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Access/Delivery Subcommittee
of the
Select Committee on Mental Health and Substance Abuse Services
September 14-15, 2005
Central Wyoming Counseling Center
Casper, Wyoming
Senator John Schiffer, Co-chairman
Representative Colin Simpson, Co-chairman
Senator Pat Aullman
Senator Ken Decaria (September 14 only)
Senator Rae Lynn Job
Senator Tony Ross
Representative Keith Gingery
Representative Jerry Iekel
Representative Jane Warren
Senator Ken Decaria (September 15 only)
Senator Wayne Johnson
Representative Patrick Goggles
Representative Doug Osborn
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 Simpson called the meeting to order at 8:30 a.m.. The following sections summarize the Committee proceedings by topic. Please refer to Appendix 2 to review the Committee Meeting Agenda.
Minutes from the July, 2005 Committee meeting were approved.
Mr. Buck Gwyn, Protection & Advocacy Systems, Inc. (P&A), appeared before the Committee to testify on P&A's findings with respect to Big Horn Hall at the Wyoming State Hospital (WSH). Chairman Simpson advised that the Committee had received P&A's report, so testimony on the matter would not be necessary. Senator Schiffer indicated he had toured the facility the previous week and was satisfied that the WSH was adequately addressing issues identified. The building is down to 5 residents now and the WSH is being proactive to correct problems. Perhaps the mission of the WSH should be redefined with respect to the physical facilities and if any needs are identified, those should be taken to the State Building Commission with potential legislation. He suggested that perhaps there should be legislation to fund and train a P&A person at WSH as an independent advocate to identify problems and seek solutions, there should be a building assessment study and WSH should go from 8 hour shifts to 12 hour shifts to ameliorate staffing issues. Senator Decaria also stated he had toured Big Horn Hall the previous week. He is satisfied that staff at WSH are attempting to resolve problems.
Ms. Ginny Mahoney, Department of Health, distributed Appendix 3, Response to Investigative Report of Conditions on Big Horn Hall.
Mr. Gwyn said some patients were moved to Carbon Hall which is the second floor of Big Horn Hall and is not ADA approved. There is severe understaffing at WSH and Big Horn Hall is just the tip of the iceberg.
Senator Schiffer replied that P&A allegations only worsen the stigma against the mentally ill. The stigma attaches to both patients and staff and lowers morale at the facility. P&A potshots from Cheyenne are not constructive. Senator Job added that she is distressed by P&A's hyperbole. She wants facts, not overstatements.
Mr. Gwyn said his statements are summaries of over 7,000 incident reports provided by WSH to P&A.
Chairman Simpson said that since P&A and the Attorney General are approaching litigation, the matter should not be discussed any further by the Committee. LSO staff will be tasked with drafting legislation for the November meeting, at which time the Attorney General will be invited to comment.
Dr. Kevin Robinett, replying to the prior topic, said WSH compares favorably with respect to national statistics when considering the suicide rate at the facility. There is always difficulty in balancing patients' freedoms and safety. Dr. Robinett discussed the information contained in Appendix 4. There are currently 37 psychiatrists practicing in Wyoming and another 3 locum tenens for a total of 40. To reach the regional average on a per capita basis, Wyoming would need to recruit 13 more psychiatrists. Dr. Robinett added that possibly using Dr. Hernandez' method of hiring psychiatrists to operate in various regions of the state may be a good approach. He advised that it would cost about $240,000 to recruit the number of psychiatrists needed, exclusive of salaries.
Dr. Fredstrom recommended a line item in the state budget to establish a recruitment position. The Wyoming Health Resource Network is currently doing most of the recruiting. Other alternatives include hiring full-time state psychiatrists and earmarking funds specifically for psychiatric services rather than bundling them with other mental health services. She presented the proposals for an educational program for primary care physicians (Appendix 5). Chairman Simpson said the physicians in Park County did not react favorably to the concept. Senator Schiffer asked if there is a role for the Legislature in implementing the educational component. Dr. Fredstrom said the provider community should be able to implement the program without involvement of the Legislature, if there is enough interest. The University of Wyoming has a psychiatric nurse practitioner program and may be establishing a clinical residency rotation program for psychiatrists.
