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September 25, 2006
Senator John Schiffer, Cochairman
Representative Colin Simpson, Cochairman
Senator Pat Aullman
Senator Ken Decaria
Senator Rae Lynn Job
Senator Wayne Johnson
Senator Tony Ross
Representative Keith Gingery
Representative Patrick Goggles (September 25
only)
Representative Jerry Iekel
Representative Jane Warren
Representative Doug Osborn
Representative Patrick Goggles (September 26
only)
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.
The Committee met
for two days in
The Committee will
meet again at a time and place yet to be determined to consider draft
legislation requested and other issues as the Cochairmen may determine.
Chairman Schiffer
called the meeting to order at 8:15 a.m.
The following sections summarize the Committee proceedings by
topic. Please refer to Appendix 2 to
review the Committee Meeting Agenda.
Brent Sherard, M.D., Director of the Department of Health, discussed
the philosophy and management aspect of WDH, and stressed that teamwork and
better relationships with providers and Wyoming Association of Mental Health
and Substance Abuse Centers (WAMHSAC), as well as improved interdepartmental
collaboration have been important steps.
However, Dr. Sherard pointed out that more direct input from clients is
needed. In addition, Dr. Sherard
indicated that accountability issues and contracts have been addressed to
reflect the need for harmony between outcomes and the services the WDH pays
for, and that the WDH and providers are generally in agreement as to what
performance-based contracts and standards should be. Dr. Sherard stated that performance-based
contracts for both mental health and substance abuse should be in place in one to
two years in order to give stakeholders enough time to provide input. Dr. Sherard reported that WDH has hired a
chief information officer whose goal is to integrate the various human
resources and Medicare and Medicaid Information System databases and create
common client identifiers to provide the Legislature with better
information. However, federal Medicaid
has been somewhat hesitant to allow this integration due to system funding.
Dr. Sherard addressed the progress WDH has made on the directives set
forth in 2002 HB 59, and reported that WDH has visited communities in response
to the methamphetamine initiative and that the Governor has been
supportive. Dr. Sherard indicated that
WDH is committed to a local level approach to help communities deal with
methamphetamine-related issues. Dr.
Sherard noted the capacity for treatment has improved from 2000 to 2005, and
that more clients are being served.
According to Dr. Sherard, WDH is in the process of working toward more
prevention measures. Dr. Sherard
informed the Committee that the WDH will be kicking off its social marketing
campaign in early November, which will be targeted to the 12-24 age group, and
then the general population as a whole.
Dr. Sherard noted there was a management audit review for the drug
court program, and informed the Committee there are now 26 drug courts (23
receive state funds, 3 do not) in Wyoming.
However, he acknowledged there are still some issues with outcome
measurements, but that these issues are being addressed. In addition, Steve Gilmore, Substance Abuse
Division administrator, acknowledged that the Management Audit Committee would
like to know how the programs are functioning and if they should all be run
similarly or not. Mr. Gilmore stated
that drug courts are set up at the local level so the drug courts reflect the
needs of each community, which he acknowledged may create variability in the
approach of the various drug courts.
However, according to Mr. Gilmore, the various approaches should still
produce the same outcomes. Mr. Gilmore
further stated that drug court management is administered by WYSAC, and that
the courts have access to court data through a web-based program. The WDH agreed to provide to the Committee
supplemental budget request information for the drug courts.
Dr. Sherard stated that drug courts work, however they have not been
subject to rigorous scientific study, and it might be useful to see a
comparison between individuals who go through the regular court system and
those who go through the drug court system.
He further reported that WDH is continuing the drug court program and is
currently looking for someone to fill the position vacated by Heather Babbitt,
who was the drug court administrator.
Mr. Cary Heck is currently the interim drug court administrator. Mr. Gilmore reported that, at this point,
there is enough available funding to maintain the status quo for the drug
courts, but if expansion is desired, additional funding will be needed for the
biennium.
Cochairman Simpson, referring to 06RM047 Mental Health and Substance
Abuse Provider Funding (Appendix 5), prepared by LSO for the Committee,
questioned whether or not an increase in Medicaid reimbursement would be the
best investment of dollars. Dr. Sherard
indicated his belief that this would be the best use of dollars and that the
Department would support legislation to increase the reimbursement rates. Dr. Sherard also informed the Committee that
there is currently a study by Navigant underway for the MHD that is looking at
Medicaid reimbursement rates, and believes this information might be available
around December of this year.
