The Subcommittee of Senate Finance and Assembly Ways and Means on K-12, Human Resources was called to order at 8:10 a.m., on Thursday, March 18, 1999. Chair 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, Chair

Mr. David Goldwater

Mr. Lynn Hettrick

Mr. David Parks

ASSEMBLY SUBCOMMITTEE MEMBERS ABSENT:

None

Senator Bob Coffin

Senator Bernice Mathews

Senator William Raggio

Senator Raymond Rawson, Chairman (Excused)

STAFF MEMBERS PRESENT:

Steven McGuire, State Public Defender, explained the State Public Defender’s office was responsible for offering services in rural counties to represent indigent criminal defendants and indigent juvenile defendants. The office defended people in trials at every level: misdemeanor, gross misdemeanor, and felony. The office handled appeals and administered a fund for post-conviction reimbursement, and currently served seven rural counties. Its main office was in Carson City, with regional offices in Winnemucca and Ely.

Decision Unit M-200 noted the State Public Defender’s office had a substantial increase in its caseload in Carson City and Storey Counties, which were served by the Carson City office. Since 1994, the Carson City District Attorney added two full-time criminal deputies and the Storey County District Attorney added a half-time criminal deputy. During that time, the State Public Defender’s office had no increase in positions and therefore requested an additional full-time trial attorney position in Carson City. Mr. McGuire said he had discussed the position with the Carson City finance officer and the Storey County secretary to the county commissioners. Both counties felt the position was reasonably appropriate and both First Judicial District judges supported the position, as did both county District Attorneys. The position was necessary to meet past and future growth.

Mr. McGuire said the other major change in the State Public Defender’s budget was shown in Decision Units E-125 and E-127, which he would discuss together. One of the services the office should offer was to not only serve the seven counties it presently served, but to make a proactive effort to biannually assess the needs of counties the office did not serve that were eligible for the office’s services. The office could then create a proposal for service to show the counties what the State Public Defender’s Office could do for them. As a pilot project, over the last 2 years he had gone to Lander County several times and met with its district judges, with whom the office worked through Humboldt and Pershing Counties. He had also met with Lander County’s District Attorney and County Commissioners. He discussed what the State Public Defender’s office could offer the county, in terms of indigent defense service. In response to the discussion, the office had prepared two alternate proposals. One proposal, which Lander County favored in every way except the cost, was Decision Unit E-127, which would provide a new regional office in Battle Mountain, a half-time secretary, and a full-time trial attorney.

Mr. McGuire explained the cost of E-127 was $27,000 to $30,000 higher than the alternative plan, which he had proposed. The alternative plan would add an extra attorney in Winnemucca who would work with the existing secretary in existing office space and serve Lander County from the Winnemucca office. The plan had a substantial cost advantage. To address the county’s concern of client ability to contact their attorney, the proposal also included a Watts line so Lander County clients would be able to talk to the attorney in Winnemucca without expense. Lander County decided it wanted to go out to bid with a request for proposals. The county had been discussing the matter for some time. Mr. McGuire said he had been informed the request should go out March 19, 1999. The county anticipated the proposals would come in April 9, 1999, and the decision would be made April 12, 1999. He recognized with the new legislative time frame and the budget process, that was not as timely as needed.

Mr. McGuire encouraged the committee to consider that the proposal involved entirely county money, not General Fund money. If Lander County chose the proposal, all revenue would be collected in county payments and all services would be provided to Lander County. If the proposal could be left open, recognizing the county may not choose either proposal, the State Public Defender’s Office would have the budget authority, but would not serve Lander County or purchase any equipment for it. He did not know how feasible it would be, but Lander County had expressed an interest in having that option.

Chair Evans said she was in her seventh legislative session on a money committee and she did not recall ever seeing a budget request of that type. She was surprised the Budget Division approved the request. She hoped the request would not become routine because it made it very difficult for the committee. The budget documents were several months old. She asked Mr. McGuire to express to Lander County the committee’s dismay at its approach to budgeting. Unlike past sessions, the legislature was under very real time constraints and would have to be closing budgets a lot earlier than in the past. Budgets had already been closed and the process would soon be accelerated. She was not pleased with the date of April 12, 1999. She asked Mr. McGuire to ask Lander County if there was a way to speed up the process. If there was no way to accelerate the process, April 12, 1999 had to be the "drop dead" date for the county’s decision. As Mr. McGuire stated, the proposal was not for General Fund dollars, which made a difference, because if the request was for state dollars, the committee would be inclined to eliminate the entire proposal.

Don Hataway, Deputy Director of the Budget Division, said the Budget Division had hoped Lander County would have already made the decision. The division’s main concern was getting the proper language into the authorization bill for to authorize the public defender to collect fees from counties. Because it was county money, when it came time to close the budget, if Lander County had not made a decision, the committee might want to consider closing the budget with the highest option available and putting the authority to collect up to that amount in the authorization bill. If Lander county decided, through its RFP process, it did not want to use the State Public Defender, then staff would not be hired and it would not be served by the State Public Defender. If Lander County selected the least expensive option, up to that amount would be collected. Mr. Hataway said that would be the best alternative and the Budget Division would be happy to work with staff on proper language of the authorization bill. He agreed it was unfortunate Lander County had not yet made a decision.

Chair Evans said Mr. Hataway was correct. There was the financial aspect as well as the proper authorization. She told Mr. McGuire the issue did not appear to be very important to Lander County, because if it was, the county would have quickly taken action. Mr. McGuire said he could not speak for Lander County, but noted the county had been provided services by two attorneys in a partnership. One attorney had been elected District Attorney and the other attorney had moved some distance away, but may still be interested in serving Lander County. The county had experienced instability in its service.

Mr. McGuire said the previously mentioned items were the highlights of the State Public Defender’s budget. Also included in the budget were equipment replacement and other miscellaneous items, but unless the committee had questions, he had covered the salient points.

Referring to performance indicators, Chair Evans asked Mr. McGuire to explain the circumstances leading to the reduced number of cases for direct appeals and cases involving inmates. Mr. McGuire said he had no way of advising the committee of any systemic reason for the reduced number of direct appeals, other than perhaps a high level of client satisfaction with the work the State Public Defender’s office was doing at the trial level. There had been no change in the number of counties it served and the number of cases had increased. The decision to appeal was made by individual clients. The office was contemplating formulating a client exit sheet, where at the termination of the office’s service, clients would be asked about the level of satisfaction. As the office had not yet done that, he could not say definitively why fewer people were appealing. He thought fewer appeals was a positive performance indicator.