Senator Job asked the Department of Health to provide a one page description of the Wyoming Health Resource Network, how its staffed, what it has actually accomplished, not how it keeps busy, and why recruitment of psychiatrists was not part of the goals when the organization was initially created.
Ms. Carol Boal, Natrona County School Nurse, distributed Appendix 6, outlining her presentation before the Committee. She said school health is not just about physical health, but includes mental and social health. A state school health consultant position could oversee school nursing programs for all school districts that have nursing programs and help others establish such programs. Forty-four states have a statewide school nurse position. She described the duties and functions of the proposed position.
Mr. Tom Pagel, Casper Chief of Police, introduced Dr. Diane Galloway and Mr. Steve Miller, who are consultants conducting a study of the drug problem in Natrona County. Dr. Galloway advised the study results are due October 1, 2005. Originally, the consultants thought Natrona County was the "methamphetamine capitol" of Wyoming, but its trends are similar to trends in the rest of the state regarding arrests for males and females, both adult and juveniles. Their research shows that more women than men and more juveniles than adult men use methamphetamine. New research nationally indicates that methamphetamine use displays symptoms similar to Parkinson's Disease and there is a fear that the nation may have a generation of people displaying early onset Parkinson's disease as a result of methamphetamine use.
Mr. Pagel expressed a frustration he is experiencing with the gaps in arrest and dispositional data collection statewide. He believes the state needs a standardized reporting system that is readily accessible by law enforcement and courts. A uniform template should be developed for data input, with the data submitted to a state agency that will manage the data and make it available to appropriate agencies. There are currently disconnects within and between state and local agencies. The data is necessary for early intervention, or the need for correctional and social services will grow significantly. Every community should put together a community strategic plan to address the data collection and use of the data.
Mr. Brian Christensen, Natrona County Deputy District Attorney, distributed Appendix 7, Criminal Justice Substance Abuse Residential Treatment Program, described his frustration with recidivism. He is concerned that enhancement of penalties from misdemeanors to felonies has been counterproductive. He was directed by District Attorney Michael Blonigen to establish a residential treatment program. The program has funding through the end of this year, using state and county funds as described in his handout. He would like state funding from the Departments of Health and Corrections to continue the residential treatment program for the next biennium. Senator Decaria asked for outcomes measures data to determine if continued funding is appropriate. Mr. Christensen advised the program does have such data because it is required by the federal government.
Mr. Christensen also described a youth diversion program in Natrona County, whereby all drug offenses are taken to circuit court. The diversion program is a model program that could serve as well in other communities.
Ms. Lisa Brockman, Mental Health Division (MHD), distributed Appendix 8, Children's Mental Health System of Care Issues, Medicaid-Funded Options and Solutions. Currently, there are 317 children placed in residential care as children in need of supervision (CHINS). The families of the CHINS are required to relinquish custody to obtain the services the child needs. The children entering the system are entering at a younger age and with more severe symptoms than in the past. Even the KidCare program has limits on mental health services because it is structured like private insurance, so Medicaid becomes the provider for families without other viable options. The cost of foster care for seriously emotionally disturbed children is about $30,000 a year. From FY01 to FY05, the mental health costs for foster children has increased, most of whom are placed in institutional care which may not necessarily be the best placement for them. Other states use voluntary placement agreement that allow the child to remain with the family if the parents make certain commitments in the agreement. The agreements are used mainly in circumstances where the child's needs are moderate or less severe.
Ms. Liz Mikesell, MHD, distributed Appendix 9 containing her testimony before the Committee. The Department of Health is developing a federal waiver request to substitute a home and community-based placement for inpatient psychiatric hospitalization. Forty-nine states have home and community-based waivers for the developmentally disabled (DD), but only five states have mental health waivers.
Chairman Simpson directed LSO staff to draft a bill authorizing the Department to apply for a home and community-based mental health waiver and to work with Ms. Brockman and Ms. Mikesell for an appropriation that may be necessary.
Dr. Steven Nelson, Jackson psychologist, advised that, for purposes of the DD waiver, a psychological evaluation is necessary upon application, as well as a highly qualified person to oversee the case and a "point person" to address needs as they may arise.
