power legislatively. The relationship with OCS was frustrating at times. The CRP has realized that if they looked at OCS like a family in crisis, then they approach it differently. Workers work with families in crisis. CRP thought what if they approached OCS like that. They don't have the power to say they have to do what they tell them, so how do they garner that rapport, collaboration, and reception that they need from OCS. They have taken a different approach to acknowledge how difficult the work is. These things need to be fixed. He said he is experiencing a completely different conversation with OCS. Rather than OCS bracing for a visit from CRP, it's been a thank you for coming. A month after visiting with the Anchorage office, the leadership had gone down the checklist and completed everything CRP had recommended. The answer to his question is they have no legislative power, but they can when they garner that collaborative relationship. SENATOR STEVENS thanked him for what he is doing. 2:23:17 PM CHAIR WILSON said the CRP went six years without a forum or being recognized for the important work it does. He reported that he asked CRP before the committee so all Alaskans can see the work they do and have their functions recognized at a higher level. SENATOR BEGICH thanked the chair because he didn't know anything about the CRP until the CRP hearings in the committee. At the first hearing significant issues were brought up and the committee asked for responses from OCS. They didn't get responsive answers from OCS, and the following year with the persistence and desire of the panel and the department to work collaboratively, they got responsive answers. "We end up, by virtue of listening to the panel, becoming the legislative power, if you will," he said. MR. OUELLETE thanked the chair for helping them have a voice and a sense of legitimacy with the work that they do. He shared Goals 4 and 5 of 2017-2018. GOAL 4: Expand public outreach in collaboration with efforts under the Tribal-State strategic plan. GOAL 5: Strengthen the panel through aggressive recruitment of new members, enhanced website, and tools to reach diverse groups of stakeholders. MR. OUELLETE said last year they reached out to tribes to make sure communication between tribes and state was where it should be. He recounted a story of how beneficial it was to have someone from Bethel on the panel when they did a site visit in Bethel. CHAIR WILSON asked how someone gets involved. MR. OUELLETE replied that people can go to crpalaska.org and send a message to the coordinator. MR. OUELLETE reviewed recommendations for 2017-2018 and noted that he would go over the highlights, but not all recommendations. Overall, CRP recommendations fall into five categories: • Quality Assurance • Management • Practice • Public participation • CRP's role and functions MR. OUELLETE reviewed Recommendation 1 for 2017-2018: Improve Administrative Review Process Recommendation 1: The Panel recommends that OCS not transition to a judicial review process as was proposed but fine-tune the current administrative process to make it more comprehensive. MR. OUELLETE said that over time they have realized there was lack of information about the purpose of the administrative review process. Now that they know about the process, they are asking where in the continuum of care to address things that used to be in the review process. 2:29:22 PM SENATOR STEVENS asked what a judicial review is and why it is a bad thing. MR. OUELLETE said that instead of having cases reviewed internally at OCS, they were going to go before a judge. The feedback they received in every region was that they would need more judges. Judges already have a backlog and there is a backlog of administrative review cases. MR. OUELLETE reviewed Recommendation 2 for 2017-2018: Improve Outcomes for Family Reunification: Recommendation 2: The Panel recommends that OCS take the following measures: ACTION: OCS should target recruiting efforts to workers with life experience in or near the regions they will be serving. ACTION: OCS should provide orientation and training that explains the often overlooked cycle of trauma children endure when separated from their families, and the reason family reunification is a priority. OCS supervisors and trainers should encourage a strengths- based approach to working with parents. ACTION: OCS should support and train workers to practice early intervention / in-home efforts to prevent removal. We suggest drawing from the experience of more seasoned workers who do this very well in their regions to provide mentorship opportunities. MR. OUELLETE said that regions that have workers invested in their communities have better family reunification outcomes. Regions with workers who are transplanted from out of the community, out of the state, and at times, from out of the country, often do not possess the information to work with families in that region. The panel felt a child's trauma of being removed was not stressed enough. When a case worker understands that, the case worker can prioritize exhausting all measures before removing a child. MR. OUELLETE reviewed Recommendation 3 for 2017-2018: Strengthened Cultural Competency   Recommendation 3: The Panel recommends that OCS leadership look in to identifying the cultural differences that can contribute