The Assembly Ways and Means and Senate Finance Joint Subcommittee on
K-12 / Human Resources was called to order at 8:07 a.m., on Thursday, February 25, 1999. Chairwoman Jan Evans presided in Room 3137 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List.

ASSEMBLY SUBCOMMITTEE MEMBERS PRESENT:

Ms. Jan Evans, Chairwoman

Mr. Joe Dini

Mr. David Goldwater

Mr. Lynn Hettrick

Mr. David Parks

SENATE SUBCOMMITTEE MEMBERS PRESENT:

Senator Rawson (Excused)

Senator Coffin

Senator Matthews

Senator Raggio

STAFF MEMBERS PRESENT:

The Chair addressed the audience and expressed her appreciation for their attendance and interest in the mental health and mental retardation programs. She explained the morning session would focus exclusively on the budgets and the afternoon session would consist of a videoconference to Las Vegas for the purpose of receiving testimony.

The Chair recognized Dr. Carlos Brandenburg, Ph.D., Administrator, Department of Human Resources, Division of Mental Health and Mental Retardation (MH/MR) to present the budgets for that agency. She told Dr. Brandenburg committee members wanted to hear MH/MR’s progress on the various augmentations that had occurred in the previous legislative session, the status of medication (meds), as well as comments regarding the "hole" in the agency’s budget.

Dr. Brandenburg referred committee members to The Executive Budget, page MH/MR-1, Budget Account 3168. He explained MH/MR’s Administration budget account was responsible for the operation of the division of MH/MR and was funded to operate budgets that provided services in the inpatient psychiatric arena, forensic area, community mental health centers, and mental retardation programs. By statute, Budget Account 3168 was responsible for the planning, administration, policy setting, monitoring, and budget development of all mental health and mental retardation. During FY 1998, the division provided services to over 20,000 individuals; 18,000 in the mental health area and 2,000 in the mental retardation area.

Dr. Brandenburg said the total MH/MR budget for FY 1999 was $94 million and provided the following explanation of the division’s administration budget. Decision Unit M-100, page MH/MR-2, requested increased funding for the inflation factors described in the Department of Administration’s Budget Instructions. Decision Unit M-300, page MH/MR-2, reflected the benefits and changes as the result of the occupational study conducted by the Department of Personnel. Included were fringe benefits and personnel costs. Decision
Unit E-710, page MH/MR-3, reflected the cost of replacement equipment for the central office, and replacement of data processing equipment over five years old.

Dr. Brandenburg alluded to three questions raised by Legislative Counsel Bureau staff and provided the following explanations. The first question asked concerned MH/MR’s relationship to the National Disabilities Advocacy and Law Center (NDALC). He explained for the last eight months, NDALC had stopped conducting any investigations for MH/MR. The division had appointed key staff to conduct its own internal investigations. The roster included in-house personnel that could be called upon to investigate allegations of abuse and neglect. NDALC had stopped its investigations due to lack of resources and funding. Dr. Brandenburg said there had been a situation where state funds had been withdrawn from NDALC and the only investigative resources MH/MR had were its own personnel.

The Chair questioned the independence factor in terms of conducting investigations and asked if MH/MR was able to take a hard objective look at abuse and neglect allegations. Dr. Brandenburg assured the Chair MH/MR staff selected by agency administrators took a very objective view of reported incidents of neglect and abuse. There was, however, the appearance of a conflict of interest. He said if he had the choice, an outside investigative entity would be preferred. The division continued to make referrals to NDALC, even though chances were there would be no investigation. Dr. Brandenburg said that situation put MH/MR in the position of conducting those investigations and the division would always be subject to a potential conflict of interest.

The Chair asked if a report was prepared on each incident of abuse and/or neglect that included a good explanation, the parties involved, and detailed findings. Dr. Brandenburg said there was a very detailed paper trail, the funding for which was couched in The Executive Budget under a quality assurance study. That budget placement allowed the details of a case to be considered a "non-discoverable" document. He explained Deputy Attorney Generals were involved in the investigations and document review. He added the paper trail was not shared with any person or entity outside MH/MR. The Chair asked if a report was provided to the Commission on Mental Health and Mental Retardation regarding those investigations. Dr. Brandenburg said the Commission was provided with the allegations, a case history, and subsequent disciplinary action. The Chair asked if it would be feasible for MH/MR to engage another outside entity that would be able to conduct an investigation on a contract basis in view of the situation with NDALC. Dr. Brandenburg responded there were no dollars available in the MH/MR budget to engage another outside entity. He reminded committee members NDALC monies had previously been appropriated to the Department of Business and Industry and that agency’s current budget request did not contain any monies for NDALC. The Chair said if the legislature felt funding for NDALC was important, it could choose to place that funding back in The Executive Budget. Dr. Brandenburg said MH/MR would rather have an independent, neutral, third party to review all alleged abuse and neglect cases. The Chair asked if MH/MR had any knowledge of NDALC having made a request to the state Budget Office for consideration, and
Dr. Brandenburg said he had none.

Dr. Brandenburg said the second issue raised by the Legislative Counsel Bureau, Fiscal Analysis Division, was regarding the Psychiatric Residency Program. He said $174,720 had been deleted from MH/MR’s budget in each year of the biennium. Those dollars represented the funding for the Psychiatric Residency Program at the Nevada Mental Health Institute (NMHI). Dr. Brandenburg said the decision to eliminate those funds had been very difficult for the Governor. MH/MR felt the Psychiatric Residency Program, which provided a partnership with the University of Nevada Medical School, was very important. That partnership allowed MH/MR to recruit and hire an excellent psychiatric staff. Dr. Brandenburg explained Dr. Ole Thienhaus, chairman of the Department of Psychiatry at the University of Nevada Reno School of Medicine, had always been available to the division as a consultant and was employed by Rural Clinics as a provider of services.

The Chair said committee members were interested in the impact of the Psychiatric Residency Program on MH/MR. Dr. Brandenburg said the impact was significant at the NMHI which was both Joint Commission on Accreditation of Health Care Organizations (JCAHO) and Health Care Financing Administration (HCFA) accredited and certified. Closure of the program would have minimal impact on the Southern Nevada Adult Mental Health Services (SNAMHS) because there was no residency program in southern Nevada, nor would the closure have an impact in the rural clinics. MH/MR had an excellent partnership with the University of Nevada Medical School during the last six years. The residents were actually part of MH/MR’s treatment staff and were used to assist with both inpatient and outpatient caseloads. Dr. Brandenburg’s concern was the residents in the program would lose the ability to be involved and deal with the severely mentally ill population in the State of Nevada if the program was closed.

Dr. Brandenburg said the third question Legislative Counsel Bureau, Fiscal Analysis Division staff had raised was regarding the transfer of the Clinical Program Manager position from Budget Account 3167 (Rural Mental Retardation) to Budget Account 3168 (MH/MR central office). He explained the move was the division’s first step to centralize its quality assurance functions between mental health and mental retardation as had been discussed during the 1997 Legislative Session. MH/MR’s plan was for the position to focus its duties on mental retardation quality assurance activities and recover some of the costs by billing Medicaid for quality assurance services. Dr. David Luke, Associate Administrator, Mental Retardation Services, would continue to supervise all regional centers. The division would have more central office involvement in the quality assurance process for both mental health and mental retardation clients.

The Chair asked for an estimate of how much Medicaid funding might be collected and recognized Michael Torvinen, Administrative Services Officer, MH/MR. Mr. Torvinen said there was no firm estimate at that time, but guessed the collections would be in the range of $5,000 to $10,000. Dr. Brandenburg added those figures were based on Medicaid billing experience of the current mental health quality assurance staff.

Dr. Brandenburg said he had no further comments regarding Budget Account 3168. The Chair advised there were no further questions from committee members and pointed out there were nice improvements in the division’s performance indicators. Dr. Brandenburg commented MH/MR’s performance indicators were tied into the national performance indicators under the Mental Health Statistical Improvement Grant that allowed Nevada to compare its indicators and outcome measures to those of other states.

Dr. Brandenburg deferred explanation of this budget to David A. Rosin, M.D., State Medical Director, Nevada Mental Health Institute (NMHI), and
Robert A. Harnish, Jr., Business Manager, NMHI. He reminded committee members the Governor and legislature, during the 1997 Legislative Session, had given MH/MR a 132 percent increase in medications which totaled $6.7 million statewide. That increase proved to be an extremely important part of the division’s therapeutic program.

The Chair recognized Dr. David Rosin, State Medical Director, Nevada Mental Health Institute (NMHI) who referred committee members to The Executive Budget, page MH/MR-6. He explained the institute’s Base budget reflected $17,027,989 in FY 2000 and increased to $17,225,261 in FY 2001. Pages MH/MR-7 through MH/MR-13 of The Executive Budget listed the programs at NMHI. He explained the institute was a full-service psychiatric health system that provided broad community-based services with an acute care inpatient psychiatric teaching hospital and teaching clinic.

Dr. Rosin began by thanking committee members for the support given during the 1997 Legislative Session which resulted in the Jim Miacawa Residential Treatment Center. The center began operation in August of 1998 and had been at the bed capacity of eight clients since December of 1998. The center had been contracted to EduCare and consisted of three levels of treatment care that ultimately lead to independent living in the community. Dr. Rosin explained the program was designed to assist clients who had been unable to maintain themselves outside the hospital due to their lack of living skills. The program was designed to improve those living skills and thereby prevent clients from returning to inpatient care. He said there were five clients that had completed the program through level two. One client was at the most independent level, level three, and was awaiting community placement at that time.

The Program for Assertive Community Treatment (PACT) program had also been funded during the 1997 Legislative Session and provided a treatment center in the community designed to treat 72 of NMHI’s most severely disturbed clients that had resided in the hospital for extended periods of time. The PACT team included psychiatric caseworkers, registered psychiatric nurses, a half-time psychologist, and a half-time psychiatrist. Dr. Rosin explained PACT was not operating at full capacity as the result of the budget shortfall. The team was functioning at half strength and was able to extend service to 28 severely disturbed clients in the community. Those clients could be seen
24-hours-a-day, 7-days-a-week. The PACT team was always on-call and did not operate under normal working hours. He said the outcome data looked very good for the first three months of operation. Since its inception, the PACT team at NMHI had reduced the average monthly inpatient days from 214 to 9. PACT went into the jail, into the community and into the hospital. No patient assigned to the PACT team was admitted to the hospital without team involvement.

Dr. Brandenburg explained what Dr. Rosin in northern Nevada, and Dr. Northrup in southern Nevada, had done was take those severely mentally ill clients with a high propensity to be readmitted to the hospital and reduced those occurrences dramatically. The Chair wondered, with the PACT team’s level of success, what the caseload would look like over a period of time. Dr. Brandenburg explained it would be necessary to analyze a 2-year period of operation before he could answer that question. He said NMHI hoped to return to the 2001 legislature with PACT accomplishments. The Chair commented NMHI performance indicators should include numbers of persons participating in the PACT program and what the costs would have been had those individuals been admitted to inpatient programs. Dr. Brandenburg said those cost factors would be reflected in future performance indicators and added that while costs savings were being incurred on the inpatient side, there was a tremendous increase in costs on the outpatient side.

Continuing, Dr. Rosin explained to committee members that clients of NMHI were receiving the most modern psychiatric medications available, both in the newer anti-depressant medications and the newer atypical anti-psychotic medications. During the 1997 Legislative Session, Dr. Rosin said he had provided an estimation of what the community standard would be and had requested funds accordingly. That estimation was based on the polling of psychiatrists that practiced within the State of Nevada. He pointed out that prescribing practices had changed over the last two years, especially for the atypical anti-psychotic medications. At the time Dr. Rosin initially polled psychiatrists, the newer atypical medications were just beginning to become first-line anti-psychotics. He said the use of those types of medications was higher than initially estimated, and that increased use was reflected in the prescribing practices at NMHI. However, on the Selective Seratonin Reuptake Inhibitor (SSRI) anti-depressant side, NMHI had found that clients in their clinical practice who were able to maintain themselves reasonably well on the older anti-depressants had, in some cases, requested to be returned to those older medications due to their familiarity. That resulted in a somewhat lower subscription rate of SSRI meds than NMHI had projected. Dr. Rosin said the initial outcome data of the new Atypical anti-psychotic medications was very encouraging. NMHI had performed a study which compared the number of hospital days and associated costs before and after the use of both the anti-depressant as well as the newer atypical anti-psychotic medications. The study examined 221 clients who had been treated with the newer anti-depressant SSRI medications. The clients were evaluated for a period of time prior to and after the use of the medications. In those cases, the number of inpatient episodes fell from 48 to 30, and the number of inpatient days fell from 1,008 to 688. The number of observation unit days, which included those clients who were in and out of NMHI within three days, fell by 13.6 percent.

Dr. Rosin said it must be noted there was an initial across-the-board increase in community-based service costs. NMHI housing and medication costs, as well as clinic visit costs, had increased as the result of clients becoming healthier and requiring more services in the community. He said the same was true for those clients receiving atypical anti-psychotic medications. That study involved 628 NMHI clients who were evaluated before and after the use of the newer atypical anti-psychotic medications. Of that population, the number of inpatient episodes fell from 113 to 69. The number of bed days decreased from
3,423 to 1,821. The number of observation unit episodes fell 12 percent.
Dr. Rosin explained a second study was performed regarding quality of life and symptom reduction. That study involved 55 clients who had received the atypical anti-psychotic, Clozaril. All 55 clients had failed in the treatment with the older anti-psychotic medications. There was a drop in baseline score of the Brief Psychiatric Rating Scale (BPRS) which measured psychotic symptoms. That drop in baseline score was from 60 to 30 within the first 90 days of treatment using the newer medication and reflected a marked reduction in psychotic symptoms.