Dr. Ajaki Hassler, Powell marriage and family counselor, said that private providers and Wyoming Association of Mental Health and Substance Abuse Centers (WAMHSAC) based clinicians don't often work together. There is a suicide crisis in Wyoming (see Appendix 10) and private and public mental health workers should work together to address the crisis. This is important because of the lack of psychiatrists in Wyoming. She believes master's level practitioners need to be supervised by primary care physicians. Thus, the 1,500 private providers in the state could be better utilized to address mental health issues. As a doctoral level practitioner, she would like to be Medicaid approved without supervision. Montana allows master's level practitioners to be Medicaid approved, thereby allowing them to be reimbursed directly for their services to Medicaid eligible clients. Senator Schiffer expressed concern with that proposal because Montana's Medicaid costs have skyrocketed since implementation of that provision. Dr. Hassler replied that checklists could be created to ensure cost-containment. Ms. Brockman advised the Department is amending its rules to liberalize Medicaid enrollment to allow reimbursement to mental health professionals who are supervised by psychologists or primary care physicians.
Ms. Marilyn Patton, Department of Family Services (DFS), distributed Appendix 11, her report to the Committee. She advised that, in the past, agencies have been in a rush to place a child out-of-home to ensure the safety of the child, without regard to the actual needs of the child. DFS is developing a 3 step process for screening and assessments prior to placement. The process includes:
The Maysi-2 is a research based tool created by Dr. Thomas Grisso, Ph.D., Professor of Psychiatry at the University of Massachusetts Medical School. The model Wyoming will use is being developed with the assistance of New Mexico to assist in local placement decision-making. Within a week of this Committee meeting, the draft proposal will be sent to Dr. Grisso for review. The goal is to conduct assessments of 100% of children who may be placed out-of-home by a court, as compared with the LSO Court-Ordered Placement of Children Report that found that only 25% of those children are currently being assessed.
The Committee recessed at 5:10 p.m.
Chairman Schiffer called the meeting to order at 8:05 a.m.. The following sections summarize the Committee proceedings by topic. Please refer to Appendix 2 to review the Committee Meeting Agenda.
Mr. Chuck Hayes, Acting Administrator of the Substance Abuse Division (SAD), advised the Committee of his role as acting administrator after the resignation of Ms. Alfrieda Ortega. The Division normally has 32 staffing positions, but is currently operating with 13 staff who are trying to save federal grants while setting priorities for the Division. The reliance on short-term federal funding does not lend itself to long-term planning. Some Committee members expressed the opinion that perhaps the SAD should be remerged with the MHD. Dr. Brent Sherard, Director, Department of Health, stated that option is among several being considered, but no consensus has been reached on the issue.
Dr. Ann Reyes, SAD, distributed Appendix 12, Continuum of Care Options, and Appendix 13, SAD's Additional Projected Costs to Maintain Re-Structure and Build Existing Division Programs. She advised that SAD opted to propose establishing 9 regions in the state for substance abuse treatment programs to coincide with the 9 judicial districts. This would provide for more specificity in data collection and sharing and would be consistent with law enforcement data. The problems cited by Mr. Pagel are being addressed within the Department of Health on a transactional basis. She described the differences between "medically managed", "medically monitored" and "clinically managed", how those systems can fit together in a full continuum of care and when each system is most appropriate. She said she would provide the Committee with the written definitions. The pre-admission process is well in place around the state. Detoxification is being worked on and she suggests that it should be made available in all proposed service regions of the state. WAMHSAC providers say, with the processes they have in place for social detoxification, they have no problems with their insurers. Representative Simpson said the medical providers in Park County have concerns with the concept of social detoxification. Dr. Reyes said she would talk with the medical community to address their concerns. She recommended 2 pilot projects to test SAD's proposals. The proposals will be available within 2 weeks, after the approval process within the Department is complete. Social detoxification and recovery support services are being proposed for all residential programs. Any detoxification funds requested are for the residential programs and would not be directed toward acute care beds.
