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May 15, 2006
Central Wyoming Counseling Center
Casper, Wyoming
Senator John Schiffer, Co-chairman
Representative Colin Simpson, Co-chairman
Senator Pat Aullman
Senator Ken Decaria
Senator Rae Lynn Job
Senator Wayne Johnson
Senator Tony Ross
Representative Jerry Iekel
Representative Doug Osborn
Representative Jane Warren
Representative Keith Gingery
Representative Patrick Goggles
John Rivera, Senior Staff Attorney
Joy N. Hill, Associate Research Analyst
Please refer to
Appendix 1 to review the Committee Sign-in Sheet
for a list of other individuals who attended the meeting.
Chairman Colin Simpson called the meeting to order at 9:09 am. The following sections summarize the Committee proceedings by topic. Please refer to Appendix 2 to review the Committee Meeting Agenda.
Chairman Simpson remarked this is the first meeting of the year, discussed the presenters for the day, and remarked about the critical need for attention to this area.
Mady Chalk, Ph.D., Director, Center for Performance-based Policy at the Treatment Research Institute (TRI), provided a brief background of TRI and presented a PowerPoint presentation (see Appendix 3). Dr. Chalk remarked she has presented this talk all over the country to those that have asked for briefings on the current state of addiction treatments. In addition, Dr. Chalk commented on the current state of Wyoming’s mental health system based upon the Wyoming reports she has reviewed. She stressed the importance of paying attention to the location of the substance abuse division in the state system. For example, Washington State’s Division of Alcohol and Substance Abuse is located within the Department of Social and Health Services. This location facilitates access to other agencies necessary for cross-agency sharing of information. In addition, Dr. Chalk stated, based upon the Wyoming reports, state staff need to receive the kind of information necessary to make appropriate decisions about Wyoming’s mental health system.
Dr. Chalk discussed implementation of a continuing care model, concurrent recovery monitoring, recovery management support, and what other states are doing, such as braided funding. Dr. Chalk also stressed the fact that collaborative efforts can be a very difficult task and it is a process that takes time to achieve. She described what Delaware did with its mental health system using block grant funds, and the Pennsylvania, Hazelton, Betty Ford Center, Iowa, and Massachusetts examples. Dr. Chalk related how drug courts are a good example of information systems that assist the efficiency of the substance abuse system.
Representative Iekel remarked on the importance of the continuity of treatment and that it is critical that the administrative structure parallel that paradigm. In addition, Representative Iekel questioned Dr. Chalk about a comment she made during her presentation relating to political pressure. Dr. Chalk responded the comment was made with an eye to the fact that many providers may have difficulty meeting certain requirement criteria. As a result, existing providers may put pressure on legislators that should be resisted. Representative Iekel also questioned whether or not this paradigm exhibits elements of disease management. Dr. Chalk remarked the paradigm is very akin to disease management in its approach.
Representative Warren questioned the idea of enhancing retention of patients and whether or not there are any studies that correlate factors as to what increases or decreases retention. Dr. Chalk indicated there have been studies done that have suggested 90 days as the ideal length for retention of patients with substance abuse issues. Currently, according to Dr. Chalk, the average retention time is 5 days, but stressed this is outpatient data. Dr. Chalk further discussed the chance of failure if support services after treatment are not available due to the fact that many offenders return to the same unhealthy environment in which they became addicted. Studies show 98 percent of prison offenders not receiving treatment and support will recidivate. Dr. Chalk stressed the importance of linking the treatment program with the primary care system (e.g., physicians, regional services, etc.) so patients can get needed medications. In addition, the committee and Dr. Chalk discussed the need to map outpatient treatment programs to primary care clinics likely through a GPS mapping system that will overlay the clinics and primary care systems within geographical regions.
Chairman Simpson asked if, as a general practice, a recommendation is provided by a substance abuse counselor to a primary care provider and other service providers. Dr. Chalk indicated that is the case and a standardized intake tool (module) should be in place to decide a course of action for a patient (i.e., will medications be helpful, where should the patient go next, etc.). Dr. Chalk suggested looking at “Drawing Together” (no specific reference was provided) online which discusses creating a module for certification of counselors and other providers in treatment programs.