Dr. Rosin went on to explain the capital improvement projects of NMHI. He said the plans for the new hospital had been finalized and the bidding process was to begin the summer of 1999. NMHI had also received funds during the 1997 Legislative Session to restore several buildings on campus. He reported the restoration of Building 8, the inpatient psychiatric hospital, had been completed the week of February 8, 1999. That restoration allowed for a habitable environment for NMHI clients until the new hospital was completed. The outpatient clinic was also in the process of being remodeled. Additionally, NMHI had been given funds to prepare Building 7 to function as a psychiatric emergency service facility. Building 7 would be completed by July 1999.

Dr. Rosin referred committee members to The Executive Budget, pages
MH/MR-7 through MH/MR-13, which reflected NMHI programs. He said outcome indicators had been provided for each clinical program and added the institute had developed a broad base of outcome measures reflecting symptom reduction, time in the community, level of function, productivity, and others.

Referring committee members to The Executive Budget, pages MH/MR-7 through MH/MR-10, Dr. Rosin provided the following budget explanations. Decision Unit M-100 reflected increases for those inflation factors defined in the Department of Administration’s Budget Instructions. FY 2000 reflected $140,606 and FY 2001 reflected $207,989. Decision Unit M-300 requested funds for fringe benefits and personnel cost increases precipitated by the occupational studies. FY2000 reflected $331,647 and FY 2001 reflected $470,430. Decision Unit E-376 requested increased funding to comply with NRS 284.174 which required independent contractors who provided security services to NMHI to possess the skills required of, and meet the same physical requirements as law enforcement personnel certified by the Peace Officers Standards and Training Program (POST) created pursuant to NRS 481.053. FY 2000 reflected $ 38,471 and FY 2001 reflected $38,296. Decision Unit E-710, Replacement Equipment, reflected monies for replacement equipment at the institute.

Dr. Rosin called for questions. The Chair commented on the naming of the residential treatment center after Dr. Jim Miacawa, and said the Division of Mental Health and Mental Retardation (MH/MR) made an excellent choice.
Dr. Miacawa was a fine professional and a fine human being, and the treatment center was a nice tribute to him.

The Chair said she noticed the average length of stay at the institute was being increased from slightly over 14 days in FY 1998 to 19 days in FY 2001, and asked for an explanation of that projection. Dr. Rosin said the institute’s budget was built with the understanding there would be psychiatric emergency services (PES). The institute had become user friendly in the last four years and had gone out of its way to open its doors to all referral services, including the Washoe County Detention Center. He said those projections had been based on NMHI’s actual census data regarding average length of stay. The Chair said the institute was staffed for 52 inpatient beds, but for some time she noticed the institute’s census had averaged in excess of 52 clients, and Dr. Rosin said that was correct. The Chair asked what affect those excess clients had on caseload management. Dr. Rosin said one of the problems at NMHI was that admission unit staff functioned both as a triage unit and an acute psychiatric admission unit. Because of that circumstance, 42 percent of admissions came and went from the hospital within three days, putting a tremendous strain on its treatment teams. Those treatment teams included psychiatrists, social workers, psychologists, nurses, and mental health technicians. Dr. Rosin again commented the institute’s budget had been constructed with the understanding funding would be available for PES which would, in turn, relieve the inpatient unit of that workload. He said NMHI would provide care the best it could with the resources available. Dr. Brandenburg pointed out the client figures were contaminated by the fact the PACT program was not being operated on a
full-time basis, in conjunction with the fact the Jim Miacawa Residential Treatment Center had only been opened since 1998. Dr. Rosin said another issue was that NMHI’s second-year psychiatric residents treated six inpatients each and that inpatient population turned over at a rate twice that of the southern Nevada facility. In the absence of those residents, NMHI would have to pick up an additional third of the turnover rate in the 52 beds.

The Chair asked how the loss of the Psychiatric Residency Program at the institute would affect care. In terms of caseload management and treatment at the institute, Dr. Rosin said the residency program provided relief in inpatient services. Residents carried a caseload in outpatient services which was part of the attending psychiatrists caseload. Attending psychiatrists treated people at the rate of 20 minutes per visit. Residents treated people no more frequently than every 30-minutes, but did provide stability in the clinic by assuming
walk-ins and emergency cases. Those walk-ins and emergency cases were the result of NMHI’s inability to triage and provide direct focus towards emergency services. Again, The Chair asked how vital the Psychiatric Residency Program was in terms of work and, in the absence of residents, how the overall work would be affected. Dr. Rosin replied NMHI would continue to provide services the best it could. It was difficult for Dr. Rosin to determine the exact level of effect. He pointed out that NMHI, being a teaching hospital, had attracted some very good attending psychiatrists. The institute had been able to hire one of the residents that had graduated from the program and was planning on hiring a second, and possibly a third resident from the program. The Chair asked the longevity of the psychiatrists. Dr. Rosin explained one of the difficulties at the institute was the turnover rate. He said that rate could be attributed to burnout. The high burnout rate was directly related to the amount of volume processed through the 52 beds and the outpatient clinic, which was faced with 10 to 20 interruptions per day in terms of walk-ins and emergencies. He said the inpatient services burnout rate was high because they ran both triage and a psychiatric inpatient unit. Having been at the institute since
July 1995, Dr. Rosin had the longest tenure. The Chair asked if having a residency program had any kind of effect on recruitment efforts. Dr. Rosin said one of the positives of being a teaching hospital was that case conferences were conducted and there was residency supervision. Those benefits attracted people to an institution.

The Chair commented on Dr. Rosin’s earlier testimony regarding building restoration to be completed by July 1, 1999, for psychiatric emergency services (PES) and asked if that facility would be a fully-operational psychiatric emergency unit and how that unit would be operated. Dr. Rosin explained there were no plans under the current budget to be able to operate that facility. The Chair noted there would be a facility in place, however, there were no funds to operate that facility. Dr. Rosin said as soon as funds became available, the facility would be staffed. Dr. Brandenburg added MH/HR had been directed by the 1997 legislature to seek and secure operating funds for PES during the current legislative session but because of the budgetary shortfall, there were no monies available for that service at the institute. The Chair noted PES were available in southern Nevada, but none in northern Nevada and Dr. Brandenburg responded that was correct. As the result of the budgetary constraints, the Chair clarified there was an additional 2-year vacuum in northern Nevada for PES and Dr. Brandenburg responded that was correct. The Chair asked if a budget had been developed for those services and Dr. Brandenburg said that budget would be $2.4 million for the biennium. The Chair asked if the
$2.4 million represented General Fund monies. Dr. Brandenburg said three quarters of the total would be General Fund monies.

On the subject of revenue, The Chair requested an explanation of MH/MR’s ability to collect from insurance companies. Dr. Brandenburg deferred the question to Bob Harnish, Administrative Services Officer, Nevada Mental Health Institute (NMHI). Mr. Harnish said NMHI had been working on a billing summit. The institute had billing issues that differed between southern Nevada and northern Nevada. The summit would ensure NMHI was obtaining all funds possible. The Chair expressed the committee members’ interest in the area of billing and the need to tap as many available resources as possible.

On a similar subject, The Chair commented on the contract for the 8-bed residential treatment center with EduCare and said there was concern the contract called for the state to pay for beds even though those beds may not be filled. Mr. Harnish said that interpretation was correct. When the contract was originally negotiated, prior to his original knowledge, the only way a contractor would come on board was to be guaranteed the payment for the 8 beds whether they were in use or not. To date he explained, there was a total of 778 paid bed days. The stated had paid unfilled bed days totaling 566. He said the business office of NMHI had billed Medicaid under the rehab option for $102.51 of the daily total allowance of $132. The remaining $29 per day represented room and board fees. Staff had diligently attempted to obtain all or a portion of room and board fees from clients.

The Chair asked if EduCare was providing adequate client information for billing purposes. Mr. Harnish said he had recently requested the number of hours EduCare had submitted for payment, and EduCare had been unable to provide that information. In researching the Medicaid instructions, NMHI staff had discovered the rehab option of billing. That option allowed the institute to perform direct billing and provided for greater control of the expenditure of state funds. Regarding the vacant bed issue, Dr. Rosin explained that during program startup, EduCare had an untrained staff and clients had initially been added to that center at a slow rate. With the exception of clients that had entered the hospital, or those that were absent for several days, the center had maintained the 8-bed capacity since December 1998. The empty beds at startup represented a major number of bed days paid for by the agency which had not been projected. Dr. Brandenburg embellished on the relationship of NMHI with EduCare and said that partnership was extremely valuable on both the mental health and mental retardation sides. The institute had no experience in the development and operation of community-based mental health services and the startup of the 8-bed facility was bumpy for both entities. There was no doubt in Dr. Brandenburg’s mind that EduCare would be able to provide the information necessary for billing purposes. The Chair recognized there were issues with the startup of any new program.

Referring committee members back to the PACT program, The Chair questioned the reclassifications and reassignment of positions. She was particularly interested in the request to change the Occupational Therapist position to a Psychiatric Case Worker position. Dr. Brandenburg explained when the PACT program had been put together, there was an Occupational Therapist position for both the north and south. After discussions with PACT team members, it was determined it would be very difficult to recruit and retain an Occupational Therapist at the salary those individuals demanded and, as a result, MH/MR had decided to reclassify that position to a Case Manager II, grade 32, the same grade as an Occupational Therapist. No cost would be incurred by the state. The reclassification would allow MH/MR to tie in its psycho-social programs and provide auxiliary services as well. The Case Manager would have a caseload of 12 and would provide an interface for the existing leisure time and occupational activity programs.

The Chair recognized Dr. Brandenburg who explained Lake’s Crossing Center was the state’s maximum security forensic facility. The facility received referrals from all courts throughout the State of Nevada. Dr. Brandenburg introduced Harry A. Dudley, Director, Lake’s Crossing Center for the Mentally Disordered Offender (LCC). Mr. Dudley, in turn, introduced Dave Hansen, Administrative Services Officer, LCC. Mr. Dudley said the agency’s budget was approximately $4.5 million in FY 2000 and $4.6 million in FY 2001. He explained LCC was responsible for inpatient care of individuals who had been found incompetent to stand trial. Competency evaluations were conducted for the courts throughout the state. The demographic distribution of admissions during FY 1998 was 39 percent from Clark County, 25 percent from Washoe County, and 36 percent from Nevada’s rural counties. In addition to its inpatient caseload, LCC provided mental health services at the Clark County Detention Center and Las Vegas City jails through a cooperative contract with EMSA Correctional Care, the medical provider for those facilities. Mr. Hansen said there were four clinicians at those facilities. EMSA paid one-half the cost of those positions. Additionally, LCC had an inter-local agreement with Washoe County to provide competency evaluations for the district courts in Washoe County pursuant to A.B. 225 (1997). That bill provided for Washoe County to split costs evenly with the state. In the last two years the center had two to three outpatients being treated for competency restoration. He explained Chapter 174 of the Nevada Revised Statutes provided for outpatient competency restoration in cases where the people were not a danger to self or others. While no new positions had been requested this biennium, the
17 positions previously approved for FY 1999 to staff the addition to LCC had been carried forward to the current budget. Mr. Dudley said the increases in LCC’s budget were reflected in the separate decision units and would be clarified by Mr. Hansen.

The Chair recognized Dave Hansen, Administrative Services Officer, LCC. Mr.
Hansen referred committee members to The Executive Budget, pages
MH/MR-12 through MH/MR-13 and explained Decision Unit M-100, represented inflationary increases primarily for printing, insurance, medical, food, postage, and utility-type items. Decision Unit M-200 provided additional expenses to take on the 12-bed addition scheduled for completion in July 1999. Included in that package, in the Professional Services line item, was a contract psychiatrist at $49,400 in each year of the biennium. Decision Unit M-300 provided funding for the Occupational Study salary increases and salary fringe benefit adjustments. Decision Unit E-710 provided for replacement equipment, the primary item being an antiquated dictation system for which parts were no longer available.

The Chair asked for a roll-out date for the 12-bed addition and Mr. Dudley said Public Works would be asking the legislature for an extension of appropriations into early July 1999. He explained the drop-dead date for completion of the project was June 18, 1999, however that date would not be met due to a number of project delays. The project would be totally completed (superstructure, furnishings, and equipment) and ready to staff by the middle of July 1999.

In view of the fact there were no requests for additional staff, the Chair asked how the additional responsibility of the 12-bed addition would be handled.
Mr. Dudley explained 17 positions had already been approved in anticipation of the opening of the new project. Mr. Hansen clarified those positions were included in LCC’s base budget.

The Chair questioned the ability of LCC to accommodate the needs of the entire state, specifically southern Nevada. Mr. Dudley said LCC had been able to avoid some admissions to the center as the result of the absence of a determination of competency. The Chair commented the state would reach a point where a second facility would be required. Dr. Brandenburg said the
12-bed addition to LCC was an attempt to defer the cost of a new southern Nevada forensic facility for at least another four to six years. Estimates received four years ago, to construct a 50-bed facility in Clark County, were in the neighborhood of $15 per square foot, with an additional $4 million to
$5 million in operating costs. In lieu of a new facility, MH/MR had presented its request for the 12-bed addition. He said MH/MR felt 50 beds represented a manageable population and within the next two to three biennia MH/MR would be requesting funding for the construction of a southern Nevada forensic facility.

Dr. Brandenburg explained Rural Clinics provided services in 16 of the
17 counties in Nevada. He introduced Charles L. Buel, Ph.D., Acting Administrator, Rural Clinics. Dr. Buel introduced James W. Bryant, Administrative Services Officer, Rural Clinics.