The Committee inquired about WAMHSAC’s response to WDH’s
regionalization plan, which expressed some resistance to regionalization and
more support of local community-based plans.
Chuck Hayes, Mental Health Division administrator, indicated the most
enhanced services will be at the local level, but available to the region. In addition, Mr. Hayes acknowledged there
appears to be some anxiety, resistance, and a lack of understanding about
regionalization. The Committee expressed
an interest in seeing a report of where more resources are needed in
communities and how to address any bottlenecks that occur.
The Committee inquired about the designation of other hospitals around
the state to help address acute adult
psychiatric care services. Dr. Sherard informed the Committee that
three hospitals have expressed interest in being designated: hospitals in Lander and Gillette and the Wyoming
Behavioral Institute. Two of the facilities are currently
certified and a third is in the process of certification.
A question was posed
concerning whether or not the WDH has an internal process to monitor the
programs and divisions within the WDH.
Dr. Sherard indicated he was unaware of any formal process, but reported
that WDH has a centralized fiscal department to which each division’s fiscal
reports. In addition, for programs that
use federal funds, WDH is audited through the federal government, and the reports
submitted to the Legislature can likely be considered internal audits.
Marla Smith, WDH
Information System Administrator, provided the Committee with information about
the
Jerry Isbell, WCIS project manager, provided an update on the status of
the system (Appendix 3). Mr. Isbell
reported that providers are currently inputting data into the web-based system
and once FY06 data is completed, they can begin collecting FY07 data. In addition, part of the program will be
tested within the next two weeks. Mr.
Isbell stated, in response to a question posed by the Committee, that weekly
status reports are sent out, and there are close collaborative efforts with
various agency heads and providers to gather data. Mr. Isbell also assured the Committee that
there is still access to the information in the old system. Mr. Isbell commented that currently
integration among agencies does not exist because there are no common
identifiers, but the way the system is built right now, that is a possibility.
Ms. Smith discussed a report about Section 10 of House Bill 91, Mental
Health Outcomes Development/Data Infrastructure, prepared for this meeting
(Appendices 3 and 4). She discussed the
status of the program regarding performance and outcome measures.
The Committee questioned Ms. Smith about tracking patients in the
system. Ms. Smith indicated that
tracking patients is a very complex process and largely depends on where the
patient entered the system, and where the patient ends up. There have to be enough identifiers of
“uniqueness” to track patients from program to program. Chairman Schiffer commented that in order to
get “unique” patient information,
Cochairman Simpson moved to have legislation drafted along the lines of
the
Chairman Schiffer inquired as to whether or not the 7 FTE’s provided
for in the HB 91 had been hired. Ms.
Smith informed the Committee that the positions were still being classified by
A&I, which has had the positions for classifications since July. She also informed the Committee that the
three AWEC positions will report directly to the mental health program manager
and will be responsible for quality improvement functions and will be part of
the quality management programs.
Police Chief Dave Hockett, Lander Police Department, discussed recent
successes and early failures of the Lander
Drug Prevention Task Force, and commented that the Wind River Police
Department has been integral in pulling enforcement efforts together. Chief Hockett further asked the Committee to
continue supporting the Task Force.
Marti Stensus, public health manager for
Renee Griggs, Lander Drug Prevention Task Force, discussed with the
Committee the fact that law enforcement have been given the tools to enforce
methamphetamine issues, but that the actual substance abuse problems in the
community and for the individual have not been appropriately addressed. She stressed that alcohol-based treatment
paradigms are not appropriate for addressing methamphetamine-addicted
individuals. In addition, very little
assistance is available at the community level, and there is no state plan to
address methamphetamine-related issues.
Ms. Griggs, in response to a question posed by the Committee, stated
that methamphetamine addicts need long term residential inpatient treatment.
Terry Meyers stated that once methamphetamine addicts are arrested,
there is no treatment available until they are formally court-ordered to
treatment. Mr. Meyers further stated
that educating kids about methamphetamine now will help prevent dealing with
future methamphetamine addicts in the future.