Chairman Simpson asked about primary care physicians prescribing medications in Wyoming. Dr. Brent Sherard, M.D., Director, Department of Health, stated currently any primary care physician may prescribe Schedule I and Schedule II drugs, but that does not mean they are skilled in prescribing those drugs. Senator Decaria suggested providing a continuing education program for physicians regarding mental health and substance abuse medications, and also addressed the necessity of looking at mental health and substance abuse treatment with an understanding there may be an organic cause that must be addressed as well. Dr. Chalk suggested that a number of studies have addressed this issue and she would be willing to provide those studies to the Committee.
Senator Job asked about Wyoming data systems for quality and effectiveness. Dr. Chalk indicated there is a substance abuse data entry system installed and that the drug courts are currently using the system, but treatment providers are not. Additionally, there continues to be discussion about various data systems not communicating with each other. Dr. Chalk indicated there are ways around this, but someone needs to be responsible for spearheading such a project. Dr. Chalk further indicated, according to the data system developer, there is still some money left over to complete the data system.
Dr. Chalk, in response to questions posed from several Committee members, discussed the difference between performance standards and outcomes and the DENS computer system and the ASI system.
Dr. Antoinette Krupski, Research Administrator, Washington State Division of Alcohol and Substance Abuse discussed the main points of her PowerPoint presentation (see Appendix 4) and remarked that the problems in Washington State are likely not all that different from Wyoming's problems.
Chairman Simpson asked Dr. Krupski if her analysis of methamphetamine treatment costs takes into account the length of treatment required for methamphetamine related issues. Dr. Krupski indicated that treatment for methamphetamine does not take any longer than for other stimulant addictions. Allison Colker, Program Manager, National Conference of State Legislatures, clarified for the Committee the existing misinformation about methamphetamine treatment and the brain physiology of the drug.
Chairman Simpson and Dr. Krupski discussed the performance measures Washington State uses and how long it takes providers to collect the necessary information. Dr. Krupski stated there are over 400 data elements collected for each client and that it can take up to 45 minutes to collect this information. The length of time required, according to Dr. Krupski, is a complaint of the providers. Dr. Krupski also discussed the TARGET database and how it is used to track treatment progress of patients and allows providers to track their own progress as well.
Senator Job inquired as to the common definition of treatment completion. Dr. Krupski indicated that is determined by the treating agency, and although the definition appears ephemeral, it is not because everyone uses a clinically-based definition and they all seem to find the same information. In addition, treatment is also evaluated based upon the portion of the treatment process each patient completes.
Chairman Simpson asked Dr. Krupski if Washington State is currently using incentives for providers. Dr. Krupski indicated Washington State is not using incentives currently, but there exists an excellent collaboration between the state and providers and the state must be very careful to not create an adversarial relationship with providers. Dr. Howard Shapiro, Executive Director, State Associations of Addiction Services, said providers want to do the right thing, but are faced with an under-funded infrastructure. According to Dr. Shapiro the key to successful programs is the development of collaborative relationships with providers because incentive payments are not magic bullets.
Senator Ross inquired to what degree the substance abuse database is integrated with the mental health database system for purposes of sharing information to track co-occurring conditions of patients. Dr. Krupski indicated that the two systems can share data as long as the identifiers remain the same. The Committee further discussed tracking individuals with identifiers.
Dr. Krupski further discussed the need for more data-driven research to promote the concepts discussed in her presentation. Although the research is available nationally, Washington lawmakers want research directly pertinent to Washington State populations. Dr. Krupski further indicated she has a very small staff size (herself and three researchers), and therefore must contract out most of the work. In addition, there can be credibility issues when the work remains in-house.
Burke Grandjean, Ph.D, Director, Wyoming Statistical Analysis Center (WYSAC) at the University of Wyoming, discussed data needs and database structure that currently exists, particularly for the drug court (See Appendix 5 for a handout of Wyoming Drug Court Case Management). Dr. Grandjean emphasized the importance of finding out what all parties want and the need for dialogue with people who will input data in the database. People involved with the database need to understand what information is needed from them and how that information ties into the database.