Data collection has identified several gaps in adolescent treatment and residential treatment. Chairman Schiffer asked why the Girls' School is at 1/3 capacity yet fully staffed and funded. Dr. Reyes replied she isn't able explain that because those placements are not determined by the Department of Health. She will attempt to find out why the facility is operating with such a high vacancy rate. Chairman Schiffer also asked about the projected costs for SAD as listed in Appendix 13. Dr. Reyes advised the projected costs are to maintain previously authorized programs. Funds provided under the Temporary Assistance to Needy Families Act (TANF) were monies that were diverted from one-time bonus funds and partially sustained by other TANF funds.
Ms. Patricia Guzman, KidCare Program Manager, distributed Appendix 14, consisting of an explanation of the mental health services available under the state KidCare program and the psychotherapeutic services paid by the program through 8/31/2005. After explaining the caps on mental health services provided by the program are a result of shifting from a Medicaid "look-alike" program to an insurance program run by Blue Cross/Blue Shield of Wyoming (BC/BS), with benefits established similar to private insurance policies by a statutorily created health benefits plan committee, the Committee asked if the health benefits plan committee might consider removal of the caps. Ms. Guzman replied she can present the suggestion to that committee, but it is important to understand that it may adversely affect premiums paid to BC/BS for the KidCare program. The current premium is $156.65/child/month. Under the Medicaid "look-alike" program, the Department only paid for services when they were utilized. Under the current program, the Department pays the monthly premium for each enrolled child, whether the insurance is used or not. Costs are lower under the current program, which may be partially explained by the fact that DFS previously made the eligibility determination and was finding eligibility for some high-cost children who should not have been found eligible because they had private insurance and the Medicaid "look-alike" program was paying for services that the private insurance should have been paying. About 500 children found eligible by DFS were determined to be ineligible when the eligibility determination function was transferred to the Department of Health. There are about 4,500 children now enrolled in the program, but not all potentially eligible children, i.e., those whose family income is below 200% of the federal poverty level, are enrolled. Chairman Schiffer asked Ms. Guzman to look at the dollar caps and the limit of days caps in the program, in light of the appropriateness of services for the population served and what the price tag might be for any premium increases that would occur as a result of amending those caps. Representative Warren asked how many children in the program have a dual diagnosis, can that information be tracked and does a dual diagnosis increase the limit on the number of days the child may receive treatment services?
The Committee agreed by a straw poll to direct staff to draft a mental health parity bill with the 7 diagnoses shown in Appendix 14 as eligible conditions for parity and a second bill to include those 7 mental health diagnoses and substance abuse.
Mr. Chuck Hayes, MHD Administrator, distributed Appendix 15, describing the mental health system improvements the MHD is proposing and the costs associated with those improvements. For the majority of the services the MHD would like to establish regional boundaries, but even those boundaries should be flexible to ensure the delivery of services statewide. Mr. Hayes would like to get local input on the creation of the boundaries. Under the proposal:
The goal is to equalize services within regions by equalizing pay at $26 per capita. Chairman Schiffer expressed concern with this proposal because not all programs will have available the same level or quality of programs and services and should not be rewarded for their failure to establish the same level of high quality that other programs may have. Mr. Hayes said the MHD would consider looking at differential pay rates, based on performance. Representative Simpson asked for governing board training so they can do their job effectively. The Committee was advised that the Department does provide board training, but attendance is voluntary at the training seminars.
Ms. Carol Day, MHD, explained the costs associated with the MHD's proposed plan. Among the proposals was a 10% increase in the base contract rate paid to the community mental health centers (CMHCs), amounting to about $70,000/CMHC/year. Additional funding is necessary if CMHCs are to hire the 12 additional psychiatrists proposed by MHD and support staff for screening, intensive care and triage. Funding is also requested for outcomes development and data infrastructure, early intervention for children. The proposal called for two regional pilot projects to include medical detoxification and crisis stabilization, but cost estimates did not include acute care inpatient beds for all proposed regions at $700/day/bed, with a minimum of 2 beds/regions. More such beds might be required for some regions with higher populations and needs. Chairman Schiffer suggested adding criteria in the requests for proposals (RFPs) for the regional pilot projects to include transportation for acute care inpatient clients, transitional case management and cost of medications. Mr. Hayes said the proposals would provide for a one month's supply of medications, unlike the current program at WSH that only provides 2 weeks' supply. Because of the shortage in prescribing psychiatrists, 2 weeks' supply is cutting it close for patients who may not have the opportunity to see a prescribing psychiatrist or physician before the supply of medications is exhausted.
