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Access/Delivery Subcommittee
of the
Select Committee on Mental Health and Substance Abuse Services
July 20, 2005
Central Wyoming Counseling Center
Casper, Wyoming
Senator John Schiffer, Co-chairman
Representative Colin Simpson, Co-chairman
Senator Pat Aullman
Senator Rae Lynn Job
Senator Wayne Johnson
Senator Tony Ross
Representative Patrick Goggles
Representative Jerry Iekel
Representative Doug Osborn
Representative Jane Warren
Senator Ken Decaria
Representative Keith Gingery
John Rivera, Senior Staff Attorney
Please refer to
Appendix 1 to review the Committee Sign-in Sheet
for a list of other individuals who attended the meeting.
Chairman Schiffer called the meeting to order at 8:10 a.m. The following sections summarize the Committee proceedings by topic. Please refer to Appendix 2 to review the Committee Meeting Agenda.
Chairman Schiffer advised of 4 preliminary items.
Chairman Schiffer also reminded the Committee of some constituent letters they received previously from a Mrs. Webb and a Mrs. Henderson, the latter of which Senator Decaria wanted the Committee to specifically consider.
Cochairman Simpson stated the Committee should look at getting the best services for the dollars provided. He distributed Appendix 4, a letter from Big Horn County Counseling. The Department of Corrections advised him that it has a contract with PHS for healthcare services which include mental health services. The cost per inmate per day is $21.92 for healthcare services, but the costs for mental health services can not be broken out from that figure.
Mr. Chuck Hayes, Administrator, Mental Health Division, distributed Appendix 5, a PowerPoint presentation of the Mental Health Division's proposals, and Appendix 6, Transformation Begins: The First Leg of a Long Journey. He stated that people still have the same needs they did 19 years ago when he appeared before a legislative committee in another state. In his PowerPoint presentation, Mr. Hayes described the silos of services that still exist.
Mr. Will Shepard, Campbell County Mental Health Center (CCMHC), described his facility, which is located within the Campbell County Memorial Hospital Facility. The registered nurse manager is a trained psychiatric nurse and the facility has a registered nurse and psychiatric technicians at all times for the 5 psychiatric units in his facility, which are regular hospital rooms. Admissions can be by psychiatrist or emergency room referral or Title 25 emergency detentions. Informal referrals from other programs to the admitting psychiatrist can also be used to admit patients from other counties. Chairman Schiffer asked if this process can be formalized with state funding. Mr. Shepard replied that he is comfortable with the concept of regionalization. On rare occasions all five beds are filled. Usually, only 2 or 3 are occupied. If the facility was regionalized, it might be necessary to expand capacity by doubling the mental health beds and probably adding more beds for substance abuse treatment or co-occurring conditions. The Wyoming State Hospital (WSH) has provided some funding for patients whose stay at the CCMHC exceeded 72 hours. Mr. Hayes added the Veterans' Administration Hospital in Sheridan has been willing to share telemedicine services. Mr. Shepard advised his facility services primarily adults. Juveniles are usually housed at other programs, with his agency providing psychiatric services.
Ms. Linda Acker, Sweetwater Counseling Center, advised that she has more work to do with Sweetwater County Memorial Hospital to eliminate the lock-up rooms. Her facility is recruiting 1, and possibly 2, psychiatrists and may be get additional psychiatric beds. Currently the facility has a nurse practitioner with prescriptive authority. She has been able to recruit the psychiatrists by ensuring that they will not be required to seek full hospital privileges, which would then require that they be on-call. She is paid about $1 million from the county, so she provides free services to Sweetwater County Memorial Hospital. She may ask for more funding from the county if she does hire the psychiatrists. Her facility is primarily adult oriented also. Juveniles who need mental health services usually go to Sweetwater County Memorial Hospital or Wyoming Behavioral Institute. Services for juveniles statewide really need to be expanded.
Ms. Jean Davis, Wyoming Behavioral Institute (WBI), explained that WBI is a specialized hospital with a strong emphasis on serving juveniles with behavioral problems. Treatment at the facility is more intensive and therapist-oriented than the program in Campbell County. WBI has arrangements with 5 other counties to accept involuntary commitments. It also collaborates with the WSH to keep both adolescents and adults. WBI has an adult psychiatric assessment team that consults with a psychiatrist by telephone. The agreements with other counties are at a reduced rate of $550/day, which is not even a break-even rate. She stated the quickest way for a person who may want services is to be involuntarily committed, because a voluntary commitment usually requires identifying a funding source before the person will be accepted into a facility. Medicaid will pay for services for persons under age 21 years and the new agreement between WBI and the State is acceptable to WBI.
Dr. David Birney, Ph.D., Peak Wellness Center, advised that Peak Wellness Center has psychiatric units in Laramie and Albany Counties, but not in Goshen County as shown in Appendix 5. He believes formal arrangements are necessary to provide stability and predictability for programs. Currently most agreements are informal. The existing system is fragile and needs the continuing participation of community mental health centers. He believes there is an enormous need for diversion services, not just in-patient beds, but both have to be increased. Both Peak Wellness and United Medical Center (UMC) in Cheyenne have their own psychiatrists who work together, but Peak's psychiatrists don't have admitting privileges at UMC. Dr. Jane Robinett does work in the UMC emergency room, though she is employed by Peak Wellness.
Mr. Mark Russler, Fremont Counseling Center, said his program assessed 526 persons under emergency detention in Fremont County last year. Of these, 256 were held for further services. Except for 90 patients admitted to Pineridge Hospital, the majority were sent to WSH, WBI or jail because Pineridge won't accept voluntary commitments who lack a means of paying for the hospitalization. This illustrates the need for more "voluntary" beds in the State. Pineridge charges $650/day for involuntary commitments. Fremont Counseling receives $20 thousand from the State for substance abuse services. About 60-70% of Mr. Russler clients have co-occurring conditions.
Ms. Alice Hall stated the northwest corner of the State has no access to psychiatric beds, a psychiatrist or acute crisis stabilization. The only inpatient mental healthcare that is available is at WSH and that must be the result of an involuntary commitment, although many patients are willing to voluntarily commit themselves but for the lack of means to pay for a voluntary commitment. Even those who are involuntarily committed must remain between 7-10 days at a local hospital without treatment before transfer. Some patients in the northwest were sent to WBI, with WSH paying the costs because WSH did not have any beds available. The counties in the northwest have 2 hospitals and 2 mental health centers and they are working together in an effort to recruit and pay the salary of a psychiatrist. Ms. Hall expressed concern that many suicides in the state occur because of the stigma and fear associated with placement at WSH, so those persons may not seek help they need. In response to a question from Chairman Schiffer, Ms. Hall replied that the counties are trying to work out the details of using one psychiatrist, but each county will probably want to function as the gatekeeper for its residents needing mental health services.
Mr. Darwin Irvine, Big Horn County Counseling, advised a nurse practitioner has been hired jointly by Big Horn and Park Counties. It is difficult to recruit a psychiatrist because of the on-call duties he may have to assume at the local hospitals that may contribute to his salary.
Mr. Hayes described the regional makeup the Mental health Division and WAMHSAC are proposing on page 13, Appendix 5, but those boundaries may be flexible for individuals who want a particular service outside the region of residence. Pages 14 and 15 describe the range of services for adults and children, respectively. Chairman Schiffer suggested the various programs will have to give up some turf responsibilities and the state may have to contract for a single gatekeeper to ensure appropriate placements are made throughout the state. Cochairman Simpson believes most services, except the most intensive, can be available in most counties. Regionalization should only be necessary for the most intensive services. Mr. Hayes said the most important matter is ensuring that policy, funding and decision-making are all aligned. The least restrictive environment is required by law and that requires a community-based system. In response to a question from Chairman Schiffer, Mr. Hayes indicated he would be comfortable with establishing some pilot projects.
Ms. Peggy Nikkel, Director, UPLIFT, distributed Appendix 7, consisting of a copy of her presentation to the Committee and a brochure describing UPLIFT. She said children's issues have already been framed in the earlier presentations, but children at risk also place their families in a dilemma. Mental health issues for children are on the rise in the state and nationally. About 6-7% of children are seriously emotionally disturbed (SED), but many children need services before they reach that point in their lives. They are at risk for failure in school, the home and within the family unit, as well as being susceptible to substance abuse and violent behavior. Service availability poses a dilemma for families, because travel is often difficult for a family of a child in crisis. Currently, only WBI has intensive inpatient treatment services for children under the age of 13 years. Child specialists just aren't available in the state. Regionalization is most critical for children to avoid separations from family. While having a psychiatrist in every county is not practical, other advance health practitioners with appropriate psychiatric training, such as nurse practitioners or physician assistants could be recruited. Families should not have to relinquish custody of a child under a CHINS petition to obtain services that the child may need and the family can't afford. Chairman Schiffer stated the solution to the relinquishment problem may require a Medicaid waiver, but waiver funds may be capped at $35 million. Cochairman Simpson believes the number of relinquishments in the state may be low enough that the cap won't apply. Ms. Nikkel said early intervention services would eventually require more funding because the intensive services would still be necessary until the early intervention services effect a reduction in the need for intensive services.
Ms. Nikkel stated child development centers in every county do assessments, but they are not fully funded statewide and are focused more on the physical and developmental problems than the social and emotional problems that may exist. Senator Job asked staff to check with the Budget and Fiscal Division with respect to proposed cuts to the child development centers because she believes those programs were put on notice by the Department of Education of potential cuts in funding. The proposed funding cuts may have been a result of legislative or executive branch actions. Another problem is that not all child services agencies make the referrals to the child development centers for the assessments. Senator Aullman expressed a concern that many children aren't seen for possible assessments until they enter kindergarten.
Ms. Nikkel stated the biggest problem remains the stigma on the family. For example, her oldest son has asthma, but she has never been blamed for that condition. On the other hand, she has frequently been blamed for her younger, adopted son's mental illness. The parents are often the best source for the child's recovery, provided there are no safety issues for the child in the home. While we can't have a perfect system, the state can make strides to help communities develop the partnerships to provide the services.
Cochairman Simpson asked staff to provide a summary of the Department of Education's early screening initiatives. Dr. Nance Shelsta, Department of Education, advised there are 2 initiatives the Department is currently undertaking. The first initiative is a K-12 intervention program to increase the success of students with behavioral problems by creating a more positive school environment before the students are identified as having behavioral problems. The second initiative is a K-3 intervention program that uses a triage pyramid. The program is conducted in cooperation with Montana. Five school districts in Wyoming have agreed to participate, along with the Universities of Wyoming and Montana and 4 Montana school districts. At the bottom of the pyramid are all children who are screened and are being taught reading readiness, with some focus of behaviors. If more intervention is necessary, the child is placed in a smaller group. If even more intervention over a longer period is necessary, the child is referred to special education classes. Individual school districts are also conducting specific efforts to address the needs of students with SED. WBI is the only facility in the state that can deal intensively with children with SED, so the Department of Education is also interested in regionalization.
Cochairman Simpson asked why there is more focus on a program such as exists in Natrona County where the school district and Central Wyoming Counseling Center work together to conduct early assessments and provide early intervention to avoid the need for long-term treatment.
Chairman Schiffer provided Appendix 8, illustrating graphic changes that occur to the metabolism of the brain when a person uses methamphetamine. He advised members who may want a copy of the document to contact LSO.
Dr. Ann Reyes, Ph.D., Deputy Administrator of Clinical and Community Services, Substance Abuse Division (SAD), distributed Appendix 9, consisting of a copy of her PowerPoint presentation, the SAD proposal for regionalization, and the SAD Strategic Plan. She described the organizational structure of the SAD, its duties and budget. She stated that Wyoming is sorely lacking transitional/recovery support for persons being treated for substance abuse. Methamphetamine users require about 50% more treatment than other substance abusers, i.e., 135 days vs. 90 days, respectively, if they are to have any chance for successful recovery. That extended time for methamphetamine users further limits the availability of treatment beds. An increase in the number of methamphetamine users also exacerbates the shortage of beds.
Representative Osborn asked for a county-by-county breakdown of Synar compliance for tobacco use reduction. Dr. Reyes indicates she would provide that information. She added that prevention programs have to be multi-faceted and must be of long-term duration to be effective.
The cochairmen asked why no single assessment tool is used for both mental health and substance abuse, with additional assessments conducted at the discretion of the person conducting the assessment. Dr. Birney and Mr. Ed Wigg, WAMHSAC President, both expressed opposition to the use of a single assessment tool because of differing purposes of a substance abuse assessment and a mental health assessment. Representative Warren asked the SAD for a cost estimate of implementing a standardized assessment tool for both the MHD and SAD. Dr. Reyes indicates she may be able to provide a rough baseline estimate.
Dr. Cherri Lester, Ph.D., SAD Treatment Program Manager, discussed Comprehensive Substance Abuse Communities (CSAC), its intent to involve communities and its requirements, experiences, plans and recommendations. Those recommendations include establishing an independent assessment process, creating a voucher system for services and increasing the system of quality evaluations. The program is at a standstill with respect to funding expansion of a continuum of services. Dr. Lester requested time to update the funding requests of CSACs before providing the data to Cochairman Simpson.
Drs. Reyes and Lester both stated they are working with Mr. Hayes and the MHD to collaborate goals and priorities which are already quite similar. The quality practice initiative has been discussed and explored, with a finding that a common theme of co-occurring conditions in clients of both MHD and SAD. Chairman Schiffer advised that the Select Committee will meet again on September 14 to receive some training from NCSL on outcome measures and he would like SAD representatives at the meeting to observe the training. Cochairman Simpson asked for an explanation of the SAD appropriation because the $32 million per year figure is not consistent with a previous biennial estimate.
Mr. Ed Wigg stated he would be president of WAMHSC for 10 more days. He wanted to comment on testimony made by others earlier in meeting. The community mental health centers are all in favor of regionalization. Most centers do their work on a community basis daily and are also working with schools. Earlier testimony may have given the impression that the partnership between Natrona County School District No. 1 and Central Wyoming Counseling Center is unique, but that is not the case. The partnerships between school district and the centers may need to be expanded, but the first steps have been taken in many counties. Despite the apparent large increases in the budget of the MHD and SAD, the funding for centers has been stagnant. Most centers have moved to variable length treatment, which has increased the length of stay without a corresponding increase in bed capacities. There is a need for more capacity to treat methamphetamine abuse, but that capacity can be met in part by developing a step-down system to allow for transitional treatment. With respect to a single assessment tool, Mr. Wigg said too many assessments or a single assessment tool would both bog down the system. It does no good to have staff perform an assessment for which they are not qualified to perform. WAMHSAC does look for appropriate outcome measurement systems. Mr. Wigg distributed Appendix 10, consisting of WAMHSAC's recommendations, which he would ask the Committee to consider and discuss with WAMHSAC at its next meeting.
Chairman Schiffer was concerned that WAMHSAC hasn't participated in the Wyoming Healthcare Commission's I/T study. Mr. Wigg responded that if WAMHSAC knew about the meeting, members would have participated. Ms. Marian Schulz added that she had spoken with Ms. Anne Ladd, Executive Director of the Healthcare Commission, who discouraged WAMHSAC from participating because Ms. Ladd believes the mental health and substance abuse issues are too large to be included in the Commission's study.
Dr. Birney says the Division of Vocational Rehabilitation (DVR) has been a barrier to employment for the serious and persistent mentally ill population. The community mental health centers obtain employment for their clients more quickly by by-passing DVR. Some of the requirements for regionalization include shoring up the existing centers. This is not to suggest that each center can, or should, be able to provide all services. The centers should be allowed to improve the quality of the services each provides, then decisions can be made regarding which services have to be regionalized and where those regional services can best be provided.
Cochairman Simpson asked what does it take to fund medically-managed, as opposed to clinically-managed, residential treatment. Dr. Lester advised the SAD limits are $115/day/male client, $140/day/female client, and $120/day/juvenile client, which rates may prohibit the use of medically-managed treatment facilities whose costs are significantly higher.
Chairman Schiffer asked the Committee to focus discussion on the list he had compiled (Appendix 11) as a starting point and add, delete or amend that list through discussion to hone in on what can be done this interim. He proceeded to read the items listed for persons who may not have a copy of the list. It was suggested item 3d substitute "primary care physicians on psychiatric issues" for "general practitioners and others." Regarding item 3b, the advance directive program, Chairman Schiffer stated he believes the Joint Judiciary Interim Committee will be looking at that issue so the Select Committee may not have to pursue it further. For item 3d, Chairman Schiffer suggested members read the report on Medicaid waivers they had recently received. Research on item 3f may be necessary to determine what the issue is with respect to the problem with using out-of-state psychiatrists.
Representative Warren presented 3 additional matters. First, the Committee should look at incentives for nurse practitioners to get psychiatric training. Second, it would be helpful to get information on the costs of psychotropic medications and whether patients are able to obtain the medications they need. Third, there has been testimony that the community mental health centers have difficulty recruiting and retaining qualified staff and the Committee should look at what compensation is necessary to meet that need of the centers. WAMHSAC representatives advised they would provide that information. Some of the problems are the unavailability of qualified staff and the competition for those people who are seeking employment.
Representative Iekel said he had 2 issues noted from the June meeting. The first related to the possibility of expanding crisis stabilization rooms in hospitals. The second issue related to developing the unused space at the Retirement Center in Basin for psychiatric beds. Chairman Schiffer advised the Committee has received an explanation of why that space was not used as planned. Without community buy-in, efforts in that regard would be doomed to failure.
Cochairman Simpson asked if the Department of Health could provide a breakdown for the last 3 biennia of the distribution of treatment dollars provided to community mental health and substance abuse centers for mental health treatment and substance abuse treatment. The Department will attempt to prepare those numbers before the next meeting.
Senator Ross advised he had reviewed 2 Attorney General opinions, with respect to whether the Department of Family Services may contract with private, for-profit entities to provide services to juveniles. The second of the Attorney General opinions suggested a minor wording change may be helpful in the statute to clarify the authority of DFS to enter into such contracts and pay the private, for-profit agency for treatment provided. He will work with staff to prepare a bill for the Committee's consideration at the next meeting.
In response to a question from Senator Job, Chairman Schiffer said he has been advised that the correct term is a "single screening tool" rather than "single assessment tool".
After discussion, Chairman Schiffer advised the Committee would meet as a full committee again on September 14 and 15, 2005, to receive the training from NCSL on outcome measurements and to continue with its deliberations.
Cochairman Simpson asked staff to try to get reports from the counties that did not provide the costs reports on Title 25 emergency detentions. Perhaps Mr. Joe Evans should be contacted to assist in getting the non-reporting counties to cooperate.
Representative Osborn suggested the continuum of care for juveniles needs to be emphasized.
Senator Job was concerned that integration of services at the community level have been discussed, but there hasn't been much discussion about integration of services at the state level and the 2 relevant divisions that deal with the issues the Committee is considering will not integrate themselves. Chairman Schiffer offered that it may be possible to hire a contractor who will work with both divisions, thus achieving integration. Ms. Ginny Mahoney, Department of Health Chief of Staff, said the 2 divisions are talking and working on integration within the Department.
Senator Aullman said that county commissioners should be involved in the Committee meetings since they will have to buy-in if regionalization is to have a chance for success. Cochairman Simpson suggested both the Wyoming Association of County Commissioners and the Wyoming Association of Municipalities should be invited to the next meeting.
There being no further business, Chairman Schiffer adjourned the meeting at 5:50 p.m.
Respectfully submitted,
Senator John Schiffer, Co-chairman Representative Colin Simpson, Co-chairman