to bias among OCS workers and minorities, then find ways to improve their cultural competency. ACTION: This can be done through more observation, listening, and engagement, as well as targeted and evidence-based trainings like "Healthy Families" and "Knowing Who You Are." ACTION: Cultural competency training from local village councils or other tribal training partners to build from a collaborative foundation between OCS and the tribes and give caseworkers an opportunity to engage with tribal representatives establishing better lines of communication for achieving ICWA objectives. ACTION: Collaborate with tribes to ascertain if and where the ICWA specialist could leverage relationships with local elders and community leaders to help case workers develop effective strategies for community engagement and interaction with Tribal resources. MR. OUELLETE said in almost all regions tribal partners have good trainings about the families they are working with and the values of those families that workers need to understand. Sitka has done a great job of collaborating with their tribal partners. At times he has seen silos between state and tribal partners, and families suffer from the lack of collaboration. CRP is working on how to broker those relationships better and be a facilitator of that communication. 2:34:54 PM SENATOR COGHILL arrived. SENATOR BEGICH noted that the CRP travel budget is funded by the state. He asked if CRP is affected by the proposed budget restrictions on travel. MR. OUELLETE answered that he is not aware that CRP is affected by travel restrictions. SENATOR BEGICH asked if the department knew the answer because he wanted to know if their work would be limited. CHAIR WILSON said the department would be before the committee on Friday to give the response to the presentation and could answer his question then. MR. OUELLETE said they had begun a conversation about allowing more panelists to travel before the proposed budget cuts. He hoped travel would not be cut because face-to-face interactions in the community are vital to the work they do. SENATOR BEGICH said the CRP is seeking to have collaborative and participatory relationship. He understood the adversarial role with the department response, but he hoped that in the long run the relationship would be more collaborative and they would see CRP and the department present side-by-side. CHAIR WILSON said the vice chair of the committee had had a bill to move the CRP from the administrative branch to legislative oversight, but the bill didn't' get the momentum to pass last year. He did not know if that was still a goal of CRP. MR. OUELLETE said it was not still on the goal list because they have reprioritized. He thanked Senator Coghill for his help for getting that bill on the floor. Because it didn't pass and they are going to be housed within OCS, they asked themselves how to make sure their autonomy is clear. The relationship with OCS shows they are receptive to feedback. Their feedback is not swayed by being housed within their budget. As he had mentioned earlier, because of the changes CRP had made, their criticism is better received and followed up on. It used to take six to 12 months to get a response to recommendations. For his last meeting with the former director of OCS, she said she cut the requirement to three months with a focus on replying within one month. He thinks that they are going to be more responsive because CRP is supportive of the things that OCS needs to do. 2:39:57 PM SENATOR COGHILL said that Bethel, which has some of the toughest cases, has added a public defender to work with OCS. He asked about the impact. MR. OUELLETE recapped that Senator Coghill was talking about the addition of a public defender, who represents parents. He said he did not know the answer from a CRP perspective. Vocationally he is mediator in CINA [Child in Need of Aid] cases. It depends on the defender. He has seen it be very effective when the public defender is a strong advocate for families who say, "Hey, the reason that we're here at a termination trial is because no one has given this family a case place for six months and now we are at termination. That's not the way it's supposed to work." He has also seen defenders who are just used to the way things go. It is unfortunate, but it's the way it works in some areas. SENATOR COGHILL said Bethel is probably one of most unique places in Alaska because OCS deals with tribal and state groups, IWCA [Indian Child Welfare Act] and state laws and tribal groups that don't always have to follow the IWCA laws. He asked how the OCS office in Bethel is bridging the different approaches. MR. OUELLETE replied that his last site visit was to Bethel, and that is where the watchdog function of the CRP really came out. But it is balanced with constructive feedback. The Bethel office is having a hard time. CRP's recommendations for 2018-2019 were formed largely as a result from the visit to the Bethel office. MR. OUELLETE reviewed Recommendation 4 for 2018-2018: Increased Community Engagement Recommendation 4: CRP to facilitate the constructive exchange of vital information between stakeholders increasing collaboration. ACTION: Encourage local/regional OCS leadership to help arrange and facilitate townhall or "talking circle" type meetings during each site visit that the CRP conducts in 2018-2019. MR. OUELLETE reviewed Recommendation 5 for 2017-2018 and noted that work burnout and vacancies has been a problem for a long time for OCS and is still a problem: Worker Burnout and Vacancies Recommendation 5: Recruiting, supporting, and retaining workers that have the skills, character, community investment, and resilience to serve the needs of Alaskan families is key. ACTION: Tighten OCS hiring policies in the following ways: • Acquire or develop a tool that screens job applicants for resiliency. • Require applicants have field-related experience and/or education. MR. OUELLETE said finding a tool to screen job applicants for resiliency may not be possible, but it should be looked into. He has seen that OCS is tolerating vacancies longer before just putting someone in a position. While it hurts not to have someone there, it hurts more to put someone there who shouldn't be there. MR. OUELLETE reviewed Recommendation 6 for 2017-2018 and noted they were getting good feedback on progress for this: Improve Centralized Intake Recommendation 6: While regions are adapting to what may be an irreversible change, there are still significant concerns about the efficacy of the current intake process. Stakeholders across the regions shared frustration over the inconsistency of the process and the intake worker's inability to facilitate necessary actions in a region they are unfamiliar with in a timely manner. ACTION: Equip centralized intake workers with region- specific resources and a concise standardized assessment tool for prioritizing calls based on already existing OCS policies and procedures. 2:45:19 PM MR. OUELLETE reviewed progress on the 2017-2018 goals: • 2017 was, we hope, the pinnacle of a tumultuous period for OCS involving much public scrutiny, incredibly high worker turnover, lack of (though growing) collaboration and communication between OCS and CRP, and internal frustration with statewide changes such as admin review and centralized intake. • Many of the recommendations went unaddressed and appear under new headings for 2018-2019 as the CRP reimagined its role moving from "watchdog" to broker and facilitator of effective communication while remaining critically objective. MR. OUELLETE said CRP had to reimagine its role from just giving recommendations to giving support and building a relationship to make it possible to meet the recommendations: Moving into 2018-2019  • Acknowledging the crisis OCS was facing, the CRP adapted its approach to site visits looking deeper into core contributing factors leading to burnout, turnover, backlogged IAs, and less-than-optimal results for children and families. • CRP developed this year's goals to address the relationship between worker wellness, community collaboration and best efforts toward family reunification. • CRP began pre-site-visit teleconferences to collaborate with leadership toward a fruitful site visit. MR. OUELLETE said the pre-site visit briefings give OCS plenty of time to review CRP priorities and think of thoughtful responses to questions. Typically, CRP visits were met with consternation. They are trying to change that and have seen good results. MR. OUELLETE reviewed Goal 1 for 2018-2019. GOAL 1: Assess Family Reunification Efforts & Best Practices • What are practices that are working well in the regions to promote family reunification and how can we replicate that in other regions? • What are barriers workers and families face to moving toward reunification? • What needs to be done to eliminate those barriers? He said Goal 1 will probably always stay a goal, but the questions are changing from "are you meeting the objectives" to "how are you meeting the objectives and what are the barriers." MR. OUELLETE reviewed Goal 2 for 2018-2019: GOAL 2: Evaluate OCS Staff Wellness Efforts and Community Engagement • What efforts are in place to promote wellness, safety, healthy office culture, and community engagement (particularly in remote regions)? • How can the CRP help promote wellness among staff? MR. OUELLETE said as he visited each region, he was grieved by the lack of emphasis on wellness for workers. For people who have some of the hardest and thankless jobs in the state, there is no sense of self-care, no sense of helping each other, or that awareness that they have a hard job that is killing them if they don't take care of themselves. It is a problem that there is no room in the budget for wellness. He doesn't know that CRP can address that, but they can ask about what supports are in the community for wellness. Sometimes the OCS staff doesn't appreciate the effects of secondary trauma on them, which can be devastating. The Anchorage office has started suicide awareness and secondary trauma training. The union gives trainings on how to access benefits. CRP feels that healthy OCS workers are going to contribute to healthy families in Alaska. MR. OUELLETE reviewed Goals 3-5 for 2018-2019: GOAL 3: Region-Specific/Culturally-Appropriate Training for OCS Staff • What are current requirements for staff? • What offerings available through tribal partners? • How can the CRP facilitate better communication and collaboration with tribal partners in this area? GOAL 4: Awareness of Tribal-State Strategic Plan • At what levels do different staff engage with the Plan? • Are the efforts coming from the Plan tangible to stakeholders? GOAL 5: Coordinate Panel Activities & Improve Panel Participation • Streamline regular schedule for panel activities. • Focus recruitment efforts on regions outside of Anchorage. MR. OUELLETE reviewed progress on the 2018-2019 goals: Progress on 2018-2019 Goals Our change in approach has • Highlighted the strengths and improvements in each region and given honor where due: o Recognized to state leadership where regional and local leadership has played a significant role in improving outcomes for families o Recognized supervisors who model effective and supportive leadership • Acknowledged the challenges faced by all stakeholders and contributed to building unity among OCS and its partners. o Naming and normalizing the stress incurred by those who work directly with families in their greatest time of need o Providing empathetic and positive feedback from the community to OCS workers o Communicated to all stakeholders the common goals of OCS and community partners • Tailored recommendations for success by collaborating with leadership and seeking out sources of support from community partners. o Worked with stakeholders to provide tangible solutions to challenges in communication, collaboration, and cultural competency o Provided OCS leadership with ideas from staff and contact information for support available in the community • Resulted in a positive and collaborative relationship between CRP and OCS leading to unprecedented responsiveness, and successful implementation of CRP recommendations. 2:54:50 PM MR. OUELLETE concluded with the following: The CRP is an institution, with a statutory role and responsibility. It is an organization of the state. It facilitates citizen participation. It must cultivate a critical, but constructive lens. It exists to help OCS. Its success depends on its relationship with OCS. MR. OUELLETE said the success of the CRP is dependent on its collaborative relationship with OCS and the success of OCS depends on collaboration and support with their community partners. If he could advocate for anything today, he said cutting in areas that decreases access to those partners or diminishes the capacity of those partners to be a support system for OCS is detrimental to families. He asked the committee to take a hard look at how any proposed cuts for DHSS impact families. SENATOR COGHILL said collaborative work is expected, but another set of eyes to shed light on what is going on is also necessary. He thanked Mr. Ouellete for taking the responsibility seriously. OCS has said it is looking at new ways of training and that might percolate up this year. He asked whether he had heard employees were anticipating this or dreading this. MR. OUELLETE asked for clarification of the question. SENATOR COGHILL said there are more efforts at training for OCS workers on the frontline with the new money and new positions the Legislature funded last year. They are trying to mitigate turnover and vacancy rate. His comment is not meant to be a criticism, but he wondered if had heard any discussion about the training. MR. OUELLETE replied that there has been a lot of talk about that. More training is going to be very welcome. One of the things they hear the most from case workers is that they don't have enough training to do this. An emphasis on training is only going to be helpful to case workers. It will create a delay in getting workers to the field, but his assumption is that it will pay dividends. SENATOR COGHILL said he thought the law that passed last year placed a limit on caseloads, so they need to hire people and get the training completed. CHAIR WILSON said today's presentation in some ways served as a preliminary audit of HB 151 since issues regarding training, placement times, wellness, and collaboration were part of the bill. He has great hopes that progress with OCS continue and that the gains will multiply. 3:00:10 PM SENATOR STEVENS commented that being a case worker is a stressful job. Last year the committee heard case workers were quitting faster than they could be hired. The most valuable part of any accreditation for a college or university is the self- study before the auditors arrive. He asked if CRP can do something similar. MR. OUELLETE replied that they made a change for that reason. CRP usually starts the presite visit briefings several weeks ahead and request data so that they know what they are looking for and also give OCS all the questions they are going to ask so they can review those. It used to be a concern that by doing that, OCS could stage the environment, but there is not time to do that. Since CRP started doing this, they are more receptive when they are given a heads up. He wanted to speak to an earlier comment about the effectiveness of putting more people into the workforce. That has been helpful and the emphasis on worker wellness will hopefully keep people. They can keep spending money on putting more people there, but if the conditions are terrible, why would they stay. While the legislation is helping to get more people in there, the CRP is helping people to stay. 3:02:17 PM CHAIR WILSON announced that the committee will hear the response from OCS on Friday and the status on the implementation of HB 151. 3:02:45 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee at 3:02 p.m.