Dr. Grandjean discussed the database and the fact that the server is behind the UW firewall, and therefore is very secure. Information will only need to be entered once and can be outputted to meet reporting requirements the system might be asked to provide within the drug court process. Dr. Grandjean indicated this database will be operational next month with drug courts putting information in the system.
WYSAC is currently in the process of building a database for the Substance Abuse Division’s prevention needs assessment for middle and high schools throughout the state. Dr. Grandjean did address the difficulty of obtaining consistent and reliable data on recidivism, and emphasized this is vital for outcome measures after treatment. In addition, Dr. Grandjean stated the circuit courts and Supreme Court systems are in the process of being linked and that the court system is in the talking stages of moving toward centralization with the potential of linking in the drug court system.
Chairman Simpson asked about a feasibility study on how to create a management system for the municipal courts. Dr. Grandjean indicated that is something he has been asked to look into and is in the process of working on, but is optimistic the integration will happen. Additionally, part of the integration system will hopefully include connection with substance abuse treatment providers so patient information will be on the same system.
Co-Chairman Schiffer questioned whether or not there is enough money for the integration. Dr. Grandjean stated that the contracts run on fiscal year cycles. The drug court system and feasibility study will expire on June 30, 2006, although the integration with the Ranger system will be complete by then, as will the drug court integration.
The issue of confidentiality was discussed. Chairman Simpson asked if it is possible to share data and preserve confidentiality by removing identifiers. Dr. Grandjean indicated the agencies have significant concern about protecting their data. Dr. Mady Chalk commented other states working with a national data-sharing model are using carefully drafted sharing agreements, and these are available online (although the location of these agreements was not provided).
Lee Clabots, Deputy Director, Department of Health; Traci Lindsten, Chief Information Officer, Department of Health; and Jerry Isbell, Information Technology Project Manager, Department of Health, provided a brief outline of the Wyoming Client Information System (WCIS) data system development (see Appendix 6), and indicated the update was fairly technical. Mr. Clabots indicated the system was brought in-house in January 2006 and the Department performed a thorough analysis to decide how to move the project forward. Based upon that analysis, it was decided to totally re-program the system because the original programming would not provide the relational database links desired.
The Committee discussed who makes programming decisions and about the WCIS sponsorship committee. Mr. Chuck Hayes, Administrator, Mental Health Division, stated the WCIS system is being pursued to have all outcomes on the mental health side, but he is not sure about the substance abuse side. The goal is to have a system with information that is identifiable by client, reportable by incident, etc., similar to that of Washington State’s. They are close to being able to do that, but it depends upon the infrastructure and providers. Senator Ross expressed concern that the system created one year ago was being scrapped and started over. Mr. Clabots and Mr. Hayes both explained that the agency initially spent $1.4 million on the system and the vendor stated it would need another $702,000 to complete additional work. The agency failed to obtain the money and, at that time, had to either scrap the system or bring it in-house. They thought they had a fully-functional system, but realized it was not a relational database and could not integrate it or change it in the future if necessary. Dr. Sherard indicated there was great concern at that time that the vendor was not doing what was asked and now believe they can create a better system with what they have left, and are working hard to get the system fully operating.
Jerry Isbell provided, and discussed with the Committee, a flow chart (see Appendix 6) illustrating the structure and timing of this project. Mr. Isbell discussed with providers the complexity of the system and indicated things have not gone as well with providers as he would have liked. Mr. Isbell also stated in order to get caught up with the FY06 portion of the project requires getting an entire year’s worth of provider data, working the data and entering it into the database. The current best scenario time frame for completing this task is August 15, 2006. The length of the time frame is partly due to the fact that 5 providers’ data exists in paper form, and that information needs to be gathered and entered into the system. Mr. Isbell also discussed the added complexity because reporting requirements have changed each year. Chairman Simpson indicated he would like to focus on language found in 2006 House Bill 91, subsection 12(e) and wants the Department of Health on the agenda at the next meeting for an update on its progress relating to this subsection. In addition, Ginny Mahoney, Department of Health, indicated she can provide bi-monthly updates on the WCIS system as well as progress on House Bill 91 requirements.
Liz Mikesell, Department of Health, discussed the status of the Children’s Mental Health waiver request. She is preparing to submit corrections and additional information requested by the Centers for Medicare and Medicaid (CMS) and is on schedule to implement the waiver on July 1, 2006.
Ms. Mikesell provided a handout with a breakdown of the implementation plan and projects currently in progress (Appendix 7). She stated she is currently working with Susie Markus from Laramie on the project, and indicated the plan can be changed. Any proposed changes would be submitted to CMS as an amendment for approval.
Ms. Mikesell also indicated she is working on CASII training through which trainers will come and work with providers who are interested in working with children’s mental health eligibility. She is also working with the Department of Health for interfacing with MMIS, and that she will be visiting each county that will have waiver services available for children.
Chief Tom Pagel, Casper Police Department, discussed the status of the Casper Substance Abuse Project and provided to the Committee some recommendations. Based upon the report provided from a consultant used for the project, the first recommendation Chief Pagel made was that there should be a standardized data collection system. Chief Pagel indicated he is currently looking at the WIT program provided through SAMSHA money and suggested that it is a program that will meet their needs. In addition, it is compatible with the DENS system.
Chief Pagel also discussed the community facilitation citizen group that came up with 84 recommendations, and that the project is currently in the third phase which is drafting a specific plan. The report on this plan will be done the first of July and a timeline will then be in place, as will an estimate of cost. The fourth phase, implementation and evaluation, was discussed.
The second recommendation offered was that all communities need to undergo a local evaluation to identify gaps in services. According to Chief Pagel, once that is done state money could then address those issues in each community. Chief Pagel emphasized the greatest need is for long-term residential treatment beds for adults and juveniles which are severely lacking in the communities throughout the state. In addition, Chief Pagel, based upon his knowledge of methamphetamine treatment, believes the presenters from Washington may have presented a timeframe for treatment that is too short. Through his experience and the studies he has read there is indication that detoxification takes at least 30 days and 3 to 4 months are required for treatment afterward. Representative Warren suggested a couple of missing pieces are intensive outpatient treatment capacity and the lack of providers. Senator Job further commented that there is a prevention aspect of this issue that needs to be considered as well.
Chief Pagel discussed the felony drug court program in Davison County, Tennessee, stating that the program has a judge with very strong personality who controls the program from a client’s entry into the program through the exit of the program, in addition to owning the residential treatment facility used by the program. The first 30 days consists of detoxification services; afterwards, 3 to 4 months of treatment is provided. The typical time in the program is 13 months. There are currently 100 people in the program with another 20 slots being added. Chairman Simpson inquired about a felony drug court in Natrona. Chief Pagel indicated Judge Huber is in the process of getting one started.
Co-Chairman Schiffer questioned the concept of drug therapy in lieu of inpatient treatment. Chief Pagel stated that is the approach that has been taken thus far and it has been ineffective, and is merely substituting one drug for another.
Chairman Simpson advised the Committee to obtain and review the Mental Health Division's Implementation Report, dated May 15, 2006 (Appendix 8). He asked staff to contact Dr. Krupski to obtain clarification about the treatment options used in Washington for methamphetamine addiction.
Chairman Simpson advised he would like the Committee to focus at the next meeting on the state plan for substance abuse and obtain an update on the WCIS program development.
After discussion, Committee members who wanted specific data on the waiting lists for treatment and the utilization of beds at community service providers were advised that information is available on a weekly basis from the Substance Abuse Division. Co-Chairman Schiffer stated he does not want the Committee to focus on the need for beds exclusively because looking at a single component in the continuum of care is meaningless. The entire spectrum of care needs to be reviewed as a whole.
There being no further business, Chairman Simpson adjourned the meeting at 5:06 pm.
Respectfully submitted,
Senator John Schiffer, Co-chairman Representative Colin Simpson, Co-chairman