The Committee on Health and Human Services was called to order at 1:40 p.m. on Wednesday, April 28, 1999. Chairman Vivian Freeman presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

Mrs. Vivian Freeman, Chairman

Mrs. Ellen Koivisto, Vice Chairman

Ms. Sharron Angle

Ms. Merle Berman

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

Mr. Wendell Williams

GUEST LEGISLATORS PRESENT:

Senator Ann O'Connell, District 5

Senator Maurice Washington, District 2

Senator Raymond D. Rawson, District 6

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Freeman reminded those present the committee was a body with subpoena power and expected witnesses to testify truthfully.

Mrs. Freeman then opened the hearing on S.C.R. 11.

Senator Ann O'Connell, representing District 5 in Clark County, explained the resolution was prompted by her friend and constituent Linda Flatt whose son was a suicide victim.

Nevada had the highest suicide rate in the United States. In 1997 there had been 272 suicides in Clark County alone. It was an issue few were willing to talk about, but because of the mounting statistics many people had joined the effort to address the problem. Senator O'Connell had received letters of support from Senator Reid, Mayor Jan Jones, Senator Bryan, and she said the governor was planning on becoming active in the issue. She added that people were often unaware of the tremendous toll suicide took on families, friends, and even neighborhoods. It was an issue that deserved attention. A group of young people from Douglas High School had accompanied Senator O'Connell when presentations on the issue had been made in the past, however, due to a memorial service for the victims of the recent tragedy in Littleton, Colorado, they were unable to be present.

Senator O'Connell provided a packet of material (Exhibit C) which included the written testimony of Linda Flatt as presented to the Senate when S.C.R. 11 had been introduced, as well as statistical data and news clippings, which she said supported her reason for bringing the bill forward. She added the next two witnesses would share their personal experiences with the suicide of family members.

Joyce Newman, next to speak, explained she was a registered lobbyist, however, had come before the committee as a private citizen in support of S.C.R. 11. She explained both her mother and brother had committed suicide. The impact on her family had been devastating and far-reaching, extending to friends and colleagues. Because of the stigma attached to suicide the subject was not often discussed and was frequently covered up. Her father had, in fact, succeeded in having the cause of death on her mother's death certificate changed from "suicide" to "undetermined." The impact on families was enormous and one had only to look at Littleton, Colorado, where two young men were suicidal to see the impact suicide could have on a nation. Although most suicide victims did not murder others, the suicidal warning signs of the two young men in question had not been recognized and as a result 25 young people were dead and the nation was in mourning.

In closing Ms. Newman urged passage of S.C.R. 11 to help recognize and stem the problem of suicide in Nevada, and she thanked Senator O'Connell for bringing the bill forward.

H. Jill Smith, advocacy director, Nevada Disability Advocacy and Law Center, a nonprofit agency providing legal and advocacy services for individuals with disabilities, did not take a position for or against passage of specific legislation, but would provide information and technical assistance when invited to do so as was the case with S.C.R. 11. She expressed gratitude for the individuals who had worked to bring the resolution forward, namely, Senator O'Connell, Assemblywoman Tiffany, Assemblyman Perkins, Senator Bryan, and Senator Reid. Senator Reid had also cosponsored a mirror of S.C.R. 11 to the U.S. Senate on May 7, 1997, which had passed as Senate Resolution 84 by the 105^th Congress in a unanimous vote on that same date. The U.S. House of Representatives passed a similar resolution on October 9, 1998. Those two pieces of landmark legislation had laid the groundwork for recognition of suicide as a serious national problem and suicide prevention as a national priority. Those efforts resulted in increased federal funding for suicide prevention research. The National Center for Suicide Prevention Research was established in Nevada at the University of Nevada School of Medicine in September 1998.

Ms. Smith explained those who had testified at other hearings but been unable to attend the present hearing had asked her to relay their support of S.C.R. 11. One in particular was Linda Flatt who led the Survivors of Suicide Support Group, was community organizer for the Suicide Prevention Advocacy Network, and was instrumental in working with Senator O'Connell to forward the resolution. Linda's 25 year old son Paul took his own life on June 29, 1993.