He would like to set up a proactive program that allows kids to be
involved. The SAD provided seed money to
create a video project for the state, which will cost around $60,000. Mr. Meyers stated he would like to get the
Department of Family Services, the Department of Education and the Department
of Corrections involved as well. He also
indicated they would like to have a facility that will generate money to
perpetuate the program year after year.
Christy Stocks, Snake River Citizens Against Drugs, addressed the
Committee and discussed community efforts to tackle methamphetamine-related
problems in the Baggs/Dixon area. Ms.
Stocks reported they had their first meeting with over 100 people in
attendance. At this point, the community
has nothing available, such as counseling or public health, to assist the
community deal with these issues.
However, they are currently focusing on education. She also discussed a neighborhood watch, but in
such a small community, people do not want to “tattle” on their neighbors. She proposed implementing a hotline where
people can call anonymously. In
addition, Ms. Stocks stated she would like to create a listserve so several
communities can discuss the issues together and try different models from
different communities.
Police Chief Tom Pagel, Casper Police Department, provided the
Committee with an update on efforts in Casper to address
methamphetamine-related issues, including the 4th Annual Methamphetamine
Conference to be held in Casper in January; 180 businesses have signed up to do
drug testing; and, Casper has applied for a “weed and seed” grant from the
federal government. Chief Pagel
described the “weed and seed” project (the federal grant is a $1 million
competitive grant) as a community effort.
In addition, Chief Pagel described the 100 bed residential treatment
center that many foundations in the community are supporting that will be
attached to
The Committee discussed Appendix 5, 06RM047 Mental Health and Substance
Abuse Provider Funding prepared by LSO for the Committee, and asked for an
update on funding from the Department of Health.
Mr. Hayes and Mr. Gilmore discussed funding issues, including
performance-based funding. They reported
to the Committee that contracts with providers will gradually change as WDH
develops measures of quality of service and outcome measures, and will only pay
for best practices. Mr. Gilmore informed
the Committee that the SAD pays each county $50,000 annually to keep centers
open for treatment. However, getting
people to treatment is sometimes difficult, and transportation and access are
important issues to consider.
Dr. David Birney, president of WAMHSAC and administrator of
Chairman Schiffer suggested a review of how the annual base-rate
payments of $50,000 and $70,000 to the counties, intended to keep centers open,
were established, and whether or not this is still applicable.
Cochairman Simpson began a discussion about how it is determined that
providers meet contractual requirements.
In response, Carol Day, MHD, suggested a baseline needs to be
established showing where the programs are at currently, performance standards
related to outcomes need to be set, and then contracts need to be adjusted to
reward those providers that have better outcomes. Mr. Hayes indicated that the need to provide
incentives in different areas is important, but has not thought through what
those incentives should be.
Cochairman Simpson asked what type of analysis would be helpful in
looking at funding issues (apart from what LSO prepared). Nancy Callahan, WDH consultant, informed the Committee that maximizing Medicaid
dollars is the better use of state dollars.
In addition, she suggested targeted funding for providers may no longer
be appropriate. This ties the hands of
providers to use the money as needed.
Ms. Callahan further stated that, currently, providers need to bill all
Medicaid clients under the Medicaid program rather than under state funded
programs.
The Committee discussed how to increase Medicaid reimbursement
rates. Dr. Sherard reiterated that
Navigant is currently conducting a study on Medicaid rates for the WDH, and
there may be recommendations available by December. Cochairman Simpson further questioned the
disparity between the funding for mental health and substance abuse
providers. Dr. Sherard responded that he
would like to have Bob Peck, WDH chief financial officer, look at the
information since it raises many funding issues and administrative costs
issues. Dr. Sherard acknowledged that
there is no formal task force within WDH to address funding issues, but such a
task force would require stakeholders to be involved as well in order to
approach a funding analysis correctly.
Mr. Gilmore provided an update on the
substance abuse control plan. He
commented that all agencies are to utilize science-based practices, and they
need to identify barriers between services provided and the service
providers. In addition, he stated that
standards need to be uniform to promote efficiency and accountability. Standards promulgation was established in
July, and SAD is currently working with CASAT (
Mr. Gilmore discussed prevention initiatives funded by the substance
abuse control plan, including the First Lady’s Underage Drinking Initiative.
