MINUTES OF THE MEETING OF THE
JOINT Subcommittee on HUMAN RESOURCES/K-12
OF THE
SENATE COMMITTEE ON Finance
AND THE ASSEMBLY COMMITTEE ON WAYS AND MEANS
Seventy-first Session
March 1, 2001
The Joint Subcommittee on Human Resources/K-12 of the Senate Committee on Financeand the Assembly Committee on Ways and Means was called to order by Chairman Raymond D. Rawson at 7:35 a.m., on Thursday, March 1, 2001, in Room 3137 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
SENATE COMMITTEE MEMBERS PRESENT:
Senator Raymond D. Rawson, Chairman
Senator William J. Raggio
Senator Bob Coffin
Senator Bernice Mathews
ASSEMBLY COMMITTEE MEMBERS PRESENT
Ms. Christina R. Giunchigliani, Chairman
Mrs. Barbara K. Cegavske
Mr. Joseph E. Dini, Jr.
Ms. Sheila Leslie
Ms. Sandra J. Tiffany
ASSEMBLY COMMITTEE MEMBERS ABSENT
Mr. David E. Goldwater
STAFF MEMBERS PRESENT:
Bob Guernsey, Senate Principal Deputy Fiscal Analyst
Jim Rodriguez, Program Analyst
Judy Jacobs, Committee Secretary
OTHERS PRESENT:
Charlotte Crawford, Director, Department of Human Resources
Myla C. Florence, Director, Department of Employment, Training and Rehabilitation
Jon L. Sasser, Lobbyist, Washoe Legal Services, Inc.,
Carlos Brandenburg, Ph.D., Administrator, Division of Mental Health and Developmental Services, Department of Human Resources
Michael Torvinen, Administrative Services Officer IV, Division of Mental Health and Developmental Services, Department of Human Resources
Harold Cook, Ph.D., Clinic Director, Nevada Mental Health Institute, Division of Mental Health and Developmental Services, Department of Human Resources
Elizabeth Neighbors, Ph.D., Director, Lake’s Crossing Center for the Mentally Disordered Offender, Division of Mental Health and Developmental Services, Department of Human Resources
Larry Buel, Ph.D., Clinic Director, Rural Clinics, Division of Mental Health and Developmental Services, Department of Human Resources
James Northrop, Ph.D., Clinic Director, Southern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources
Brian L. Lahren, Ph.D., Lobbyist, Washoe Association for Retarded Citizens, Inc.
Aimee Wittler, Executive Director, Disability Resources
LaVonne Brooks, Lobbyist, Executive Director, High Sierra Industries
Lavinna DeGino, Interested Citizen
Paula Berkley, Lobbyist, Educare, Community Living Corporation
Rosetta Johnson, Chief Executive Officer, Human Potential Development, Incorporated
Vic Davis, President, Nevada Alliance for the Mentally Ill (NAMI)
Ed Guthrie, Executive Director, Opportunity Village
Anne Gaffner, Member, Human Potential Development
Jonathan Andrews, Deputy Director, Department of Human Resources
DEPARTMENT OF HUMAN RESOURCES
HR-DIR, Community Based Services – Budget Page HR ADMIN-40 (Volume 2)
Budget Account 101-3266
Senator Raggio commented on the concern regarding transfer of the Developmental Disability Council and Community Based Services budgets from the Department of Employment, Training and Rehabilitation (DETR) to the Department of Human Resources (DHR) as outlined in The Executive Budget. He pointed out the transfer has been withdrawn, which should save time by allaying fears of those who were troubled by the proposed move. Senator Rawson instructed staff to make appropriate changes when each of the items is addressed.
Charlotte Crawford, Director, Department of Human Resources, reported she and Myla C. Florence, Director, Department of Employment, Training, and Rehabilitation, met with staff and members of the disabled community concerning the proposed transfer to develop a strategic plan for Nevada citizens with disabilities. She said the meeting was arranged to facilitate the planning process, and most of those present at the meeting felt it would be an impediment to planning to make the transfer. She indicated the decision was memorialized in a memorandum dated February 21, 2001 (Exhibit C), and the Governor agreed to the conclusion reached. She stated the request for the transfer is, therefore, withdrawn. As a consequence, Ms. Crawford said Ms. Florence would introduce the budgets since they will be returning to the aegis of DETR.
Ms. Florence handed out a document regarding developmental disabilities (Exhibit D) entitled Developmental Services Program Evaluation: Personal Outcomes & Satisfaction. She concurred with Ms. Crawford that both departments have a strong commitment to move the planning process forward to deliver services to the disabled community by working in cooperation with each other. She said the Community Based Services budget follows the Governor’s instructions to remain flat. She noted it supports six full-time equivalent (FTE) positions related to various programs within the office of Community Based Services, primarily developing services in communities through local providers.
Ms. Florence noted the most significant changes in the budget, which are being recommended based on cost-allocation plans, appear in enhancement modules E‑275, E-910, and E-912. She explained those transfer the chief position for the office of Community Based Services and Developmental Disabilities out of the rehabilitation administration account to the direct charge of budgets 101-3266 and 101-3154. She said it was determined that the position, under the cost-allocation scheme, could not be charged to all rehabilitation accounts.
Ms. Florence said enhancement module E-277 would be eliminated. She explained when the proposal was made to transfer the functions to the Department of Human Resources, rather than using cost-allocation method used in DETR, staff support was recommended for the two accounts.
Senator Rawson surmised the cost will amount to approximately $30,000 in General Fund and asked why the salary is divided into two accounts. He suggested the salary could be paid through an appropriation in just one account. Ms. Florence replied that under accounting procedures, the position serves more than one program, is supported from more than one revenue source, and should be allocated accordingly. She noted that the chief’s position is recommended to be paid through General Fund and module E-276 recommends fully charging another position to telephone surcharge funds in order to minimize the impact on the General Fund.
Senator Rawson asked to review module E-450, which includes a rate increase for personal attendants. He wanted to know how many attendants there are and what the general pay range is. Ms. Florence said the personal care attendants in the account are hired by contract through community-based providers, and are not direct staff under the account. She acknowledged rates are not consistent through all divisions and departments, and Ms. Crawford intends to perform a comprehensive rate study to address the issue.
Ms. Florence explained that at the time the budget was built, DETR was under the impression a 3-percent increase would bring the payments for Community Based Services more in line with Medicaid and other providers, but it still fails to bridge that gap. She said the average payments are now between $8 and $8.75. Senator Rawson admitted a small 3-percent increase might not result in any more satisfaction.
Ms. Giunchigliani asked how moving the position would comply with federal law. Ms. Florence responded the position was formerly in the rehabilitation administrative account, and, under the cost-allocation rule, for a position to be generally allocable it must perform overall administrative duties for all budgets within the Rehabilitation Division. She said, as the result of an audit, it was determined that the position was being charged improperly to administration, since it did not perform administrative functions for the other bureaus within the Rehabilitation Division.
Ms. Giunchigliani asked whether relocating the position in another budget will allow the position to comply with federal guidelines under the cost-allocation plan. Ms. Florence replied she is convinced the change will comply. She explained the position has been improperly allocated for some years, and when the position became a direct supervisory position for the two accounts it should have been charged to those accounts at that time.
Ms. Giunchigliani asked whether the personal-care assistants will be retained. Ms. Florence reiterated that is administered at a local level, but historically it has been very difficult to recruit and retain those assistants. Ms. Giunchigliani asked whether the 3-percent increase will help attract more people. Ms. Florence admitted the 3-percent raise might not help very much.
Ms. Crawford remarked the personal-care attendant problem is a good example of the proposed rate study and need for establishment of consistent methodology. She said a number of agencies in the Department of Human Resource and DETR contract for personal-care services, and the same rate is not paid throughout the agencies, nor has a sound basis been set on how the rate should be established. She said a one-shot allocation for $500,000 is intended to be used for many rate areas in the two departments.
Senator Raggio expressed concern regarding the funding for a deaf-coordinator position. He asked what impact there will be on the hearing-impaired program if the position is entirely funded by surcharges. Ms. Florence replied there should be no impact, and the position funding will offset the General Fund allocation to the chief’s position. She said there will be an impact on client services in the structure of the overall budget, given the cap on both General Fund and federal funds.
Senator Raggio asked whether there will be some impact throughout the budgets relating to the hearing-impaired program. Ms. Florence responded there should not be any impact. She said the deaf resource centers will remain intact.
HR-DIR, Developmental Disabilities – Budget Page HR-ADMIN-48 (Volume 2)
Budget Account 101-3154
Ms. Florence explained budget account 101-3154 is funded by a federal grant with a state match of 25 percent. It supports three full-time positions for start-up grants, she said, and systemic change with respect to developmental disabilities. She noted the most significant change to the budget is E-275, where it indicates that a portion of the chief’s position is funded out of the grant.
Senator Rawson noticed a slight increase in performance indicators, with a reduction in the federal developmental disability grant award. He asked how performance can increase while funding decreases. Ms. Florence replied the grant actually did not change. She said there was some carry-forward funding from the prior year. She noted there may be some enhancements related to federal funding for disabilities as the federal budget details become available. She related every state will be automatically eligible for a small planning grant, and there may be other enhancements available. She said if those materialize during session, DHR will work with the legislative staff to make adjustments, and if those occur after session, the department will come before the Interim Finance Committee (IFC).
Senator Rawson said the budget information indicates a decrease, and he asked whether the performance indicators and the level of funding are really tied together. Ms. Florence replied the performance indicators were built on a flat budget.
Ms. Giunchigliani asked why all the funds are not allocated to budget 101‑3266 to simplify the reporting on allocations. Ms. Florence responded normally the Legislature does not favor combined budgets. However, she opined there may not be any accounting problems. She offered to look into the matter. She pointed out the Developmental Disabilities Council has been criticized for not controlling its budgets, so there may be a strong desire to keep the budgets separate.
Jon L. Sasser, Lobbyist, Washoe Legal Services, Inc., said that under the proposed reorganization all of the $2.4 million in planning funds would have been transferred to the new office. He agreed that long-term strategic planning is very important and asked that his remarks not be misconstrued. He stated there are two areas that do not need more study, which are ready for action, and he distributed a statement expressing his view (Exhibit E). He said one is the Ticket to Work and Work Incentives Improvement Act of 1999, for which the department has received a reported $625,000 federal grant for the first year, and $500,000 for the 3 following years to study the measure. He said the act allows the disabled who are receiving Supplemental Security Income (SSI) to return to work and not lose their Medicaid eligibility. He said the loss is an extreme barrier to folks returning to work, because even if they are employed where they receive insurance from their employer, many of the services offered by Medicaid, such as personal care attendants or home health aides, are not available through most programs.
Ms. Sasser noted the planning grant was funded under Title I, and it deals with a large range of supportive services that might be offered to a disabled person returning to work, such as Braille services or job training. He explained the eligible would receive a ticket that entitles them to those services. He acknowledged planning is necessary before moving forward into that area.
Mr. Sasser said Title II allows for the same people to return to work and continue to receive Medicaid, and to buy into Medicaid to remove the barrier (Exhibit D). He said there is a bill pending that will come to the committee, Senate Bill (S.B.) 207, which came out of the Interim Legislative Committee on Health Care.
SENATE BILL 207: Requires department of human resources to establish program for provision of medical assistance to certain working persons with disabilities who are ineligible for Medicaid. (BDR 38-227)
Mr. Sasser noted the same proposal was given to the IFC two years ago and was recommended to the Legislature at the last session. He said the program could be nearly cost-neutral, depending on how it is structured. He noted that Medicaid would be paid whether the person is sitting at home or going to work, and it would be cheaper for working people because they would be buying into Medicaid and contributing toward their cost of care. He expressed the need for a long-term strategic plan for the disabled, and said that because a federal grant is available under Title I action will not be delayed for another 2 years.
Mr. Sasser testified a recommendation had been made by an interim committee chaired by Senator Mike McGinness on long-term care to move forward on assisted living. Mr. Sasser said there are adequate facilities for people who make about $35,000 in the private market, but there is nothing for those on Medicaid who do not have anything in between the Community Home-Based Initiative Program (CHIP) waiver and going into a nursing home. He noted those who do not really need a nursing home, but need help around the clock, do not have anywhere to go.
Mr. Sasser indicated the state applied for a $100,000 Coming Home grant to match federal funds to put together a plan for affordable housing. He asserted it takes a minimum of 2-years’ advanced planning to obtain housing funding, and then it is necessary to know that, once the housing is constructed, Medicaid service funds will be available. He noted that a 2-year study of strategic needs for the disabled, added to the 2-year-housing planning, means it will be 4, 5, or 6 years before any housing is actually available.
Mr. Sasser recommended part of the study funds be allocated to infrastructure rather than used for study for another 2 years. Senator Rawson said the Interim Committee on Health Care recommended those ideas. He said there are bill draft requests (BDR) pending that will allow for a full hearing on those concepts. Mr. Sasser remarked the first problem related to Medicaid benefits for the working disabled is addressed in S.B. 207, but no bill is out yet to address the assisted living plan.
Mr. Sasser reported he was aware of a BDR for a pilot project, but he was unsure whether there is a BDR to replace the $100,000 grant that was not received. Ms. Leslie requested that Mr. Sasser write a brief statement explaining what it would mean to develop the infrastructure and how much it would cost. Mr. Sasser agreed to do so.
Senator Rawson suggested the BDR for a pilot project can be used to expand any of the proposals discussed. He requested that Mr. Sasser not allow the matters to get lost during the busy legislative session and the difficulty with tracking.
DIVISION OF MENTAL HEALTH AND DEVELOPMENTAL SERVICES
HR, MHDS Administration – Budget Page MHDS-1 (Volume 2)
Budget Account 101-3168
Carlos Brandenburg, Ph.D., Administrator, Division of Mental Health and Developmental Services, Department of Human Resources, noted the budget provides for the psychiatric residency program at the University of Nevada, Reno (UNR). He reported there are two second-year students and two third-year students who are undergoing their residency requirements at the Nevada Mental Health Institute (NMHI) because it is the only Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited psychiatric hospital in the state.
Dr. Brandenburg said Governor Kenny C. Guinn recognized the importance of the suicide crisis hotline. He recalled it was introduced last session and is scheduled to sunset, but the Governor has indicated it should be included in the budget at $200,000. Dr. Brandenburg said the funds are in the form of a pass-through to the northern Nevada Crisis Call Center and provide a suicide call center throughout the state. Statistics on the call center are attached as Exhibit F.
Dr. Brandenburg took note of enhancement unit E-900 for the transfer of the Quality Assurance (QA) positions from Southern Nevada Adult Mental Health Services (SNAMHS) and NMHI to the central administration budget. He explained it will allow the administration office to execute consistent performance improvement standards throughout the state. He noted the fiscal audit indicated there are different standards and methodologies used throughout the division, and this will enable development of a standardized way to measure and improve quality.
Senator Rawson acknowledged a lot of ground was lost after the cutbacks during the 1991 session, and there has been an attempt at recovery in recent sessions. He noted there has been a long-term plan to develop psychiatric residencies, but the plan has never really developed in southern Nevada and has developed slowly in northern Nevada. He asked whether the fact there is only one hospital that is approved by JCAHO is what is holding up the program, or whether it is funding to the medical school. Dr. Brandenburg responded the primary obstacle is the fact that the southern Nevada hospital is not JCAHO accredited.
Dr. Brandenburg reported he has held conversations with Dr. Ole J. Thienhaus, Chairman of the Psychiatry and Behavioral Sciences of the School of Medicine, who indicated he has no objections to expanding the residency program in the south. Dr. Brandenburg said the primary obstacle is not having JCAHO accreditation in southern Nevada. He said there are no funds in the budget to pursue JCAHO accreditation.
Senator Rawson noted there has been a general policy to obtain accreditation and to give the highest standard of care. He acknowledged this is a difficult budget year, but asked what would be involved to proceed to seek accreditation. Dr. Brandenburg responded the problem is primarily financial. He said it would be necessary to have funds in the southern Nevada budget for them to be able to bring in the JCAHO surveyors to determine whether the school meets the criteria for hospital standards.
Senator Rawson asked whether the systems would be able to comply. Dr. Brandenburg said he believes the system is in place to meet the standards. He admitted he did not know how much the survey would cost, but he offered to find out. Senator Rawson said he would like to know what is involved in obtaining accreditation statewide before closing the budget.
Senator Rawson asked whether it is helpful to be able to use the residents in northern Nevada. Dr. Brandenburg replied, “Absolutely.” He called it a “double-edged sword” because it allows for a training environment for students and staff, and allows staff to participate in supervision and be constantly involved with the medical school. He said that in the past the division has been able to hire residents who worked for the division and have graduated, providing a very positive relationship.
Senator Rawson opined it reflects badly on two institutions when there is no certification and when the residency program does not go forward. He said it is difficult to keep a qualified dean, and it is difficult to represent to people that the state is doing the best it can in providing mental health services. He reiterated his desire to find out what it will require to achieve accreditation.
Ms. Giunchigliani voiced her agreement with Senator Rawson that the problem regarding psychiatric students is one the Legislature has grappled with for several years. She asked whether psychiatrists are allowed to maintain private practice. Dr. Brandenburg answered they are, and the only ones prohibited from engaging in private practice are the medical directors. He noted most do not, but some do. He said the issue of recruitment and retention is national, not just difficult for Nevada. He stated a colleague from Sacramento told him the psychiatric vacancy rate for Sacramento County in the public mental health system is over 23 percent, yet they pay their doctors more than Nevada does.
Senator Rawson interjected that is one of the reasons the Legislature pressed for dual appointments with the medical school, so that more faculty members could be recruited. Ms. Giunchigliani noted that is not happening, so other means must be used to obtain faculty. Senator Rawson wondered whether expansion of the residency program would allow for more faculty as well as more residents.
Dr. Brandenburg stated it might help. He said the salary increase proposed by the Governor should help. He recalled that when he recruited for the position of statewide medical director, he considered use of a national recruitment firm, but the firm told him the offer by Nevada was between $40,000 and $60,000 short of what other states pay. He reiterated the increase proposed by Governor Guinn should go a long way toward helping recruitment. Dr. Brandenburg pointed out the state is competing with every other public entity.
Ms. Giunchigliani asked whether the suicide hotline is now statewide, and whether it seems to be effective. Dr. Brandenburg replied that it is working and seems effective. He noted it is a public/private nonprofit relationship and it has allowed the crisis call center to interface with clinics in the rural areas and in Las Vegas. He said the outcomes have been very positive.
Ms. Giunchigliani noted there are two one-shot appropriations, one for $75,000 for the National Alliance for the Mentally Ill (NAMI) and $250,000 for Opportunity Village. She disclosed she is a member of NAMI. She asked what the appropriations are intended to help. Dr. Brandenburg said NAMI is a partner with the mental health division and the funds have been used for family education and training, which allow family members to know how to interface with the system. He said that as a result the families have become strong advocates of the program.
Ms. Giunchigliani asked how the $250,000 in funds for Opportunity Village will be used. Dr. Brandenburg replied that he did not know. Ms. Giunchigliani said whatever it is earmarked for should be available for providers statewide.
Senator Rawson remarked a recent audit of NMHI identified approximately $650,000 that was not collected, much of which may be bad debt. He suggested it might be worthwhile to establish an office or position to deal with the problem. Michael Torvinen, Administrative Services Officer IV, Division of Mental Health and Developmental Services, Department of Human Resources, voiced agreement.
Mr. Torvinen said the audit was released in December, forestalling any opportunity to put together information for the Governor’s consideration in preparation of the budget. Mr. Torvinen reported packages are being developed that will be totally funded by sources other than General Fund revenues. He suggested a full-time position to monitor collections should be able to generate sufficient funds to more than pay for the position. He said the $650,000 is bad debt, which should be recoverable. As a result of work with the contract accounting firm, he opined forthcoming amended cost-reports will indicate that the estimate of $650,000 was high, and most of the funds will be collected.
Senator Rawson counseled Mr. Torvinen to impart that information as soon as possible because the Legislature will start closing budgets soon. Mr. Torvinen responded the information should be ready within a week.
Dr. Brandenburg noted a rate study was done on the outpatient side of the budget, and the agency has been able to maximize some federal funds. He explained the case management billing rate was increased from $71 to $92 per hour, and the psychosocial billing rate was increased from $18 to $82 an hour. He reported the rate increases will bring an additional $1 million from Medicaid into the budget. He said the Legislative Counsel Bureau (LCB) audit was of great assistance by focusing on the inpatient side, because NMHI did not have sufficient staff to do so.
Senator Rawson turned to the next budget while copies of a report prepared for the hearing entitled Outcome Measures, Nevada Mental Health Institute, Fiscal Year 2001 (Exhibit G) were distributed.
HR, Nevada Mental Health Institute – Budget Page MHDS-7 (Volume 2)
Budget Account 101-3162
Senator Rawson noted the agency has budgeted staffing for 50 beds, but the new hospital will have two wings with 40 beds each. He suggested the staffing provide for 40 beds or for 80 beds, with the possibility of savings if the number of beds is kept at 40. He noted the census shows the number of beds in use has been in the 30s.
Dr. Brandenburg responded savings should be possible. He said the division proposed reducing the number of beds by 10 at the institute, because during the last legislative session approval was given to fund emergency services for psychiatric residents. He said the week before the Psychiatric Emergency Services (PES) came on line the census at the hospital was around 52, but a week after the emergency center came on line the census was down to 42, a nearly 25 percent reduction.
Dr. Brandenburg reported the agency proposed a 10-bed reduction, but the analysis was not finalized. He said the analysis has been resubmitted, and as soon as it is complete the agency will forward its recommendation to the Governor. He agreed there should be substantial savings. Because it will be cost-neutral, he said the agency is considering expanding the community service section.
Senator Rawson commented there are areas where 5 to 7 positions may be needed that are not included in the budget, and there will be positions saved if the budget accommodates 40 beds. Dr. Brandenburg offered to work with the LCB staff on the issue.
Ms. Leslie asked whether Dr. Brandenburg’s statement meant that the funds from the 10‑bed reduction will be reinvested in community housing and supported living arrangements. Dr. Brandenburg answered that was correct. He said there are individuals who have historically been unable to succeed in the community because, even though there are supportive living arrangements (SLA) and group homes in the community, they have been unable to adjust. He said there are clients who can be moved from the hospital to SLAs with 24-hour per day supervision for the clients. He acknowledged they are a little more expensive than the regular SLAs, but certainly less expensive than ongoing hospital rates.
Ms. Leslie asked whether the homes would be off the campus of the institute. Dr. Brandenburg responded they would be, that they would be under contract with a provider in the community.
When asked whether the homes would accommodate people from Carson City, Dr. Brandenburg responded negatively, saying the clients in the institute who have been identified so far are from Washoe County. He said there are people from Carson City at the institute, but the high-frequency users of the hospital, who have been unable to succeed outside, are primarily from Washoe County. He stated a Carson City citizen could be one of those, and there have been Carson City citizens in the past who have gone into residential treatment programs, and it makes no difference where the clients come from.
Ms. Leslie asked whether the savings may also be used for more housing in the rural areas. Dr. Brandenburg responded the Rural Clinics budget expands residential housing by 100 percent, and there will be housing funds included there. He indicated that increase should provide around 25 additional slots.
Senator Raggio noted the new hospital is complete, but no patients have been admitted yet. He asked why, when patients will be admitted, and what is in store for the old hospital buildings. Dr. Brandenburg replied the new 90-bed hospital was completed 6 months early. He admitted he did not plan for the project to be completed during this fiscal year. He said public works has the funds for furnishing the hospital, and the project manager recently ordered the final furnishings. He said he anticipates the furnishings will be installed in the hospital by late June, and the Bureau of Licensure and Certification should be able to come in by early July to inspect the hospital and approve certification. He announced a tentative grand opening on Friday, July 27, and shortly after that, he said, patients will move in.
As to the current hospital, which is Building 8, Dr. Brandenburg said the agency is in negotiation with a mental health facility that provides services for adolescent sexual offenders. He said the company wants to rent the entire building, because the building is sufficiently secure for adolescents and children. He said preliminary negotiations indicate the company will pay 65 cents per square foot plus utilities. He expressed hope the deal will be finalized before the end of the legislative session.
Senator Raggio asked where the emergency services unit is presently housed. Dr. Brandenburg answered it is in Building 7, and the services will move to the new hospital. He said the service has been effective in providing immediate attention and in preventing hospitalization for those who do not need it. He said the data shows that the psychiatric emergency service is doing what it was supposed to do. Dr. Brandenburg related that the week after PES opened, the hospital inpatient service dropped by 25 percent.
Senator Mathews asked whether the agency will have to renovate Building 8 before it is rented. Dr. Brandenburg responded the only renovation will involve removal of asbestos, because a couple of sessions ago the Legislature approved $1.6 million to renovate Building 8. He stated the building is in fair condition except for the asbestos.
Senator Mathews asked what will happen to Building 7. Dr. Brandenburg replied a variety of options under consideration include moving the Program for Assertive Community Treatment (PACT) into the building because its present location is not very accessible to clients.
Senator Mathews observed that the average length of stay in the hospital has increased from 14.9 to 19 days. She asked why that has happened. Harold Cook, Ph.D., Clinic Director, Nevada Mental Health Institute, Division of Mental Health and Developmental Services, Department of Human Resources, responded that as the PES has been implemented, treatment is being provided for many people who would have gone into the hospital for short periods of time, and they are no longer counted in the analysis of average length of stay. Because they are not counted, and those who are admitted generally have more problems and require a longer stay, the average length of stay has gone up.
Calling attention to the addition of 1 Psychiatric Caseworker under unit M-200, Senator Rawson asked what the average caseload is per caseworker. Dr. Cook replied the typical caseload is 35 clients to one case manager. He said he anticipates there will be enough clients added to the system to require another caseworker.
Ms. Giunchigliani asked whether the report regarding the effectiveness of medications will be ready prior to adjournment. Dr. Brandenburg replied the information could be found in New Generation Psychiatric Medications in Nevada (Exhibit H. Original is on file in the Research Library), astudy report he distributed to the committee. He stated the medications are an integral part of the program, and an expensive part of the program. He drew attention to the executive summary on the first page showing the outcomes for new medications.
Ms. Giunchigliani concurred that the new medications are expensive, but observed they justify the cost through the dignity that people are able to maintain, and the reduced impact of their illness on their lives in other ways. She said she is glad to see that the new medications are cost-effective. Dr. Brandenburg agreed the medications have been responsible for greatly improved quality of life.
Ms. Leslie expressed concern that the medication formulary at the Washoe County Jail, which she characterized as the “biggest mental health facility” in the county, does not match the state formulary. Although she opined the state is much more progressive through the use of the new medications, she noted many of the clients re-circulate, and when they get to the jail they are forced onto the old generation of medications, which causes problems. Dr. Brandenburg responded the division has been in negotiation with county jails statewide to change the formularies. He said the agency has tried to impress upon the staffs of Washoe County and Clark County the need to continue the medications being prescribed by the mental health division. He stated most of the time the counties are attempting to order the newer medications on a case-by-case basis, even though it is not in their formularies.
Ms. Leslie asked whether a judge is able to interact with the counties to ensure the clients receive the appropriate medications. Dr. Brandenburg replied that the mental health system often does not have proper jurisdiction, whereas the courts do have the jurisdiction and are able to do certain things the division can only accomplish through alliances and rapport, in which the agency can explain the consequences.
Ms. Tiffany repeated a story she had heard that a Clark County administrator in the department had a heart attack but had to wait for an emergency room (ER) for 7 hours due to overcrowding. If true, she asked, what kind of communications pass between emergency rooms and community-based organizations of all kinds so that mentally afflicted people can be removed from emergency rooms when they are well enough to be released and placed in mental health beds or temporary housing and free up hospital beds. Dr. Brandenburg said the division has been working with emergency rooms in both the North and South. He agreed that is a crucial issue. He acknowledged that emergency rooms are being inundated with a great deal of traffic to the point where they must often divert patients.
Dr. Brandenburg explained that for over a year the division has been working with the emergency rooms in an attempt to discern what issues cause the most problems. He acknowledged the mental health division system may not have been as user-friendly as it should have been. However he said, the problems are often compounded by the fact that ambulance services are not able to pick up clients from the ER in a timely manner and deliver them to mental health facilities. He added the ERs are not expediting the clients into the mental health system.
Dr. Brandenburg continued, saying the communication is ongoing, and last week a new process was instituted between the ERs and the mental health system in Clark County. He noted the division deals with seven emergency rooms in Clark County that bring people into the mental health system. A lot of the clients also have medical complications, he said, so the division insists that they are medically cleared prior to accepting them. He noted there is an issue as to whether patients should be cleared outside or onsite, and the agency indicates it simply needs the clearance, because once patients are admitted to the mental health system, the system is liable.
Dr. Brandenburg reported another issue involves whether people entering the ER are actually mentally ill or whether they are having a toxic reaction to drugs or alcohol they have ingested. He said the new system instituted by two physicians from the mental health division appears to be working, but he admitted it may not solve the problem of the high volume of people going into ERs.
Ms. Tiffany reported she has been working on the dual diagnosis in which patients are medically cleared before they are admitted to a psychiatric emergency room. She said she requested a bill draft to access a U.S. Housing and Urban Development (HUD) program under Chapter XX that will pay for an integrated system on such services. She explained an ambulance driver, ER employee, or policeman could log onto a computer with a program similar to hotel reservation programs. The person would be able to find out what beds are available in every state, county, or community agency. She asked how the state would apply for the HUD program. Dr. Brandenburg replied he was unsure whether mental health would be the primary agency for Title XX funds in that situation. He offered to research the matter. Ms. Tiffany noted those are the people that tend to wind up in jail or in ERs. She asserted an integrated system would help the communication problem.
Ms. Tiffany asked how vacant beds are filled, and whether there is a waiting list. Dr. Cook responded that in Washoe County most patients who are admitted are admitted on an emergency admission order. He explained they are referred by the emergency rooms to psychiatric emergency service, and if they cannot be treated and released successfully, they are then admitted to the inpatient program. He said everyone comes to the program through the psychiatric emergency service.
Dr. Brandenburg interjected Clark County has the same system. He said that psychiatric emergency services acts as a triage for the system, like a funnel. He explained all clients come in either as emergency or as ambulatory patients. He noted they can be retained in the psychiatric emergency center for up to 72 hours if the staff feels they should be observed; or if they need intensive psychiatric hospitalization, they go from the psychiatric emergency services right into the mental health hospital.
Ms. Giunchigliani asked whether National Disabilities Advocacy and Law Centers (NDALC) have been of any help. Dr. Brandenburg replied the state funding was discontinued during the last session. He said since then no cases have been referred to them.
Ms. Giunchigliani asked who is used as a resource now. Dr. Brandenburg answered that investigative teams have been formed in all regions to respond to any allegation of abuse or neglect. He explained two or three staff members in each facility have been provided training and orientation so that, when an incidence occurs, the deputy administrator from the central office selects a team to go to the site to conduct an investigation. He said the results are submitted to him, and if the case is very serious or involves abuse or neglect, it is also reported immediately to the police, and then the sheriffs’ department in Washoe County or Clark County makes a determination as to whether they should conduct their own investigations. He said most of the time the division conducts its own investigation.
Ms. Giunchigliani commented that a well-trained officer in Clark County has been designated to handle senior abuse cases. She asked whether the division has found one individual with that expertise. Dr. Brandenburg answered affirmatively, and said there are one or two in Clark County who are usually designated to investigate reports in the mental health system or the developmental services system.
Mrs. Cegavske recalled that there was a concern expressed by a hospital worker at an IFC meeting regarding the waiting time and whether or not adequate resources for the mentally ill have been provided. She said the agency responded to the problem immediately and initiated a plan to help so that in the future the subject of the concern would not be repeated. She commended the agency for taking such a proactive stance.
HR, Facility for the Mental Offender – Budget Page MDHS-13 (Volume 2)
Budget Account 101-3645
Dr. Brandenburg pointed out Lake’s Crossing Center for the Mentally Disordered Offender is the only maximum-security agency within the division that provides services throughout the state. He noted Lake’s Crossing has five staff members housed at the Clark County jail, who provide services to both the jail inmates and to the two Las Vegas city jails. He explained that is a partnership between the state and the county in which the county paid for some of the positions and the IFC approved turning them into state positions.
Dr. Brandenburg said the same procedure was approved for Washoe County during the last session. He noted a full-time psychologist included in the budget is funded equally by the state and Washoe County to provide services at the Washoe County jail.
Noting that the performance indicators failed to specifically address the program, Senator Rawson asked how many people from the facilities are being seen, and how a determination is made as to the success of the program.
Elizabeth Neighbors, Ph.D., Director, Lake’s Crossing Center for the Mentally Disordered Offender, Division of Mental Health and Developmental Services, Department of Human Resources, responded regular statistics are gathered monthly from Clark County and Washoe County. She explained the programs are somewhat different, so the indicators would be different for those two counties. She said the staff has between 300 and 400 contacts at the Clark County Detention Center each month, and nearly 100 contacts are made at the Las Vegas City Jails.
Dr. Neighbors said evaluations are made at Washoe County, and since the beginning of November the agency has completed about 50 competency, health safety, morals, and guardianship evaluations there. She stated services are currently being provided by a psychologist at Lake’s Crossing for those people because of a death of one psychologist, but a new psychologist, due to start on March 12, will handle those cases.
Dr. Neighbors offered to provide that information to the legislators if they would like to have it.
Senator Rawson said the legislators are aware that there have been payments for sanity evaluations, and he asked whether a budget adjustment should be made if the evaluations will be done in-house. Dr. Neighbors replied that if the change is made it should reduce the budget by $65,000 to $80,000 per year, which should then revert to the General Fund. Senator Rawson noted a bill is being introduced on that.
Senator Raggio asked whether the present sanity commission is composed of three persons, and whether the law requires them to be medical doctors or psychologists. Dr. Neighbors replied they must all be licensed psychologists or psychiatrists unless the judge specifies how many should be psychiatrists.
Senator Raggio asked whether Dr. Neighbors is proposing that the commission could be comprised of all in-house staff members. Dr. Neighbors replied that is true, and the agency already makes complete psychiatric, psychological, and psychosocial evaluations for every client treated at the facility. Senator Raggio asked whether that is a different analysis than would be required for a court as to competency to stand trial. Dr. Neighbors responded the evaluations always address that issue, that the psychologists and psychiatrists on staff are all trained to do those types of evaluations, and that those are the types of evaluations routinely done.
Dr. Brandenburg interjected the fundamental review process provided an opportunity to take a look at the evaluations. He said at that time the agency recognized that at least 60 days could be saved in the average daily census because most of the time the psychologists and psychiatrists coming in from the community to make evaluations were using the existing agency reports to make their reports. He said that after conferring with both Clark County and Washoe County, an agreement was reached that, since the agency had already been performing evaluations for the rural area courts for the last 15 years, the agency has the competency to do so for the two populous counties.
Ms. Tiffany asked whether those being evaluated are already felons, or are on their way to trial, have been homeless, or were dually-diagnosed. Dr. Neighbors answered there have been quite a number of individuals who have been homeless, and nearly 60 percent are mentally ill, are substance abusers, and may also have medical problems.
Ms. Tiffany related that Clark County Sheriff Jerry Keller has expressed concern that many of the homeless coming in have committed a crime and are found to have a diagnosis indicating alcoholism or substance abuse and are mentally incompetent. She asked whether the problem is growing. Dr. Neighbors replied affirmatively, and said the incidence may be higher than 60 percent. She said the beds are mostly filled with felons, and though the agency tries to handle misdemeanor clients in the city detention centers, on occasion some are handled at the Lake’s Crossing facility. She said the number of people with severe problems often also have severe medical problems because of their circumstances.
Ms. Tiffany asked whether that could be diverted by more intense outreach on the streets. Dr. Neighbors responded early intervention would help. Dr. Brandenburg interjected he has met with Yvonne Sylva, the Administrator for the Health Division who has authority for the Bureau of Alcohol and Drug Abuse (BADA). He reported she has invited the mental health division to participate in developing a strategic plan to address the issue and develop a policy for both divisions.
Dr. Neighbors added she has made a request for an interim study on that topic. Ms. Tiffany took note of the recommendation in The Executive Budget for $88,000 each year for sanity evaluations. She asked whether it will be possible for the division to absorb it within the budget if the legislation is approved. Dr. Brandenburg responded he is sure the $88,000 would be reverted back.
HR, Rural Clinics – Budget Page MHDS-17 (Volume 2)
Budget Account 101-3648
A document setting forth performance indicators for Budget Account 101-3648 was distributed to the committee (Exhibit I).
Senator Rawson asked how many are on waiting lists for each of the clinics, and the condition of staffing. Dr. Brandenburg recalled that last session of the Legislature the Rural Clinics agency was unable to provide valid, reasonable numbers. As a result, he said, they did not receive any funding for demographic growth. He explained a new data tracking system has recently been implemented by Dr. Larry Buel that allows Dr. Buel and the central office to review the situations at the various clinics.
Dr. Brandenburg stated one problem facing Dr. Buel is that demographic growth has been lumped together for rural Nevada, but positions have been delineated by specific sites. As a result, Dr. Buel must determine in which site the position fits best. Dr. Brandenburg stated when demographic growth supports a position, the legislators should be aware that Dr. Buel must then determine to which site it should be assigned.
Larry Buel, Ph.D., Clinic Director, Rural Clinics, Division of Mental Health and Developmental Services, Department of Human Resources, testified that decision unit M-201 applies specifically to the deficit of positions that were not funded during the last legislative session. He handed out copies of a memo reporting caseload data (Exhibit J). He said the agency is attempting to build an infrastructure in Rural Clinics to include a nurse and a case manager in each office. He said today that is not the situation, and many rural clinics have no designated case manager. He reported a half-time position for case management will go to the Mesquite Mental Health Center because it has a caseload of 67 and psychologists and social workers are presently providing management services.
Dr. Buel said that in Pahrump there are 130 cases for which he has designated 1.5 FTE case managers. He said one half-time case manager is designated for Ely to meet the needs of 96 individuals who are being provided services by other individuals, sometimes including nurses. Elko is slated for one FTE case manager, he said, with a special situation. He indicated that at present there are 39 individuals in the case management caseload.
Senator Rawson suggested that Dr. Buel work with the LCB staff to make an outline of the locations and staffing problems. Senator Rawson acknowledged there may be difficulty justifying some of the positions for particular offices, but he suggested it would be better to prepare a visual representation, with different objectives, not only fiscal, but also how service is being delivered and what the individual needs are. Dr. Brandenburg agreed to do so.
Ms. Leslie indicated her agreement and suggested that housing resources be added to the list. She clarified that she would like to know where housing facilities are located and how many slots there are. Dr. Brandenburg agreed to add in the information she requested.
Ms. Leslie expressed her interest in a proposal for Incline Village. She noted the Children’s Cabinet at Incline Village has offered space and support staff if a mental health counselor can be assigned there. She asked whether any progress has been made toward meeting that proposal. Dr. Brandenburg replied there has been progress. He pointed out that because Incline Village falls within Washoe County, the Division of Child and Family Services will have jurisdiction. He said Dr. Buel has been working to assist child and family services there.
Mr. Dini asked whether there are enough psychiatrists working for the Rural Clinics. Dr. Buel replied there are contract psychiatrists who travel to each of the 16 locations in Rural Clinics. He said they come primarily from Washoe County, and there are some from southern Nevada. He said currently he figures to spend every last dollar in that line item of the budget for that service, but he has been able to add a few days in two or three offices that were not available in prior years. He acknowledged it is a close call, but the Rural Clinics are keeping up while acknowledging the problems caused by overspending.
Mr. Dini asked whether there are any unique situations with medication programs in the Rural Clinics. Dr. Buel responded there is a problem. He explained the Rural Clinics budget has remained budgeted at about $116,000 for medications for the current year. He said he has worked with pharmaceutical companies that have donated 80 percent of the total needs for medication, and thus budgeted funds account for just 20 percent of all medications distributed. He added there are nurses and support staff who work very closely with the pharmaceutical companies to garner medications valued in excess of their monthly salaries.
Mr. Dini asked whether that allows the clinics to provide the right medications. Dr. Buel replied affirmatively and said it has allowed the clinics to work with the agencies in Washoe and Clark Counties, and the psychiatrists prescribe in a manner similar to those two areas.
Senator Coffin asked whether the donated medications are of the older generation or close to the dates of expiration. Dr. Brandenburg replied the medications donated by voucher or coupons are state-of-the-art drugs of the newer generation. He said they are not trial medications, they are safe, and they are the typical selected serotonin reuptake inhibitors (SSRI). He reiterated the pharmaceutical companies have supplemented the budget not only in the rural areas, but also in Washoe and Clark Counties. He noted that is particularly true for the psychiatric emergency services, because often there are clients coming into the clinics who do not follow up, and are not in the system, so they are given vouchers. He stated that allows for expansion of the budget through cost-containment.
Senator Coffin asked whether the people in the rural areas are aware that sometimes there are trials available. Dr. Brandenburg responded the agency has a clear policy on trial medications and research. He said there is an extensive protocol to which the division must adhere, and if any clients go into a trial program they are notified regarding the trial and its purpose. He said they can elect to participate in a trial if one is offered.
Senator Raggio commented the pharmaceutical companies were derided during the last election period, and it is interesting to learn that they provide medications for people with problems in strained circumstances. He surmised that if they are providing 80 percent of the cost of the medications for Nevadans, they are probably doing the same elsewhere.
HR, Southern Nevada Adult Mental Health Services – Budget Page MHDS-25
(Volume 2) Budget Account 101-3161
Senator Rawson commented on the life safety issues identified in the hospital building at the West Charleston campus. He asked what is needed to make the necessary repairs to the buildings to resolve the problem. Dr. Brandenburg responded that recently the division received an estimate of approximately $363,000 to make repairs to the building.
Dr. Brandenburg related that the hospital was built in 1988, and the Bureau of Licensure and Certification conducted a survey in January 1999 in which it was discovered there were life safety code violations. He said DHR allocated $350,000 to the division to make the repairs. When the contractor started work on the project, he found additional life safety code violations. Dr. Brandenburg said since then he has asked the Public Works Board to determine which violations are mandatory to correct and which are not. He reiterated the latest figure received from the Public Works Board is nearly $365,000.
Mr. Torvinen said another estimated $363,000 will be needed to complete the project. He stated that March 31, 2002, is the final date by which the repairs must be completed. He said a letter from the Health Care Financial Administration (HCFA) extended the certification to that date, and if the work is not completed the division is in jeopardy of losing Medicare funding for the hospital.
Mr. Torvinen told of a conversation with Daniel K. O’Brien, Manager of the Public Works Board, and John P. Comeaux, Chairman of the Public Works Board and budget director, regarding the best way to meet the deadline. Mr. Torvinen said Mr. Comeaux has some emergency funds, but not sufficient to cover the cost, and if those are used another appropriation would be necessary to replenish his fund.
Mr. Torvinen said Senate Bill (S.B.) 247 is being introduced that requests supplemental medication funds for the north, utilities for the new hospital, and funds for the Division of Child and Family Services (DCFS).
SENATE BILL 247: Makes supplemental appropriation to Department of Human Resources for unanticipated shortfalls and expenses at Nevada Mental Health Institute and in Division of Child and Family Services. (BDR S-1257)
Mr. Torvinen reported Mr. Comeaux proposed amending S.B. 247 to include funding for the repairs to the SNAMHS hospital building. Mr. Torvinen said the contractor told Dr. James Northrop, Clinic Director, that if the repairs are not started soon, they will not be completed by March 31, 2002, and thus there will be a serious licensure and Medicare funding problem.
Senator Rawson suggested that Mr. Torvinen be prepared to offer written amendments when S.B. 247 comes up for a hearing. Mr. Torvinen confirmed he will do so.
Ms. Giunchigliani recalled that in March 2000 the staff submitted a number of questions regarding the Mojave Mental Health Clinic, and no response has been received. Mr. Torvinen responded that he would take responsibility. He explained that because there were some issues that have not been resolved, he had not responded, but he promised to deliver a response to the staff the following week. He said the response has been drafted, with extensive information, but he is still attempting to resolve one issue.
Ms. Giunchigliani expressed interest in how much Medicaid funding is appropriated for each budget, and which agencies receive that funding. She admitted she is new to the subcommittee and the information will assist her in understanding the sources of funding. To clarify, she said she would like the information for the entire Department of Human Resources.
Ms. Leslie reported most of the complaints she receives relating to the mental health budget are not related to service but are about the lack of competition because Mojave is the only nonprofit agency that is allowed to use direct Medicaid funding. She voiced concern that as the Mojave Mental Health Center expands into the north, it might drive other nonprofit clinics out of business. She said the other nonprofit clinics are concerned that they may not be able to compete, and she asked why the Mojave clinic receives special treatment.
Dr. Brandenburg responded the Mojave Mental Health Center was created in fiscal year (FY) 1991-1992 when there were revenue shortfalls. At that time the Mental Hygiene and Mental Retardation (MH/MR) Division had to make some “devastating” cuts in outpatient services, he said. He noted the director had to find a way to provide services, because people receiving Medicaid are entitled by federal law and regulations to “reasonable access to mental health services.” He said the university medical residency program was willing to provide those services since the program was a Medicaid provider.
Dr. Brandenburg reported the state only restricts targeted case management services under Medicaid, and any other provider can bill for Medicaid outpatient services. Ms. Leslie opined that may not be entirely true. She said:
Marriage and family therapists and social workers cannot provide. That is just one example, because our Medicaid plan is not checked in that box. . . . I do want this committee to look into it, deeply, and I would just say, for the record, that that decision that was made back in 1991 may have been a good decision, because people did get services. However, it is now 2001, and I think we need to revisit it, and I just do not think it is fair for one nonprofit to have such an unhealthy advantage over every other nonprofit providing mental health care. So I am not sure it is the best model in 2001 to provide mental health care to our people.
Senator Rawson commented that at the time there were some differences between Las Vegas and northern Nevada. He suggested services may not have been available so people were sent back out into the community, or perhaps fewer were negatively affected by it. In any case, he asserted, the people of Nevada lost a safety net.
Senator Rawson said the medical school saved the state during a difficult time, yet concern lingers. He asserted the state must decide whether it really meets the federal guidelines. He noted case management can be handled as a sole source, but the state may be in violation regarding treatment and counseling. He suggested the matter needs further discussion and should be addressed in a work group.
M-202 Demographic Caseload Changes – Page MHDS-27
Ms. Tiffany asked whether positions will be eliminated for inpatient hospitals in order to fund additional transitional housing. She asked why bed reductions are being made when Clark County is growing so fast, and what the transitional housing consists of.
James Northrop, Ph.D., Clinic Director, Southern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources, responded that when the agency realized the addition of community-based resources and modern medications, inpatient projections were decreasing, and a feasibility study of reducing beds was conducted. He said maintenance module M-202 proposes the addition of eight intensive supportive living arrangements, which are apartment-like facilities with up to 24-hour wakeful supervision. Clients are provided approximately 10 hours per day of training and treatment.
Dr. Northrop said a number of long-term stay individuals in the hospital have been identified who could move from the hospital into intensive supportive living homes if they were available. He noted that would potentially reduce the census by a continuous number of six to eight clients at a minimum.
Dr. Northrop added the current rate of pay and the competency of group-home providers often makes it difficult to treat persons with significant psychiatric disorders and concurrent medical conditions and keep them out of the hospital. He said the addition of 12 special-need group-home beds is being proposed to address the need.
Ms. Tiffany asked whether the funding for the 12 beds will come from a federal grant. Dr. Northrop replied it will not, although Medicaid revenues will be collected for the treatment. Ms. Tiffany inquired how the housing will be funded. Dr. Northrop replied it will come as a result of the bed-reduction savings in decision unit M-202.
Ms. Tiffany recalled a discussion in which it was indicated some funds were available for transitional housing, and a letter subsequently said the funds were already committed. She asked where the funds were committed. Dr. Northrop answered the agency uses funds called HUD “shelter-plus monies.” He explained the funds are designated for homeless individuals, and those funds are used for supportive living arrangements (SLA) in which the agency provides the services as a match for the money that is paid for rent and utilities by the HUD grant.
Ms. Tiffany stated she understood $2 million is available for housing, and she asked whether that $2 million is going to be used for “shelter-plus” funding. Mr. Torvinen responded the U.S. Department of Housing and Urban Development (HUD) “shelter-plus” carries a federal grant that was appropriated to Nevada over 5 years ago. He said over the years the state has drawn down against that amount, and has received an extension of time, but the money is nearing depletion. He explained the funds support an SLA, usually a private provider, in which HUD pays for rent, deposits, utilities, and inspections to ensure that the facilities are up to standard.
Ms. Tiffany asked how much of the federal grant funds remain that have not been used yet. Mr. Torvinen replied there is no HUD shelter-plus funding left that has not been committed in the budget. He admitted the funds may even be slightly over-committed. He explained anything in category 19 is committed to residential supports, and some of the funds have been allocated to the Rural Clinics budget and the Nevada Mental Health Institute budget.
Mr. Torvinen stated the funding source from HUD will not be renewed. He explained the fund is now called Continuum of Care Program, and it must be requested annually. He voiced his understanding that a group in Las Vegas has been able to secure funding annually, and he proposed working with the group in an attempt to replace the funds.
Ms. Tiffany suggested that the information should be readily available if the clinics in southern Nevada have been able to obtain the funds. She reiterated the critical need for housing. She asked what is being done to coordinate the grant requests so that regions will not be competing against each other for funds, and whether there is a plan in place. Dr. Brandenburg responded the central office has put together a housing consortium in which the directors are brought together to avoid the issue of fighting for the same funds. He acknowledged the division has difficulty interfacing with local agencies, because, he said:
The HUD issue cuts across numerous principalities, cuts across agencies, and we, at our level in the central office, have a hard time just dealing with the local folks regarding the issue of providing services to the disabled.
Dr. Brandenburg said most of the HUD funds do not go to a single population. He acknowledged having difficulty in the past interfacing with HUD and trying to convince them to allocate housing funds to the division slots. He reiterated his attempts to take a leadership position for housing because it is so crucial. He complained that even though clients are provided with proper medication, they may become homeless if the division has no place to send them.
Ms. Tiffany reported she had a meeting with HUD scheduled for the afternoon in Clark County and she declared she would discuss the matter with them. She asked whether Dr. Brandenburg had specifics to discuss. Dr. Brandenburg responded he would like the name of the person whom he should contact.
Ms. Tiffany asked what agency received Continuum of Care Program funds. Mr. Torvinen pointed out there is a large number of non-profit entities in southern Nevada, ranging from homeless to substance abuse agencies. He said the Continuum of Care Program funds go to the group, and from there are distributed based upon responses to the request for proposals (RFP).
Senator Rawson announced public testimony would be heard.
Brian L. Lahren, Ph.D., Lobbyist, Washoe Association for Retarded Citizens, Inc., spoke from an outline depicting problems in Nevada (Exhibit K). He called attention to a handout entitled Crisis in Nevada’s Developmental Disabilities Services (Exhibit L). He pointed out the graph shows that for the past 23 years Nevada has put forth the lowest level of fiscal effort in the nation for people with developmental disabilities. He noted developmental disability (DD) services are funded better than other disability services in the state, which he described as sad.
Dr. Lahren stated Nevada has one-seventh of the enrollment in developmental disability services anticipated by the Center for Disease Control (CDC), based on a statistical model. He acknowledged it is highly unlikely that the model is incorrect, but even so, whenever the Legislature attempts to fund the waiting lists, it becomes apparent at the next session that the waiting lists are about as long as there were in the previous session. He surmised that will continue until the service system in the state more closely approximates the incident rate throughout the nation.
Dr. Lahren added that another major problem is there has been no rate increase since 1966 for the state’s system of contract service provision. He said the 1966 increase was simply a rate adjustment for two rates that applied to a small fraction of the population to provide staff for clients requiring intensive services. As a result, he said, state providers of services to persons with developmental disabilities have turnover rates in direct-care staff that range from 130 to 240 percent. He noted this is a violation of Medicaid law, it impacts issues under the Olmstead Decision, and it creates liabilities. He complained it creates huge liabilities by compromising the quality and continuity of client care.
Dr. Lahren asserted the state has begun to shift its responsibilities for case management to providers without fair compensation; and, he charged, the state “continues to draw down $85 an hour on its side, but does not pass those costs along to providers of case management services in any reasonable way.” As a result, he said, Nevada has the lowest provider pay rate in the western United States, and he made the assumption that the same is true nationally. He stated the average direct-care salaries are about $7.50 per hour, and he questioned whether it is reasonable that anyone would be willing to, for example, change an adult’s diapers for less pay than fast-food worker earns at a place like MacDonald’s. He condemned the consequences of bad pay with few or no benefits, hard work, huge responsibilities, personal liabilities, and little or no chance for improvement unless the Legislature acts during the present session.
Describing it as an exact parallel of the situation in Nevada, Dr. Lahren read a paragraph on a case being heard in a class action lawsuit on the rate issue in California. He said:
Now and for the last decade, California’s program of service to people with developmental disabilities has been administered by them and their predecessors in such a way that the wages and benefits paid to direct care and professional staff in the community-based services are, and have continuously been, far lower than wages and benefits in institutions. Wages and benefits in community-based services are among the lowest and least competitive wages and benefits paid in any sector of California’s economy, at par with fast-food jobs. Community-based services experience high staff turnover rates . . .
Dr. Lahren noted the statement indicated the turnover rates cited were 50 percent in an average year, which he noted is one-half to one-quarter of Nevada’s turnover rates. He continued reading:
Community-based providers are unable to recruit, hire, and retain the personnel required to expand and create new community-based services, as well as maintaining stable, well-supervised existing services. The state’s methods have violated the law, have the effect of subjecting or threatening to subject individuals in the class of people with disabilities to unnecessary segregation and institutionalization, and do not ensure, in the language of Title XIX, the efficiency, economy, and quality of services necessary to them.
Dr. Lahren reiterated the parallels in California and Nevada. He requested that the committee hear testimony from people from the disabled community regarding personal crises they have had as a result of the low level of funding.
Senator Rawson acknowledged the Legislature would like to deal with some of the problems this session, and that there are several BDRs dealing with the problems. He added it is the intent to bring in members of the community to address their needs and be part of the planning process. He said, “The irony is that we have a Governor now that has actually listened to some of this and built it into his budget, and he has tried to do things, and yet this may be the time that we take a hit legally or otherwise.”
Senator Rawson stated there is a spirit of cooperation in which everyone wants to work together. Dr. Lahren agreed. He reported he has three proposals, which he believes are cost-effect, and perhaps less costly than the proposal from the director’s office. He agreed that Governor Kenny Guinn has his heart in the right place, but it may be that the community’s concerns have not been adequately communicated to him. Senator Rawson noted the process includes both the Executive and Legislative Branches.
Aimee Wittler, Executive Director, Disability Resources, spoke on behalf of Mary Bryant, mother of a child with Down’s syndrome, who was formerly an executive at the Hilton Hotel. Ms. Wittler read a letter from Mrs. Bryant (Exhibit M) who attempted to enter her child into Sierra Regional Center. Mrs. Bryant described the difficulty she met with the application process, with the rates, with billing for case management, and with her attempts to get anyone to listen to her plight. In exasperation, she withdrew her child from the center. Mrs. Bryant asserted that, if she had such a hard time, a person with less experience and drive might have even more problems dealing with the agency.
LaVonne Brooks, Lobbyist, Executive Director, High Sierra Industries, reported she was in private enterprise for 23 years where she earned twice as much prior to taking the job with High Sierra Industries. She presented the subcommittee with copies of a document (Exhibit N) indicating statistics, including costs and reimbursements, relating to High Sierra Industries.
Ms. Brooks asserted there is an immediate crisis. She referred to her handout, which she noted included her restatement of an initial draft prepared for The Executive Budget to fund a waiting list of all people receiving case management services. She interpreted the draft to mean services equal case management, but she declared it does not. She said when the case management workload is between 1:45 and 1:50, people fall through the cracks.
Ms. Brooks related the situation of an Oregon family whose daughter with disabilities was in an SLA and a community training center (CTC). The family wished to retire to Reno, but because there were not sufficient funds to put the daughter in an SLA for a year prior to moving to Nevada, and then for a year afterwards, the family had to move back to Oregon.
Ms. Brooks said there are supposed to be quarterly integrated team meetings for every person receiving state assistance, driven by the case manager. When she first took the job in July, Ms. Brooks said, she asked her director of programs and instruction to conduct an audit. She recited several cases in which persons who should have been the subject of 8, 12, or 13 meetings had only had one review in a team meeting.
Ms. Brooks complained of a lack of staffing, lack of funding, hiring and retention problems. She said the clients in CTC often have accidents, many of which are embarrassing, unpleasant, and degrading, but because of lack of staff the SLA provider does not plan for assistance to the individual while the person is at work. Ms. Brooks explained there is nobody at the SLA to come get the person who needs help because there is no staff, often for as much as 2 hours.
Ms. Brooks reported many of the SLA residents working at CTC are sick, and twice people have come to work with pneumonia, because of lack of staff at the SLAs. She said one person suffering from seizures died and was not found for 2 days. She reiterated the crisis cannot wait for 2 years.
As the parent and legal guardian of a 45-year-old, severely retarded, autistic daughter, Lavinna DeGino, Interested Citizen, told her story of what happens to this type of client. She said that her daughter had good care at a home in Reno that was adequately funded and the staff was paid properly. Ms. DeGino said her daughter had a wonderful house manager for 14 years, and the technicians had worked there for many years. Ms. DeGino reported her daughter has now been moved to the community because the Sierra Regional Center (SRC) has had to downsize, and she lives in a home with a provider.
Ms. DeGino said the staff, which serves a very difficult population, is only paid $7 to $7.50 per hour. She noted many clients have seizures, medical problems, and complicated medication and the staff comes and goes. She acknowledged the providers try to train the staff, most of which are compassionate, but some have difficulty even caring for themselves, let alone such a difficult population.
Ms. DeGino averred, “You cannot have care for these people at $7 an hour.” As a consequence, she asserted, her daughter’s behavioral problems have escalated, because autistic people cannot deal well with constant upheaval and constant change. She said every time she visited her daughter there were new staff members, and there is not one person left who was working there when her daughter was placed in the home.
Ms. DeGino expressed dismay that the state has under-funded mental health services for so many years. She asserted the budget has been balanced on “the backs of the most innocent, helpless people in their population.”
Ms. Wittler drew attention to a letter from Don Stromquist, Executive Director of Easter Seals Nevada (Exhibit O), who was unable to attend the hearing. Ms. Wittler noted Easter Seals Nevada provided supportive living arrangements from 1995 through 1998, but at that time closed because they felt they could not provide a quality of care meeting their standards. She noted the Easter Seals’ problem is indicative of the problem facing community-based providers.
Paula Berkley, Lobbyist, Educare, Community Living Corporation, distributed a statement offering suggestions on developmental disability budgets with 9 pages of charts attached (Exhibit P). She pointed out no rate increases were recommended for The Executive Budget by the mental health division or the Department of Human Resources in January, nor was access provided to the $76 million set aside for rate increases for other health-care providers. However, she said, there were funds set aside for the waiting list of people with developmental disabilities. She opined most of those waiting for assistance will not be served because there are an estimated 20,000 people in Nevada who could qualify for services, many more than the 2,700 being served or the 281 on the waiting list.
Ms. Berkley noted the second chart shows that Nevada serves 50 people with developmental disabilities for every 100,000, compared to Colorado, which serves 100, or North Dakota, which serves 300 people per 100,000 population. She attributed the disparity to the difficulties facing those who attempt to enter the system, which she called “very unfriendly.” She noted the chart shows which states have been subject to legal actions because of the problems of waiting.
Ms. Berkley asserted the division errs by using the present waiting list to make projections, taking into consideration the demographer’s projected growth. She pointed out approximately 18,000 people are never counted. She stated another problem with the waiting list is shown on the third chart, which depicts every provider of services in the state except one. She noted the providers listed were asked to estimate how many new clients they could serve in the next 2 years, and most providers decided to hold down growth because of a shortage of staff. She pointed out the total estimated growth will provide for 95 people, which will not even take care of the 281 on the waiting list. She warned, “What is going to happen there is you will have a greater and greater opportunity for lawsuits.”
Ms. Berkley reported each provider was asked to rank the problems holding up expansion, and the prime reason was the inability to hire and retain qualified staff. She noted her client, Educare, raised wages at its own expense to $8 per hour, but even at that higher rate the company has been unable to obtain qualified staff. She added Educare has empty houses because of lack of staff.
Ms. Berkley said the second greatest concern to providers is the quality of care, which could put patients at risk. She said case management is the third reason for lack of expansion, because providers are being asked to take on additional responsibility without a commensurate rate increase.
Ms. Berkley drew attention to the fourth chart depicting the actual cost relating to administrative fees per month compared to the actual payments received. She pointed out 68 percent of costs are not covered. Referring to the chart provided by Ms. Brooks (Exhibit P, chart 5), Ms. Berkley commented that most of the CTC programs must contract with private enterprises in order to stay in business. She said the programs run coffee shops, Santa’s Workshops, computer repair shops, thrift shops, and similar businesses in order to provide for their services. She opined this should be a responsibility of the state, not of the non‑profit groups. Other charts compare salaries of providers, and COLA raises given to other state workers compared to service providers. The final chart, she said, shows the turnover rates. She indicated the Sierra Regional Center, which pays $12 per hour, has just a 2 percent turnover rate, whereas the providers paying $7 per hour have a 200 percent rate of turnover.
Ms. Berkley summarized her comments by noting the waiting list cannot be eliminated because there are uncounted people who need services, putting the state at great legal risk. She noted there has not been a rate increase for 6 years, and the providers do not intend to expand, which she called a problem for them in the long run, but a problem for the state in the short run. The third point, she said, is that there is no existing way to determine effectively what the state rate is to fund services.
Dr. Lahren made three proposals on how the state could resolve the problem. He said first there should be an immediate rate increase. He proposed that the providers receive the same 7.5 percent raise that was given during the interim to the long-term care industry, which has similar problems, and the same increases they will receive during the coming biennium, which he cited as 9.6 and 4.8 percent. He explained that every 7.5 percent of increase in the basic reimbursement rate allows a raise in staff wages of 55 cents, so one 7.5 percent increase would bring wages to over $8 per hour. He stated each 7.5 percent increase costs $933,000 within the community training center program.
Dr. Lahren said 80 percent of the people served are Medicaid eligible, and he suggested the raise should have been included in the $73 million that was set aside for Medicaid rate increases by the director of the Department of Human Resources. He asserted adequate information was provided to the department about the crisis, but the pleas were ignored.
Dr. Lahren offered another solution, suggesting the establishment of a commission to review and recommend adjustments to the rates paid to providers. He stated a bill draft is coming out that is sponsored by Senator Randolph Townsend, Bill Draft Request (BDR) 38-931.