Additionally, Ms. Smith related her personal interest in the issue was as a result of her mother Helen's suicide on June 4, 1995. She had ingested a bottle of pills and placed a plastic bag over her head and killed herself by asphyxiation. Ms. Smith commiserated with those who had gone forward with the legislation in light of their personal tragedies and understood well their pain.

Ms. Smith provided her written testimony (Exhibit D) including supporting documentation and statistics, some of which had been presented earlier and noted above. She pointed out suicide happened to people from all walks of life and occurred in Nevada almost twice as often as the national average yet resources in the state were limited for prevention, intervention, and bereavement support. Suicide among the elderly was at the highest ever, most as a result of undiagnosed depression and the inability to access effective mental health services. Equally disturbing was that suicide was the third leading cause of death among adolescents. Children were dying in record numbers by their own hand. The incidents of suicide among 15 to 24 year olds had tripled, and the rate among 15 to 19 year olds had quadrupled.

In closing, Ms. Smith said it was heartening to see the State of Nevada continuing to make efforts to address the serious issue, but the first step was passage of S.C.R. 11.

Assemblyman Manendo agreed a strategy and plan was needed to combat the problem. He asked about the "community based initiative" mentioned on page 2 of S.C.R. 11 and suggested Family Resource Centers (FRC) might be a place to start. However, he believed funding was needed for education in order to accomplish prevention and asked what type of initiatives Senator O'Connell had in mind.

Chairman Freeman asked about the federal money available.

Senator O'Connell said she was shocked to discover the suicide hotline in Clark County had to be disbanded because there were no funds to continue it. She was heartened because Mayor Jan Jones was very supportive of the resolution. However, whether that support would equate to funding to continue with the hotline was unknown. She believed the first thing legislators needed to do was to approach the counties they represented and determine what they could do about it. They should be aggressive in seeking the hotline service as well as having a place where families could find support.

Mr. Manendo felt since S.C.R. 11 was a state resolution, the state needed to come up with some funding to start a statewide hotline. The state should take the first step and show by example its interest and what could be done and then look for the counties to participate as well.

Senator O'Connell said she hoped the governor would see some funding went to that issue in light of his recent expression of support.

Ms. Smith apprised the committee of some positive steps taken nationally. The Surgeon General had unveiled a strategy for prevention of suicide that included an emphasis on community based mental health services. She added Dr. Carlos Brandenburg, Department of Mental Health, who was present, could provide information on what the state was trying to do. Another community prevention effort in Minden-Gardnerville called the "Yellow Ribbon Campaign" had been undertaken by Cindy Marchant whose 14-year-old son committed suicide. Ms. Smith believed the Clark County hotline was still hanging on, which was a key prevention component. However, she also believed the research money that had gone to University of Nevada, Reno, would not be going to those types of support entities and that was a major concern.

Chairman Freeman asked if the hotline was not in the current budget. Ms. Smith said she was not familiar with the funding streams; however she understood the hotline relied on "soft money." Moreover, many of the calls were referred to the crisis unit at Southern Nevada Adult Mental Health which, according to its director, was not equipped to handle those calls.

Vice Chairman Koivisto asked if it was known why suicide occurred twice as often in Nevada than elsewhere, because if the reason was unknown how could the problem be addressed.

Dr. Carlos Brandenburg, administrator, Division of Mental Health and Developmental Services, said the ideology of suicide was the subject of the Community Training Center (CTC) grant that Nevada had received. It would examine the issue statewide and from the methodology develop a strategic plan as to how Nevada would cope with the suicide problem. Dr. Brandenburg was a member of the advisory group to the grant through the University of Nevada Medical School. They were seeking to obtain documentation of suicide because different individuals in different counties reported it in different ways. What might be a suicide in Clark County might not be a suicide in Elko, because the coroner in Elko might not report it as a suicide. The advisory group would try to standardize the methodology of the reporting and once that data was available they would examine the ideology of what was causing the high rate of suicide in Nevada.

Assemblywoman McClain asked if a mechanism existed for reporting attempted suicides. Dr. Brandenburg said "No." Ms. McClain said she was from Colorado where someone she had known had attempted suicide. When the person was out of danger, the authorities were immediately notified and the woman could not leave the hospital until she talked to a counselor, which had been effective in the long run. Dr. Brandenburg said that mechanism was not in place in Nevada.

Joyce Newman asked to speak again to emphasize the importance of dealing with the survivors of suicide. Survivors themselves had a much higher incidence of suicide. There were "clusters" of suicides and often the suicide of one family member precipitated another suicide. There had been a survivors group in Washoe County but she believed it was no longer active. There was also a loose network of people who tried to keep track of individuals with suicide in their families, but overall the support network needed to be formalized and strengthened.

Ms. Angle said she had experiences with teen suicide in her county and in fact there was often a pact between two teens. She would be very interested in an educational element to S.C.R. 11 because the relationship to the subculture of death present in teen music, internet sites, and so on, was coming to the surface again. There was definitely a problem with the subculture to which the teens were exposed and education was needed to warn parents it was not as benign as it seemed to be.

Assemblywoman Leslie said she had followed the issue for many years and had been in meetings with Dr. Brandenburg at times when cyclical suicides had occurred in downtown Reno and Ely. The value of the resolution, she believed, was limited. It would raise public awareness in the same way that a cyclical suicide raised public awareness. Nevertheless, the crisis call center in Reno limped along providing the hotline for all of northern Nevada yet were unable to get the funding needed to do the training and education in schools. It was staffed by a dedicated group of volunteers and would not exist without them. In essence, Ms. Leslie concurred with Mr. Manendo, the state should take the lead in the public health "catastrophe" in the State of Nevada. The problem was compounded by the fact from a resource standpoint it was even worse in Las Vegas than the rest of the state. Ms. Leslie's frustration, often repeated when resolutions came before the committee, but especially with S.C.R. 11, was it would not take too much money to provide the most basic service: a hotline throughout the state. The state agencies should not have to depend on a church or anyone else donating funds; the state needed to provide some base funding, and she would much rather put that forward than pass the resolution. Because, she added, she did not want everyone leaving the committee believing they had really done something by adopting S.C.R. 11 when in fact not much had been done at all. In order to do something funding was needed.

Ms. Leslie said the part of the resolution she liked best was the last paragraph that stated the legislature ought to encourage the development and promotion of accessible and affordable mental health services. Individuals prone to suicide had mental health issues. Hundreds of children in northern Nevada were on the waiting list for mental health care. She acknowledged the list was prioritized and the suicidal kids were taken first when that information was known; however, that meant the other kids got pushed back on the list until they became suicidal. Why was it necessary to wait until a child was actively suicidal to get mental health care. Until the state was willing to put money into the issue, each session would bring more resolutions and it would never be impacted in a meaningful way.

Chairman Freeman asked Ms. Leslie's opinion about dealing with the problem through the Family Resource Centers as Mr. Manendo suggested. Ms. Leslie responded some training was done in northern Nevada with the crisis call center to try to alert people. The problem was after those individuals were identified where could they be sent except to a waiting list. It was important to get those prevention mechanisms down to a neighborhood level, but it should be kept in mind the resources were not there to treat the problem once it had been identified.

Jill Smith agreed with Ms. Leslie's assessment of the situation and regretted Cindy Marchant had not been present to explain her "Yellow Ribbon Campaign." Ms. Marchant, following three suicides in Douglas County in 2 years, had taken on education in the schools as her mission. Ms. Smith went on to say that once students realized they had those difficulties the school district was not prepared to deal with it. Through the survivors of suicide group led by Linda Flatt with which she had been involved for 4 years, they had tried to accommodate a number of children who had tried to come into the group. However, children did not have the vocabulary to process the shattering they felt when a suicide occurred. Children needed a separate survivors program. She felt S.C.R. 11 was an important start because it tracked the federal resolutions and Surgeon General Satcher's national strategy. There would be an interim study group to address a number of mental health concerns, which both Chairman Freeman and Assemblywoman Leslie had promoted, but to attach a fiscal note to the resolution now would probably mean it would not go through.

In closing, Ms. Smith said S.C.R. 11 was being taken to Washington, D.C., on May 5 to join nationally with all 50 states to try to get more federal funding. It was Senator Reid, who disclosed his own father's suicide, who was able to get the money for the research center in Nevada.