Dr. Buel explained Rural Clinics was a community-based program that stretched from the western part of Nevada along the Sierra’s to Elko, in the northeast down to Ely, and in southern Nevada, Mesquite, and Pahrump. The Mesquite and Pahrump offices were part of the enhancement budget from the last biennium and were both opened in 1998. He said there were 16 offices, 10 of which were satellite operations. Rural Clinics traveled to Wendover, Caliente, and Eureka to provide services, although no office was maintained in those locations. Rural Clinics was the only agency that provided services to children, and in view of recent attempts to return children to Nevada from out-of-state placements, the spotlight had been placed on Rural Clinics to work with those seriously disturbed children. Rural Clinics was working with the division of Child and Family Services (DCFS) to do just that. Continuing, Dr. Buel said Rural Clinics provided outpatient therapy, emergency services, case management, psycho-social rehab, medication clinic services, consultation education, and housing programs in each of its satellite offices.

The Chair recognized James W. Bryant, Administrative Services Officer, Rural Clinics. Mr. Bryant referred committee members to The Executive Budget, pages MH/MR-16 through MR/MR-18 and explained the agency’s budget request for the next biennium was slightly over $7 million for each of the two years. Decision Unit M-100 included a modest inflationary increase for postage, printing, and insurance. Decision Unit M-200 reflected $6,000 in the first year of the biennium and $8,000 in the second year of the biennium and represented increased medication costs. Decision Unit M-300 was the result of an occupational study and reflected salary increases and salary fringe benefit adjustments. Decision Unit E-710 reflected costs for equipment replacement.

The Chair recognized Mr. Hettrick who expressed his concern with the overcrowding in Douglas County and other rural clinics and asked if those situations were addressed in the budget. He said if the Decision Unit M-200 dollars of $6,000 and $8,000 were for meds, how would the overcrowding issues be addressed. Mr. Bryant said Rural Clinics currently occupied an
1,800 square foot building in Douglas County that included eight staff. Group psycho-social rehab services were provided to seriously disturbed people. Rural Clinics was loaned space by Parks and Recreation and the Cooperative Extension Service on a weekly basis. Rural Clinics estimated they would need approximately 3,000 square feet to accommodate the existing staffing pattern and the needs of the clients. The budget had no dollars to effect a move.
Dr. Brandenburg interjected an enhancement unit had originally been submitted for such an expansion, however due to budgetary shortfall, those funds had been removed from the budget. The total amount for the biennium for the Douglas office to move and expand was $94,000. Mr. Hettrick asked if there had been enhancements for any of the other rural clinics. In terms of office space, Dr. Brandenburg said the only other enhancement request was for the Carson City office. However, discussions with the office manager in the Carson City office determined there was sufficient space for the next two years.

The Chair referred committee members to the outpatient waiting list numbers for FY 1998-99 that reflected the number of clients waiting 15 days or longer for their initial visit. In Douglas County, that number was 22. Fallon was at
21, and Carson City was at 28. Having already received an explanation for Douglas County, The Chair requested information regarding the waiting list numbers in Carson City and Fallon. Mr. Bryant said Carson City began as the largest Rural Clinics community served and, with the exception of Douglas and Lyon Counties, continued to have the highest growth rate. Rural Clinics was looking at modifying intake procedures and Mr. Bryant felt the Carson City office was running efficiently. The Chair asked what it would take to decrease the numbers on the waiting lists. Dr. Brandenburg responded it would take the funding of the demographic growth package that had been deleted because of the budgetary shortfall. The Chair asked if Rural Clinics served both adults and children, and Mr. Bryant said that was correct. Dr. Brandenburg added
25 percent of the Rural Clinics caseload represented children and adolescents, while 75 percent represented adults.

The Chair asked if the capacity existed at any Rural Clinics office to deal with patients on an emergency basis. Since its inception, and with a major grant from the Federal Government in 1977, Mr. Bryant said Rural Clinics had provided emergency services 24-hours-a-day, 7-days-a-week. Every clinic had an emergency on-call schedule and time allotted for emergencies. The Chair asked who made the decision of whether or not a case was to be considered an emergency. Mr. Bryant responded the clinician either receiving the call or making the observations, based on clinical judgment, would make that decision. The Chair asked if emergencies were frequent, and Mr. Bryant said they occurred on a regular basis. Dr. Brandenburg added one thing that separated rural clinics from northern and southern Nevada was that staff in the rural areas had to be eclectic and know a little bit about a lot of things to include adolescents, adults, and sexual offenders. More often than not, a case manager was also the social worker entering the schools to participate in suicide assessments. The Chair observed everything was tougher in the rural areas and the committee members would have to revisit those issues. The Chair noticed the new Pahrump office already had a long waiting list for initial visits.
Dr. Brandenburg reminded committee members that in order to open both the Pahrump and Mesquite offices, the agency had been unable to fund both a psychologist and caseworker position in each of those offices.

Referring back to Dr. Brandenburg’s testimony regarding funding of demographic growth in an effort to reduce waiting list numbers, The Chair asked if funding would have included positions. Dr. Brandenburg said the demographic growth package included six positions; three social workers and three case managers.

The Chair requested an explanation of the 999 Unfunded Decision Unit and clarification of the M-200 Decision Unit. Dr. Brandenburg clarified the
$6,234 in FY 2000 and $8,084 in FY 2001 represented medication caseload growth only. The Chair clarified the 999 Unfunded Decision Unit would have included funding for the six positions to assist with waiting list reduction. Additionally, the Chair noted Rural Clinic’s outpatient medication waiting list for FY 1998-99 in the Carson City office showed a patient would wait on the average of 21 days to receive medications. Dr. Brandenburg clarified that item actually reflected 21 patients waiting an average of 15 days or more. He said Dr. Buel and his staff were to be commended because they had developed a very accurate tracking system for the waiting lists. The Chair requested an explanation of 15 days "or longer." Mr. Bryant said "or longer" meant three to four weeks from the date of visit. The Chair also recognized the same pressure in the Yerington center. Mr. Bryant said the Carson City office was trying to increase its psychiatry time by a few hours and Douglas County had agreed to add five hours per month. Those additions would help trim down the waiting lists.

The Chair asked which was of more concern, the waiting list for the initial visit, or the waiting list to receive meds. Mr. Bryant explained Rural Clinics was an outpatient organization and the port of entry. Individuals waiting for the initial visit for outpatient services would include all incoming clients. A portion of those would require medication. The medication list was developed from the initial intake visit. There was a second waiting list for the medication clinic itself. Mr. Bryant said the Rural Clinics clinicians did a very good job analyzing clients and processed the more severely disturbed clients very quickly to see the psychiatrist. Individuals in an obvious crisis were not kept waiting for medication.

The Chair referred committee members back to Decision Unit E-710 and asked if the request reflected current expenses in view of rapidly changing prices, particularly in the area of computer hardware and software. Mr. Bryant responded the figures for computer equipment were derived from the Executive Budget Memo which told the agency the amounts to request. The market was surveyed regarding prices of additional equipment requests.

Dr. Brandenburg introduced James T. Northrop, Ph.D., Director, and
Gwen S. Bush, Administrative Services Officer, Southern Nevada Adult Mental Health Services (SNAMHS) to present the budget for the agency.

Dr. Northrop referred committee members to The Executive Budget, page MH/MR-21 and said the agency had proposed a budget of $28,759,450 in
FY 2000 and $30,147,773 in FY 2001. Dr. Northrup reviewed several programs funded by the 1997 legislature. The first was medications. He pointed out the new medications had profound effects on both rates and length of hospitalization. Adding to Dr. Rosin’s presentation, Dr. Northrup commented the positive use of atypical anti-psychotic medications was reflected in decreased hospitalization. SNAMHS had been saving approximately $4.45 per day on the new medications. Additionally, costs had been reduced for the SSRI’s by approximately $9.69 per day.

While prior testimony had reflected some incorrect projections, SNAMHS had seen a large growth in patient utilization which, to date, had exceeded some projections. Dr. Northrup said the latest projections seemed to suggest the trend was more closely following the projections. Costs had been higher because SNAMHS had attempted to predict prescriptive practices. As the committee members were aware, SNAMHS had requested some switching of funds in its budget to accommodate cost overruns that were not predicted. Also funded by the 1997 legislature was the Bruce Adams Residential Treatment Program, a 16-bed facility to provide moderate-term care and training for seriously impaired individuals. Although the contract was approved, there had been some initial delays in zoning. As part of SNAMHS’s reversion program, a delay was incorporated. As of February 22, 1999, Dr. Northrup had been advised Mojave Mental Health (MOJAVE) planned to open at partial capacity (9 clients) in May 1999.

Dr. Northrup reported intensive care management had a reduced caseload that served individuals that were seriously mentally ill and had involvement with the criminal justice system. Intensive care management had been started as a demonstration program with a limited number of staff. The program had begun data recording in November of 1997 and Dr. Northrup was pleased to report that only one client had re-offended. There were three admissions to psychiatric emergency services (PES), and 12 admissions to inpatient. Putting those statistics in context, PES were down 75 percent and the admissions to inpatient program were down approximately 66 percent.

Dr. Northrup explained the 1997 legislature also funded the new Program for Assertive Community Treatment (PACT). That program was currently operating with a caseload of 54. Since its inception, PACT had shown a reduction of approximately 60 percent in hospitalization frequencies. In addition to the success of the PACT team, the program included a psychiatrist who made house calls to patients.

Referring committee members to pages MH/MR-22 through MH/MR-26 of
The Executive Budget, Dr. Northrup explained Decision Unit M-100 represented increased funding for inflation factors defined by the Department of Administration instructions and totaled $319,177 in FY 2000 and $502,819 in FY 2001. Decision Unit M-200 was based on projection of need, and the agency had proposed to add 3.51 psychiatrists and 3.51 nurses to provide services to the projected population. Also included were 1.76 management assistant support service positions. Dr. Northrup said the medication caseload had exceeded projections during the current biennium. Due to the explosive nature of the medication caseload category, SNAMHS was requesting committee members consider a letter of intent for the next biennium requiring consistent review and intervention as needed. Decision Unit M-300 requested fringe benefit changes that had occurred as the result of occupational studies. That decision unit totaled approximately $521,000 in FY 2000 and
$713,000 for FY 2001. Decision Unit M-825 was a Y2K accommodation for the upgrade of a heating ventilation air conditioning control computer unit. The total cost of that package was $3,600. Decision Unit E-125 represented funding for environmental care, namely, a contract for air duct cleaning to avoid health problems. The cost was $50,000 for FY 2000. Decision Unit E-130 reflected anticipated reductions in Title XX funding which had been used to fund various independent living and supported living arrangement programs.
Dr. Northrup said SNAMHS believed it could collect more compensation from Medicaid, however there were $26,141 in General Fund dollars requested in FY 2001. Decision Unit E-375 allowed SNAMHS to comply with NRS 284.174 to have its security guards trained at the Peace Officers Standards and Training program for both the North Las Vegas and West Charleston sites. The total cost for FY 2000 was $45,696 and the same for FY 2001. Decision Unit
E-710 reflected funds for replacement equipment, predominantly aged computers. The cost was $131,031 in FY 2000 and $109,780 in FY 2001.

The Chair recognized Senator Raggio who asked how SNAMHS programs were coordinated with MOJAVE, how clients were distributed to that program, and how was quality control monitored. Dr. Northrup described the referrals to MOJAVE as being the patient’s decision. SNAMHS’s psychiatric ambulatory unit identified whether or not an individual was a Medicaid recipient, and, if so, those individuals were offered the opportunity to be referred to MOJAVE for services. There was a standard referral form and procedures used to accommodate transfers. He said SNAMHS had a Ph.D. social worker who visited MOJAVE on a weekly or biweekly basis to evaluate persons not referred by them. The social worker would determine if the person was seriously mentally ill, a requirement for Medicaid reimbursement, and processed them into the SNAMHS system. A check and balance system was in place. In terms of quality control, Dr. Northrup explained there were two levels of monitoring provided by both SNAMHS and by the division of Mental Health and Mental Retardation (MH/MR). MOJAVE participated as a regular sitting member of MH/MR’s quality improvement committee and made presentations just like every other department of the agency. Presentations by MOJAVE were on a cycle of reporting every second meeting and rotated between medication clinic, counseling program, and case management. In most cases, MOJAVE had adopted the same kinds of indicators used by MH/MR divisions. Additionally, MOJAVE was included in MH/MR’s audit system and was audited on a regular basis. MOJAVE was in existence only as the result of Medicaid collections. SNAMHS served as the gatekeeper as MOJAVE could not serve or bill until verification was provided by the division.

The Chair asked if MOJAVE served children. Dr. Northrup said he believed a contract existed with the Division of Child and Family Services (DCFS) in southern Nevada and that those services were being expanded to northern Nevada. The Chair asked the status of the removal of children’s beds in the SNAMHS facility. Dr. Northrup explained for several years space had been provided to DCFS on the second floor of its hospital facility that was licensed as a group home. During that time 22 persons had been placed. In January 1999 half of those individuals were moved to the new Desert Willow facility. The move of the balance of those individuals was delayed as the result of the Medicaid certification process which would allow for their placement at Desert Willow. Dr. Northrup said the empty beds were designed to be used as an acute psychiatric hospital unit and no determination had been made regarding their usage.

The Chair requested clarification of the difference in inpatient bed days between southern Nevada and northern Nevada. Dr. Brandenburg said the primary factor was that southern Nevada had psychiatric emergency services (PES) and was able to deflect cases from the hospital. The absence of PES in northern Nevada contaminated the data.

Referring to Dr. Northrup’s earlier comments regarding medications, The Chair asked how conservative was the funding request. Dr. Northrup deferred to Gwen Bush who had a better handle on the specifics of the calculations.
Ms. Bush explained SNAMHS had presented several estimates of average costs of prescriptions, along with its estimates of caseload growth. She indicated they used a 17-month average, that included part of calendar year 1999, and FY 1999. The atypical anti-psychotic drugs were just being phased in during FY 1998 and the average was $41.34 per prescription. For the
17-month average, the cost was $45.72 per prescription. For FY 1999 the cost was $55.79 per prescription. With economics in mind, she said the 17-month average of $45.72 was chosen. She said the agency was not completely satisfied with those figures and would appreciate the safety net provided by a letter of intent. The Chair said it was clear the agency had made its best estimate regarding prescription costs but was not secure in the fact that estimate would hold. Dr. Northrup said the agency had looked very carefully at the specific needs between traditional and modern medications without jeopardizing, or in any way influencing, community standards. Dr. Brandenburg added another important variable in the area of prescription costs was the agency being on target with its projected caseload. At the time the budget was constructed, the figures were above the caseload.

The Chair questioned the request for two new Accounting Clerk III positions. Although information provided to committee members indicated those positions were not recommended, after close re-examination, the agency determined the two positions could be self-funded. Ms. Bush advised that while her billing and financial staff were few in number, they were doing a fabulous job. With the additional caseload, new programs, and new site offices, the agency felt with better financial services and more services to the site offices and directly to the PES site, the agency could increase its non-state revenue enough to cover the two positions previously requested. The Chair clarified that if the legislature would authorize the two positions, the agency could fund them. Ms. Bush said if the revenues did not present themselves to cover the first position scheduled for FY 2000, the second position scheduled for January 2001 would not be filled.

The Chair asked for these regional budgets to be considered at the same time and recognized Dave Luke, Associate Administrator, Mental Retardation Services. Dr. Luke introduced Marcia Bennett, Ph.D., Director, Rural Regional Center and StanLee R. Dodd, Regional Director, Desert Regional Center.

Dr. Luke covered general issues that applied to both budgets. First, he recognized and expressed his appreciation to committee members for their action during the 1997 Legislative Session to provide approximately $5.6 million to help address excessive waiting lists. He said there were currently two major issues facing mental retardation services. First was the continued waiting list demand, and second were conditions related to mental retardation (related conditions). "Related conditions" was a federal designation as the result of a lawsuit, Perry vs. Crawford, in which Nevada was identified as needing to provide services to individuals beyond the sole diagnosis of mental retardation. That issue would be addressed in each of the mental retardation budgets.

Dr. Luke said the M-200 packages in all mental retardation budgets covered caseload growth, separate from "related conditions." Separate packages were being presented for consideration with the eventual plan being once the additional impact of the lawsuit was understood, "related conditions" would be consolidated into the M-200 decision unit. Regarding caseload growth, he said the legislature had funded a phase-in of services through FY 1999. The recommended budget was built on those phase-in services. In other words,
Dr. Luke said the funding proposed for FY 1999, some of which had not been brought on-line yet, was used essentially to augment the base above what would normally be the FY 1998 level. Additionally, the budgets proposed demographic growth using high-level demographics in the southern part of the state, and mid-level elsewhere. He said the agencies had relied on state demographers’ projections. Services were then projected using utilization rates in respective areas and the funding of anticipated case management growth. These projections were somewhat related to the issue of "related conditions" in that the agencies needed to process people and give them an eligibility determination within a reasonable time frame. In the past there had been quite extensive waiting lists to conduct intake reviews. In addition to the 100 percent coverage of case management services, Dr. Luke said 25 percent of all additional projected growth in family support (respite program), jobs,
day-training program (community training centers), and residential programs was funded in the M-200 package.

Continuing, Dr. Luke said the second major package beyond the regular anticipated caseload growth was the "related conditions" decision unit. He said surrounding states were surveyed to ascertain what the agencies should expect as a service system. Idaho and Oregon had an 8 percent additional utilization rate. He said some states were higher than 8 percent. Since the "related conditions" issue was new to Nevada, the agency chose the more conservative number. The 8 percent additional utilization rate was funded at a 100 percent level in regional budgets. Those services would be phased in over the biennium. Due to the agency’s uncertainty of the "related conditions" lawsuit, it requested a letter of intent from the legislature to address impact and demand totally out of line with what the agency had planned. Dr. Luke clarified that "related conditions" meant that some people could have autism, epilepsy, or cerebral palsy and would not normally fall under the definition of mental retardation. Under federal guidelines, if people with those disorders, or other disorders closely related to mental retardation such as traumatic brain injury or some other type of genetic problem that affected their lives in the same manner as if they had mental retardation, could benefit from the same services, the agency would be obligated to serve them. Dr. Luke said the agency would not have to create new types of programs. Rather, existing programs would have to be opened to more people that could benefit from them.

The Chair said she noticed there was no in-state base line budget in terms of the number of patients and Dr. Luke said that was correct. She pointed out the increased utilization rate was an estimate and that if the rate turned out to be higher than estimated, the agency wanted to be able, through a letter of intent, to return to the Interim Finance Committee for discussion of caseload. Dr. Luke said that would certainly be appreciated. Associated with the "related conditions" issue was a bill draft request that clarified the definition of the service group within the Nevada Revised Statutes. In view of the fact the bill had not been introduced, The Chair asked the agency to "ride herd" on the bill draft request so that no deadlines were missed.

Dr. Luke said that given the budgetary constraints, the agency had worked very hard to project anticipated need requirements. He said over 700 cases would be brought on-line over the next two years statewide. Over 130 cases were expected in respite, or support to keep families intact. An additional 126 cases would be served through residential programs, and 136 cases through jobs and day-training. Additionally, in the Medicaid budget, there were 54 intermediate care beds recommended to serve individuals with mental retardation. He said that was an entitlement program and the agency had been very successful in keeping its placements in state, but without some additional in-state beds, that success would not continue.

Dr. Luke concluded his overview of the mental retardation budgets. The Chair requested an explanation of how the 25 percent / 50 percent split in the M-200 decision unit was going to work. Dr. Luke explained, of the projected need by the end of the biennium, the agency would serve 100 percent of the case management, even though waiting lists would grow. In many cases, the thinking was if the agency could get families into the system, get them some emotional support and have case management services tie them into some of the family respite activities, some of the demand on some of the more expensive services may be deferred. The Chair recognized the new program would involve a learning process for the mental retardation agencies. Dr. Luke said the mental retardation agencies had used their traditional service utilization rates but did not know if those would follow through with the "related conditions" group.

To clarify for committee members, The Chair said those testifying represented north, south, and rural Nevada and were using the same ratios. All areas would be operating on the same basis. Dr. Luke responded the budgets had been developed in the same fashion. There were, however, different utilization ratios between the regions for historical reasons. The Chair requested clarification of any budgetary distinctions between regions. Dr. Luke deferred the question to Dr. Marcia Bennett. Dr. Bennett explained the Elko office currently covered the entire northern region of Nevada. There were enough cases open in the northwestern part of the state to justify the opening of an additional office in Winnemucca. The funding of additional case management would provide for a full-time person in Winnemucca by the end of FY 2000. That office would cover Winnemucca, Lovelock, Battle Mountain, and surrounding areas.

Commenting on the southern mental retardation program, Dr. Dodd explained southern Nevada had experienced a great deal of growth in the last two years. It had been very difficult to make residential placements in-state. Individuals were given the opportunity for intermediate care facility (ICF) placements
in-state. If all in-state placements were full, out-of-state options were available. He said the south would receive 36 new beds in the Intermediate Care Facilities for the Mentally Retarded (ICF-MR Small) program through the private sector. The goal of the agency was to keep all Nevadans in-state. Regarding the performance indicators for the current biennium, Dr. Dodd said the agency anticipated it would reach all projections by year-end. There were no other significant issues with the southern program at that time.

The Chair noted the ICF-MR Small program consisted of 96 beds. She said the cost-per-day for a regular ICF-MR Small bed was $225 and the cost-per-day for an intensive medical support bed was $350 and asked if those beds were the best use of state dollars or was there another method of using those funds in a different type of facility, at the same level of care, at a lower cost. Dr. Luke verified the cost for an intermediate care bed was between $225 to $350 per day. The agency had a waiver pending before the Federal Government that would allow the use of alternative placements in lieu of intermediate care beds that would lower the cost to $2,000 to $3,000 per month versus $6,000 per month. He said not every person in an intermediate care bed could be served in a less costly supported living arrangement. The agency was interested in moving ICF services in the direction of alternative placements. The care was high quality while making financial sense for Nevada. The Chair asked the status of the waiver. Dr. Luke explained it was a Medicaid waiver written jointly with state Medicaid staff. Although a current waiver was in effect, the new waiver would expand coverage and bring in additional federal monies. He explained that at this time, the way the budgets were structured, the agency provided the waiver services through its budgets, and the private intermediate care beds were purchased through the Medicaid budget. The Chair asked if a waiver had been submitted to Medicaid on the agency’s behalf and, if so, when it had been submitted. Dr. Luke said the waiver had been submitted approximately nine months ago. The Chair asked if that was typical turnaround time and whether or not agency representatives had been in contact with the Medicaid office as to when the waiver would be approved. Dr. Luke advised the target date to start the waiver was October of 1998. The Federal Government had a number of time frames within which they could ask questions, and each time frame started a 90-day clock. The agency was at the end of the second or third clock and anticipated hearing from Medicaid within the next few weeks. He said many of the agency budget revenues had been built assuming the waiver would be granted. The Chair asked if there were a sufficient number of alternative placements available if the waiver was approved and if contracts would be entered into with those entities. Dr. Luke said the agency currently had providers and was able to purchase alternative placement services to the extent monies existed within its budget categories. Medicaid would only purchase the ICF-MR Small type of services with its funds.

The Chair called attention to the importance of sorting out the details of these programs because both MH/MR and Medicaid budgets could be affected. The Chair requested MH/MR staff contact Medicaid and notify committee members the exact status of the waiver. She said the goal of the legislature was to maximize the use of state dollars and requested Mark Roberts, Department of
Human Resources, to assist MH/MR with the Medicaid office to get the waiver moving.

The Chair recognized Rosemary Melarkey, Mental Retardation Program Manager II, Division of Mental Health and Mental Retardation. Ms. Melarkey explained she worked very closely with Medicaid in the coordination of the home and community-based waiver. MH/MR was in daily contact with Medicaid in Nevada and in weekly contact with the Federal Government to obtain waiver approval. The waiver renewal would be for five years. Pursuant to discussions with Medicaid, Ms. Melarkey said the waiver had already been approved, it was just a matter of preparing the actual document. She said the waiver would be approved before the end of March.

Addressing Dr. Brandenburg, The Chair said committee members would require a plan from MH/MR agencies. In view of waiver approval, and the fact dollars would be saved, a reallocation plan would have to be developed within MH/MR’s budget. The Chair asked when the issue could be revisited.
Dr. Brandenburg said the variable was the Federal Government. To be very honest and blunt with committee members, he said the reason MH/MR received the last waiver approval was because he was able to elicit assistance from Congressional leaders and would do so again if action were not taken in the near future. MH/MR was in contact with the "feds" on a daily basis trying to impress upon them the need for the waiver information to be passed on to the legislature. The Chair said the legislature may follow-up on Mr. Hettrick’s suggestion to send a letter on behalf of committee members. Dr. Brandenburg said MH/MR could report back to committee members on the status of the waiver within two weeks. That would allow time for a letter of necessity to be submitted and show the "feds" how intent Nevada was to obtain the waiver approval. The Chair asked Dr. Brandenburg to work with Bob Guernsey, Principal Deputy Fiscal Analyst, Legislative Counsel Bureau, to draft and send the letter.

The Chair recognized Senator Mathews who asked if MH/MR had problems with providers. Dr. Brandenburg responded MH/MR had worked very closely with its providers as they were an important part of the service delivery system. Overall, Dr. Brandenburg was personally extremely pleased with providers both on the mental health and mental retardation sides. Senator Mathews asked for a list of those providers and Dr. Brandenburg agreed to provide that information.

The Chair said the only concern committee members had with this budget was the name change. Rather than just calling the budget "Resident Placement", The Chair asked if there had been some discussion of changing the name to Rural Nevada Mental Retardation Services (RNMRS). Dr. Brandenburg said that was correct.

The Chair recognized Mr. Goldwater who asked what budgetary impact the name change would have as it related to signage, letterhead, etc.
Dr. Brandenburg said the impact would be insignificant. The existing letterhead reflected the new name.

The Chair recognized Rosemary Melarkey, Mental Retardation Program Manager II, Division of Mental Health and Mental Retardation (MH/MR) to present the budget for this agency. Mrs. Melarkey also administered the Family Preservation Program. She said that program provided monthly cash assistance to families who had profoundly or severely mentally retarded relatives in the home. She thanked the 1997 legislature for its statutory changes and allotment of monies that allowed the agency to add the severely mentally retarded families to its program. She advised there were 82 severely mentally retarded families participating in the program.

Ms. Melarkey reported there were currently 202 families being serviced, 130 of which were under the age of 18; 72 were 19 years of age and older. She said the program was very cost effective. The families were paid a minimal monthly payment based on a sliding fee scale. In some families, this program provided their only income besides those benefits provided by the Social Security Administration. She advised the program was twenty times less the cost of institutionalizing an individual in an ICF-MR. There was no waiting list for the program. When new applicants qualified, payments to existing participants were reduced. The program stayed within budget resources. Ms. Melarkey said enough demographic growth had been added to the budget to continue the FY 1999 base.

The Chair pointed out there were 30 additional families under the M-200 decision unit and asked if that was a conservative estimate. Ms. Melarkey clarified there were not really 30 additional families, but rather the decision unit continued growth in the FY 1999 base. She added the average payment had increased. Almost 80 percent of participating families received 100 percent of benefits. The budget had been based on 287 families, while the current average was closer to 300 families.

The Chair recognized Liz O’Brien, CPA, Administrative Services Officer, Division of Mental Health and Mental Retardation (MH/MR). She explained the base budget for this agency had been built on 187 clients. The Chair asked if caseload growth would be accommodated by simply lowering the amount paid to each family and Ms. O’Brien said that was correct. Payments had been lowered from $326.40 per month to $264.30 per month. As clients were added to the program, those monthly payments would be reduced. The Chair pointed out that as caseloads grew, the agency may reach a point of insignificance, i.e., the allotment per family could be so small as to not make any difference. Ms. O’Brien said that assessment was correct. Those families may then fall back into institutional care. Dr. Brandenburg said in that case, MH/MR would come back to Interim Finance and make them aware of reduced payments. He said the difficulty in developing the budget for this agency was that a crossover payment amount could not be determined.

The Chair recognized Michael Torvinen, CPA, Administrative Services Officer IV, Division of Mental Health and Mental Retardation (MH/MR) to present the budget for this agency.

Mr. Torvinen explained the budget for this agency had been established during the last biennium to consolidate the costs of the MH/MR Management Information System (known as AIMS). The budget during the last biennium contained funding to implement the system throughout the rural clinics. Billings were generated from all three facilities; the Nevada Mental Health Institute, Southern Nevada Adult Mental Health Services, and Rural Clinics. While the system was experiencing some difficulties, billings were current. Mr. Torvinen pointed out the budget did not include any growth other than the inflationary factors and occupational study decision units. The system was at least
10-years-old and MH/MR Administrative Budget Account 3168 had requested funds to perform a business process reengineering study in anticipation of system replacement. Due to lack of tax revenues, that decision unit had been cut from Budget Account 3168. He said he had come in contact with some people that thought they could perform a study for the agency for a lot less than what was reflected in Decision Unit E-278. That decision unit had been based on a model prepared by the Department of Information Technologies (DoIT), from experiences at DMV, Secretary of State, and several other state agencies.

The Chair pointed out this budget required work on its performance indicators. Mr. Torvinen explained the performance indicators mainly represented counted devices and users. More extensive explanation could be found in the agency’s expanded program narratives.

Mr. Torvinen added all of the mental health facilities throughout Nevada were using AIMS to bill and data was being gathered on caseloads and productivity of direct-care staff. The Chair asked if the goal of the agency was to replace AIMS entirely. Mr. Torvinen said the agency’s preference would be to replace the system in its entirety and include the mental retardation programs within the same data system. He said the agency had struggled over the years with its relationship with the software supplier for the AIMS system. The E-278 decision unit that had been deleted from the budget included funding for a planning process and design phase. The plan would then be to present a very detailed plan to the 2001 legislature to purchase and implement the new system. The E-278 decision unit had requested a total of $800,000.
Dr. Brandenburg added MH/MR’s responsibility was to monitor over $200 million with very antiquated PC’s that were unable to communicate. Accurate and timely responses to requests made by Legislative Counsel Bureau staff were difficult to accomplish. AIMS was an inpatient system that had been bastardized to the outpatient-type system through programs that were, on occasion, incompatible with each other. It was very difficult to run MH/HR as a business.

The Chair reminded committee members the meeting would reconvene at
3:30 p.m. in room 3137 for additional public testimony. She announced the conclusion of the agency’s portion of the hearing and invited anyone from the audience that wanted to testify prior to the floor session. She clarified the
3:30 p.m. session would be a videoconference between Las Vegas and Carson City and would allow for testimony from northern and southern Nevada.

The Chair recognized Ed Guthrie, Executive Director, Opportunity Village.
Mr. Guthrie explained Opportunity Village was an agency that had been started 45 years ago by a group of concerned parents of children with mental retardation. The agency was one of the oldest advocate groups in Nevada in terms of advocating for people with mental retardation. They were also the largest provider of vocational training and employment services. Mr. Guthrie expressed his thanks to the leadership of the Assembly and Senate, to include Senator Raggio, Speaker Dini, Assemblyman Perkins, Assemblyman Hettrick, Senator Rawson, Senator Schneider, Senator Titus, as well as members of the committee and others that had stepped to the plate during the 1997 Legislative Session and made a significant effort to address the waiting list crisis. Without the help provided by the 1997 legislature, there would be a waiting list of crisis proportion. He also thanked Governor Miller and Dr. Brandenburg and his staff for making a very sincere effort to address the needs of people with mental retardation in a very tight budget situation. Even with the valiant efforts made, there would still be a number of people who would not be served as the result of budgetary constraints.

Mr. Guthrie spoke to the senior caregivers, those individuals who provided services to their children or loved ones when they were not receiving services from either a residential provider or a day services provider. Although there would be no unmet need in service coordination in FY 2001, the unmet need in residential placement would be for 162 people. The unmet need in jobs and day-training would be for 129 people, and the unmet need in family support services would be 137 people. He said most adults with mental retardation continued to live with their families, and many caregivers were over 65 years of age. Nationally, 25 percent of families (caregivers) who continued to provide care for their sons and daughters who were adults with mental retardation were over 65 years of age, and another 35 percent were middle-aged caregivers for whom residential placement was a near-term issue. That trend was magnified in the State of Nevada by the number of caregivers who retire to Nevada and bring their adult son or daughter with them. During the last session of the legislature, Mr. Guthrie remembered seeing some information from Southern Nevada Mental Retardation services that said of the adults who applied for services for the first time, approximately 40 percent were people over the age of 35 years. That meant those caregivers were now 65 years of age or older. He said that situation was compounded by the fact that people with mental retardation were living substantially longer than ever before. In the 1920’s, a person with Downs Syndrome died by the age of 9. In the 1960’s that same person died by the age of 30, and in 1993 that same person lived in excess of age 55 on the average. Today, a family caregiver would be over 85 years of age.

Mr. Guthrie said the state of Maryland’s Developmental Disabilities Administration performed a study of individuals on its waiting list. 39 percent of those people lived with caregivers who were over 60 years of age.
24 percent of the caregivers were over 70 years of age, and 14 percent were over 80 years of age. He said more testimony later that afternoon would include comments from a lady named Rose Anderson, who was providing care for her son Richard, at home, and had been for years. Rose was over 80 years of age, continued to provide services, and wanted to continue to provide those services as long as possible. However, for those families that could not continue to provide those services, they had two options. They could either continue to provide services to their children, sometimes at risk to their own health and well-being and hope for better times, or they could sue the State of Nevada to receive access to intermediate care facility services based on the precedent of Doe vs. Childs. Mr. Guthrie said that precedent had been shared with both the Governor’s office and the staff of the Legislative Counsel Bureau. Doe vs. Childs was a lawsuit in federal court against the state of Florida that said intermediate care facility services were included under the state plan and Medicaid plan and, as such, had to provide service in a reasonable amount of time. A "reasonable amount of time" was determined by the federal courts to be within 90 days of application for service. He said most parents did not want Intermediate Care Facilities for the Mentally Retarded (ICF-MR SMALL) services because those services were very expensive, between $225 and $350 per day, and were often unnecessary if other levels of service were available.

Mr. Guthrie explained Opportunity Village felt although the State of Nevada had been generous in trying to deal with the waiting list issue, the current legislature needed to make further provisions to deal with those individuals who were in crisis situations and needed access to services. Opportunity Village suggested the committee place $1 million to $2 million in reserve with the Interim Finance Committee which would allow the state to access those funds and match them with Medicaid dollars. If, in fact, MH/MR was unable to meet the needs of those individuals projected, one or more of those families would be filing a lawsuit, either individually, or jointly, asking for access to intermediate care facility services.

Opportunity Village suggested one way to accomplish the reserve would be to use tobacco settlement monies. Mr. Guthrie advised research had shown maternal smoking during pregnancy lead to significantly higher incidences of mental retardation. In fact, he said, if a woman smoked a pack a day during pregnancy, there was a 75 percent increase in the incidents of mental retardation. That situation would make smoking during pregnancy one of the most expensive forms of healthcare problems resulting in mental retardation. Referring to The Executive Budget, Mr. Guthrie pointed out that $350 per day for institutional services times the lifetime of a child (over 55 years), resulted in much more than $1 million per person that it would cost for each individual that had been born mentally retarded as the result of maternal cigarette smoking.

Mr. Guthrie said Opportunity Village felt there were a number of senior caregivers who would be put in desperate situations and would take whatever measures were needed to ensure the well-being of their sons and daughters. He said Opportunity Village felt there was a logical reason for using the tobacco settlement monies because of the increased incidence of mental retardation as the result of maternal smoking.

The Chair commented on Mr. Guthrie’s earlier testimony that provided numbers of unmet needs in different categories and asked those figures to be submitted to the committee. Mr. Guthrie explained Opportunity Village had obtained those numbers from MH/MR.

The Chair recessed the meeting at 10:53 a.m., to be reconvened at 3:30 p.m.

The Assembly Ways and Means and Senate Finance Joint Subcommittee on
K-12 / Human Resources was reconvened at 3:35 p.m. on Thursday, February 25, 1999. Chairwoman Jan Evans presided in Room 3137 of the Legislative Building, Carson City, Nevada. The meeting was video-conferenced to the Legislative Counsel Bureau, Las Vegas Office, 555 East Washington Avenue, Room 4400, Las Vegas, Nevada.

The Chair explained the meeting was a continuation of a session that began at 8:00 a.m. that morning hearing budgets from the division of Mental Health and Mental Retardation (MH/MR). She welcomed the audience back and thanked them for their patience. Committee members felt it was vital to hear testimony from all over the state. She pointed out the meeting was being
video-conferenced and explained the lack of committee members present was the result of meeting conflicts and not a boycott. Committee members would come and go as their schedules permitted. She assured the audience committee members took its testimony very seriously. The remarks made would be recorded and transcribed and become part of the permanent record of the committee, available not only to committee members, but to all legislators or any other interested parties. Copies of written testimony or exhibits would be welcomed by committee members. The Chair introduced Senator Raggio and Senator Mathews to the audience. She asked that remarks be kept as concise as possible and said testimony would follow in order, alternating between northern and southern meeting rooms. Should time run out and individuals not be able to speak to the issues, committee members would be happy to accept written remarks.

The Chair recognized Assemblywoman Sheila Leslie and Senator Mike Schneider. Assemblywoman Leslie said she represented Assembly District # 27 in Reno, Nevada, and was testifying before committee members in that capacity. She was also the facilitator of the Mental Health Committee in northern Nevada which was part of the Community Unity Coalition with which she and Senator Townsend worked very closely. There were many members of the coalition in the audience and Assemblywoman Leslie felt the legislature was better served hearing from the people rather than another legislator. Being the facilitator of the coalition, Assemblywoman Leslie wanted to hit some highlights and one budget priority in terms of mental health. She explained the coalition represented 40 to 50 different groups, entities, and individuals that ranged from advocates to people that worked in the field, to concerned citizens. Over the past two years, the coalition had worked very closely with the legislature and, on behalf of the coalition, Assemblywoman Leslie thanked both Senator Raggio and Assemblywoman Evans for their hard work in increasing the mental health budget, to include funding for the new mental health institute in Sparks. She went on to say over the last two years the coalition had revised its priorities and, during the current session, would be working on some non-budget issues such as mental health parity and the move of the Bureau of Alcohol and Drug Abuse as identified in Chairwoman Evan’s bill, A.B. 181 (1999).

Assemblywoman Leslie explained the coalition had three priorities for budget enhancements, one of which committee members would hear about from other individuals (resources to address the mental retardation waiting list). Another issue was expanded mental health services for children and adolescents. The third issue was the development of psychiatric emergency services (PES) at the Nevada Mental Health Institute (NMHI). As committee members were well aware, PES existed in southern Nevada. However, that type of service was not available to northern Nevada. Assemblywoman Leslie explained PES in northern Nevada would provide a point of entry for clients into the system where evaluation and referral to appropriate services could be made. It would also provide a supervised stable environment during which intervention techniques and medication management could be employed. She explained the one identifiable and serious weakness in northern Nevada at the present time was the absence of a PES program. She could not stress enough the importance of the program to the coalition. During the last fiscal year, 42 percent of the acute psychiatric admissions into the inpatient hospital service would have been triaged, diverted, treated appropriately, and referred to a lesser level of care if there had been a fully-operational PES. The rapid client turnover rate in the north was twice that of the Las Vegas hospital. That turnover rate diluted the care and attention necessary to focus on the severely ill clients that resided in the Las Vegas hospital and required extended care. Consequently, neither the severely ill client nor the short-stay client, whose admission could have been prevented, received the full attention of the treating staff of psychiatrists, nursing staff, psychologists, and social workers.

Assemblywoman Leslie went on to say the outpatient clinic operated efficiently when it could see its clients on a regularly scheduled basis. Without PES, the smooth operation of that program was interrupted. Case management was handicapped in providing sufficient crisis care to its clients. PES would provide a 72-hour stable supervised environment, during which medications could be adjusted and emergency crisis de-escalation could be provided. She said in the absence of PES, case managers were left to deal with destabilized situations in the community.

Assemblywoman Leslie ended her testimony by saying on behalf the coalition she hoped committee members would take a hard look at PES services for northern Nevada. The coalition was aware money was a huge issue. However, if made available, PES would be the coalition’s priority.

The Chair recognized Senator Raggio. Senator Raggio commented from earlier testimony it was his understanding staffing was the problem related to PES service in northern Nevada. He asked if committee members had been told the cost for such a facility would be $2.3 million over the next biennium and that three quarters of that amount would have to come from the General Fund. He agreed PES services in northern Nevada should be a high priority. Assemblywoman Leslie responded if half of that funding could be found, it was her understanding the program could be phased-in or started at a lower level. Senator Raggio asked if the facility was to include 10 beds and Assemblywoman Leslie said that was correct.

The Chair recognized Senator Mike Schneider. Senator Schneider said he represented District # 8 in Las Vegas and was also a board member of Opportunity Village. To be perfectly blunt, Senator Schneider said he was before committee members to ask for money. Opportunity Village had been established in 1954 and had a 45-year history of advocating for services for people of mental retardation and related disabilities. Opportunity Village was also the largest provider of vocational training and employment services for people with mental health and retardation and related disabilities in the State of Nevada.