Chair Evans asked Mr. McGuire to explain the new equipment requested in
E-720. Mr. McGuire said E-710 requested $1,854 for all three State Public Defender’s offices. The offices disposed of a large amount of documents as they became out of date and case files were closed. The office requested a paper shredder because documents were currently shredded manually. A paper shredder would be an enormous help. The office requested three card files because, as the office’s records expanded, there was an increasing volume of cards that needed to be filed. The office requested one filing cabinet. The office tried to make sound decisions about discarding paperwork it did not need. Much of the office’s paperwork was redundant and could be disposed of, but the volume of paper the office needed to file was growing. In addition, the office’s safety coordinator thought a first aid kit was needed in each office. He felt $1,854 over the next biennium was a modest request. Chair Evans agreed.

Chair Evans asked Mr. McGuire to explain E-721. She asked whether the State Public Defender’s office was currently using Internet law services. Mr. McGuire replied the office was not. E-721 would provide internal modems, access to the Internet, and subscriptions to Internet law services for the attorneys in the Carson City, Elko, and Winnemucca offices. Chair Evans asked how the State Public Defender’s office conducted its research. Mr. McGuire said research was done using law books. He expected E-721 would give the office enormous gains in productivity and the office was immensely looking forward to Internet law services, if approved by the legislature.

Senator Raggio asked if the office had access to those services at law libraries. Mr. McGuire replied yes. Senator Raggio said he did not mean the office should not have access to Internet law services, he was only noting it was available through law libraries. Mr. McGuire said he thought each of the State Public Defender’s three offices should have Internet access. In addition to the benefiting the offices, Internet access was a tremendous recruiting tool. Telling new attorneys the office did not have Internet access looked bad, because new attorneys expected Internet access, and reasonably so. Chair Evans agreed.

Chair Evans said the Assembly Committee on Ways and Means had held a hearing the previous day on a bill that would supplement White Pine County for a large murder trial in the county. Large trials always had an adverse impact on budgets of smaller jurisdictions. In reviewing the county’s costs, a question was raised regarding public defender fees. She asked Mr. McGuire to explain how public defender fees impacted county budgets.

Mr. McGuire said the public defender’s fees covered the service of attorneys and investigators. When the State Public Defender’s office was assigned to a case, including murder cases, the office provided attorneys. Typically, if the case was a capital case, the office provided a death-penalty-qualified lead counsel, and second counsel, who may or may not be death-penalty-qualified. The office also provided services of its investigators. The office had two investigators who had recently returned from a capital penalty seminar. The office’s service covered in-state travel, but did not cover additional things attorneys may need, such as the assistance of experts if fingerprints or firearms comparisons were in question, or if a psychologist or psychiatrist was needed. For those services, the attorney would file a motion stating why the service was needed. If the judge approved the service, the cost came out of the county’s budget. If out-of-state travel was required, as was often the case in a capital case, the office would apply to the court for funding.

Mr. McGuire explained the State Public Defender’s office typically handled one murder case every other year, or maybe every year, but in 1998, the office handled five murder cases. He was pleased the office was able to respond to the extraordinary increase in murder cases. The office’s funding typically did not increase during the course of a capital case; the office just worked a lot harder.

Chair Evans asked Mr. McGuire to be in touch with legislative staff on the issue in Lander County. Mr. McGuire said he would do so.

Carlos Brandenburg introduced himself as the Administrator of the Division of Mental Health/Mental Retardation (MH/MR). Also present was Dr. David Luke, the Associate Administrator for Mental Retardation Services and Mike Torvinen, Administrative Service Officer IV.

Chair Evans said the committee wished to revisit issues previously discussed in committee hearings. The first issue was the needs of Mental Retardation clients on waiting lists. She asked Dr. Brandenburg to review what occurred in 1997 and what was recommended for 1999. In come cases, there was a continuation of services, and in other cases, there were new issues. The most pressing issue was the Perry vs. Crawford lawsuit, which dealt with services for those persons under the heading "related conditions." She said the committee had asked Dr. Brandenburg to review how the projected caseload would be handled, usage of Intermediate Care Facility for the Mentally Retarded (ICF-MR) small beds, what was in the budget versus the division’s needs, and whether there were less costly services available that would provide good service to clients.

Dr. Brandenburg said he would first address the ICF-MR small beds. The division requested 30 ICF-MR small beds in E-355. The division felt those beds were needed in order to return children housed out-of-state, as well as service children and adults currently housed in nursing homes. There were currently 54 ICF-MR small beds in the division’s budget. There were 24 more beds in the current budget than the division requested. He said Mr. Torvinen would explain the calculations Dr. Luke and Mr. Torvinen made for the final fiscal analysis regarding the saving of 24 beds.

Chair Evans reminded the committee three MH/MR budgets were being discussed: Budget Accounts 3280, 3279, and 3167. She asked Dr. Brandenburg to inform the committee if one specific budget account was being discussed.

Mike Torvinen, the Administrative Services Officer IV for MH/MR, said he would explain the division’s March 12, 1999 submission to staff ("Exhibit C, Proposed Alternative Use of Medicaid Private ICF/MR Funding"). The top of page 1 of Exhibit C, showed the Governor recommended funding 54 beds: 12 beds in northern Nevada, 24 medical beds in southern Nevada, 12 dual diagnosis beds in southern Nevada, and 6 medical beds in rural Nevada. The beds had been budgeted at the daily rate of $350 for medical beds and $225 for dual diagnosis beds. The beds had been budgeted for 365 days in each year of the biennium. In FY 2000 the total cost of the 54 beds was $6,351,000. The total cost would be the same in FY 2001. The total cost for the beds for the biennium would be $12,702,000.

Mr. Torvinen explained the next line was titled Actual Funding Per Health Care Financing Policy via Mark Roberts. The amount identified in the Governor’s recommended budget for the 54 beds was slightly different than MH/MR’s total. As he compared the available funding, he would use the amount in the Governor’s recommended budget, which was $12,987,465 over the biennium, and would be funded half by Medicaid and half by the General Fund. So, for the biennium, there would be approximately $6.5 million funded by Medicaid and $6.5 million funded by the General Fund for those 54 beds.

Mr. Torvinen said MH/MR’s proposed alternative was to reduce the number of beds by 24. As Dr. Brandenburg stated, 30 beds were requested for medical needs and an additional 12 beds were requested for the dual diagnosis program. The Governor did not recommend funding the dual diagnosis program, due to lack of funds. Those 12 additional beds, plus the 12 medical beds, totaled the 24-bed reduction, leaving the division with 30 beds.

Mr. Torvinen said the rates used in the original estimates were high. The division was budgeting at the highest Intermediate Care Facility (ICF) rate in the state, mainly for budgeting purposes. The division now felt it could budget at the rate the division was currently paying, plus a medical component. Stan Dodd, Administrator of the Desert Regional Center in Las Vegas indicated approximately $43 per day for the medical portion of the ICF-MR rate. When that computation was originally done, the division estimated it would be $273 per day. If the current rate of $225 was added to the $43 medical cost, it would total $268. He computed that amount separately, which saved approximately $100,000 over the biennium. However, it had been computed at $273, so there was an additional $100,000 that could be saved.

The bottom half of page 1 of Exhibit C showed how much funding 30 beds at the decreased rate would save the division. In addition, the start had been delayed 60 days in the first year to allow time for the proposal process to enter into contracts with private providers, so there would be no people in those beds. The new rate had been calculated with 30 beds for 305 days in FY 2000 and totaled $2,497,950. At the same rate, with the same number of beds for 365 days, the cost in FY 2001 totaled $2.99 million. The total cost for the biennium was $5,487,300.

Mr. Torvinen stated by comparing the proposed alternative to the actual funding in the Health Care Financing program budget of $12,987,465, the potential saving totaled $7.5 million. As the saving would be half Medicaid’s and half General Fund’s, the General Fund would save $3.75 million for the biennium.

Mr. Torvinen said page 2 of Exhibit C showed the proposed use of the $3.75 million saving to the General Fund. The General Fund saving would be $1,741,759 in FY 2000 and $2,008,324 in FY 2001. The division had recently received approval to increase its case management rate from $71 per hour to $81 per hour, based on a cost study performed by MH/MR on its agencies. The division divided the cost of providing case management services by the number of hours of service provided, and derived the rate of $81 per hour, which would be applied to all three budget accounts. The new rate of $81 per hour accounted for the 7 percent increase in the Medicaid portion. Also listed on page 2 of Exhibit C was the Medicaid revenue in the Governor’s recommended budget. There had recently been a 7 percent increase and the budget had been based on $71 per hour, so with the new rate of $81 per hour, the division would be able to generate an additional 7 percent in Medicaid dollars in case management revenue. The 7 percent increase ($81) had been applied to the Governor recommended case management Medicaid revenue in each budget, and found an additional $137,000 in Medicaid revenue in FY 2000 for case management, and an additional $153,000 in FY 2001, for a total of $290,843.

Chair Evans asked to what did the rate of $81 per hour apply. Mr. Torvinen said the rate applied to the division’s case management services to mental retardation clients in Budget Accounts 3280, 3279, and 3167. Dr. Brandenburg said page 2 of Exhibit C showed, for the division’s north, south, and rural regions, the increase in revenues that would be brought into Budget Accounts 3280, 3279, and 3167. The total for the biennium would be $290,843.

Chair Evans asked how the rate increase would impact MH/MR’s client services. Mr. Torvinen replied there would be no impact. Services would be provided to the same number of clients the division originally anticipated, but the division had been authorized a higher rate of reimbursement from Medicaid. The division had been funded all along to provide service to 100 percent of its case management clients. All the proposals had included that; it was the division’s other services that had not been funded.

Chair Evans said she appreciated Mr. Torvinen’s explanation of the proposed alternative use of medical private ICF-MR funding. It was important new information for the committee. She said the issue that had been raised regarding client services, specifically client placement, was that the division had not been able to service 100 percent of its clients. She wanted to know how the division could impact services, other than case management, because the committee felt calculations of the number of clients served in the Governor’s recommended budget would not be adequate. She asked what, if anything, could be done to address the issue. Dr. Brandenburg said he would like Mr. Torvinen to continue his presentation of Exhibit C and explain M-300 and the proposal that had been negotiated with the Budget Division and the Department of Human Resources.

Mr. Torvinen directed attention to the section of page 2 of Exhibit C titled
M-300 Occupational Study Additional Revenue. As shown, MH/MR’s increase in revenue for its north and south regions totaled $290,843 for the biennium. The rural region’s budget, Budget Account 3167, did not operate ICF-MR beds, and therefore, there was no ability to increase revenue in that budget based on the additional cost. When it was originally put in the division’s budget, it was funded 100 percent from the General Fund. Those costs were part of the ICF-MR cost, of which the division recovered 50 percent in its rate and through the cost reporting process every year. For that reason, when those costs were calculated into the budget, the division would generate an additional 50 percent of the cost in Medicaid dollars. The division estimated it could collect an additional $586,000 in Medicaid revenue, based on the rate increase. The division could probably get a rate adjustment early in the year and begin collecting revenue right away, as opposed to waiting a year and having a cost report settlement for a half-million dollars. The division would rather receive the money now and settle a smaller amount later.

Mr. Torvinen said in combining the case management increase with the occupational study cost report, the division estimated it could generate an additional $877,536 in Medicaid revenue. Combining the $877,536 with the General Fund saving from reducing the number of beds would provide an additional General Fund saving in increased revenue of $4,627,000. The proposal made by the department in the Budget Office was to make no changes in FY 2000, which proposed to serve 25 percent of the estimated need in the purchase services category. The purchase services category included residential support, family support, and jobs and day training. The proposal was to serve 50 percent of the projected need in FY 2001, at a General Fund cost of $722,513. The additional estimated revenue would entirely fund the $722,513 for the additional service, with money left over.

Mr. Torvinen said $722,513 was only the General Fund portion and an additional $429,000 in Medicaid revenue would be generated, just by providing those additional services and billing Medicaid. The total cost was approximately $1.1 million, but the General Fund portion was $722,513. Therefore, the net saving of the proposal would be $3.9 million, generated by increased revenue of $877,000 and a General Fund saving of $3,027,570.

Dr. Brandenburg said with service of 25 percent of the estimated need in the purchase services category, which was currently in the Governor’s recommended budget, the waiting list at the end of 2001 would be 162 for the residential, 129 for jobs and day training, and 137 for family support. Whether or not Medicaid would be able to fund 50 percent in FY 2001 was predicated on Medicaid having the ability to pay. When MH/MR met with Charlotte Crawford, the Director of the Department of Human Resources, she indicated she had a substantial financial problem in the Medicaid budget. Ms. Crawford could not guarantee 50 percent funding until FY 2001. If Medicaid was able to fund 50 percent for FY 2001, the waiting lists for residential services would decrease from 162 to 109; jobs and day training services would decrease from 129 to 89; and family support services would decrease from 137 to 89. Therefore, the division would serve an additional 53 people in residential services, an additional 40 people in jobs and day training, and an additional 48 people in family support.

Chair Evans asked if the division would be able to serve everyone in case management services only, while people would remain on waiting lists for other services. Dr. Brandenburg replied that was correct.

Chair Evans said she understood the funding would begin in FY 2001. Dr. Brandenburg said, yes, if funding was available. Chair Evans asked if there was any way to calculate the length of time people were on waiting lists. Case management would help, and that was crucial. Dr. Brandenburg said his understanding was the waiting for residential services was between 8 and 14 months. Dr. David Luke, Associate Administrator for Mental Retardation Services, said the division tracked only the waiting list for residential services, not other services. Any estimate would be speculative, but he thought the waiting lists for other services were a few months.

Chair Evans asked if there were any regulations regarding the length of time a person could remain on a waiting list. Dr. Luke said case management’s goal was get people on board and that was fully funded within a 30 to 60 day period. He did not think there were any regulations, but a precedent set in a Florida lawsuit deemed 90 days a reasonable length of time for people accessing intermediate care services to wait. Chair Evans asked if the term "reasonable time" had been defined. Dr. Brandenburg said a Florida court deemed 90 days to be a reasonable time.

Chair Evans asked why, if 90 days was deemed to be a reasonable time to be on a waiting list, were people waiting between 8 and 14 months for residential services. Dr. Brandenburg said Medicaid would offer out-of-state placement to the family members for individuals who felt they wanted residential services.

Chair Evans asked how the cost of out-of-state placement compared with in-state placement. Dr. Luke clarified out-of-state placements would be for individuals with ICF-MR need, which cost approximately $200 per day and was probably equivalent to in-state ICF-MR care.

Chair Evans said the issue needed clarification. As she understood, the division was not planning for additional clients, but if a person was on a waiting list for more than 90 days and requested placement, then the person would be placed out-of-state. Dr. Luke said the offer of out-of-state placement would be made to the family of the individual. If the family wanted more immediate placement than could be provided in state, the individual could be placed out of state. Chair Evans asked if the assumption for out-of-state placement was that no placement was available in

state. Dr. Brandenburg asked Chair Evans if she was referring to the 109 people who would be on the residential services waiting list at the end of FY 2001. Chair Evans replied yes. Dr. Brandenburg said those 109 people would meet the ICF-MR requirement and would be offered Medicaid placement out-of-state, since the state would not have space available.

Chair Evans asked who currently provided ICF-MR small beds. Dr. Brandenburg said the state had contracts with several different providers for those services. Chair Evans asked if there was a need for placement, would placement be found in state. Dr. Brandenburg said there would be 109 people on the waiting list for residential services at the end of FY 2001.

Chair Evans asked how many ICF-MR beds, occupied or not, currently existed in the state, from all providers. Dr. Luke said there approximately 90 to 100 ICF-MR beds in Nevada. Chair Evans asked how many of the 90 to 100 beds were currently occupied. Dr. Luke said they were all full and remained full on an ongoing basis.

Chair Evans asked if more funding was available, would more community beds become available. Dr. Luke said more facilities could become available or people might choose to be served in other types of community setting, such as supported living arrangements. Dr. Brandenburg said it was not the division’s primary choice to utilize the ICF-MR beds. The division would prefer a least restrictive environment. The division used ICF-MR beds when it needed to, but preferred to move people into intensive Supportive Living Arrangement (SLA) beds or into the community. In 1995, when the division was directed to bring back children who had been placed out-of-state, the division returned the children to Nevada and placed them in ICF-MR beds. On a gradual and systematic basis, through the division’s clinical intervention, the children were moved to a least restrictive environment, such as an SLA bed or into the community. The division was able to do that because the division’s staff worked with children in state and provided a continuity of care and services. When children were placed outside the state, the division lost the ability to determine whether the children could be put into a least restrictive environment. The division needed ICF-MR beds as an option because there were clients who needed to be in those facilities. Because of the division’s expertise and ability to treat clients, the division was often able to move people out of ICF-MR beds into the community in the least restrictive setting.

Chair Evans said the issue of costly ICF-MR beds had been discussed in the committee’s hearing the previous week. She asked what types of SLA beds could be used to increase the number of placements, not speaking of ICF-MR small beds. She asked if more people could be placed if the division could place people in a different type of setting. Dr. Brandenburg said if the division was able to get community resources, it could place more people. Chair Evans asked if the problem was that there were not enough SLA beds available. Dr. Brandenburg replied there were not enough SLA beds available to utilize that option. The division was currently attempting to stay ahead of the curve on the residential waiting services. It was difficult for the division to seek community resources when it was putting its efforts into reducing the waiting list. He said he was confident in Dr. Luke’s ability to maximize efficiency, if Dr. Luke had community resources. The division’s approach was to provide services for its clients in the least restrictive manner, which was often the most cost-effective manner.

Chair Evans said the committee had the same goal of servicing more clients and offering more options. The committee was clearly troubled by the length of the waiting list. Dr. Brandenburg said the division shared the committee’s concern and assured the committee Dr. Luke’s 30-bed proposal was "bare bones." The division needed those 30 beds and had promised staff the administrator would review the existing ICFs to determine what could be done to move clients into the least restrictive environments. There were children and adults out of state and in nursing homes who needed to be moved into the division’s ICF-MR small beds so the division could start the client’s active treatment process.

Chair Evans asked for public testimony on alternatives to ICF-MR beds.

Brian Lahren, Administrator of the Washoe County Association for Retarded Citizens (WARC) said it was troubling the division had enough money to send Nevada children out of state, which broke up families, and provided them residential services at the same rate as it would cost to provide residential services in Nevada. He said it seemed the committee had correctly identified the problem: the length of time people were on waiting lists for residential services. He had testified at a previous hearing if the waiting list continued to exist, the state would have the same risk it historically had. The issue, legally, was waiting lists for whatever services identified in the state Medicaid plan, not merely residential services. He thought it was encouraging to hear there was a way to increase the number of people who could be taken into residential services in the second year of the biennium, with little additional expense. He thought that would be a very good move, but added it was important to establish a contingency plan in case the division guessed wrong about the waiting lists. The problem was not provider availability. There were numerous excellent providers in the state who were willing to go to work and provide services. Medicaid money was available to place children out of state, so if that money was made available in Nevada, providers in the state would be very willing to provide those services. He thought in-state providers would provide services as soon as funding became available.

Chair Evans said she had asked for alternatives to ICF-MR small beds, because it would be less expensive. She was hoping to determine how the division could accommodate more people in a different setting. She asked Mr. Lahren if he believed there were other options, such as SLAs, at a lower cost that were available or could become available. Dr. Lahren said he thought that was the case. He said most people on the waiting list were eligible for ICF-MR care and, therefore, also available for waiver services, which allowed Medicaid dollars to be directed to community placements in less restrictive environments than ICF-MR care. It may include some community-based ICF-MR beds, but could also include a number of other residential services. If those residential services were not available under the existing waiver, it was possible to amend the waiver in a timeframe consistent with getting people into services. He thought that would be a wise decision, especially since the state would spend the money out of state. He thought the division should be directed to make necessary accommodations to get Nevada children served in state with the least expensive Medicaid-funded waiver services possible.

Chair Evans said the issue had been raised in a previous hearing and believed a waiver had already been submitted. Dr. Lahren said given the increased numbers, it may be necessary to make another amendment to expand the number of beds proposed under the waiver in the future. Chair Evans said the issue of waivers would be revisited later.

Dr. Lahren concluded by stating the division provided ICF services and had community-based ICF homes. He thought it seemed an unusual and unnecessary thing for the division to be a direct service provider of ICF services because there were providers in the community. In addition, the division’s state operated ICF services were more expensive than the most expensive private provider in the community.

Jill Smith introduced herself as the advocacy director for Nevada Disability Advocacy and Law Center (NDALC). She agreed with Dr. Lahren’s testimony and said she would follow up on Chair Evans’ questions and offer additional information. Regarding the home and community-based waiver, the funding had been allocated in the 1997 Legislative Session and there were subsequent difficulties between the Healthcare Financing Administration (HCFA), MH/MR, and others in getting it implemented in time to meet deadlines. There were four waivers, and that one would specifically address physical disabilities and was identified for approximately 42 people. It was unclear whether that waiver would reduce the waiting list to an acceptable number.

Ms. Smith said she was pleased Dr. Brandenburg clarified the funding of the waiting lists at the 100 percent level was just for case management services and was only 25 percent for residential services, supportive services, and job placement. There were already waiting lists of over 2 years, which was a problem.

Ms. Smith said institutional care should be used only when absolutely necessary and as a last resort. She said Dr. Brandenburg stated that was also the division’s goal, but the Department of Health and Human Services (DHHS) and the Attorney General took the position against the community integration mandate under the Americans with Disabilities Act (ADA) in L.C. and E.W. vs. Olmstead, which was now currently before the United States Supreme Court. The DHHS took the position that the state should make the choice of whether to provide services in an institution and the decision would be driven by costs, which were not substantiated.

Ms. Smith said Ms. Crawford indicated the Medicaid numbers, which were not forwarded to the Attorney General prior to the filing of the brief in opposition to community integration, were based on an impression of Medicaid by Chris Thompson, former Director of Nevada Medicaid. She said the division had subsequently promulgated a justification for the proposed drastic step at a cost increase to the state. She had not had an opportunity to review the division’s explanation, but had heard it "did not hold water."

Ms. Smith thought it was unbelievable the department felt it was more cost effective or better in any way to send children out of state without the support of their families instead of reallocating resources into the community. It had been clearly demonstrated that it was more cost effective and humane to place children in the community. She did not feel the department was following through on its commitment to community-based services and least restrictive environments. Nevada was ranked 50^th in the provision of community-based services. She said that did not make sense and would appreciate a rational explanation for the division’s actions.

Chair Evans said there was no plan or conspiracy to gang up on clients of MH/MR. She said it was tough to find an overall balance that must occur when dealing with Medicaid dollars, because the funds had to be distributed among a lot of agencies with different needs. There were competing issues and concerns that must be served.

Paula Berkley said she was present to represent EduCare. She said the redirection of the budget toward SLA dollars, away from ICF-MR was prudent. EduCare was the main provider of ICF-MR beds in the state, so for her to make that statement was an indication of support for the judgement of MH/MR to provide services and make the division’s dollars go a little farther.

Ms. Berkley said she was sure the committee would be discussing tobacco settlement issues in the coming month. She acknowledged the committee was trying to do as much as possible with state dollars, but there were other issues to consider. For example, if a mother smoked one pack of cigarettes per day during pregnancy, her child’s chance of mental retardation would be increased by 75 percent. Some tobacco settlement dollars would be well spent on health care, specifically mental retardation, and possibly for matching dollars from Medicaid. Ms. Smith reiterated, in closing, addressing MH/MR’s waiting list would be a good "bang for the buck."

Chair Evans asked Ms. Crawford to comment on MH/MR’s budget.

Charlotte Crawford, Director of the Department of Human Resources, said she thought the committee was well aware MH/MR had struggled for many years to develop an array and balance of residential and other services for mentally retarded individuals. That was done to offer individuals an opportunity to live in the least restrictive and most appropriate setting. However, growth sometimes made it difficult for the division to achieve its objective. She thought the committee reasonably requested the division to determine whether there was an alternative way to provide more residential placements in less restrictive, less expensive, community-based SLAs. In evaluating that, it came to the division’s attention there was a discrepancy between the number of ICF-MR small beds in Medicaid’s budget (54) and the number the number the division felt it needed (30). The General Fund for ICF-MR beds was in Medicaid’s budget. She felt the division prepared an alternative that would have met 100 percent of its waiting list with freeing up what was the General Fund for the 24 ICF-MR small beds in Medicaid’s budget.

Ms. Crawford said the division referenced a saving with which she did not agree. The Medicaid budget might not be adequate to meet the ongoing obligations for entitled clients on that caseload. In view of that, she had asked the division to consider General Fund dollars that would then be unobligated by freeing up the 24 beds requested, not as a savings. Rather, it would be a real dollar need to cover the ongoing Medicaid caseload. There were no increases or rate increases in Medicaid’s budget; it was just a maintenance budget. The division drafted a plan, as requested, that would, if the funds were available in the second year of the biennium, meaning Medicaid was able to meet its obligations, move toward meeting 50 percent of the residential waiting list. She would like the division to be able to meet 100 percent of its waiting lists, but the Medicaid budget may not be able to support the obligations it already had.

Chair Evans reiterated the committee’s appreciation for Medicaid’s balancing act across many budgets in several divisions. She asked Mr. Torvinen to join Ms. Crawford and explain how the division derived its proposed alternative plans so there would be a basis for discussion and comparison between MH/MR’s two plans (Exhibits C and D).

Mr. Torvinen said page 1 of Exhibit D was identical to page 1 of Exhibit C. There was no change in the estimated savings. For both plans there was a reduction of 24 beds with a delayed start in the first year of the biennium and a reduction in the rate. Page 2 of Exhibit D was the same as page 2 of Exhibit C, through the total increased revenue amount. Both plans showed the same rate increase for case management, which would generate the same amount of money. Both plans also showed the occupational study, which would recover 50 percent of that cost through the ICF-MR cost reporting process. There would be available a General Fund saving in additional revenue of $4,627,619. The only difference between the plans was the estimated General Fund cost to serve a different level of clients. Exhibit D showed the estimated cost to serve 100 percent of the division’s estimated demographic growth. The amount listed was the General Fund portion only. In FY 2000, the cost to the General Fund to serve 100 percent of estimated demographic growth was $1,287,097 and in FY 2001 it was $2.9 million, totaling $4.2 million over the biennium. The net saving would be $388,743 over the biennium. In FY 2000 there would be a surplus of $826,000, comprised of increased revenue of $371,000 and General Fund savings of $454,000. In FY 2001 there was a net deficit between the savings and the additional cost, comprised of $506,000 in increased revenue and $ 943,000 in General Fund revenue, which would have to be allocated to FY 2001. Over the biennium, there would be a $388,743 combination of saved General Fund revenue and increased revenue.

Chair Evans asked Mr. Torvinen to explain the General Fund figures again. Mr. Torvinen said in FY 2000 the General Fund saving and increased revenue would be $2.1 million. The General Fund cost to serve 100 percent of the division’s estimated demographic growth in FY 2000 was estimated to be $1,287,097. By serving those people, more Medicaid dollars would be generated, but the plan showed just the cost to the General Fund. For FY 2000, if $1.7 million in General Fund money was saved, and an additional $371,000 in revenue was generated, and $1,287,097 was applied to cost, then the division actually generated $826,000 above the cost. That would be comprised of $371,000 in increased revenue and an actual General Fund saving of approximately $455,000.

Mr. Torvinen explained in FY 2001 the combination of increased revenue and saved General Fund from ICF-MR beds was $2.5 million. The cost to serve the estimated number of clients in FY 2001 was $2.9 million. It was a shortage of $437,000. That would be recovered through the increased revenue and a reallocation of General Fund money to FY 2001 of $943,000. Over the biennium, there was a net saving of General Fund money of $388,743.

Senator Raggio said the explanation was very helpful. The committee was mindful of its limitations, but those should not be the criteria. The waiting lists needed to be fully addressed. He thought the division’s two proposed alternative plans would give the committee a good opportunity to review types of accommodations. The committee may not take either plan, but there was certainly room for revisitation of what was originally proposed.

Chair Evans asked what affect the additional waivers and different residential options would have, if any, on the figures the division provided. Mr. Torvinen said the division constructed its budgets based on the assumption the waiver the division requested in June 1998 would be approved. The previous day, the division received a letter approving the waiver. Chair Evans asked if there were any waivers the division was failing to utilize. Mr. Torvinen replied he believed the division was utilizing every waiver available to it.

Chair Evans agreed the two plans presented by MH/MR were very helpful to the committee, in terms of making a comparison. The committee would review the figures and, in light of other needs for Medicaid’s budget, make a decision, which would not be easy.

Ms. Crawford said she thought the division’s alternative plans showed the range of options. She would like to talk with the division. The people in the division told her they felt the number of ICF-MR small beds, and perhaps the number of ICF-MR the division requested in the past, may have had something to do with where the funding was located rather than the type of bed the division most needed to develop. She hoped the division would be able to look clearly at the type of bed relative to the type of clients the division had. If the bed was an SLA, even though those General Funds were in MH/MR’s budget, the division would face the problem and be able to deal with it. Clearly, the division was in a difficult position.

Ms. Crawford expressed concern about adding only 30 ICF-MR beds. If the division was accurate about being able to transfer people from ICF-MR beds to less restrictive environments, she fully supported the division in that effort. There were currently 12 Medicaid clients under ICF-MR care out of state. The division had faced a dilemma and had to make extraordinarily expensive placements out of state, sometimes at a higher level of care than ICF-MR. The division had been unable to accommodate the level of need of the individual, because the individual’s situation had been more acute than the division was able to provide for. She was sensitive to the fact that the entitlement was to ICF-MR care, through Medicaid. The division did not hold the entitlement. Individuals who qualified for an ICF-MR were entitled to that program. The division did not place people out of state by choice, but if a person qualified for an ICF-MR, the division had to make a reasonable accommodation and offer services. If the service was not available in state, the division was obligated to offer out-of-state placement. She emphasized the division did not prefer to place people out of state or provide services to clients at a higher cost than necessary. She hoped the division would not be bound by 30 ICF-MR beds if it would be better off with 25. She encouraged the division to carefully consider the type of bed for which it asked, relative to the client’s need.

Chair Evans asked what action could be taken to ensure the division pursued the least restrictive residential placement. She did not want it to just be the division’s goal; rather, she wanted a plan of action from the division to ensure that. Ms. Crawford encouraged that and said, as Dr. Brandenburg indicated, the division had become more skillful over time in its ability to treat clients. She admitted perhaps the division had designed its beds more by budget than by the need of its clients.

Chair Evans asked who had the responsibility of determining whether the division was maximizing its resources, knowing there would never be enough funding. Ms. Crawford said the division had the expertise to identify the needs of its clients and Medicaid had the responsibility to be very clear about what medical program it offered and what entitlement was carried with the offer of an ICF-MR bed. Therefore, it was a joint responsibility between MH/MR and Medicaid.

Chair Evans asked if there was good communication and collaboration between MH/MR and Medicaid to make sure the best job was done. Ms. Crawford said the 24-bed discrepancy attested there was not very good communication. The communication was not ideal, but it had gotten better. The Department of Human Resources was struggling to get MH/MR and Medicaid to understand the others’ responsibility. She had not seen Medicaid’s budget, but assumed it was also tight. Everyone had been guilty of using the Medicaid budget to put things in because it wouldn’t get the level of scrutiny it would if it was in MH/MR’s budget. Part of the division’s problem might have been due the way MH/MR’s budgets were planned. MH/MR needed to be very clear about what its clients needs were.

Dr. Brandenburg said he respectfully disagreed with Ms. Crawford’s comment about planning MH/MR’s budget. The division did not design beds by budget. He did not think it was the division’s intention or practice to do that, but he understood why she might make that comment. In response to Ms. Evans questions, he could provide figures to the committee. As the committee might recall, when the division was directed to return the children who had been placed out of state, most of the children who had been brought back to MH/MR’s facilities were now in least restrictive environments. He would be happy to provide figures to show the actual number of people in the division’s facilities who had been moved to least restrictive environments. However, without the resources from the community, it was difficult for the division to do that.

Chair Evans thanked Dr. Brandenburg for the information about the division’s and the department’s options, which gave the committee a good basis for comparison. She asked Dr. Brandenburg to review the alternatives one more time, considering Medicaid and the division, and perhaps community participants. She asked Dr. Brandenburg to rework the division’s proposal, understanding the legislature ultimately had to make a decision, and see what might be achieved to get closer to the 90-day timeframe. The figures the division provided to the legislature were still of concern and were a good step forward, but the committee was still concerned about the 8 to 14 months a person would possibly be on a waiting list. The committee would like to see a proposal that might close that time gap. She said Mr. Guernsey would help the division in its huge undertaking, if the division wanted. She realized the committee was asking a lot of the division, but one more alternative would give the committee three options: the two that had been presented that morning and another one that would hopefully shorten the waiting list. Dr. Brandenburg asked when the committee would like the third plan. Chair Evans answered as soon as possible.

Chair Evans told Dr. Brandenburg the committee would like to further discuss the Psychiatric Emergency Services (PES) issue. Dr. Brandenburg said the division provided to staff a proposal for funding the PES with the least staff the division would need for the initial startup. The initial proposal was for 29 full-time equivalencies (FTEs). The alternative proposal requested by the committee offered 16 FTEs to fund the same facility 24-hours-a-day, 7-days-a-week. In 2000 the cost would be $698,000 and in 2001 it would be $917,000. The original proposal totaled $1.3 million for 2000 and $1.7 million for 2001. At the committee’s request, the division had also provided to staff the cost to staff the projected inpatient census. When the division designed the budget, the PES was a possibility, so the average daily census was kept at 52. Staff then requested the division recalculate, increasing to 56 beds by the end of the biennium. Increasing to 56 beds would be 4 positions—1 R.N. and 3 mental health technicians.

Chair Evans asked whether PES were accounted for when the division built its budget and made its estimates on needed bed space. Dr. Brandenburg replied yes, the division built its budget with the narrative in its budget clearly indicating the division was keeping the census at 52, with the understanding the PES would be funded. Chair Evans asked if the assumption was that if the division did not have PES, more residential beds would be needed. Dr. Brandenburg replied that was correct. For FY 1998, the division’s average daily census was 52. Chair Evans said if the division got started on PES, in terms of adjusting the estimates on inpatient services, did the division think 56 would be the approximate census. Dr. Brandenburg said yes, that was based on the projection of FY 1998. The division felt it would increase to 56, but the previous Monday, he believed the census at the Nevada Mental Health Institute was 64, and by the following day the census had decreased to 52.

Dr. Brandenburg said the issue of cost avoidance was very important to staff. He said Mr. Guernsey had been trying to pin down the division on what would be the cost avoidance dollar on the PES. The cost avoidance dollar would presently be difficult for the division to determine, as it did not have a baseline. If PES was funded and the division was able to move staff from the hospital into PES, instead of requesting the additional staff in the next biennium, the division would reallocate the existing staff from the hospital into PES and ask the committee for the appropriate amount.

Chair Evans asked Dr. Brandenburg to discuss rural clinics. When the committee previously met with the division, there had been discussion about getting accurate data on the number of clients. In addition, there had been unevenness among rural clinics, with some clinics overloaded and having waiting lists. She asked Dr. Brandenburg what ability the division had to move people around. The problem appeared to be staffing and available space to perform the division’s work. Dr. Brandenburg said that was correct. The caseload analysis the division had provided to the committee was misleading. Rural clinics had generalists and the division’s other two sites did not. In rural Nevada, there might be a social worker who spent 25 percent of the time in case management and 75 percent of the time in outpatient therapy. When he calculated the difference between outpatient care and case management care, he calculated duplicate numbers because it was the same client going into the same type of service. After reviewing those numbers and spending a great deal of time and energy with the acting director of rural clinics and rural clinic staff, he felt confident that with the current staff the division should be able to reallocate resources to the sites that needed it. The division did not feel it needed any additional staff in rural clinics. However, the vacancy savings built into the budget hurt the division. He acknowledged he was supposed to fill positions and make the vacancy savings, but in reality he had to direct his staff to keep positions vacant to ensure the vacancy saving was kept.

Dr. Brandenburg said another factor was the difficulty of recruiting in rural Nevada. On the one hand, there was the issue of recruitment and retention of staff, and on the other hand there was the vacancy saving. If he was allowed to move staff from a highly productive mental health clinic to a center that was not as productive, that would allow him more flexibility. The committee needed to be aware that since July 1998, the division had been performing a productivity analysis on its entire case management and outpatient staff for northern and southern Nevada. Because the division had been implementing the Advanced Information Management Systems (AIMS), he had not yet reviewed the productivity of rural clinics. There was no doubt the division could increase its productivity and efficiency with its current staff if he had the flexibility to move staff between centers.

The only issue was the space problem in Douglas County. However, the division felt it would be able to bring in the revenue. He currently had a psychiatrist and psychologist sharing an office, so when one used the office the other could not. If each had a separate office, revenue could be increased. Mr. Torvinen had shown him the increased revenue would offset the cost of moving. He did not need any additional staff in rural Nevada if he was given the flexibility of working with LCB staff to move resources form one clinic to the other. The division had also looked closely at the money for the psychiatrists and felt there were sufficient monies in the budget to increase psychiatric coverage, thereby reducing waiting time. It had been very difficult for the division to get data that had integrity from rural clinics. However, in the previous 4 to 5 months, he thought the division had been able to achieve that. He asked the committee to allow him the next biennium to review the recent data.

Mr. Dini said the juvenile center in Silver Springs was already overloaded and if another 24 to 28 children were put in the facility, that would put a heavy load on the Silver Springs office. He thought the staff there needed to be increased. Dr. Brandenburg said he was looking at the projection from the division’s data on waiting lists and had not anticipated the Silver Springs facility. He agreed with Mr. Dini and said if the committee wanted the division to provide mental health services to the Silver Springs juvenile detention facility, the division would need additional resources. Mr. Dini said he thought the most efficient place to treat the children would be at the rural mental health clinic because it was next door and would alleviate duplication.

Mr. Hettrick said he appreciated the division’s efforts and it seemed something could be done about the state space requirement in Douglas County. He said he had no problem allowing staff to be moved among sites to manage workloads. He was concerned that given it was already difficult to staff rural clinics, staff may be unhappy about being moved among rural areas. Dr. Brandenburg agreed, and said the division would most likely move a vacant position from one of the hard-to-recruit areas into an office that had a higher caseload.

Mr. Hettrick said the division had forwarded a note to the committee regarding moving two offices. He said the east Las Vegas office asked for additional space, but Douglas County said its office could move into almost 3,000 more square feet of office space for $48,000 per year with a moving cost of $3,750. The East Las Vegas office said the additional space would cost $80,000 more and would cost $70,000 to move. Dr. Brandenburg said the east Las Vegas office’s staff felt it needed $70,000 to remodel. The difference was in the cost of remodeling the Las Vegas office, but he division would be happy to review the figures again. Mr. Hettrick said he understood, but thought the division should look around to find someone who either had a suitable building or would be willing to remodel for a lease with the State of Nevada. Dr. Brandenburg said the division would look into that.

Chair Evans said, in summary, the division sought increased space in Douglas County and in the East Sahara office. Dr. Brandenburg said that was correct and would work with LCB staff and present an alternative proposal.

Mr. Goldwater asked what was requested in the division’s $781,000 999 Unfunded Decision Unit in the rural clinics’ budget. Dr. Brandenburg replied most of that was due to demographic growth, increased psychiatric coverage, and increased psychiatric rates. Mr. Torvinen said there were also some small items requested for office remodeling to allow for security doors when there were less that two people in the office. Dr. Brandenburg added it was also for psychiatric nurses and increased staff in Mesquite and Pahrump, and he believed for a contract site in Laughlin.

Mr. Goldwater said there was nothing that could be done about the demographics, but apparently the division could do without the other items requested. Dr. Brandenburg said the division had been very fortunate, had been supported by the legislature, and had been able to add six or seven new sites in the last two bienniums. He wanted an opportunity to look at the division’s productivity and caseloads and give the committee accurate figures with integrity, regarding waiting lists. Dr. Brandenburg reiterated the division could provide resources to rural Nevada with its current resources.

Chair Evans said Dr. Brandenburg’s statements needed to be taken to heart, in terms of factors that affected the division’s work. If the division was not able to staff due to the hiring freeze, vacancy savings, and money that was required to revert, that would cut into the division’s work.

Chair Evans said she thought there had been some effect on the division’s PACT program due to staffing problems. She asked Dr. Brandenburg what he foresaw for the Program for Assertive Community Treatment (PACT), and if it could get full staffing. Dr. Brandenburg replied once the division was able to get full staffing, it should be able to have the complete PACT program operational by November 1999. Chair Evans said the PACT program could not be run with only a few people.

Chair Evans said, regarding the division’s administration budget’s loss of an accounting position, numbers were very important for the division’s work, as well as the committee’s. She asked what effect the loss of that position had made on the division’s work. Dr. Brandenburg said it made it difficult for the division’s fiscal staff to monitor over $200 million in state and federal funds over the biennium. He said it had been a difficult decision for the Budget Division to make and he understood why it was done. MH/MR had been having a difficult time filling the position and became aware of one of the division’s budgets possibly overextending its resources. He did not have the staff to review the division’s accounting, which greatly concerned him. He did not like asking the Interim Finance Committee (IFC) for money because the division’s agencies had overspent their budgets.

Chair Evans said she had discussed the issue with Mr. Guernsey and made a note of the importance of the restoration of that position when drafting closing sheets for the division.

Chair Evans asked for the potential impact on the work of the institute. In the new budget, funding had been eliminated for the residency program. She knew the division utilized the residents who were in training. She asked if there was any way, short of restoring the $174,000, to keep the program operational. Dr. Brandenburg said he had met with April Townley, Deputy Administrator for Nevada Medicaid, to try to find a way to recover billing for the residents. He had been told there was no way, in terms of Medicaid regulations and policy, that he would be able to bill for those services. There was currently no way to come up with $174,000 needed to fund the residency. Chair Evans said that issue would be kept under consideration.

Chair Evans said the subcommittee had been in Las Vegas the previous weekend and had the opportunity to visit the Mojave Center. It was a very impressive experience, especially the "wraparound" services that took care of the clients top to bottom. The facility itself and the staffing were quite impressive. She acknowledged all the facility’s referrals were from MH/MR. The facility had flexibility the division did not have, and perhaps the division should consider using the facility as a model to find other ways to help its clients. Dr. Brandenburg agreed and said the division had a great relationship and partnership with the facility, which was able to provide services to 70 percent of the division’s Medicaid clients. It was the division’s hope to move the east Las Vegas office into the second floor of that building. By having the east Las Vegas and Mojave Center together, it would enhance the partnership. Chair Evans said the committee looked for the division’s guidance and leadership to reach that goal because the Mojave Center was a model facility.

Chair Evans thanked the division for its presentation and said she was very encouraged by the morning’s discussion. With a little more effort, she thought the division could come up with several options from which the committee could choose.

Chair Evans asked if anyone would like to testify on MH/MR’s budget.

Brian Lahren said he was speaking on behalf of the Nevada Mental Health Coalition. Outside of the division, he recognized two programs as exceptionally important to the division, particularly in northern Nevada. The first was the Psychiatric Emergency Services (PES) program. He was pleased the committee recognized how critical the PES program was and how impossible it was for the mental health services system to function in northern Nevada without the program that had served southern Nevada so well. He was pleased the division had drafted an alternative funding proposal that seemed much more fiscally feasible.

Dr. Lahren said the second problem with the division was psychiatric residency. Parton Parcel of psychiatric services in northern Nevada had been the psychiatric residency in close relationship to the University of Nevada for a long while. He thought that was a critical relationship to maintain. One of the most difficult things to maintain at the institute had been a full compliment of psychiatric staff. The opportunity to attract highly competent individuals was lost when the working conditions were difficult, as they were when there were no PES, and when there was not a good relationship with the university. As a consequence, patients at the Nevada Mental Health Institute were served by doctors who were traveling psychiatrists with a contract, provided through a medical services agency. It compromised the quality and continuity of patient care when people traveled through the institution delivering services and then left, because those people did not have a commitment to the institution or the community.

Dr. Lahren stated the best thing that could be done to help the staffing and working conditions and the professional standards of care in the Nevada Mental Health Institute was to help maintain the psychiatric residency program. Students in the residency program had a vested interest in the quality of care in the institution and provided the professional community-based oversight the institute needed to maintain its standing as a credible facility.

Jack Mayes introduced himself as the Executive Director of the Nevada Disability Advocacy and Law Center (NDALC). He complimented Chair Evans on her understanding of the issues that affect people with disabilities, such as himself. He said in the division’s previous presentation, Chair Evans had asked NDALC questions related to investigations of abuse and neglect. If the committee was interested, he was available to provide any information the committee wanted. Ms. Smith had submitted a prepared statement to the committee after the prior meeting. Chair Evans said the statement contained excellent information and had been very helpful.

There being no further business before the committee, Chair Evans adjourned the meeting at 10:30 a.m.

RESPECTFULLY SUBMITTED:

Christina Alfonso,

Committee Secretary

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APPROVED BY:

Assemblywoman Jan Evans, Chair

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Senator Raymond Rawson, Chairman

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