The control plan also includes the development of a web-based resource sharing
program in which providers can share ideas and information about prevention
resources and education; support for DARE training for officers; and compliance
checks for alcohol and tobacco being purchased by minors. Mr. Gilmore added there is a decrease in the
number of businesses that sell alcohol and tobacco to minors, and that
community meetings about the methamphetamine initiative have been well
attended. Mr. Gilmore further commented
that, regarding methamphetamine issues, it is important for communities to
develop their own resources and discover what their real needs are so plans
they implement can be sustainable. Mr.
Gilmore briefly discussed the social marketing campaign that will kick off in
November and the need to keep awareness of substance abuse issues high.
Chairman Schiffer
inquired as to whether or not the $22 million additional appropriated funds for
substance abuse treatment is having the desired results. Mr. Gilmore responded that there have been
positive results, such as more access to treatment services. Mike Huston,
Kevin Smith, interim
manager for the Office of Telemedicine and Telehealth, reported to the
Committee that he has been in his current position since May and informed the
Committee that many demonstrations have been done that point to the value of
telemedicine, including less time traveling for service providers and more time
treating patients. There is a need to
continue to gather information about the technology and promote the use of
telemedicine and telehealth. Mr. Smith
indicated he would like to be able to begin addressing these issues in
November. According to Mr. Smith, at
this point, the penitentiary in Rawlins uses a telemedicine system for limited
connectivity with the
Chairman Schiffer
adjourned the meeting at 5:20 p.m.
Chairman Simpson
called the meeting to order at 8:10 a.m.
Carol Day, Mental Health Division Regional Consultant, provided an
update to the Committee about HB 91 activities (Appendices 7 and 8). She further reported to the Committee that
the five regions have submitted plans on regional medical management services
(Appendix 7 – Report on the Implementation of HB091). Ms. Day pointed out to the Committee a
correction on page 9, which should read 4.46 FTE psychiatrists. In addition, Ms. Day discussed community
services enhancements, and that WDH is preparing a proposal for the next
meeting about how to address salary adjustments for service provider
staff. Ms. Day also informed the
Committee that WDH has entered into a contract with Dr. Chris Rayburn from
Ms. Day further
informed the Committee that the acute inpatient project was only funded for one
year, and the crisis stabilization service project was appropriated in
perpetuity for one project. She indicated she would like both projects to be
expanded. Chairman Simpson questioned
the length of time for the appropriations for each of the projects and
suggested WDH re-read the legislation to determine if WDH’s interpretation is
correct.
The Committee questioned what slowed down the regional pilot
project. Ms. Day explained that only one
response to the RFP issued in July was received. Once the application was reviewed, major
problems were identified regarding the applicant’s approaches and funding
request. The RFP application was
rewritten to be clearer and will be re-issued with a return date of
mid-November. Ms. Day noted that the RFP
process is too rigid and not conducive to systems building because it limits
the amount of interaction with the applicant, but WDH was statutorily obligated
to issue an RFP for this project.
Navigant was the consultant that helped write the RFP. Ms. Day further commented that WDH wants to
work with the regions to develop services rather than guessing what the regions
need. Ms. Day indicated that part of
the application process this time will include mandatory technical assistance
for the applicants so they understand what is needed to complete the RFP
properly.
The Committee asked where restrictions against “bricks and mortar”
being included in the RFP application came from. Ms. Day stated that the funds that were
appropriated were only for services (section 600), but that buildings and
renovations may be something for the Legislature to consider. In addition, the Committee inquired why other
regions did not submit bids, and had concerns about the appearance of collusion
among the regions. Ms. Day informed the
Committee that when one region put in a bid, the other regions backed off.
In response to the Committee’s question about clarifying legislation,
Ms. Day stated WDH would like to have legislation to remove the RFP
requirement, to expand services and include start up costs, renovations, brick
and mortar, etc. Mr. Hayes commented
that WDH will bring to the Committee a comprehensive plan and a set of recommendations
for the Committee’s consideration. He
further reflected the need for flexibility in this process. Mr. Hayes suggested that those
recommendations may include training for nursing facilities, supported employment,
housing, transportation and daycare assistance; the need for the state to
provide funding when federal dollars drop off; enhancement of therapeutic
foster care and regular foster care; and, respite care for families. Ms. Day informed the Committee that WDH will
be providing more detail to the Committee at the next meeting about an expanded
system of care.
Chairman Simpson asked WDH to provide a list of desired draft
legislation to the Committee to be worked at the next meeting. Mr. Gilmore agreed also to get more
information to the Committee about Section 12 of HB 91. Mr. Gilmore discussed appropriations for
prevention and treatment services, as well as treatment beds and funding
pursuant to HB 308. In addition, he
stated that they are currently working to get contracts through the system for
HB 308 appropriations, a portion of which goes to communities for
methamphetamine initiatives. Mr. Gilmore
discussed an increase in beds for social detoxification, and reported that
rates for treatment services were adjusted, and are now $115 for adult male
treatment, $145 for women, $175 for women with children, and $200 for
children.
Mr. Gilmore briefly discussed the contracts structure with the
Committee. WDH is currently working with
Mr. Robert Lanter in the Attorney General’s Office to prepare the
contracts. Once all signatures are
affixed to a contract, the funding is then available. The problem the WDH is experiencing is that
contracts are falling behind because there are so many, and sometimes it takes
6 weeks to get one completed.
Mr. Gilmore and Dr. David Birney presented information on systems of
care (Appendix 9). Dr. Birney indicated
it is not feasible to have social detoxification in each community because a
certain volume of patients is necessary to justify the cost of the service,
which is a 24 hour inpatient service.
Mr. Gilmore informed the Committee that WDH has had discussions with the
Pablo Hernandez, M.D., Wyoming State Hospital (WSH) Administrator,
discussed the progress of the directives for the WSH as a result of HB 91, as
well as submitted the WSH Strategic Plan and a letter he wrote to the
Cochairmen (Appendices 10 and 11). Dr.
Hernandez informed the Committee that there are not enough available adult
acute care psychiatric beds because 14 of the beds are occupied by patients
with severe dementia, or are geriatric or neurotic patients that cannot be
discharged due to the severity of their conditions. Chairman Simpson asked if there was another
facility on the WSH campus that could be used for acute care psychiatric
patients. Dr. Hernandez indicated that
there is, but he has no one to staff such a facility.
Dr. Hernandez further informed the Committee that over the next 10
years, 30 to 40 additional acute care psychiatric beds will be need to address
the geriatric patients who are persistently mentally ill. Even the hospitals WSH works with are running
over capacity for acute care psychiatric patients. The average stay for an acute care
psychiatric patient is 36 days, and the patients WSH is admitting are much
younger, more aggressive and have more substance abuse problems. Chairman Simpson suggested draft legislation
for 14 adult acute care psychiatric beds and $1.2 million in funding per
year. Cochairman Schiffer asked Dr.
Hernandez to provide LSO staff with information about the amount of funding
necessary for 8 FTEs to staff a co-occurring substance abuse/mental health
unit.
The Committee questioned Dr. Hernandez about designated facilities in
which individuals would receive treatment in lieu of transfer to the WSH, or
held until transferred to WSH, and commented that the legislative language has
caused some confusion for the county attorneys as they make Title 25
recommendations. Dr. Hernandez informed
the Committee that formal designations have not been made yet, but he has
relied on “relationships” with hospitals that have agreed to take these
patients. Dr. Hernandez further informed
the Committee that once formal contracts are in place with the hospitals, $2.5
million will be needed to fund the contracts.
Dr. Hernandez discussed forensic examinations, and indicated that these
do not have to be done by WSH staff, but that trained clinicians around the
state can do the examinations.
Rodger McDaniel,
Director, Department of Family Services (DFS), discussed the therapeutic foster
care program and the roles of DFS and WDH, and indicated that in the next few
months there will be a request to expand the program. Dr. Birney informed the Committee that the
therapeutic foster care (TFC) program reimbursement rates have remained static
for the past few years, but costs of the program have increased. Chairman Simpson noted that the monthly
reimbursement total for a TFC child is just over $2,000, but that the TFC parents
actually get between $900 and $1,000 per month, and questioned what the
remaining monthly amount is applied to and if that amount is high in comparison
with other states. Dr. Birney indicated
the remainder of the monthly amount goes toward operational costs, such as TFC
parent recruitment, expenses for children in foster care placement, travel
costs, staffing, etc., and indicated that he did not know if this amount was
high compared to other states.
Chairman Simpson
asked if there is a need to increase the number of TFC providers. Dr. Birney indicated that he did not think
that was necessary, and that the reason the programs are at risk is because of
the migration of parents. Mr. McDaniel
indicated there has been discussion about an analysis of rates and if they need
to be adjusted, and that collaborative work would be required among DFS,
WAMHSAC and WDH. Mr. McDaniel also
indicated there is not a supplemental budget request for DFS for TFC at this
point.
Janet Jares, WDH, provided an update on the status of the Tobacco
Settlement account (Appendix 12).
Cochairman Schiffer stated that agencies are drawing money from the
settlement before it goes into the trust fund, and that there may be
alternative ways the money could flow if the Legislature felt it was appropriate. The Committee noted that general fund dollars
would have to fund the programs until enough interest is earned on the
settlement account to fund the programs if the Legislature decides to direct
the monies automatically to the trust fund.
Ms. Jares also informed the Committee that any unexpended funds
appropriated from the settlement funds revert back into the trust fund. Ms. Jares informed the Committee that $7.3
million (1999 dollars) is needed to fund the tobacco control program each
year. Cochairman Schiffer stated the
corpus would need to be around $130 million to generate enough interest to fund
the programs currently relying on settlement funds. The Committee agreed to pass the information
on to the Joint Appropriations Committee for consideration.
Chairman Simpson
provided the Committee with an update on the Children’s Mental Health
Conference held in Lander on August 24-25, 2006. Ms. Peggy Nikkel, UPLIFT, expressed her
appreciation for the legislative representation at the conference. Ms. Nikkel further informed the Committee
that WDH has received a six year grant from the federal government for
children’s mental health issues and that the intent is to implement a wrap-around
program, and identify barriers to community implementation. Ms. Nikkel stated that two pilot sites will
be funded (
Liz Mikesell, WDH,
provided the Committee with a summary of provider qualifications (Appendix 14
-06FS059 Summary of Provider Requirements to Provide Services Under the
Children’s Mental Health Waiver prepared by LSO). Ms. Mikesell informed the Committee that WDH
would like to provide a quarterly training calendar for the regions in which
the waiver will be implemented, and wants families to be able to participate in
the training sessions as well.
The Committee
discussed the various pieces of draft legislation they would like to consider
at the next meeting. In addition to
legislation requested earlier in the meeting, the Committee asked for draft
legislation or information as follows:
Title 25 revisions to include allowing emergency
detention hearings to occur in the county of detention, if the county of
residence and of detention have executed a contract, and amending the
language specifying the WSH as the hospital of last resort, with direction
from Representative Gingery;
Enhance telemedicine program and
transmission of electronic medical
records in a manner to allow additional providers to participate in the
program, with assistance from Mr. Kevin Smith and Mr. Hayes;
Equalize the state and Medicaid rates
for mental health and substance abuse patients to leverage federal funding
for services;
Equalize annual base funding rates at
$77 thousand for mental health and substance abuse centers;
Appropriate funding for the operational
costs of an in-patient treatment facility for drug addiction in Casper,
contingent upon capital construction funding being raised locally;
Provide a distillation of needs for
substance abuse treatment, based upon information provided by MHD, SAD and
WAMHSAC;
Authorize salary increases for mental
health and substance abuse direct care providers;
Provide an internal salary rate analysis
of mental health and substance abuse direct care providers and other
professionals;
Authorize a pilot project to treat
methamphetamine-addicted mothers, using the Hawaii legislation as a model.
There being no
further business, Chairman Schiffer adjourned the meeting at 3:40 p.m.
Respectfully
submitted,
Senator John
Schiffer, Cochairman Representative
Colin Simpson, Cochairman