Mrs. Freeman commented she saw no reason not to introduce a bill simply because it had a fiscal note. She then asked to hear from Steve Shaw.

Steve Shaw, administrator, Division of Child and Family Services, concurred with everything said so far and what everyone wanted was a more focused funding for suicide prevention. When money was spent in preventing delinquency, child abuse, or substance abuse, concurrently suicide was also being prevented. The prevention strategies in many cases were the same. Many of the efforts were benefiting from federal initiatives, some from state initiatives like the Children's Trust Funds were the best funded trust funds in the U.S. and were funded through a surcharge on birth and death certificates.

He explained with the rapidly growing population in Nevada there were a lot of people with few roots, with minimal extended family, and few "bail-out" systems, and the more those things existed the higher the state would be on a lot of social indicators.

Mrs. Freeman asked about state funding just for the hotline; that would give people at least one resource. Mr. Shaw believed that was fundamental.

Assemblyman Manendo was disturbed that legislators were encouraging themselves to do something they already had the power to do with those "feel good" resolutions. He said, "If we have a problem then let's address it and let's go get the money. Let's get a hotline, do brochures, make sure that people have help. It's one thing to do a resolution urging the Federal Government because we don't have that power here. But urging ourselves that we want to recognize suicide as a serious problem—was there anyone who didn't think suicide was a serious problem." He said he would much rather go to the Committee on Ways and Means to ask for help. He asked the Chair to hold off on voting until he could see if any money was available in the budget.

Chairman Freeman felt the committee was in agreement and asked who should be contacted for a fiscal note to fund a hotline. Marla Williams offered to make some calls for that purpose.

Assemblywoman Von Tobel returned to the issue of attempted suicides and explained she had a relative in the State of Washington who had attempted suicide. The woman was kept on the mental ward for 2 weeks, and the family was notified. "It was scary to think we do not have that system in Nevada," Ms. Von Tobel added.

Jill Smith noted there were hotlines in the state with volunteer networks available, but funding was needed to activate them. It would not take that much money. Also, the problem with having calls referred to a facility was that once people found out the result was the police would pick them up, they would not call. That course of action might be appropriate at times, but other times people just needed to express the thoughts they were having.

With no further testimony, Chairman Freeman closed the hearing on S.C.R. 11 and opened the hearing on Senator Washington's bill, S.B. 288.

Senator Maurice Washington, representing District 2, explained S.B. 288 dealt with children in their formative years. The preamble to the bill described the state's bifurcated system in its two largest counties, Washoe and Clark. Both counties were in agreement that something needed to be done about the bifurcated system. In that system there was disparity between services provided by the county and the Division of Child and Family Services and disparity between the different providers of foster care. The children were often moved from place to place and was not always in the best interest of the child. In November 1997, Congress passed the Adoption and Safe Family Act which made the Justice Department determine whether or not to reunite the biological parents with their children or terminate parental rights.

Section 3 of S.B. 288 provided a pilot program set up between Civil Protective Custody (CPC) and the Division of Child and Family Services for the continuity of child care for children currently in child protective services. The pilot program also made arrangements for services that would be provided. At the end of the biennium the two divisions would report back to the legislature on their findings.

Vice Chairman Koivisto noted the committee had requested an interim study for the purpose of studying the bifurcated system and how to correct it. She asked if Senator Washington felt the pilot program would mesh with the study, or would it be premature. Senator Washington felt it would mesh with the study. It had been an ongoing problem for a long time and because of the new federal regulations that dealt with the Adoption and Safe Family Act, it put the county in a situation where decisions would have to be made within 12 months. The pilot program would provide information as the study was underway to determine how to work with the bifurcated system or eliminate it.

Chairman Freeman stated apparently a lot of people were thinking about that subject. Speaker Dini's similar bill had been passed in the Assembly.

Next to speak was Frances Doherty, juvenile court master, Family Division, Second Judicial District Court. She provided written testimony (Exhibit E), summarized as follows:

The Second Judicial District considered the legislation and the interim study request of a critical nature. The Family Division strongly supported S.B. 288 because:

• The bill was a significant step towards creating a unified protective services system. S.B. 288 authorized and facilitated implementation of a meaningful and comprehensive pilot project to unify child protective services statewide. Commitment of resources from Washoe County Social Services and the Department of Child and Family Services was necessary. Failure to commit such resources now jeopardized more substantial federal funding resources in the future. With or without a fiscal note, however, it was critical that S.B. 288 passed.

• Children were harmed by the existing bifurcated system. Most children whose situations were sufficiently serious to warrant their removal from the family home were initially placed in the county's emergency shelter. Children so removed, regardless of the abuse or neglect involved, suffered a disruption that adults could not fully comprehend, and it often left lifelong scars.

• Children were then transferred to foster homes or relative placement to await reunification with parents. They might also change schools to accommodate out of home placements. If not reunited within 3 to 6 months, children were next transferred to the Division of Children and Family Services (DCFS); once again their lives were entirely disrupted. The consequences of such a move were numerous and harmful, jeopardizing the quality of their future lives and impacting the communities in which they lived.

• The bifurcated system conflicted with the Adoption and Safe Families Act (ASFA). Nevada's bifurcated system could not accommodate compliance with the requirements of ASFA without significant improvement in its capabilities and efficiencies.

Ms. Doherty added the pilot project and the interim study were late in addressing an abhorrent system that processed children who were wards of the court. She urged passage of S.B. 288 and then working together to get the bifurcated system eliminated and creating a unified system for the children.

Assemblyman Manendo noted the bill had originated in Senate Committee on Finance and the fiscal note book indicated a fiscal note would be required when the language was finalized. Since it had been amended he asked what the fiscal note was. Senator Washington stated the earlier bill had required a fiscal note, but the amended bill had no fiscal note.

May Shelton, director, Washoe County Social Services, stated her agency had been pleased to work with Senator Washington in developing the language for the bill. The goals of the joint permanency planning project were shown in section 3 1(c) for continuity in the placement of child in foster care. Subsection (e) provided the continuity in the management of a case for the provision of protective services to a child so the child would not be transferred from Washoe County to the state. Subsection (f) allowed the agency to carry out plans for a permanent plan as required by the Adoptions and Safe Families Act.

Ms. Shelton explained there were two parts to the bill. There had been some question whether the state and county could have custody at the same time. Section 3, subsection 1(a) clarified that question. The second part that was necessary was section 3, subsection 2, where the DCFS could pay more than what the legislature established as the foster care reimbursement rate.

In concept she believed that would work. Staff were currently working on how to implement that provision in the event the bill passed. DCFS would contribute three social workers to the joint permanency pilot project. Washoe County would contribute a supervisor and two workers, and a paraprofessional; someone who would work with the families in the home, and probably the office space. Those workers in the special unit would be assigned the cases that had some hope for reunification with family or relatives. The cases would be worked for a year when a permanent plan would be required by the ASFA. If the child was placed in a foster home, the agency would pay the $40 per day for the contract home, the state would reimburse the county $20. The agency would also share in the cost of support services. In essence, the continuity could be accomplished in the placement of the child, continued case management with the special unit, and work more quickly toward a permanent plan.

Regarding the fiscal note, Ms. Shelton the asked Senate Finance Committee for two worker positions for DCFS, which had been rejected because it was not in the governor's budget. However, if there was extra money available she intended to pursue those positions.

Assemblywoman Leslie asked if the caseloads for the special unit would be smaller than the typical DCFS child welfare caseload. Ms. Shelton said "Yes." The ongoing caseloads were 1 worker to 18 cases or families. The state's caseload size was approximately 1 to 38. If might come down to 1 to 34 if they succeeded in getting a few more positions in the 1999 session. Ms. Leslie noted time was of the essence, and based on her experience with state and county workers asked how soon would it become operable, where would the unit be located and, finally, how would the differences in philosophy between the state and the county system be handled. Ms. Shelton replied there were groups working on the implementation. The issues had been identified. Steve Shaw and she recognized there would be culture change management and both sides would have to think differently. She added her hope the program would be in place no later than October 1999. She was also presently working on space allocation at the county.

Ms. Doherty commented she felt Ms. Leslie would be impressed with how much had been done. The legislation was the second part to meetings that had been ongoing for several months. The bill facilitated an effort that had already been started, and a presentation had been made to staff outlining the project a week earlier. There was also technical assistance from the National Council for Juvenile and Family Court Judges on addressing the culture issue.

Senator Washington added he also had an opportunity to participate in several meetings on the project and commended Court Master Doherty, May Shelton, and Steve Shaw for their willingness to recognize the problems of the bifurcated system and disparity between the two agencies. All had been willing to address the problem and find a remedy. He had also participated in Washington, D.C. along with Steve Shaw's staff member in the implementation of the Adoption and Safe Families Act. There were ramifications to the state at the judicial level for noncompliance with ASFA, and passage of S.B. 288 would aid the State of Nevada tremendously.

Assemblywoman Buckley remarked it was a great bill and a great idea. Her only disappointment was it would not be done in Clark County. She sat on the ASFA subcommittee that had been ably chaired by Vice Chairman Koivisto and already made a move to amend that bill to require bifurcation to be eliminated in both northern and southern Nevada, which failed. She would leave Senator Washington's bill alone and simply vote for it.

Senator Washington responded to Ms. Buckley he had an opportunity to speak with Kirby Burgess regarding the bill and he had given his consent to try to address that and hopefully eliminate bifurcation in Clark County, so her efforts were not in vain.

Steve Shaw thanked Senator Washington for bringing the bill forward and the Committee on Judiciary for the interim legislative study. That was part of a larger vision coupled with A.B. 158 which the committee passed, and with Senator Porter's bill, S.B. 232, which allowed privatization of part of the adoptions. He also acknowledged Ann McNebbin, a deputy in northern Nevada and member of his staff, who died tragically last summer. Although he knew intellectually bifurcation existed and had done his thesis on the subject, it was Ann McNebbin who had come from out-of-state and taken a fresh look at what bifurcation did to children who initially brought the issue to his attention. She said it could not be tolerated any longer. The average child in Washoe County was moved 3.5 times. It was an adult system designed by adults for adults and did nothing for children. There was no evil or conscious perpetration, it simply happened, and the people in the agencies had a responsibility to the children to do something about it. S.B. 288 was not a "feel good" bill, it provided the flexibility in many areas to do something about the problem. Every consultant called in to look at the present system shook his head in amazement, Nevada was the only state in the nation that had such a system. It was time to do something about it. There was absolutely no conflict with the interim legislative study. In closing, Mr. Shaw urged passage of S.B. 288.

Mrs. Freeman thanked Mr. Shaw for his eloquent testimony. With no further questions or testimony, the Chair closed the hearing on S.B. 288 and said it would be the subject of a work session in the next week or so. She then opened the hearing on S.B. 73.

Senator Raymond Rawson, District 6, said Senator Raggio, who introduced the bill, was not available and he would testify on the bill because it had been through his committee. Essentially the concern was, a second evaluation was needed for clients admitted to a facility, usually involuntarily, as a safety precaution. The law had stated the evaluation needed to be given by a physician, but all physicians were not trained in psychiatry. They might have had a rotation somewhere in their career but went on to become a specialist in another discipline and the psychiatric evaluation and training had been long forgotten. The bill was an attempt to open the second diagnosis to a psychiatrist or psychologist.

Specifically there was a concern the patient's human rights were in jeopardy if someone gave the opinion who had a financial interest in the hospital. That had been amended to specify that if a psychiatrist or psychologist was on staff it was not considered to be a financial interest unless they were investors in the operation and received some monetary contribution for that. It was a simple clarification.

Dr. Carlos Brandenburg stated the division had worked in concert with Jill Smith from Nevada Disability Advocacy and Law Center and research staff on the revised language and he saw no problem with the bill as now written.

Chairman Freeman announced she had been called to the Senate to testify on a bill and needed Marla Williams to go with her. Accordingly, the committee would vote on S.B. 73 at another time. Further, S.B. 227 had been pulled and would not be heard. With no further business, the Chairman adjourned at 3:20 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: