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Access/Delivery Subcommittee
of the
Select Committee on Mental Health and Substance Abuse Services
June 27 & 28, 2005
Central Wyoming Counseling Center
Casper, Wyoming
Senator John Schiffer, Chairman
Senators Pat Aullman
Senator Ken Decaria
senator Wayne Johnson
Senator Tony Ross
Representative Keith Gingery
Representative Patrick Goggles (June 27 only)
Representative Jerry Iekel
Representative Doug Osborn
John Rivera, Senior Staff Attorney
Nicole Novotny, Associate Research Analyst
Representative Colin Simpson
Representative Jack Landon
Representative Patrick Goggles (June 28 only)
Please refer to
Appendix 1 to review the Subcommittee Sign-in Sheet
for a list of other individuals who attended the meeting.
Chairman Schiffer called the meeting to order at 8:35 a.m. Chairman Schiffer explained the issues he would like the Subcommittee to keep in mind while considering the testimony to be received at the meeting. The following sections summarize the Subcommittee proceedings by topic. Please refer to Appendix 2 to review the Subcommittee Meeting Agenda.
Mr. Chuck Hayes, Administrator, Mental Health Division, introduced Ms. Marla Smith, Information Systems Manager, and Dr. Nancy Callahan, Ph.D., a consultant who has been working with the Division to develop a Medicaid-based data system. Ms. Smith distributed materials for the Subcommittee's consideration, including an Estimate of Unmet Need for Serious Mental Disorders in Wyoming (Appendix 3), Wyoming Medicaid Report on Mental Health Services and Substance Abuse Services for FY 03-04 (Appendix 4) and a chart describing FY01-FY04 Referral Source by Age Group for Mental Health and Substance Abuse (Appendix 5). Ms. Smith advised that approximately 50% of the Division's clients are Medicaid eligible and the information presented to the Subcommittee is probably representative of the non-Medicaid client base in Wyoming also, since there is little difference between the types and amounts of services each group would receive from the community mental health centers (CMHCs).
Dr. Callahan explained that she has a consulting firm in Davis, California and has been providing data to governments and other entities around the country for 16 years. She reiterated that the Medicaid-based data the Subcommittee has before it would likely apply to the non-Medicaid population also since the types and quantities of services received would be similar. She advised that the number of elderly patients receiving mental health services is small in Appendix 4 because many are on Medicare and therefore the Medicaid-based data would not be an accurate reflection of the number of elderly receiving services from the CMHCs. The data in Appendix 3 show an expectation that 6% of the general population needs mental health services. Because the Medicaid range of drugs is not limited in Wyoming, a Medicaid patient gets the medication that are necessary to treat the mental illness without limitation. Pharmacy costs represent about 50% of the treatment costs incurred by any one patient receiving mental health treatment. In response to a question from Chairman Schiffer, Dr. Callahan stated that there are a variety of reasons why treatment costs vary significantly throughout the state, including staff ratios and qualifications and other factors. Approximately 3,000 of the 5,000 Medicaid clients are receiving pharmaceutical assistance as part of their mental health services. She explained that day treatment includes very intensive services that are just below the level of services that a patient would receive upon being involuntarily committed. That is why there are so few persons receiving day treatment statewide.
Chairman Schiffer stated that Appendix 4 may be very helpful to the Subcommittee for purposes of designing regional service provision because the document explains where clients are located and what services they're receiving. He questioned why the cost of medications dropped from FY03 to FY04. There was a suggestion that the loss of psychiatrists statewide may be a contributing factor.
Ms. Smith distributed Appendix 6, a profile report on mental health services for FY03 and FY04 using a randomly selected CMHC to illustrate how services are provided. She indicated the selected CMHC has not had time to review the profile report so it would not be identified and there may be some changes to the profile report once the CMHC has had time to review and respond to the report.
Chairman Schiffer called for public comment on the information presented by the Mental Health Division.
Mr. Dave Nees, Pioneer Counseling Service, indicated he had worked with Dr. Callahan and the numbers she has provided are very helpful. The CMHCs started by providing group therapy to clients. Subsequently, the services evolved to day treatment, which is more labor intensive and effective. Now the CMHCs are using even more effective case management which manages individual clients' needs more quickly, effectively and efficiently. Regional services will have to be designed for flexibility, rather than for rigid application.
Dr. Stephen Brown, Casper child and adolescent psychiatrist and director of Wyoming Behavioral Institute, advised that the Wyoming Psychiatrists' Association met in Jackson with Drs. Kevin and Jane Robinett to discuss and formulate written answers to questions posed by the Select Committee at its meeting in Evanston. He emphasized that the information from the Department of Health does not include clients who are private pay patients or uninsured patients and those who receive services in offices other than CMHCs, e.g., in pediatric clinics. This missing data would be necessary to get a complete understanding of the need and services in the state. Not much is being done in Wyoming with respect to measuring outcomes. Psychiatrists are in favor of regionalization of services. Thirty-four state have laws prohibiting insurance providers from discriminating against the mentally ill. Wyoming needs a mental health parity bill to protect the rights of the mentally ill in insurance matters. Chairman Schiffer asked if telemedicine is a viable option for psychiatrist to work with general practitioners. Dr. Brown responded that telemedicine does make sense. The Wyoming Psychiatrists' Association is trying to develop a test site that can be easily replicated around the state if it is successful. He also discussed efforts to recruit more psychiatrists to the state.
Dr. Callahan suggested that private providers may not provide the same level or array of services that CMHCs provide. The Department of Health can provide data regarding the Medicaid half of the equation that uses private providers.
Ms. Peggy Nikkel, UPLIFT, stated the data provided by the Department was good, but it does not describe the effect on the mentally ill person and the person's family. In Wyoming, where the family lives affects the services a mentally ill child will receive. Without regionalization of services, there is a problem with the lack of resources in many parts of the state. She believes there is a disparity of treatment between Medicaid eligible and non-Medicaid eligible families because the former are often required to relinquish custody of their child to ensure the child's needs are met. The family shouldn't have to be burdened by the guilt caused by relinquishment. She urged the Subcommittee to understand the need for the continuing involvement of the family and community in the child's treatment. She would like the Subcommittee to look closely at expanding children's mental health services.
Senator Decaria asked what would be an appropriate radius for regionalization of services.
Ms. Elizabeth Lugg, member of the National Association of Mentally Ill (NAMI), described how her daughter died at age 24 after her struggles with mental illness. She recommended:
Ms. Carol Day, Mental Health Division, explained the Division has for two years had a pilot project for telepsychiatry in Rock Springs. The only weakness to the program that is evident is the lack of a face-to-face connection between participants. It is more effective to move the services to the client than to move the client to the services. This is the concept behind the therapeutic mobilization teams. She was asked to provide examples of the compositions of those teams and the menu of services the teams can provide. These are intensive service modes that Medicaid can pay for, according to Dr. Callahan, thus allowing a draw down of federal dollars.
Representative Simpson asked what type of psychiatric training for physicians would help them. Mr. Hayes said the request may be premature. The Department is doing some preliminary research with Dr. Robinett and consulting with a Canadian psychiatrist about these issues.
Dr. Pablo Hernandez, Wyoming State Hospital, added the State Hospital is working with the Veterans' Administration to expand the system. The telehealth concept is working between the State Hospital and the Department of Corrections, but the system is currently consultative, not therapeutic, in nature. The State Hospital previously had 14 beds for inmates, now it has none because of the telehealth program.
Chairman Schiffer advised the Subcommittee that he has applied for a grant from NCSL, which has been granted, to have a presentation on how to measure performances of substance abuse and mental health programs in the state. NCSL will be providing a program on this at the annual conference in Seattle and would likely present to the full Committee soon thereafter, for those who don't attend the annual conference. He will work out details with NCSL if the Select Committee is interested. Members present all agreed that the presentation would be valuable and indicated Chairman Schiffer should work out the details with NCSL.
Ms. Mandi Souther, NAMI member, described her experiences as a dual diagnosed individual who participated in the WINDS program in Lander to allow a transition from an institution to the community.
Dr. Karen Ouzts, expressed a concern with the new "no smoking" policy instituted at the State Hospital. As a mother of a schizophrenic smoker, she is concerned that the policy imposes a hardship greater than would be experienced by a smoker who is not mentally ill. The policy is not a best practice for treatment of mentally ill persons. Requiring patients to leave the grounds places them at risk because they leave the grounds and smoke their cigarettes on the side of the highway. Also, she believes the policy is being enforced inconsistently.
Ms. Deion Hagemeister, NAMI-WY Board Vice-President, described the problems her son has faced since his diagnoses at a very young age. By age 12, he had already used up his lifetime insurance benefits for mental health treatment. Recently he was held in a jail for 16 days while waiting for an involuntary commitment hearing, because of his paranoia and suicidal thoughts. He should have been held for that time in a therapeutic setting because he had committed no crime. Mr. Hagemeister said facilities are needed throughout the state to treat the mentally ill, not just in Evanston.
Chairman Schiffer asked staff to find out the cost, including staffing costs, of putting a psychiatric treatment room in various facilities throughout the state, similar to the rooms authorized at the Lusk facility for inmates at the Women's Correctional Facility. Facilities like the Wyoming Retirement Center in Basin, which has a new empty psychiatric wing, may be used for patients in need of psychiatric treatment.
Ms. Linda Boyce, Greybull, described a situation involved a battered woman who was held in jail for 8 days because of her mental illness. The district court judge indicated the woman should have been held in a hospital, not in jail, but the county appears to hold mentally ill persons in jail because it is cheaper.
Mr. Ed Wigg, President of the Wyoming Association of Mental Health and Substance Abuse Centers (WAMHSAC), distributed Appendix 7, consisting of WAMHSAC's recommendations for system changes for the Subcommittee's consideration. Because of the length of testimony the Subcommittee has been receiving, he would allow the Subcommittee time to consider the document and he would be available to discuss the requests at another time when the Subcommittee or the Select Committee has more time.
Mr. John Lumley, Hot Springs County Commissioner, indicated the Wyoming County Commissioners' Association will be meeting to work on solutions to the counties' problems with Title 25 of the Wyoming Statutes. He added that Dr. Hernandez has been willing to help pay part of the costs incurred by counties while holding persons for involuntary commitment hearings.
Dr. Hernandez said the state has progressed considerably toward defining systems of care. There is still a need to define "acute psychiatric hospitalization." Most persons with mental illness will need at least one such experience in their lifetime. He believes an appropriate radius to permit regional acute psychiatric hospitalization could be 150 miles, but psychiatrists are needed to make this happen because the beds can not be used without properly trained staff. Under this concept, only the northwest quadrant of the state could not be covered under this concept. Campbell, Laramie, Natrona, Albany and Fremont Counties currently have viable facilities and staff to provide acute psychiatric hospitalization for their regions. The first three of the identified counties already have hospitals that have arrangements with the State Hospital to handle patients for whom there is no room at the State Hospital. The State Hospital continues to pay the cost for those patients that are treated at those local facilities until space becomes available at the State Hospital, or the patient is released. The State Hospital selects patients with chronicity to accept at the State Hospital. If the patient only needs a shorter stay at a facility, the patient may remain at the regional facility. When asked how he pays for the beds he at the other facilities, Dr. Hernandez indicated he has shifted his budget around to pay for the beds and his budget will be in the red for the first time since he became administrator of the State Hospital because of these costs. The daily costs for a bed at the State Hospital are about $450.00. The costs at the regional facilities is closer to $1,000.00 per day for a resident and higher if the person is a nonresident because the nonresident is not eligible for Medicaid benefits and the State Hospital is liable for the full costs of the hospitalization. Although the Legislature has considered contracting for set-aside beds at other facilities to handle the overflow at the State Hospital, those set-aside beds have never been funded. The current solutions are stop-gap and do not provide viable long-term solutions. The regionalization concept would allow for mobility solutions so a patient may move between facilities as the need dictates. Because many emergency detentions are a result of an intoxicated person express suicidal thoughts, counties are aggressive in seeking emergency detentions, rather than just dealing with the intoxication first, then determining if mental illness is also an issue. Crisis responses, instead of emergency detentions, would be cheaper for both the state and the counties, through the use of temporary housing for crisis responses. Ninety percent of psychotic breaks are a result of either stopping the use of prescribed medications, a major change in the medications, or the person begins to use alcohol or other nonprescribed controlled substances. The best expenditures the state could make to address mental illness is to triple the "quality of life" funding. Recidivism to the State Hospital would be significantly reduced if released patients could have the funding necessary to survive and function in the community. The current infrastructure at the State Hospital could be adapted to accommodate every population in the state, except the aged. There is little experience in the state to deal with aging mentally ill persons.
Mr. Lee Clabots, Deputy Director, Department of Health, advised that the Wyoming Retirement Center has a new wing with 20 empty beds that can be used for psychiatric care. The problem is appropriate staffing to allow the use of those beds. The Department already has problem trying to recruit staff for the occupied beds. The BOCES facility in Thermopolis is also empty and could be used for psychiatric care beds.
Mr. Rodger McDaniel, Director, Department of Family Services, introduced Ms. Karen Melmont, Executive Director of the Citizen Review Panel, which is federally mandated. The program looks at the availability of programs in the state for children involved in child protection and delinquency cases. She stated her office reviewed 95 cases in the state. Ms. Melmont distributed Appendix 8 containing a description of issues encountered by her reviews. Two of 23 items reviewed related to mental health or substance abuse issues, including covering the needs of the parent or foster parent and assessments of the child and services provided to the child. Twenty-four of the 95 cases indicated the need for improvements.
The Subcommittee recessed at 5:05 p.m.
Chairman Schiffer called the meeting to order at 8:40 a.m.. The following sections summarize the Subcommittee proceedings by topic. Please refer to Appendix 2 to review the Subcommittee Meeting Agenda.
Chairman Schiffer advised the Subcommittee that it is important to consider the need for good assessments at the beginning of cases to ensure appropriate services will be provided.
Mr. Rod Robinson distributed Appendix 9, a hard copy of his PowerPoint presentation. Mr. Robinson stated he has 27 years experience working with substance abuse issues. He believes that separating the mental health and substance abuse programs into distinct divisions within the Department of Health was a good idea. The Centers for Substance Abuse Treatment is looking at Wyoming for its successes since establishing a separate Substance Abuse Division. He would like to see the state develop partnerships with communities to develop treatment programs for substance abuse. A minimum level of care options are needed for a successful treatment and recovery program. Appendix 9 contains a description of the various levels of treatment he advocates. It is necessary to weave these levels of treatment together by establishing a single episode of care for an individual patient. Currently most treatment is high cost, involving residential treatment or outpatient only treatment. This creates gaps in services. There should be options for formal transitioning and long-term, low-cost recovery home living. Many patients need placement into residential stabilization settings, followed by a low-cost, highly-structured out-patient setting. He recommended Subcommittee members read The Heart and Soul of Change, which describes a radical approach to model change in substance abuse treatment. Forty percent of change has to come from within the person who has the substance abuse problem. Thirty percent of change comes from a change of, or in, his environment, with fifteen percent of change coming each from the hope and expectation of success and from the model and technique of the provider of treatment. Outcomes have to be looked at closely. It is necessary to develop an integrated system of care before talking about spending more money to solve problems. He recommended what is described as a "quality practice initiative" similar to what Montana has begun, including a statutory mandate for cooperation among the state and local governments and providers. Representative Iekel asked for the Montana statutes that accomplish the quality practice initiative.
Chairman Schiffer added that the Substance Abuse Division needs to develop a data gathering system similar to the system employed by the Mental Health Division. It may be necessary to provide funding to accomplish this.
Mrs. Shirley Green, WYAMI, stated mental illness is a disease, some of which is the result of genetics, and some is not. There is a stigma attached because of the belief that mental illness is caused by emotions. This lack of understanding limits a person suffering from mental illness to obtain or keep a job, with the resulting loss of self-esteem further limiting recovery. The lack of understanding also limits the research into mental illness in ways that other diseases are not limited. Unlike the methamphetamine problem that exists because of criminal activity, mental illness occurs through no fault of the person afflicted, yet the former receives much publicity and public funding while the latter is often ignored.
Mr. Bob Green, WYAMI, reiterated a concern that the Select Committee is looking at both substance abuse and mental illness, one of which may be the result of an illegal act while the other is a no fault illness.
Mr. Rodger McDaniel, Director, Department of Family Services (DFS), introduced Ms. Marilyn Patton, who is on loan from the Department of Health to serve as Deputy Director of the Children and Families Initiative, and Ms. Korin Schmidt, Deputy Director for Policy.
Ms. Patton distributed Appendix 10, a description of systems of care; Appendix 11, a historical comparison of the achievement levels under WYCAS of children who receive free/reduced lunch and children who do not; and, Appendix 12, a chart indicating the prevalence estimate of serious emotional disturbance (SED) age birth to 20 years. She stated that 75% of the needs of children with SED are not being addressed.
Mr. McDaniel advised the Children and Families Initiative report due later this year will include a recommendation for comprehensive health programs. The Legislature will be provided a menu of services and treatments. He distributed Appendix 13, a chart illustrating the service costs for SED children by age group; Appendix 14, Policy Paper No. 1 from the National Center for Children in Poverty; Appendix 15, a chart showing how service dollars for juveniles are spent by county; Appendix 16, an informal survey of SFS offices relating to substance abuse and mental health services; and, Appendix 17, Policy Paper No. 4 from the National Center for Children in Poverty. He stated Appendix 13 showed that DFS dollars spent on the life of a child increase until age 16. Appendix 14 is a very useful document for the Subcommittee to read because it describes the Florida model for the use of mobile response teams to deliver services where the children are. Wyoming DFS can't provide an equal level of services in all communities of the state, but does provide early interventions services throughout the state because of their importance. He believes the Legislature should start thinking in terms of outcomes the way the federal government did when it enacted welfare reform in the mid-1990s, by setting goals and allowing states to develop how they would accomplish those goals within specified parameters. HB59, enacted in 2002, required a substance abuse report that showed 66% of school programs provide substance abuse education and 49% of the schools have a substance abuse treatment plan, but only 54% of the latter actually do assessments. Mr. McDaniel recommended the legislature establish maximum lengths of stay in residential treatment, because the system currently has incentives for over-treatment and keeping children out of the home longer than may be necessary. Judges often react to situations under the belief that getting the child out of the home is the best option. The question the judges should be asking is what services are necessary to keep the child safe in the home. Mr. McDaniel also recommended the Legislature consider enacting legislation to establish mental health parity, including addressing the issue in ERISA plans and possibly starting with the Wyoming Employees' and Officials' Group Insurance Plan. Another recommendation, consistent with the objective to broaden the provider base in HB59, would be for the Legislature to allow the Department of Corrections and DFS to implement a voucher program for clients within their systems in need of psychiatric treatment. In smaller communities the voucher would probably still be used at the CMHC, but in larger communities the client would have options to use the voucher at the CMHC or another private provider.
Representative Simpson asked how other states have solved the problem of relinquishment of custody to obtain services for a child and how those programs are administered. Mr. McDaniel replied that Ms. Patton has some of this data which she can share with LSO staff.
Representative Gingery stated that teachers can usually identify in kindergarten which children will have mental problems in later life. He praised Mr. Huston and the Natrona County School District for collaborating to allow Central Wyoming Counseling Center (CWCC) clinicians to do assessments for preschool children, which results in a higher rate of referrals for services early in a child's life.
Ms. Sunny Kaste, Department of Education At-Risk & School Health Program Supervisor, distributed Appendix 18, consisting of a copy of her PowerPoint Presentation and the 2003 Wyoming Juvenile Justice Youth Risk Behavior Survey, including an Executive Summary. The materials contain information on mental health issues that occur among students in Wyoming school districts. Wyoming leads the nation in suicide on a per capita basis and in drinking by youths prior to age 13 years. The state is second in the nation in methamphetamine use by youth. There is a strong connection between mental illness and school failure. Some of the promising practices in Wyoming include a Riverton High School Student Support Program, which provides an alternative to suspension, the Laramie County School District #1 has a Student Assistance Program, and the Converse County School District #1 has a Healthy Living, Healthy Learning pilot project involving the school and community. Ms. Kaste reiterated the partnership that exists between the Natrona County School District and CWCC and provides assessments in Head Start, early intervention programs and in elementary schools.
Chairman Schiffer stated he is aware of a component for health in the school funding model, but asked staff to find out if there is a component for mental health also. Representative Simpson asked if the Department of Education has data on the types of counselors, their numbers and salaries within each school district, and if the Department of Education could increase its data capacity to include such information. Ms. Kaste replied that some of the data may exist, but not data relating to the types of counselors within each school district. She would have to check to see if the Department can obtain any additional information on school counselors. Ms. Nikkel cautioned not to confuse school counselors with mental health counselors.
Ms. Lisa Applehans, Department of Education, distributed Appendix 19, consisting of a folder containing the Wyoming Department of Education Rules Governing Services for Children with Disabilities, various charts showing school district services to children with SED, data from the Court-Ordered Placement of Children Report for 7/1/2003-6/30/2004, examples of changes in federal laws, various initiatives and new programs. There are 13 categories that would allow a SED child to become eligible for 1005 state funding for services. There are new federal special education rules that would allow eligibility for SED services without meeting deficit measures, if the state elects to implement those federal rules. The Individual with Disabilities Education Act (IDEA) federal reauthorization in 2004 established timelines for school districts to provide services to students with SED and new criteria for students in correctional facilities which require school districts to work toward reintegration of the student into the home school district. The Statewide Plan on Positive Behavioral Interventions, contained in Appendix 19, is scheduled to be adopted by the end of July, 2005. The Teton County School District program, based on an Oregon plan, is the model for the Statewide Plan.
Chairman Schiffer asked Ms. Alfrieda Gonzales, Substance Abuse Administrator, if the Subcommittee could postpone her presentation on the Division's strategic plan until the next meeting so the Subcommittee could focus on the issues it may pursue at the next meeting. Ms. Gonzalez agreed to postpone her presentation.
Chairman Schiffer described the issues he has identified from the meeting including:
· Partnerships for psychiatric services and care
· Importance of case managers in mental health and substance abuse services
· Utilization and training of general practitioners and pediatricians
· Incentives for telemedicine
· Mental health parity bill or expansion of KidCare insurance
· Acute intensive psychiatric hospitalization for involuntary commitments and emergency detentions
· Crisis housing with psychological evaluations
· Intensive psychiatric team, with communication to law enforcement
· Community supports, including capacity to provide for juveniles regardless of geographic location, quality of life funds and halfway houses
· Education services that are in the block grant and are in recalibration
· Mobile therapy teams
· Assessment to determine treatment, treatment adequacy and outcomes for both mental health and substance abuse services
· Quality Practice Initiative Report
· Advance psychiatric directive program¾either statutory changes or education for consumers and families
· Relinquishment of parental rights to obtain services¾statutory changes to eliminate need to relinquish and as a component of a Medicaid waiver
· Eligibility of SED children for special education services
· Use of out-of-state psychiatrists is limited due to liability laws for Wyoming residents.
The Subcommittee discussed if the advanced psychiatric directive law, W.S. 35-22-301 et seq., had terminated under the sunset provision. Chairman Schiffer correctly advised the sunset date provision had been repealed (2003 Wyoming Laws, Chapter 184).
Representative Simpson asked what could be done about the incentives for over-treatment that Mr. McDaniel had discussed. The issue will be further explored, including the possibility of the state contracting for some set-aside beds.
Senator Decaria suggested that if the Select Committee wants to include mental health services for students, the service should be part of the school district funding formula. Staff was directed to check if this issue will be, or could be, presented to the Select Committee on Recalibration.
Chairman Schiffer advised he has applied for an NCSL grant for a presentation on outcomes measurements for substance abuse and mental health services which may be helpful to the Select Committee. If the Select Committee is interested, NCSL could provide a half day workshop in September or October, if Chairman Schiffer can determine the interest and the availability of members for the suggested dates. Chairman Schiffer will advise of the date, since members have already indicated an interest in the workshop.
Representative Simpson advised he would like to set a meeting of the Funding Subcommittee for mid- to late July. After discussion, Chairman Schiffer set a meeting for the Access/Delivery Subcommittee for July 20-21, 2005 in Casper, at a site to be determined.
There being no further business, Chairman Schiffer adjourned the meeting at 3:10 p.m.
Respectfully submitted,
Senator John Schiffer, Chairman