Mr. Bill Hardin, Natrona County Attorney, stated Natrona County has a good system of services with the Wyoming Behavioral Institute (WBI), Central Wyoming Counseling Center (CWCC), the courts and private providers. The emergency room at the local hospital is often the initial gatekeeper. If there are no medical issues, WBI will take the person prior to the emergency detention hearing. If the person stabilizes before the 72 hour hearing, the person is released. His office sends between 140-200 cases/year to WBI and the facility sees many more patients as a result of its memoranda of understanding with 5 other counties. He doesn't have a problem with persons released into Natrona County by WSH, as long as aftercare case plan is described in the release notice from WSH. Upon return to the community, CWCC then assumes the aftercare and acts as gatekeeper for the person. Title 25 of the Wyoming Statutes is pretty flexible, and the only changes that were proposed before the Joint Judiciary Interim Committee earlier in the week are intended to address financial responsibility issues. The biggest need in Title 25 detentions is for appropriate training for hospital staffs around the state to deal with mental health issues.
Mr. Joe Baron, Crook County Attorney, advised that his county has an agreement with Campbell County Memorial Hospital because the hospital has a psychiatric unit. The local mental health center in Crook County acts as the gatekeeper. The biggest problem he sees with mental health patients is aftercare case planning. He receives better aftercare case plans from Campbell County Memorial Hospital than from WSH. Regionalization of services would take care of the current problems he experiences with mentally ill persons. The problem with implementing regionalization is that the Department of Health hasn't adopted the rules required under W.S. 25-10-104 to designate hospitals qualified to provide treatment under Title 25.
Representative Elaine Harvey, Cochairman of the Select Committee to Study Developmental Programs, stated that no mental health services are provided at preschool programs for the developmentally delayed.
She introduced Mr. Tiernan McIlwaine, Developmental Disabilities Division, and Ms. Kathleen Orton, Educational Consultant for Child Development Centers of Wyoming. The 2 issues facing preschools is how to identify mental health problems and where to locate services to deal with them. There is a mental health pilot project involving the Early Intervention Council and the Developmental Disabilities Division (see Appendix 16) to identify and address mental health needs of children in preschool programs. Mr. McIlwaine described a 3-tiered training program the Division is attempting to develop for parents and preschool educators to receive training in the provision of mental health services. Seven persons will be traveling to New Jersey in November to receive training as third tier trainers to provide training to first and second tier parents and other educators. By January, 2006, the program should be fully functional, but the Division won't have any outcomes data at that time.
Representative Harvey concluded by urging the Committee to coordinate with the Select Committee she cochairs and to urge CMHCs to give top priority to families with children ages birth-to-5 years who have mental health needs.
Ms. Peggy Nikkel, UPLIFT Director, distributed Appendix 17, consisting of a recommended menu of treatment services for children's mental health and substance abuse issues and a funding request for family support, education and advocacy. She explained that UPLIFT has been in existence for 15 years to provide advocacy and training for parents. In addition to the requests in her materials distributed to the Committee, Ms. Nikkel asked that at least 1/3 of any new psychiatrists recruited by the state have training to work with young children. Too few psychiatrists are qualified or comfortable in working with young children with mental health needs and the problem is particularly acute in Wyoming with its shortage of psychiatrists.
Chairman Schiffer advised the Committee he has identified topics during the Committee's deliberations that may merit consideration as draft legislation. He would present each item for discussion and conduct a straw poll to determine if the proposal should be prepared as draft legislation for the Committee's consideration at the November meeting. If any Committee member had additional suggestions, those could be presented also. The following were the provisions the Committee agreed to have drafted for consideration at the November meeting:
· Authorize the State Building Commission to contract with a building assessment firm to determine needs at WSH;
· WSH to define: acute adult psychiatric care; who will conduct forensic examinations (staff to check with Department of Corrections to see if Torrington prison will have forensic pod); scope of in- and out-patient services; scope of geropsychiatric services; and, the availability of adult voluntary and involuntary acute psychiatric care;
· Authorize and fund a liaison position for P&A at WSH, with Attorney General to work details of liaison position with P&A. Legislature to set criteria based on Attorney General and P&A agreement;
· Authorize, if statutorily necessary, WSH to convert from 8 hour work shifts to 12 hour work shifts;
· Authorize Quality of Life funds of $3.2 million to CMHCs consistent with Appendix 14, which shall include supported independent living and quality of life issues;
· Consider 06LSO-0093.W1, DFS contract for residential services-juveniles;
· Provide funding to University of Wyoming for psychiatric residency rotations under contract with an accredited medical school, as recommended by the Wyoming Association of Psychiatric Physicians;
· Authorize funding for training of advanced practice registered nurses in psychiatry, with loan repayment program and stipends to do clinical rotations;
· Authorize Department of Health to apply for federal Medicaid waiver to avoid relinquishment of parental custody when placing a child out-of-home (staff to work with Ms. Brockman and Ms. Mikesell on details, including relinquishment, level of need and social and legal needs);
· Authorize bereavement counseling centers through CMHCs for families of specified first responders, working with Senator Aullman, with funding to be exempt from flex, lapse or reversion to general fund;
· Authorize and fund incentives for recruitment of psychiatrists to include salaries of $175,000/year each for of up to 7 psychiatrists, with an additional $15,000 each for recruitment and relocation and student loan forgiveness of $100,000-200,000 if the psychiatrist remains in the recruited position for 4 years; recruited psychiatrists to be state employees under the WSH;
· Authorize Department of Health to issue 2 RFPs for separate regional pilot projects to enhance acute psychiatric care services in the state, to include: availability of psychiatrists; transportation to and from the health care provider; transition back to the community or to other mental health services; and, documentation of outcomes. The authorization for the RFPs shall be contingent upon the Department of Health: adopting rules designating authorized hospitals under W.S. 25-10-104; getting new psychiatrists hired by WSH to locate regionally into areas of most critical need; agreeing to pay transportation costs to the acute psychiatric care facility; and, developing an educational component for primary care physicians;
· Earmark MHD funds for transportation to and from the WSH for involuntary commitments under Title 25;
· Require mental health parity for health insurance policies to include the 7 mental health diagnoses specified in Appendix 14 and a separate bill for substance abuse parity;
· Authorize an appropriation under Medicaid, or other more appropriate program for $500,000 in the next biennium to be provided to UPLIFT for services to consumers, as described in Appendix 17, but specifically prohibiting use of the funds for lobbying purposes;
· Authorize funding for the Statewide System Improvements as described in Appendix15, except provide funding for 6 psychiatrists to be hired by MHD and located throughout the state, and do not authorize funding for the Outcomes development/data infrastructure line item (Mr. Hayes to provide a detailed plan of implementation as condition of receiving this funding);
· Authorize funding separately for the Outcomes development/data infrastructure line item in Appendix15, specifying details of how this funding is to be used;
· Authorize $525,000/proposed MHD region for crisis stabilization, which shall be let under competitive bid contract;
· Authorize the funding requests for SAD, as described in Appendix 13, as placeholder.
Staff may combine those provisions providing appropriations approved for consideration by the Committee, to the extent the requests can be combined into a single bill. The Department of Health shall provide in writing the bases for the funding amounts being considered by the Committee. In addition, Senator Job was requested to present a request from this Committee to the Select Committee on School Finance Recalibration that the latter Committee consider including, as part of the formula it is developing, funding for school districts to contract with CMHCs for early intervention assessments of children.
Two topics the Committee determined did not need further consideration by this Committee were:
The Committee will meet again beginning November 17, 2005, to consider the proposed draft legislation it has requested and, possibly, to receive the NCSL training session on outcome measures that was postponed from this meeting.
There being no further business, Chairman Schiffer adjourned the meeting at 6:20 p.m.
Respectfully submitted,
Senator John Schiffer, Co-chairman Representative Colin Simpson, Co-chairman