He continued saying in 1998 Opportunity Village paid over $1.1 million in wages to people that most folks would consider unemployable. Opportunity Village had also placed 120 people with severe disabilities in jobs throughout the Las Vegas community at locations like the Bellagio, Ocean Spray Cranberry Juice, grocery stores, and many other locations. Senator Schneider said Opportunity Village was very aggressive in Clark County and had raised large amounts of money. A University of Nevada Reno (UNR) study conducted several years ago indicated Opportunity Village saved the State of Nevada over $20 million per year. Opportunity Village had recently completed its own studies and, with the projections of the division of Mental Health and Mental Retardation concluded 168 additional persons with mental retardation in southern Nevada needing to receive day-training in FY 2000, would cost approximately $18 million. In FY 2001, 230 individuals would require additional services at a cost in excess of $25 million. Senator Schneider said even if those projected numbers were "tightened down," the state was still looking at the $17 million to $20 million range. Opportunity Village’s figures indicated exactly what UNR had indicated – they were saving the state a great deal of money. The recent fundraising event at Christmas had raised over
$650,000 for Opportunity Village. If a budgetary increase were not provided during the current legislative session, it would be three out of the last four sessions that no increase was provided. Senator Schneider said Opportunity Village was taking a large burden off the state, but the state needed to be more responsible and step up to help the funding situation.

Senator Schneider felt Opportunity Village was doing more than its part to help the state. He said every President of the United States in the last 15 years had visited Opportunity Village and said it was a wonderful public/private partnership. He pointed out the private side could not continue with the increased demand for use. When Senator Schneider was first on the board of directors, the hat would be passed and board members would dig into their pockets to fund Opportunity Village. He had seen large checks from private citizens. Due to increased growth, however, that type of subsidizing was no longer possible.

Senator Schneider concluded his testimony and said any help committee members could provide would be appreciated.

The Chair said committee members appreciated the Senator’s testimony and were well aware of and applauded the efforts of Opportunity Village.

The Chair recognized Jim Nadeau, Captain, Washoe County Sheriff’s Office. Speaking for the northern Nevada law enforcement perspective, Captain Nadeau said the psychiatric emergency services (PES) provided in southern Nevada had relieved some of the burden and provided an additional tool for the Clark County Sheriff’s Office to deal with the mentally ill. He explained the northern Nevada detention facility was burgeoning and PES services would provide relief for some individuals that unnecessarily ended up in Washoe County jail facilities. He pointed out sheriff’s deputies encountered individuals that needed assistance on a regular basis. PES services would provide a source for that assistance. Deputies would even provide rides, on occasion, to the PES facility.

The Chair recognized Mary Goodposture who appeared before committee members to testify on behalf of PACT. She had a son that had suffered with chronic schizophrenia for 22 years. For many years she had hoped and prayed for somebody that would take an interest in and help him as he would be discharged from Nevada Mental Health Institute. She said finally, one month earlier, her son had been placed in the PACT program in Reno, Nevada. The program was marvelous. She said even though he was in a very fine home, PACT staff had taken her son to McDonald’s and ensured his needs were taken care of on a 24-hour basis. He was now being taught to live in the community. Ms. Goodposture said PACT needed to continue for people that were severely ill and did not want to do anything outside of themselves or an institution. She said PACT was teaching her son and his roommates to want to interact with people and feel better about themselves. Ms. Goodposture provided a copy of an article entitled "Effective Treatment, What About Assertive Community Treatment? An Interview with PACT’s William H. Knoedler, M.D." as
(Exhibit C). She added the majority of services provided by PACT were delivered to the physical location of the patient. The Chair assured
Ms. Goodposture the PACT program would continue in the new biennium.
Ms. Goodposture added the PACT program was a "dream come true."

The Chair recognized Dr. Rich Siegel, American Civil Liberties Union (ACLU) of Nevada who said part of his comments were to be shared with Jill Smith of the Nevada Disabilities Advocacy and Law Center. Dr. Siegel said each committee member present and Assemblywoman Sheila Leslie had been provided with a copy of his report. That report included a summary of ACLU’s progress in mental health in Nevada. It was a positive story of the coming together politically of the state on behalf of mental health services. He recognized the decision of the Governor to provide for a solid budget increase in mental health had been an excellent move in a tight budget environment. At the same time, Dr. Siegel wanted to endorse Jill Smith’s upcoming testimony on PES, with particular reference to ACLU’s involvement as advocates for individual rights.

The Chair recognized Jill Smith, Advocacy Directory, Nevada Disabilities Advocacy and Law Center (NDALC). She said NDALC believed the importance of psychiatric emergency services (PES) in northern Nevada could not be over-emphasized. The triage ability was vital, not only for the reasons testified to earlier by Dr. Rosin of Nevada Mental Health Institute (NMHI), and eloquently by Assemblywoman Leslie, but in order to protect the civil rights of people being involuntarily picked up and detained at the hospital. Ms. Smith said without the ability to triage during the first 72 hours of a patient’s crisis, the facility could not determine who was suffering acute symptoms like psychosis as the result of mental illness, or as the result of secondary substance abuse issues. That situation resulted in persons being housed in inpatient units who would more appropriately be placed somewhere else. Meanwhile, others who may need psychiatric treatment, but for whom there was no room, could not get into the facility. She said clearly, such a situation was ripe for civil rights abuses which everyone tried to avoid. With respect to the abuse and neglect allegations that had arisen in the morning session, Ms. Smith said with all due deference, she would be prepared to postpone her testimony until the end of the day because she felt there were so many people that wanted to be heard on vital mental health issues. Or, as an alternative, set another date, or provide the testimony in writing, whichever was at the pleasure of Madame Chair. The Chair responded saying her testimony would either be heard at the end of the day, or committee members would accept that testimony in writing because they did want to hear her message.

The Chair recognized Roy Petterson who was currently enrolled at the adult rehabilitation center at the Salvation Army and was being treated in the outpatient program at Southern Nevada Adult Mental Health Services (SNAMHS). Mr. Petterson, who suffered from alcoholism and depression, said he was taking Prozac and Desyral with great results. He was in a six-month program at the Salvation Army and believed the great results were achieved by the combination of programs and services provided at the Salvation Army and SNAMHS. He did not believe he could have achieved those results, and the promise of a bright future, without the marriage of both mental health and the Salvation Army.

The Chair recognized Onita Dougherty, President of Consumers Against Unfair Stigma Through Education (CAUSE), a client and peer counselor for Southern Nevada Adult Mental Health (SNAMHS). She was testifying before committee members to address several issues CAUSE felt were important as clients, consumers, and voting citizens of the community of Las Vegas, Nevada. CAUSE suspected there were many programs that provided mental health services, however, there was one program in particular CAUSE was most interested in, that being psycho-social rehabilitation that provided clients with support, job focus and leadership training for them to be better citizens in the community. Psycho-social rehabilitation had provided clients with the opportunity to show their value in the community. Ms. Dougherty said CAUSE did have expectations of the state to ensure clients were paid in a timely fashion. Stipends had been set up for clients so they could show they were responsible, voting, tax-paying citizens of the community. CAUSE expressed the need for more office space, not only in the Charleston area of Las Vegas, but also in the Sahara office so necessary services could be provided for the clients seeking help at satellite offices of SNAMHS. She continued saying better dental and physical health issues also needed to be addressed. CAUSE had looked at and would expect the state would partnership with them in a clubhouse model. CAUSE had conducted a consumer conference, a Christmas party with over 400 persons in attendance, and was looking at a partnership with the State of Nevada in creating other kinds of client-driven programs.
Ms. Dougherty said CAUSE was asking committee members to consider making sure the services clients needed today were in place so they could become more valuable, voting citizens in the community. CAUSE was asking for and invited committee members to celebrate with them the idea of many roads and many beginnings. Committee members were invited to talk with CAUSE, see its program, and to visit and work with them.

The Chair recognized Brian Booher, who was also a member of CAUSE.
Mr. Booher said committee members had been provided with a letter outlining the value of psycho-social rehabilitation (PSR). Mr. Booher had been a mental health client for four years and had been receiving services from the State of Nevada in Las Vegas. He said when clients of CAUSE were introduced into the PSR program, the many services received were very therapeutic, but they considered themselves just "clients." The new challenge presented to CAUSE by PSR was that of a service provider for other clients. In other words, CAUSE had been empowered to provide services such as the consumer conference, the holiday parties, and other group recreational/support activities. Mr. Booher reported CAUSE had done quite well in those areas. If committee members had asked him two years ago if he would be testifying before them today, the answer would have been a very impossible dream. His presence before committee members was a great accomplishment. Because of the faith instilled in him and others by PSR, clients has been able to create CAUSE. CAUSE clients strongly believed in self-empowerment and advocating teaching each other the rights they have as individuals so they could become strong pillars of the community. CAUSE also provided education to other individuals who were not knowledgeable about mental illnesses.

The Chair recognized Dr. Brian Lahren, who represented the Washoe Association for Retarded Citizens, the Truckee Meadows Human Services Association, and also the Community Unity Mental Health Coalition.
Dr. Brian seconded Dr. Siegel’s earlier testimony about how grateful they were for the tremendous boost given to mental health and mental retardation services during the 1997 Legislative Session. He said it was very heartening and impressive to see the increases scheduled for the current biennium. Dr. Lahren first wanted to discuss mental health issues and lent his voice to those who advocated strongly for finding a way to fund a psychiatric emergency services (PES) program at the Nevada Mental Health Institute (NMHI). He said that component was absolutely essential to an integrated mental health system that would actually get the maximum amount of benefit from existing staffing. Northern Nevada had at least 40 admissions per month more than Las Vegas. Dr. Lahren wanted committee members to recognize the increased burden those admissions had on the psychiatric and clinical staff trying to provide treatment in the institution. Staff was overwhelmed with the paperwork of processing admissions for approximately one third of the patients who really did not need to be hospitalized in an inpatient setting. Those unnecessary admissions compromised the treatment of all other patients and created a very serious problem. He said one issue committee members needed to look at was how difficult it had been to keep NMHI staffed with permanent psychiatrists. NMHI had been having to function with contract physicians because it had been very difficult to retain a person that valued the quality of medical professional care knowing they would be unable to provide maximum care in the environment provided. Dr. Lahren said committee members should be able to find a way to address that issue.

He suggested committee members look at Medicaid funding and said there had been some encouragement with the bill Senator Rawson had passed out of committee, SCR 8 (1999), that would encourage the Department of Human Resources to maximize every possible way of gleaning additional Medicaid recovery dollars. Dr. Lahren said it was important to maintain the level of effort in funding for medications, a critical piece of the mental health system. He said the PACT program was an absolute delight and hoped the program could be completely funded and fully staffed in the near future. Child and adolescent services were, in his opinion, the most ignored mental health problem in Nevada at that point. Dr. Lahren said if children could be placed in early intervention programs, they could perhaps be given a stable life and not end up in serious inpatient population settings as adults. Addressing case management,
Dr. Lahren said some of the case managers at NMHI had ratios of up to
65 to 1. It was impossible to perform adequate clinical care with that type of case management level. Another area of concern was the parity in mental health insurance coverage. He understood Senator Townsend would be introducing such a bill that included innovative ideas that would make the bill palatable to both employers and big business. Finally, Dr. Lahren said there was a lack of vocational services for individuals with mental illness. He said there was a patched-together system that made an excellent effort to try to coordinate vocational rehab in a very small program funded to the mental health system. However, there was no program that even remotely compared to existing vocational programs for mental retardation, yet it was well-known that people defined who they were based on what they did for a living. Committee members were encouraged to think about that situation as critical both now and in the future.

Turning to mental retardation, Dr. Lahren reported Nevada was generally quite progressive. In the 1970’s Nevada was a national leader in the development of community based services, a benefit received as the result of wise proactive investment by its governmental leaders. Those community-based services alleviated a great deal of the turmoil associated with institutionalization. Nevada had, since that time, been the state in the nation with the lowest rate of institutionalization. Nevada was the seventh state in the nation to be awarded a waiver for community based services under Medicaid. He said now, every state in the nation drew down more free federal money than Nevada did. He said Washington D.C., which did not have a waiver, was the only political entity other than Nevada that did a worse job in drawing in Medicaid funding.
Dr. Lahren said he would like to see waivers provided in every single circumstance possible. For every single service Nevada provided, and oftentimes funded with state dollars, those services should be included under the state Medicaid plan and then Nevada should insist waivers be written to maximize the use of federal funding. He questioned why pay a dollar of state money when the state could pay 50 cents for the same service.

Continuing, Dr. Lahren advised Nevada was one of the first states to comprehensively implement individualized supported living arrangement programs. Unfortunately, the funding for residential services, and the rates they were currently being paid, made it very difficult for providers to be able to support those services. As a consequence, those individualized supported living arrangements were cynically viewed by advocates and providers as a mechanism for the planned under-funding of client services. He said that was a particularly difficult situation when funding was being sought to buy case management services to support individuals living in supported living arrangements. In many cases, there were simply not enough supports to live a safe and healthy life.

Dr. Lahren said there had long been an effective public and private partnership for funding vocational and day-training programs. Unfortunately, over the last two biennia, the state had backed away from funding its share of those partnerships. There had been no rate increase in those services. Since no rate increases were planned for this biennium, it would have been six years since any adjustment had been made to the cost of living rate for the public/private partnership and yet, to his way of thinking, Dr. Lahren said it was the most significant achievement in terms of privatization of services that Nevada had to point to. He said the current legislative session should not slip by and allow the vision for the future of mental health to evaporate. Dr. Lahren suggested committee members dedicate themselves during this legislative session and the interim to find a way to recreate a vision. Perhaps an interim study committee could address that issue. Somehow, he said, Nevada needed to find a mechanism that would bring everyone together and recreate a vision for mental retardation and mental health services.