BILL DRAFT REQUEST 38-931:
Establishes developmental services commission. (Later introduced as Senate Bill 364.)
Dr. Lahren explained the commission would consist of 3 community members, 2 members from DHR, and 2 members from the state provider or consumer system to oversee a process of standardizing the assessments of individual clients, and developing a standardized system of allocating funds based on the standardized assessments. He said most other state have a similar commission, but Nevada has never used such a system with any kind of regularity. He estimated the costs for work of the commission at approximately $200,000, a fraction of what some of the rate-setting cost estimates were in the Department of Human Resources proposal.
Dr. Lahren added that a comprehensive needs assessment planning process should be carried out involving consumers, providers, and advocates, in an Olmstead-like process. That proposal will be made under BDR S-970.
BILL DRAFT REQUEST S-970:
Creates advisory task force on long-term care. (Later introduced as Senate Bill 402).
Dr. Lahren opined many of the problems in DHR are due to policy confusion in which the expertise and knowledge of citizens and service consumers is not effectively engaged in the formation of policy and prioritization of budget initiatives. He said the Health Care Financing Administration has recommended that every state adopt a planning process such as that in the Olmstead Act that engages consumer, provider, and advocate input to plan methods of providing integrated services. He opined such a plan can be made for less than $250,000, and he asserted the job can be done for $100,000 less than proposed by the department. He said it should result in a plan that will make the consumer community very happy.
Dr. Lahren stated the net impact of the proposals should be a savings of over $100,000, Nevada citizens with disabilities will get an Olmstead-like planning process, and a rate commission, at no cost above that which is already included in the budget. He added that citizens with disabilities will finally have a position of participation in which to help design the future social policies that affect them.
Senator Rawson commented that the state is like a family in which it can be catastrophic if a member of the family has a disability. He said it is difficult to obtain services, it overpowers a family financially, and it affects every aspect of their lives. He suggested there is a tendency to view the Legislature as the entity in charge of things like highways, yet the problems facing the Legislature regarding social problems are overpowering and catastrophic to the state. He agreed there are more problems extant than recognized, and there are not the facilities to deal with them. He pointed out the Legislature will prioritize as much as possible, and citizens upset with Legislators must understand they face similar problems with similar worries.
Rosetta Johnson, Chief Executive Officer, Human Potential Development, Incorporated, stated she is also the parent of a mentally ill son. She provided a packet of information (Exhibit Q), including her written testimony in support of the mental health budget. She requested support for a bill establishing a mental health court, which she asserted will help people get the treatment they need. She reported on a meeting last December entitled The People’s Summit to End the Criminalization of the Seriously Mentally Ill, which favored establishment of a mental health court, and a commission to study services in Washoe County.
Ms. Johnson also offered support for the commission under consideration. She called attention to a statement in her packet regarding the commission that outlines the potential duties and types of people whom she proposed should serve on the commission, including several names of people who would qualify for the commission. She also drew attention to a list of contributors to the proposal. She reported the study should be done within 6 months at which time it will be given to the Governor. She said the complete study should be finished within 1 year, and it will be given to the legislators and the Governor with recommendations.
Ms. Johnson included information relating to the consequences of non-treatment in the packet, and statistics on the inmates in Nevada jails and prisons. She noted there were also six editorials from the Reno Gazette-Journal with information on the summit held in December 2000.
Vic Davis, President, Nevada Alliance for the Mentally Ill (NAMI), read from prepared testimony (Exhibit R). He offered support for mental health services, and voiced concern over the increasing lack of services. He asserted the state cannot afford any cut in funding because all services are already operating at capacity, and the outlook for the future is bleak.
Mr. Davis said new medicines are allowing the mentally ill to reduce the number of patients in hospitals, and to think more rationally and become more involved in society, but many of them lack the social skills or confidence to do so. He said if adequate funding is not provided, the number of those in jail, in the hospital, becoming homeless, or committing suicide will increase.
Mr. Davis reiterated the support of NAMI for the creation of mental health courts, expansion of psychosocial rehabilitation programs, and increased funding for services and new medications. He also requested another one-time appropriation in support of NAMI programs to conduct the Family to Family Education Program to provide teachers and classes for helping family members “cope with the trauma of losing a loved one to the agony of mental illness.” He said the program graduated 28 teachers who conduct classes in Elko, Reno, Carson City, and Las Vegas, and hopes to expand into Mesquite and Pahrump.
Ed Guthrie, Executive Director, Opportunity Village, described his organization as the largest training center in Nevada, serving over 500 people with disabilities. He said 375 of those people are sponsored by the Division of Mental Health and Developmental Services.
Addressing the question from Ms. Giunchigliani regarding the $250,000 appropriation in the budget, Mr. Guthrie explained the appropriation is being used by Opportunity Village for its thrift stores. He said the thrift stores provide employment places for people with disabilities to generate cash surpluses that subsidize other parts of the program. He stated fund-raising, thrift stores, and contract income generates over $6 million of the $8 million budget for Opportunity Village. He said $800,000 of the surpluses generated in those areas was used to subsidize the community training center programs last year, so without the surpluses generated it would not be possible to operate the community training centers with the same quality as at present.
Mr. Guthrie stated that over the past decade Opportunity Village has had to compete with other thrift stores run by national groups, both not-for-profit and for-profit, moving into Las Vegas. He said that during the decade much of the market share has been lost, with decreased sales, to the point where major changes will be needed or the thrift stores will have to close down. As a result, he said, the special $250,000 appropriation is being requested to hire a management-consulting firm to improve operations and become competitive, and to purchase fixtures and other start-up costs necessary to open two new stores. He noted it will be a one-time appropriation, and should help the stores operate for another 40 years.
Mr. Guthrie indicated his wish to address “lost hope, lost opportunities, and lost dreams.” He stated lost hope applies to parents who need residential services, but are afraid to place a son or daughter in a residential facility because of “the revolving door atmosphere” with direct service staff. He said a recent meeting with parents indicated that is their greatest concern, because staff turnover makes quality of care suspect, and many parents are afraid to die because of concern for their child once they are gone.
Mr. Guthrie said lost opportunity is because of the number of contracts that have been turned down that would have provided more jobs for people with disabilities. He said managers do not have time to research the opportunities because they are forced to spend most of their time recruiting and training new staff due to the massive turnover caused by low wages.
Mr. Guthrie stated lost dreams can be attributed to staff people that provide the services. He asserted they are wonderful people who are committed and dedicated, but who have had to choose between taking care of their families or doing the work that they love, because it is impossible to pay them a living wage. He said many of the staff members would prefer to stay, but must go on to other jobs that pay more.
Anne Gaffner, Member, Human Potential Development, thanked the Legislature for providing NMHI for treatment of the mentally ill who might otherwise receive no treatment at all. She stated she has an adult daughter who suffers from paranoid schizophrenia with mood disorders, but her daughter is one of the many who refuses treatment because she does not acknowledge that she is ill.
Ms. Gaffner described the symptoms of her daughter’s illness, but said she cannot get help for her daughter because the law prevents her from acting on her daughter’s behalf. Intervention would be considered a violation of the daughter’s civil rights. Ms. Gaffner asserted revisions to existing law are needed to allow treatment for the severely mentally ill, and she stated her support for a mental health court system. Her remarks are attached as Exhibit S.
Jonathan Andrews, Deputy Director, Department of Human Resources, declared the Governor’s human service budget, including comprehensive strategic planning, is clearly inclusive and responsive to the concerns and input of consumers and advocates. He stated the Governor is very sensitive to that, and the budget reflects it. He said the strategic planning will include all stakeholders, and is intended to identify current and future needs in the human services area, and to identify the resources necessary to meet those needs. He noted the problem is not something that can be addressed biennially, but should be projected for the next 10 years.
Mr. Andrews said he would be pleased to work with the group on the Mojave Mental Health Center project. He explained Mojave performs targeted case management for the seriously mentally ill through a coordination of mental health services for what he characterized as an extremely vulnerable population. He said federal Medicaid law allows states to limit targeted case management, and it is not a medical benefit, it is a management tool for the state to ensure quality of care. He said any qualified Medicaid provider is allowed to provide mental health services to patients, but they are not allowed to provide case management. He noted those issues will be addressed in the work group.
Ms. Giunchigliani stated the committee is very sensitive to the issues, and that the Governor attempted to take a large step with the budget. However, she opined, more needs to be done, and the issues will be considered in more depth during the session. As a special education teacher, she said, she can empathize with those who are involved in the lives of persons with disabilities. She agreed there is a tremendous need to address the problems of those who give daily care.
Senator Rawson advised those who had pertinent documents or written remarks that they would be included in the minutes. Nancy H. Neill provided a letter citing the special needs of her son (Exhibit T). Four groups offered lists of membership, including one for Community Unity (Exhibit U), the Nevada Forum on Disability (Exhibit V), Community Training Centers (Exhibit W), and the Northern Nevada Association of Service Providers (Exhibit X). Also an envelope containing 32 letters written in support of SLAs and CTCs is attached. (Exhibit Y. Original is on file in the Research Library.)
Senator Rawson adjourned the hearing at 10:46 a.m.
RESPECTFULLY SUBMITTED:
Judy Jacobs,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE:
Ms. Christina R. Giunchigliani, Chairman
DATE: