DRAFT ONLY - APPROVAL PENDING

Wyoming Legislature

Committee Meeting Summary of Proceedings

Select Committee on Mental Health and Substance Abuse Services

Committee Meeting Information

April 26-27, 2005

Wyoming State Hospital

Evanston, Wyoming

 

Committee Members Present

Senator John Schiffer, Cochairman

Representative Colin Simpson, Cochairman

Senator Pat Aullman

Senator Ken Decaria

Senator Rae Lynn Job

Senator Wayne Johnson

Senator Tony Ross

Representative Keith Gingery (April 26 only)

Representative Jerry Iekel

Representative Doug Osborn

Representative Jane Warren

 

Committee Members Absent

Representative Keith Gingery (April 27 only)

Representative Patrick Goggles

 

Legislative Service Office Staff

John Rivera, Senior Staff Attorney

Nicole Novotny, Associate Research Analyst

 

Others Present at Meeting

Please refer to Appendix 1 to review the Committee Sign-in Sheet
for a list of other individuals who attended the meeting.

 

 

Call To Order (April 26, 2005)

Chairman Simpson called the meeting to order at 8:00 a.m.  He expressed on behalf of the Committee sympathies to Representative Goggles and his family for the tragic death of Representative Goggles' niece. The following sections summarize the Committee proceedings by topic.  Please refer to Appendix 2 to review the Committee Meeting Agenda.

 

Mental Health Division ¾ Update

Dr. Brent Sherard, M.D., Acting Director, Department of Health (WDH), advised that a permanent director for the WDH may be appointed soon.  He described how the current senior administration of the WDH is staffed and introduced Chuck Hayes, Administrator of the Mental Health Division.  In response to a question from Senator Schiffer, Dr. Sherard stated he can't comment on any formal process for strategic planning and coordination between the Mental Health Division and the Division of Substance Abuse, but the divisions are collocated and do work closely together.

 

Mr. Hayes provided his professional background that led to his employment with the WDH.  He distributed Appendices 3-5, including an outline of his presentation to the Committee, a chart describing the field offices of the Division throughout the State, and charts describing expenditures in FY04 for the various mental health and substance abuse providers providing services with funding from the Division, respectively.  The Division began moving toward a community-based system for providing services in 1996.  The next phase of its efforts are being directed to addressing the imbalance that exists between the Wyoming State Hospital and community service providers. Whenever one system is overloaded, it impacts the other system.  These latest efforts have been on hold while the WDH completes the changes in administration.  Some of the organizational challenges that exist include:

 

Senator Ross expressed concern that boundaries have been created by separation of mental health and substance abuse into separate divisions within the WDH.  Mr. Hayes said that he originally opposed the separation into separate divisions, but now supports the change. He would like to maintain the separation for at least another year to preserve the gains made by the divisions.  Senator Schiffer is concerned that counties that have separate mental health and substance abuse providers are costly and inefficient.  Mr. Hayes replied that 13 0f 15 counties combine the services and if one clinician can simultaneously address both problems when they coexist, the client is better served.  Representative Warren is concerned with data when mental health and substance abuse problems coexist because a client may be counted twice when served for one or the other problem and both problems are being addressed at the same time.  Senator Decaria added that dollars can be more wisely spent if the data is accurate in reflecting that a single session may have addressed coexisting problems, rather than counting the patient separately for each problem.  Dr. Sherard advised the WDH is looking closely at how finances are being used.  Representative Gingery stated he sees a problem with 3 fragmentations, i.e., separation of the mental health and substance abuse services into two divisions within the WDH, that Park, Teton and Uinta Counties have separate mental health and substance abuse providers, and the nonexistence of regionalization of services provision.

 

Senator Job expressed the need to talk with school boards to focus on early intervention to prevent mental health problems later in life for individuals.  Chairman Simpson agreed that teachers can identify potential mental health problems as early as first or second grade, but schools won't address treatment services for those children.

 

The Committee discussed a wrap-around service model whereby lesser qualified staff who are able to perform some tasks for which they are qualified to provide can relieve the more highly qualified staff of performing those duties and focus on services they are uniquely qualified to provide.  Peer counseling, recruitment and retention of staff, transitional services, including housing and psychological and pharmaceutical support for clients, and collaboration with the University of Wyoming research program were also discussed.

 

With respect to Title 25, the Committee discussed the need to look at the involuntary commitment process and how to expedite procedures to save costs while protecting individual rights and improving the quality of psychological assessments.  In response to a question from Senator Aullman, Mr. Hayes stated that there is a shortage of psychiatrists to evaluate emergency detainees, persons who can prescribe medications and support and training for general practice physicians.

 

Mr. Mike Huston, Central Wyoming Counseling Center, provided a history of the fragmentation that occurred among the community mental health and substance abuse service providers.  In 1969, the Legislature considered state provision of local mental health services, but opted for the provision of those services through contracts with private providers.  Three county programs originally provided services on a regional basis. As time passed, some boards of county commissioners wanted their own programs, so services became fragmented as those counties created their own programs.  The fragmentation was motivated by local politics, not by program initiatives.  In 1997, the Division of Behavioral Health was divided into the Mental Health and the Substance Abuse Divisions through executive order issued by the Governor. 

 

Substance Abuse Division¾Update

Ms. Alfrieda Gonzales, Administrator, explained she was facing a steep learning curve since she has only joined the Substance Abuse Division a few months earlier.  She distributed Appendix 6 consisting of the Division's presentation to the Committee and related data.  The Division still has strides to make.

 

Ms. Cherri Lester, Substance Abuse Division, provided an overview of what is available since the enactment of 02HB0059, Substance abuse plan.  There are 60 providers certified in the state to provide substance abuse counseling, 19 of whom are funded through the Division.  Most others are private providers. Over $10 million is spent to fund 162 beds in the state, but there is still a waiting list for substance abuse services.  The intensive outpatient treatment program has increased 160% since HB0059.  The first methamphetamine initiative was implemented in 1999 and requests for proposals (RFPs) will be sent April 29 to implement 05H0308 by providing direct treatment and prevention services. 

 

Chairman Simpson expressed concern about building an infrastructure capacity without also building the human resource capacity also.  Senator Schiffer agreed that it doesn't make much sense to spend $3 million for additional beds if the treatment capacity necessary for those beds is lacking.  Ms. Lester stated there are sufficient clinicians nationally, but the state can't recruit them at the current salary levels in Wyoming.  Mr. Dean Jessup, Substance Abuse Division, added the RFPs are not just for treatment beds, but also for outpatient treatment.  Dr. Sherard explained that physician extenders, such as physicians assistants and advance nurse practitioners, could address provider shortages.  He advised the WDH has added a new epidemiologist position to gather data and look at cost-effectiveness and outcome measures for the programs that will be created under HB0308.

 

Senator Job requested the Division provide the Committee with 3-5 years history of funding for substance abuse programs.

 

Ms. Lester stated that approximately 33,000 people in Wyoming need substance abuse treatment services, but about only about 9,870 have been served so far.  In response to a question from Senator Johnson, Ms. Lester stated there are fewer women than men in treatment because women are more secretive about their problem and less willing to undergo treatment.  Drug courts in the state contract directly with service providers, who may be private or center-based.  This has occurred under an RFP process for two years. The persons treated under the drug court process are not counted in the WDH statistics because the services are paid out of different funding.  Successful drug court outcomes may be higher because of the threat of  a jail sentence that participants in those programs face if they are unsuccessful.  She suggested that cross-training between the courts and other treatment programs could improve outcomes for both. 6.1% of the Wyoming population has co-occurring disorders of mental illness and substance abuse.

 

Ms. Gonzalez stated that Dennis Embry and DataCorp. were good catalysts for implementing the methamphetamine initiative, but the WDH has no current contract with either.   In response to a Committee question, Ms. Gonzalez stated that there is no single strategic plan for all programs, but the WDH is trying to establish linkages between the different plans that exist.  Senator Job expressed frustration that she has heard this all before and wants to know when the linkages are to be implemented. Mr. Jessup said the WDH is dusting off the plans from the shelve and is reorganizing the Division to implement the plans.  Chairman Simpson stated he hopes the Division will work toward implementation and if the Legislature must do something to facilitate the implementation, the Division should advise the Committee.

 

Wyoming Association of Mental Health and Substance Abuse Centers

Mr. Ed Wigg, President of the Wyoming Association of Mental Health and Substance Abuse Centers (WAMHSAC) distributed Appendices 7 & 8, the 2005 WAMHSAC Legislative Report and a spreadsheet of services provided by each mental health and substance abuse center, respectively.  Some of the activities of WAMHSAC members include:

 

In response to questions from the Committee, Mr. Wigg stated he agrees with the concept of collaboration, but it won’t be painless.  Some centers may have to give up some of their funding to accomplish regionalization of services.  the 7300 empty bed days are a result of centers not being able to fill a bed the day it becomes available. release from jail and transportation have to be arranged, which can cause delays in filling a bed.  He does not have an exact count of the number of employees at all WAMHSAC facilities.  The Committee may have different counts as to the number of persons treated because in those counties that have separate mental health and substance abuse treatment centers, some persons may be counted more than once if they use the services of both centers in the county.  Senator Schiffer asked for a corrected, unduplicated count of persons served. He doesn’t  think that a system of county-based programs makes sense.  Chairman Simpson asked for information with respect to the types of services being provided to non-targeted populations and if the number of intensive outpatient treatment days has increased to minimize failure.

 

WAMHSAC recommendations include:

 

Chairman Simpson asked for the WAMHSAC recommendations in writing.

 

Public Comment

Dr. Jane Robinett, O.D., introduced herself, as a psychiatrist affiliated with Peak Wellness Center, and Dr. Kevin Robinett, O.D., a psychiatrist affiliated with the Veterans Administration (VA) Hospital in Cheyenne.  They distributed Appendix 9, a summary of their presentation before the Committee.  Dr. Jane Robinett stated there are 40 psychiatrists in Wyoming and 8 are planning to leave or retire soon.  Another 20 have ended their practice within the last 10 years for a variety of reasons.  Ways to address the shortage of psychiatrists is to create full-time salaried contract positions with on-call coverage, to consolidate in-patient services on a regional basis and to enhance support staff services.  Telemedicine is also developing rapidly in the state, as  another means of increasing availability of psychiatric services.  The biggest problem in the state is the fractionalization of out-patient treatment at Peak Wellness Center and in-patient treatment at United Medical Center. 

 

Dr. Kevin Robinett said telehealth has worked well for 4 years at the VA hospital as an alternative to face-to-face meetings.  A face-to-face meeting should precede use of telehealth though.  A lack of advance nurse practitioners with varying levels of expertise is another problem that could be addressed if recruitment efforts would be increased with incentives for recruitment. 

 

Stuart Thomas, Executive Director of Sweetwater County Memorial Hospital (SCMH), and members of his staff addressed issues of concern at their facility.  Ms. Kathy Ludmore expressed concern that delays in transfer of involuntary commitments to the Wyoming State Hospital (WSH) began to occur about a year ago and has increased in recent months because of the waiting list at the WSH.  She added that the average length of stay for emergency detainees at the SCMH is increasing and now averages 7 days.  Most detainees do not have the means to pay the costs of their stay at WCMH, which is not geared to keep the detainee for the 7 days.  As a result, those persons are being housed in rooms on the same floor with the obstetric nursery, pending transfer to the WSH.  In response to a question from Senator Schiffer, Mr. Thomas stated the hospital would be willing to partner with the state to provide services to persons who are in emergency detention at SCMH.

 

Chairman Simpson asked for the number of emergency detentions and the number of court-ordered placements from all hospitals in the state.

 

Concern was expressed that the court cannot order involuntary commitment to any facility other than the WSH.  The WDH never promulgated rules required under W.S. 25-10-104 to designate what hospitals, other than the WSH are qualified to provide treatment under the involuntary commitment statutes; therefore the only facility authorized by law to accept involuntarily committed persons is the WSH. Any placement elsewhere is allowed only if the person involuntarily committed agrees to the placement.  Dr. Sherard will look into the WDH's failure to adopt rules as required by W.S. 25-101-104.

 

Dr. Alan Richardson, M.D., Chief of Staff at SCMH, distributed Appendix 10, a letter he sent to Governor Freudenthal advising of the problems SCMH is facing with respect to involuntarily committed persons who are housed at the SCMH.

 

Mr. David Piaia, attorney for SCMH, stated the Colorado procedures for involuntary commitments are better than Wyoming's procedures because in Wyoming there is no treatment provided pending commitment. In Colorado, the person receives treatment upon detention and commitment is considered while treatment is being provided.  He said 9 or 10 counties in Wyoming treat patients prior to the commitment hearing, but he believes that statutes do not allow that because of ambiguous language in W.S. 25-10-101(a)(i) and 25-10-109(b).

 

Dr. Pablo Hernandez, M.D., WSH Administrator, explained that some counties interpret Title 25 of the Wyoming statutes liberally, while others, like Sweetwater County interpret the law narrowly, which causes them problems.  He added that the statutes should be clarified to allow flexibility.

 

Dr. Kevin Robinett stated that any county hospital that establishes a psychiatric unit does so knowing that the unit will operate at a loss.  Patients receiving treatment in the unit are generally indigent, while most persons with insurance or other means of payment, will receive treatment in other types of facilities.  It costs about $430.00/day on average for an adult patient being treated at the WSH.

 

Ms. Judy Catchpole, representing the Jeffrey C. Wardle Academy, introduced Dr. Earl Faulkner, who will be working with Dennis Embry and others to develop treatment programs for children with methamphetamine problems.  She said that recruitment of professionals does work because Dr. Faulkner came to the Academy from Nebraska.  Dr. Faulkner stated that methamphetamine creates organic changes in the brain, so unique protocols are necessary to treat problems created by the drug.    

 

Meeting Recess

The Committee recessed at 5:16 p.m.

 

Call To Order (April 27, 2005)

Chairman Schiffer called the meeting to order at 8:00 a.m.  He advised the Committee will use a subcommittee process to study the issues further, then meet as a full Committee in about 60 days to formulate its recommendations and final report.  He thanked Dr. Hernandez and his staff for their hospitality.

 

Wyoming State Hospital

Dr. Hernandez thanked the Committee for its interest and added that Nevada is the only other state that has created a select committee to work on mental health issues.  In the last 10 years, Wyoming has made great strides in the area of mental health.  He believes the state meets the goals of the President's Commission on Mental Health.   Community-based boards are well developed.  He stated a preference that Dr. Sherard should be appointed as permanent director of  WDH because he is well-qualified to provide the stability the WDH needs.  Dr. Hernandez wants flexibility to accomplish his goals.  The biggest problem facing the WSH is the waiting lists.  He distributed Appendix 11, a written copy of his presentation to the Committee.

 

Adolescents should not be admitted to the WSH because of the stigma and trauma that entails.  Since October, 2004, no adolescents have been admitted to the WSH.  While WSH has provided services to adolescents, those services have not included custodial care.  The Wyoming Behavioral Institute and Campbell County have better facilities for treating juveniles. Dr. Hernandez would like attention directed to defining the role of WSH with respect to teens.

 

Dr. Hernandez distributed Appendix 12, containing data on adult admissions that had been requested the previous day.  For the period March 1, 2004 through March 31, 2005, there had been 438 admissions and 430 discharges from the WSH. The average stay for civilly committed has increased from 28 days to about 36-37 days.  The lack of capacity in the Big Horn Basin area will result in more admissions to the WSH because Dr. Sullivan, who covered the area for the WSH, is leaving the state next month.   Regionalization should provide for differing levels of services to clients with the WSH being the provider of last resort.  Regionalization would require "quality of Life" funding to address the necessary levels of services within the regions. 

 

Dr. Hernandez distributed Appendix 13, a description of the Joint Re-Entry Team, a collaboration between the WDH and the Department of Corrections.

 

Dr. Hernandez' recommended elimination of misuse of Title 25, involuntary commitment procedures, because the criminally committed are being held by WSH without the possibility of treatment only to stabilize the person who is then returned to face criminal charges that have been filed.  Also, persons committed for substance abuse are misplaced because WSH no longer has a chemical dependency unit, which was eliminated 10 years ago.  If WSH is to treat persons with chemical dependency, then a clear decision to do so must be made and provisions made to reestablish the unit.  Dr. Hernandez advised that Title 25 assessments should not be conducted on a person who is intoxicated because the results are invalid for purposes of determining if the person is actually in need of mental commitment.

 

Representative Simpson asked WAMHSAC representatives what protocols are used in assessments preceding emergency detentions and commitment proceedings.  Mr. Wigg indicated he would work on  a reply to the request.  Representative Simpson also requested a poll of counties to determine where and how many people they hold under emergency detention, as well as how the emergency detention costs are paid.

 

Dr. Hernandez stated that 57% of 144 persons committed to WSH have served over 188 days at the facility.  Patients who remain up to 30 days are considered acute care patients. From 30-90 days the patients have more chronic conditions. A stay of over 120 days is considered long-term. Patients who remain over 180 days may need up to 5 years to recover.  Because of increasing use of the WSH, it is operating at a deficit.  This is the first time Dr. Hernandez has had to deal with a budget deficit.  The WSH spent $421 thousand last year for emergency detentions at other facilities because of the waiting list at the WSH.  He projects this cost will increase to $1.3 –1.4 million by the end of the biennium.  When a patient is cared for at another facility pending transfer to the WSH, the WSH has to pay for any health care the patient receives at the facility, whether the care is related to the mental health of the patient.  A protocol must be established for emergency detentions that allows for a physician to physician collaboration.

 

The WSH does about 120 evaluations a year, with 86 being conducted off the WSH grounds upon agreement from prosecuting and defense attorneys.  This allows for 40 fewer admissions to the WSH for evaluations, thus eliminating the need for an additional 100 staff at the WSH.  With projections for additional referrals to the WSH, Dr. Hernandez believes he will need additional staff  because he only has three in-house psychiatrists and three "rent-a-docs" to help.   Recruitment efforts for psychiatrists has been difficult. He has recently been given authority to enhance salaries to attract psychiatrists.   Nursing staff recruitment has been good because of an aggressive training program at Western Wyoming Community College, but salaries will have to be increased to continue attracting new staff and retaining existing staff.  Internship agreements with WWCC and the University of Utah have been very helpful. Recruiting social workers has not been a large problem. It is very difficult to recruit nurse assistants because those persons can earn more working in the energy industry. Pharmacists recruitment has also been difficult.

 

Dr. Jane Robinett advised the Wyoming Association of Psychiatric Physicians can provide current salary ranges for psychiatrists in Wyoming.  She will survey departed psychiatrists to determine why they left.  Something beyond the efforts of Dr. Hernandez needs to be developed to recruit psychiatrists.

 

Senator Decaria asked if continuing medical education training in psychiatric techniques is provided for general or family practitioners so they can become more proficient in backing up psychiatrists.  Dr. Sherard said there is training available, but its use is dependent on the comfort and skill level of the general practitioner, the comfort level in treating psychiatric problems and the willingness of the facility to assume the liability associated with such treatment.

 

Another big cost for the WSH is medications.  Those costs have escalated significantly, due in part to the need for the best medications being developed.  Without those new medications, recidivism is likely to occur quickly.  It is also necessary to increase the "quality of life" funding to assist clients once released into the community.  Without a shift to regionalization, WSH will have to grow to accept persons who would otherwise be treated within the region where they live.  It will be necessary to address an aging mentally ill population.  If the WSH is to treat substance abuse, it currently has existing space it can use, but will need additional staff to provide the necessary treatment services.  Any new programs the WSH is to implement will require additional staff, or the state's liability will be increased.

 

Mental Health Management Information System¾Update

Ms. Marla Smith, Mental Health Division, WDH, distributed Appendix 14, the current status of the Wyoming Client Information System and Divisions Data Infrastructures,  and Appendix 15, Extracts of Draft Reports of 2003 Mental Health Data: Wyoming and United States.  She explained the data system goes back to the early 1980s, but is constantly being refined.

 

In response to a questions from Representative Osborn, Ms. Smith replied that the data systems at the WDH and WSH cannot communicate; therefore, they are not integrated.  She also explained that any data inaccuracies provided to the Committee are a result of the exchange of information between providers and the state and, possibly, by the limitations created by privacy concerns and HIPPA restrictions.  Any data provided is based on the question asked, so that may also account for what appear to be inconsistency among the data.

 

Public Comment

Mr. Don Rardin, WSH, is concerned that the juvenile process is inconsistent and unclear.  The need to keep juveniles in their community is critical because WSH is not intended to treat juveniles and they can best be treated as close to their homes as possible.

 

Committee Discussion About future Activities

Chairman Schiffer suggested the study of issues could be broken down into three areas: access; delivery of services; and funding.  Perhaps there should be three subcommittees to consider those  topics. There was agreement that Title 25 revisions would be best left to the Joint Judiciary Interim Committee, with suggestions from the Select Committee. 

 

After discussion, the Committee decided to combine the access and delivery of services topics for consideration by a single subcommittee.  Chairman Schiffer appointed himself, Senators Aullman, Decaria, Johnson and Ross and Representatives Gingery, Iekel, Osborn and Goggles to serve on the subcommittee. The issues the subcommittee would look at include:

 

Chairman Schiffer appointed Cochairman Simpson, Senator Job and Representative Warren to serve on the funding issues subcommittee.  The issues the subcommittee would look at include:

 

 

Meeting Adjournment

There being no further business, Chairman Schiffer adjourned the meeting at 2:10 p.m.

 

Respectfully submitted,

 

 

 

Senator John Schiffer, Cochairman                                 Representative Colin Simpson, Cochairman

[Top] [Back] [Home]