Discussing budget issues, Dr. Lahren said his concerns included the "related conditions" component. His concern was that funding had been provided for an 8 percent increase. That was the lowest figure that could have been used based on information from surrounding states. Unfortunately, he said, the original definition in Oregon and Utah of "mental retardation" included some of the developmental disabilities. Ten years ago Nevada had a much more inclusive mental retardation definition and may be much more like the states that had a 15 to 16 percent incident rate as a consequence of having currently a more restrictive definition of mental retardation. If that were the case, he said, Nevada may have guessed wrong. He seconded the suggestion others had made that Nevada set aside funds in a special contingency fund in interim finance. He agreed with Mr. Guthrie’s earlier testimony that tobacco fund monies could be used to subsidize the contingency fund in view of the fact there was a direct relationship between mental retardation and tobacco use by pregnant women. He said he would make the same point about the waiting list. It was clear the Executive Budget chose to fund only 25 percent of the waiting lists, a risky choice. He felt if Nevada were unable to meet the needs of people who, under federal law, had a right to Medicaid services within 90 days of application, what would it have as a fallback position, if MH/MR had guessed wrong about the efficiency of its current strategies.

Dr. Lahren closed by saying there was a great need for vision and innovation. Apparently, Governor Guinn supported that idea as mentioned in his State of the state Address. It was time for everyone to get together to find innovative and cost effective ways to help Nevada provide decent quality services to everyone who met the eligibility criteria. There were many who felt they knew constructive and innovative ways to bring about changes and could outline those suggestions in an interim study committee, even though MH/MR may not agree with his perspective. Dr. Lahren asked if committee members could think of a better way than to join with the private sector to help Nevada be led back into the mainstream of quality mental health and mental retardation services. He offered his total cooperation to that end.

The Chair recognized Jeff Engelke, Vice President, EduCare Community Living Corporation Nevada, who represented EduCare, as well as a coalition of residential providers in southern Nevada. He referred committee members to the handout he had provided them, (Exhibit D). The handout attempted to present the number of families being served as well as those who would not be served. 75 percent of those families that would require services over the next two years would not be funded. He said those were not 75 percent of people’s wants, but actually 75 percent of people’s needs. EduCare was very alarmed at the strategy to only fund at 25 percent. EduCare supported Dr. Lahren’s assumption on the 8 percent ratio for figuring related conditions. Some states closer to Nevada were in the neighborhood of 16 percent which meant the projected number of 171 cases could actually be closer to 342 cases which, in turn, added to the waiting list problem.

He explained the 11^th Circuit Court had recently ruled that if clients did not receive services within 90 days, the states could be held liable – a reality that must be addressed. Referring to his handout, Mr. Engleke explained those families not receiving care within the 90 days could reach 162 by the end of FY 2001. Those families could wait up to and in excess of two years for those types of services.

Another area of concern to EduCare was the population of individuals with mental retardation in the prison system. He said it had been reported earlier there were only two consumers with mental retardation in the prison system. However, the cross study EduCare had performed suggested that total might be closer to 320. The second page of the handout contained a table EduCare had received from MH/MR to help them coordinate its numbers. EduCare realized the numbers were not exact. However, MH/MR had been working very diligently to ensure committee members had the most accurate information. The third page of Exhibit D followed up with some statistics regarding waiver spending which reflected Nevada ranked as 49^th. The fourth page of Exhibit D reflected fiscal effort rankings in which Nevada appeared 51^st. The last page of Exhibit D was a copy of an article published in The Sacramento Bee titled "Maximum Exploitation: The Criminal Justice System at its Worst." The article regarded individuals with mental retardation in the California prison system. Most critical in the article was the annual cost to maintain an inmate in that setting.

The Chair recognized Janic Rickert. Ms. Rickert advised she was a peer counselor and a member of Cause Against Stigma Through Education (CAUSE). She said when she had become involved with the psycho-social rehabilitation (PSR) program she was helped in many different ways. She had gone from someone that only came out of her apartment to go to the doctor and right back, to someone that started coming out every day, taking different classes, starting to be involved in the community. She became a CAUSE member and had been able to make friends and help with holiday parties and the CAUSE consumer conference. A few years back there was no way she would be able to sit before committee members as she was now. Ms. Rickert felt there were a lot of people that could benefit from CAUSE just like she had. PSR had given her confidence back and trust in herself and others. Most of all, she believed in herself again.

The Chair recognized Michelle Kenney. Ms. Kenney said she was before committee members representing the Salvation Army. She had just graduated from the Salvation Army’s inpatient treatment program which was a
dual-diagnosis facility. She was also an outpatient at Southern Nevada Adult Mental Health Services (SNAMHS). Ms. Kenney had been in and out of psychiatry for 14 years, and in and out of drug rehabs for 3 years. When she went to the Salvation Army and became part of its program, she was helped by counselors to go to SNAMHS where she was placed on proper medication. She had been unable to live a normal life and had been in and out of jail. She was also unable to take care of her children. Now, because of the medication and help she received through the Salvation Army, Ms. Kenney said she was able to take care of her children and was a productive member of society. Her moods were stabilized. She was truly grateful for the needed assistance both the Salvation Army and SNAMHS programs provided.

The Chair recognized Leona Case. Ms. Case said it was her pleasure to appear before committee members on behalf of the Salvation Army rehabilitation program. When she first came to the program in October, she had lost her job, her home, and her will to live. Only through the counselors at the Salvation Army was she able to take steps toward recovery from addiction to drugs and alcohol. She said the program had also allowed her to work with Nevada State Mental Health that treated her for depression. She was taking a new
anti-depressant called Remeron that had minimal side effects. Ms. Case had been able to work the therapy program, do her counseling, and work in the classroom, even while adjusting to the medications. If it were not for those two programs, she doubted very seriously she would be sitting before committee members today. She concluded saying she owed her thanks to those programs.

The Chair recognized Dean McCubbin who appeared before committee members as a representative of the Salvation Army and Southern Nevada Adult Mental Health (SNAMHS). Mr. McCubbin said he was also in despair when he first got to the program. Through the services of the Salvation Army and SNAMHS he had been able to become a productive member of society. With the help of SNAMHS he had finally been stabilized on his medication. He said he had been through all kinds of different treatments, including shock therapy. He had been in and out of the hospital for the past 10 years. Due to membership in those two programs for the past six months, Mr. McCubbin was finally learning to live a productive life. He expressed to committee members the need for those two programs to continue.

The Chair recognized Cheryl Garcia, the mother of a handicapped, mentally retarded son who lived in Wellington, Nevada. Wellington was a very rural area that did not have services or job opportunities available for a handicapped child. Ms. Garcia said she was experiencing trouble with the school district because they wanted to have her son graduate at 17-years of age. She said the family had to fight for everything they had ever received from the school district. Her son had been on a list for four years to go into a group home. Last August, the family was actually packing her son to move to a group home in Carson City. A couple of days prior to the move, the family was told there was no funding for the continuation of the home. Ms. Garcia said the family had never asked for any help from the government, they had paid all of their son’s hospital bills to include brain surgery every couple of years. She expressed the need for the funding for group homes. Otherwise, either she or her husband would have to quit their job to stay home and take care of him because he was unable to take care of himself. She hoped more money would be made available for group homes.

The Chair addressed Dr. Buehl, MH/MR-Rural Clinics, and asked if he was aware of the circumstances surrounding the closing of the group home in Carson City. Marcia Bennett, Director, Rural Regional Center for Mental Retardation, explained efforts had been made to open an intensive supported living arrangement in Carson City. There had been negotiations with EduCare but when budget projections were reviewed, the contract was deferred. The Chair questioned the four-year waiting list alluded to in Ms. Garcia’s testimony.
Ms. Bennett explained there were waiting lists for ICF-MR placement in rural Nevada and for supported living arrangements in Nevada. She was not aware personally of Ms. Garcia’s situation, but would look into it. The Chair said she would be grateful for that effort.

The Chair recognized Christien Welter who appeared before committee members as a representative of Carson City Alliance for the Mentally Ill. Ms. Welter explained the alliance was a group of people who were consumers of services as well as family members of consumers and other interested people.
Ms. Welter wanted to briefly put a face on the problem. She said she was before committee members to discuss supported living arrangements (SLA)s. A considerable amount of money was needed for the SLA program. She said the reason she had joined the alliance was because of her sister who was mentally ill. At one time, her sister could not manage her life, could not manage her rent, and was evicted because she was not aware of the notices the landlord had given her. For three days, her sister wandered the streets in her slippers and nightgown. Fortunately, because she was partially sighted and had another disability she was noticed by authorities and brought to a hospital. Unfortunately, Ms. Welter continued, that scenario was frequent. Many people were not noticed and, as a result, lived on the streets. In Carson City, on a yearly basis, there were as many as 240 people wandering the streets. Those people lived in dumpsters, in storage lockers, in and out of casinos before security kicked them out. She said it was a tragic existence and a sad commentary on our society that those types of existences were allowed to continue. If her sister had the availability of an SLA, none of those things would have happened. People in SLAs were managed by a case management team, there was a therapist involved, and there were various levels of services provided on an individual basis. In her sister’s case, there would have been someone there to see that the rent was paid, and that the utilities were paid. She would have also been educated and would have been expected at some time to take on her own care and her own responsibility. Ms. Welter said one good thing about SLAs was they provided people with a permanent address. A permanent address was required in order to access services like Social Security, SSI, Medicaid, Medicare. People who wandered the streets and didn’t have an address were a burden to the cities and counties in which they lived. An SLA would curb those situations. Ms. Welter said the average stay in an SLA was between 5 months and 1 year. Carson City currently had two apartments available for the SLA program. There was also one SLA pending. Using the most conservative estimate she could think of, with existing apartments, there was no way to process the 240 people on the streets. Funding for SLAs was desperately needed.

While Ms. Welter had mentioned apartments as SLAs, The Chair asked if there were group homes in the Carson City area. Ms. Welter replied there were no shelter care homes she was aware of. Unfortunately, she said, people did end up in jail. She pointed out many of the homeless people functioned at the level of children and were certainly not able to take care of themselves in a jail situation, nor were they able to take care of themselves in a street situation. Many times those individuals ended up in programs where they didn’t belong. If a person did have SSI and was living on the streets, they were likely to either be tricked out of money or even mugged for the money.

The Chair recognized Helen Banovich who was present to support Ms. Welter and was also a member of the Carson City Alliance for the Mentally Ill. She said she knew from first-hand experience with her own family* * *. In the 1960’s, she had an aunt in San Francisco the family had been unable to locate because she was living on the streets. The aunt had mental illness.
Ms. Banovich said some services for the mentally ill had come a long way, and others had gone the opposite way as far as she could see. She said too many people wanted to put those issues under the shelf and forget about them and not want to admit that there could be mental illness in families that required support not only from the family, but the government and others. Ms. Banovich appreciated the opportunity to say to committee members the SLA homes were much needed. She was also aware of a niece in her family with mental illness. Fortunately, that niece was on medication and was able to go to work and was doing much better. She expressed her feeling the mentally ill should be taken off the streets, treated properly, and made productive, especially in this country where the economy was supposed to be good.

The Chair recognized Ron Hartzell who was testifying on behalf of the Salvation Army. He said in June of 1997 he had arrived at the Salvation Army and joined its PATH program. Soon after that, he discovered the Lyon’s Club eyeglass recycling center and started working there full-time preparing thousands of eyeglasses to be sent overseas to third world countries. Through the Salvation Army, he learned about the new schooling program for dispensing opticians and started taking classes at CCSN in January of 1998. Currently, Mr. Hartzell’s grade point average was 3.8 and he had just been invited to join Phi Beta Kappa, the honor society for two-year colleges. He explained he was also active in the local Lyon’s Club projects. He had started to work full-time at Eyeglass World, had moved into his own apartment, and had started playing the bagpipe. In conclusion, Mr. Hartzell said with the help he had received from the Salvation Army and Lyons Club, he had become quite successful.

The Chair recognized Vic Davis, President of the Nevada Alliance for the Mentally Ill (NAMI) of southern Nevada, an affiliate of NAMI of Nevada. NAMI was an advocacy organization dedicated to the advancement of health care services for the mentally ill in southern Nevada. NAMI strongly supported several currently funded programs and was pleased to see Governor Guinn’s budget proposal recommended level funding for mental health programs during the current biennium. In a time when many budgets were cut, NAMI particularly appreciated knowing the level of care consumers had received would continue for the next two years. Mr. Davis said many families had mentally ill members that went through cycles where they were hospitalized, stabilized on medications, and released. Then, at a later time, those family members refused to take their medicines, went into another psychotic episode, and had to be hospitalized again. The advent of modern medicines had been a real blessing. At the same time a patient was being stabilized in the hospital, they received medicines that were much more effective in treating the symptoms with fewer side effects. After release, the patient tended to remain on the new medications, thereby extending the time between episodes, reducing anxiety for the family, and hospitalization costs for the state.
Mr. Davis said the patient was more productive and the state saved money. Continued expansion of the program would provide long-term advantages to both the patient and the state. NAMI asked committee members to preserve the funding for effective, state-of-the-art medications.

Mr. Davis said the second area that required continued attention was that of counseling and psychotherapy. Medicines did not solve all problems involved with mental health. Continued use of individual group and family counseling provided the necessary treatment for NAMI’s customers. Many fine results had been observed in the services provided in southern Nevada and NAMI asked that funding in the area of medicines be continued.

Case management was the third area of requested essential services. NAMI appreciated the attention the legislature had paid to those services in the past and found the PACT program to be an effective mechanism for providing mental health care for severely ill patients. Mr. Davis said PACT was comprised of a group of professionals operating as a team in addressing the needs of the individual. The cross discipline of exchange of information on individual patients allowed accurate analysis and treatment to be performed most effectively, thereby reducing hospital time and its related cost. Future budgets should consider including establishment of a second PACT team in the southern Nevada area.

Mr. Davis said a lesser-known problem was the treatment of felons with mental illnesses who resided in Nevada’s jails or prisons. Treatment for those individuals was usually restricted to the dispensing of medication, with little or no psychological treatment. In the intensive case management program, the Southern Nevada Adult Mental Health Services (SNAMHS) worked with the judicial system to provide total case management for forensically involved individuals. By providing total care, NAMI felt there was a good possibility that many of those individuals could be brought back into society and not continue to be a burden to the state by remaining in the prison system. He said that program was starting to show promising results and should be expanded in the future.

Another area NAMI advocated for was that of psychiatric emergency services (PES). Mr. Davis said southern Nevada had an excellent PES for a number of years. The program had provided an effective method for accepting new patients into the system and provided more service and attention to the individual while offering an organized, tranquil environment that resulted in less turnover of doctors. Northern Nevada NAMI members had informed southern Nevada NAMI how difficult it was for them and how much they wished they had a PES like southern Nevada’s. Should additional funds become available, NAMI requested northern Nevada be authorized a PES program. Finally,
Mr. Davis said SNAMHS hoped committee members would, in fact, approve the budget as submitted by the Governor.

The Chair recognized Elizabeth Jensen, who appeared before committee members to speak on rate increases and staff salaries for CTC’s for mentally retarded adults. She provided the following verbatim testimony:

The Chair recognized Dr. Grant Miller, Residency Training Director, Department of Psychiatry, University of Nevada Reno Medical School. Dr. Miller explained the medical school had a four-year accredited training program. The program trained physicians to become specialists in psychiatry. The goals were to increase the quality of psychiatry in Nevada and to provide psychiatrists to the State of Nevada. Regarding its history, the medical school began with four first-year residents in 1993, and added four residents in succeeding years. The Medical School had graduated seven residents, six of whom had remained in the State of Nevada; two in southern Nevada, and four in northern Nevada, one of which worked at the Nevada Mental Health Institute (NMHI).

Regarding its training for residents, Dr. Miller said residents performed supervised clinical work at both private and public institutions and participated in weekly seminars. Training was provided at a balance of private and public sites that included the NMHI, the Veteran’s Administration Hospital, Washoe Medical Center, and West Hills Hospital. NMHI was important because it provided exposure through services given to individuals having severe and disabling psychiatric disorders. Training in patient care was improved by resident involvement in psychiatric emergency services and the PACT program. Dr. Miller appeared before committee members to support those programs as well as funding for the residency program. He thought both the PES and PACT programs were state-of-the-art and residents in training should be exposed to such services. The medical school thought support of the residency program provided benefits to everyone. First of all, it provided needed services to patients, an improved quality of patient care, and helped residents learn the art of psychiatry. Staff morale at NMHI and the recruitment of psychiatrists of higher quality who wished to teach was also enhanced. In essence, Dr. Miller said patients, residents, staff, and the state benefited from the state fully supporting the medical school’s residency program, particularly at NMHI to at least the existing funding provided during the last biennium.

The Chair recognized Ole Thienhaus, Chairman of the Department of Psychiatry at the University of Nevada Reno School of Medicine. Dr. Thienhaus recalled he had testified two years earlier and repeated the compliments he had paid the government of the State of Nevada for the great foresight in investing in training of mental health professionals. He said he could never match the poignancy of the testimony he had heard earlier from people that had actually benefited from the system. He pointed out to committee members that a great number of people availed themselves of services provided by NMHI. If those services were to be continued, he said the investment had to be made to educate the people who provided those services. He said the Medical School’s residency training program, which produced psychiatrists duly qualified to provide services to the severely mentally ill, had made a huge difference in the quality of services available to the severely mentally disabled individuals in Nevada. Dr. Thienhaus had first-hand knowledge of those differences in the rural clinics as well as at the Washoe County Jail as he was the psychiatrist for those entities. Making referrals and communicating with the individuals in the public sector had dramatically improved, even over the three and one-half years he had been in Nevada. Innovative new services like PES and PACT would need a supply of adequately trained professionals in the future. Nevada’s investment in residency training and psychiatry was remarkable and had paid off well.
Dr. Thienhaus urged the legislature to continue that investment for the benefit not so much of the School of Medicine, but for the State of Nevada and the severally mentally disabled people who would benefit from those services.

The Chair advised there was no funding in The Executive Budget during the upcoming biennium for continuation of the residency program and asked if funds could be found elsewhere to continue the program at any of the sites mentioned. Dr. Miller said the quality of the residency program would be remarkably effected and would possibly face closure as the result of the loss of funding. In order to continue the program, residents had to be exposed to a public site such as NMHI. Dr. Thienhaus added the state was currently funding a full quarter of the total budget of the residency. If that funding were removed, the program would be in dire straits and might have to try to obtain funds from the private sector. The character of the residency program would be dramatically changed. The Chair clarified the request in The Executive Budget represented one quarter of the program and Dr. Thienhaus said that was correct. He added that one quarter was a large amount of money for the program.

The Chair recognized Ted Fifer who provided the following verbatim testimony:

The Chair recognized Rose Anderson, a parent of a client at Opportunity Village. Ms. Anderson said she was also a taxpayer and a resident of Nevada. It saddened her to learn that Nevada ranked 50^th in the nation in available funds for people with disabilities. Ms. Anderson calculated that by keeping her son, Richard, at home instead of institutionalized, she had saved the government at least $50,000 per year for more than 20 years. That represented a savings of more than $1 million to date. As a mom, Ms. Anderson appreciated the dedication of the staff who cared for her son, but dedication did not pay his bills. A rate increase was necessary. She said Opportunity Village had been doing the state’s work for 45 years and had saved the taxpayers millions and millions of dollars. Ms. Anderson asked when the state was going to recognize the contribution from the parents like herself and from organizations like Opportunity Village. When was the state going to show it cared enough to fund those organizations. When was the state going to say "yes." Ms. Anderson represented 500 families and implored committee members to provide necessary rate increases.

The Chair recognized Verna Weber, a secretary for NAMI of northern Nevada and the parent of a schizophrenic. She explained the big problem was caseworkers and not enough doctors that stayed.

The Chair recognized Joe Tyler, President of NAMI of northern Nevada and the producer of the television show that aired in Reno and Carson City called "Erasing the Stigma." Mr. Tyler agreed with and supported Ms. Weber’s testimony regarding case managers. He said an individual had contacted him and asked the definition of a case manager. That type of question would allude to the fact that individual was not getting proper attention. Another issue NAMI felt needed addressing was the PES would offer smoother, better care. Speaking from a personal standpoint, Mr. Tyler said the toughest time when entering the hospital was the first night. He had been hospitalized seven times himself and he felt the first few hours were the toughest. Mr. Tyler then provided the following verbatim testimony:

The Chair recognized Donna Marie Shibovich, a member and consumer representative for northern Nevada NAMI. Ms. Shibovich provided the following verbatim testimony:

The Chair recognized Everett (Ev) Kanter, a client of Nevada Mental Health Institute. Mr. Kanter said he had been a bipolar patient for 20 years. After being on Lithium for 20 years, he was cured and became a recreation therapist at Washoe Medical Center.

The Chair said committee members liked to hear those success stories. Those stories provided encouragement for others.

The Chair recognized Senator Coffin who welcomed Mr. Kanter. Senator Coffin said he knew Mr. Kanter from his childhood and asked him if he felt he had the bipolar disorder for many years but the disorder had gone unrecognized. Mr. Kanter said he had recognized the problem since high school, but not until the discovery of Lithium had his life been changed. He felt he would still be in the hospital if not for Lithium.

The Chair recognized Steve Nahrestadt, the Executive Director of Progressive Choices. Mr. Nahrestadt explained Progressive Choices was a non-profit agency that provided community training services to the developmentally disabled population in the Las Vegas valley. Unfortunately, in times of budget crisis and the challenges that faced the State of Nevada, focus was placed on what was lacking versus accomplishments. Mr. Nahrestadt personally applauded the legislature of the State of Nevada that had passed some very large increases during the 1997 Legislative Session to support individuals with developmental disabilities. However, he said, it was very important that the sacrifice, toil and hard work that went into increased services, and to make the community training centers in Nevada some of the best in the nation, i.e., the Opportunity Villages, the National Association for the Handicapped, Transition Services, and Progressive Choices, stayed strong. One way to accomplish that was to work with the providers to ensure the progress that had been made was not
under-funded. Providers in the area had stepped up and, in response to the legislature’s good faith and investment, had improved services immensely.

Progressive Choices was asking for the same opportunity over the upcoming biennium. The funding of the waiting list, in particular, was troubling to small companies such as Progressive Choices because the company not only looked at that as 75 percent of the individuals who would be unable to receive services, but as a 75 percent reduction in its ability as a company to function within the business arena. Mr. Nahrestadt said Progressive Choices would also like to advocate for the rate increase, not just more money. He said one of the temperamental parts of the current funding system was in its inflexibility. Progressive Choices was locked into two levels of funding, level II funding that made the company provide one staff to two consumers, and level III funding which locked the company into a one staff to five consumer ratio.

As Progressive Choices fulfilled the mandated charter for community-based work placement, clients often did not fall into one of those two solid categories. He said he may find himself in a position where he needed to staff 1 to 3, or
1 to 4, but in those instances the company would be reimbursed for a
1 to 5 ratio. The company was putting in more than the state was willing to reimburse them for. He was not just asking for an increase, but the ability to be flexible in the funding and for the services that were provided according to the circumstances they met in the community, according to the needs of the individuals they served, and according to the best interests of the entities that were funding the program. Progressive Choices advocated that providers could be motivated with existing funding levels. If he had the ability to move an individual from a 1 to 2 ratio which cost the State of Nevada $78.19 per day to a 1 to 3 ratio or a 1 to 4 ratio, yet still maintain that person’s productivity and safety, it would cost the state less money. Mr. Davis asked committee member to work with the providers on a more flexible proactive system and then consider cost-of-living and rate increases on the basis of not having received one over the last two legislative sessions. Again, Mr. Davis thanked committee members for the increase in funding and said he would consider it a misfortune not to capitalize on that investment and the effort and amount of improvement the state had seen in its provision of services to the developmentally disabled. He asked that committee members take another step forward during this legislative session and see clear for a rate increase.

The Chair recognized Robert Wolf, a client of the Southern Nevada Adult Mental Health Services (SNAMHS) and of the Salvation Army. Mr. Wolf said he was 44 years old and was originally from Indianapolis, Indiana. He came to Las Vegas in August of 1998 with less then $10. When he was completely broke he went to the Salvation Army. On September 2, 1998, Mr. Wolf entered the Salvation Army PATH program. He was a client of the Salvation Army because he had been dealing with chronic depression for the last 2 ½ years. He made three attempts on his life and would have made a fourth and final attempt in Las Vegas had it not been for the Salvation Army. If he could say only one thing, Mr. Wolf said anyone at some point might need the help of the Salvation Army. His life’s story was a testimony to that statement. Because of the Salvation Army, Mr. Wolf had incredible opportunity to deal with his depression. He currently attended therapy groups on depression, anger management, and self-esteem. He took anti-depressant medications daily and had developed a recovery plan. Mr. Wolf said he was an active member of a local 12-step support group called Emotions Anonymous (EA) in Las Vegas. Thanks to EA, Mr. Wolf said he had a program he could use to deal with his negative feelings and emotions for the rest of his life. He was currently actively looking for employment, was registered with the Nevada Employment Security Division, and was a client with Nevada Business Services. In summary, Mr. Wolf said programs such as the PATH program through the Salvation Army allowed people to regroup and begin to build a new life, not just for themselves, but for society as a whole.

The Chair recognized Theresa Brushfield Owens who represented Adult Care Association of Nevada. Ms. Owens said over half the association’s members were contracted with State Mental Health. Those members received approximately $1.05 per hour per client. While those members were grateful for the pending increase, there was still a problem that existed. She explained many people were being released from the hospital in the middle of the month. Discharge planners, case managers called the homes that cared for the mentally ill and asked that they take the discharged patients with no money. It was very difficult to manage home costs when fees had increased in eight years from licensing of $62.50 per year to over $800 per year. A.B. 62 (1999) and
S.B. 163 (1999) would restrict or limit homes in the future. She said while the association was willing to take clients, it needed the state’s assistance. She pointed out if the association did not take a client, that person ended up back on the street without medications and the entire process began again. The two or three weeks that person had spent in the hospital were for naught.

The Chair recognized Jill Smith, NDALC. Ms. Smith said clearly the issues were complex and she did want the opportunity to address those issues on behalf of NDALC. Given the time restrictions of committee members, however, she would be more than happy to defer her testimony. She asked that she be allowed to provide to committee members a detailed written response to the questions asked of Dr. Brandenburg as they related to issues of abuse and neglect. The Chair said committee members would welcome her written response and asked if she could summarize her issues for committee members. Ms. Smith said she would not be able to summarize, but said the facts had been mischaracterized on a number of different points and she wanted the opportunity to clarify those issues. She said there was a state audit prompted by some of the issues that resulted in several federal oversight visits and audits. NDALC had every audit and Ms. Smith wanted to address that as well. NDALC performed investigations of abuse and neglect under its federal mandates and continued to review all division referred investigations, even without money, and had not failed the citizens of Nevada or the legislature. She wanted the opportunity to respond to those issues in a detailed fashion so they could finally be brought to rest.

The Chair recognized Senator Coffin. Addressing Ms. Smith, Senator Coffin said he had noticed she had wanted to object but had been restrained. He said it was always better to hear testimony in person rather than in writing, but given the fact she would not be able to testify at that meeting, he asked her to keep her written testimony as brief as possible. Senator Raggio said committee members would probably revisit that budget one more time and invited her to attend that meeting. Ms. Smith thanked the Senator and said she would welcome the opportunity to address the body and respond to any questions. Because committee members were buried in paperwork, it was easier for them to hear objections contemporaneous with what she considered a mis-statement.

There being no further business, the meeting was adjourned at 5:23 p.m.

RESPECTFULLY SUBMITTED:

Debbie Zuspan,

Committee Secretary

APPROVED BY:

Assemblywoman Jan Evans, Chairwoman

DATE:

APPROVED BY:

Senator Raymond D. Rawson, Chairman

DATE: