MINUTES of the
joint subcommittee on Human Resources/K-12
of the
senate committee ON finance
and the
Assembly committee on ways and means
Seventy-second Session
February 17, 2003
The Joint Subcommittee on Human Resources/K-12 of the Senate Committee on Finance and the Assembly Committee on Ways and Meanswas called to order by Chairman Raymond D. Rawson at 8:08 a.m. on Monday, February 17, 2003, 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 Bernice Mathews
Senator Barbara K. Cegavske
ASSEMBLY COMMITTEE MEMBERS PRESENT:
Ms. Sheila Leslie, Chairman
Mrs. Dawn Gibbons
Ms. Christina R. Giunchigliani
Mr. David E. Goldwater
Mr. Lynn C. Hettrick
STAFF MEMBERS PRESENT:
Gary L. Ghiggeri, Senate Fiscal Analyst
Mark W. Stevens, Assembly Fiscal Analyst
Michael J. Chapman, Program Analyst
Judy Coolbaugh, Committee Secretary
OTHERS PRESENT:
Carlos Brandenburg, Ph.D., Administrator, Division of Mental Health and Developmental Services, Department of Human Resources
Edward Guthrie, Executive Director, Opportunity Village, Las Vegas
Ed Schumacher, Member, Board of Directors, Opportunity Village, Las Vegas
Patti A. Roberts, Las Vegas
The Honorable Peter I. Breen, District Judge, Second Judicial District, Washoe County
Elizabeth O’Brien, Administrative Services Officer III, Division of Mental Health and Developmental Services, Department of Human Resources
Harold Cook, Ph.D., Agency Director, Northern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources
Dr. Ira Pauly, Medical Director, Northern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources
Elizabeth Neighbors, Ph.D., Director, Lakes Crossing Center, Division of Mental and Developmental Services, Department of Human Resources
Larry Buel, Ph.D., Agency Director, Rural Clinics, Division of Mental Health and Developmental Services, Department of Human Resources
Dr. David A. Rosin, Medical Director, Southern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources
Jonna Triggs, Ed.D., Agency Director, Southern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources
Rosetta Johnson, President/CEO, Human Potential Development, Inc.Dr. Dale Carrison, Chairman, Director of Emergency Medicine,
University Medical Center, Las Vegas
Brent Tyler, Carson City
Vic Davis, President, National Alliance for the Mentally Ill, Las Vegas
Elena M. Brady, President, Asian-American Republican Club of Nevada, Carson City
Patricia Martinelli-Price, Homeless Advocate, Las Vegas
Rachel Paxton, Carson City
DIVISION OF MENTAL HEALTH AND DEVELOPMENTAL SERVICES - OVERVIEW
Carlos Brandenburg, Ph.D., Administrator, Division of Mental Health and Developmental Services, Department of Human Resources:
Many fellow Nevadans woke up this morning to face another day of coping with serious mental illness. Individuals who suffer from serious mental illness have psychotic symptoms: hallucinations, auditory and/or visual, and delusional thinking such as paranoia.
Mental illness is shockingly common, affecting almost every American family, directly or indirectly. Mental illness can strike someone of any background. It can strike at any stage of life, from childhood to old age. No community is unaffected, no school or workplace untouched. Nevadans with serious mental illness are one of our state’s most vulnerable groups. We see them in our streets, under our bridges, down by the river, and in our jails. The bottom line is that mental illness is very common and very disabling, and is not to be dismissed as a character flaw or weakness.
While many severely mentally ill (SMI) Nevadans are given good treatment and manage to recover, the reality is one out of every two Nevadans who seek mental health treatment does not receive it. The mental health agencies you will hear from today are dedicated to the single most important goal of the people they serve, the hope of recovery. However, you will hear of a system where individuals have to wait 60 to 90 days to be seen in a medication clinic; where psychiatrists are carrying a caseload of 800 clients; where, for the past 6 months, an average of 19 seriously mentally ill per day have waited an average of 48 hours each in the Las Vegas Valley’s emergency rooms before being transferred to Southern Nevada Adult Mental Health Services (SNAMHS).
Most disturbing is that 35 percent of these high-risk individuals, identified as being an imminent danger to self or others, leave with no evaluation, treatment, or follow up. Compounding all this, as most of you know, the State’s budget, which forced the Governor to request a 3-percent cut, has resulted in the mental health and developmental agencies cutting a total of $2.7 million.
Many of our consumers, advocates, family members, law enforcement representatives, and judges are here to testify about the many challenges facing the division and Nevadans with SMI (Exhibit C).
HR, MHDS Administration – Budget Page MHDS-1 (Volume 2)
Budget Account 101-3168
Senator Rawson:
We are adding 80,000 people annually to our population. What is your estimate of the number of people who will need mental health services with our projected growth?
Dr. Brandenburg:
According to the U. S. Center for Mental Health Services Center, the prevalence rate for mental illness in the State of Nevada is about 5.4 percent of the total population. If you estimate the State’s population at 1.5 million, there are about 85,000 severely mentally ill Nevadans. The Division of Mental Health and Developmental Services (MHDS) this past fiscal year provided services to 25,000. Therefore, about 50,000 SMI Nevadans are not receiving any form of treatment.
Senator Rawson:
We work on a 10-year budget cycle of ups and downs with a serious recession ending each cycle. Just as we just get the mental health program where we want it, we have a budget problem and cut everything. How many more people can we serve today than we could serve 10 years ago? We obviously have not kept up with the need, and the growth is “killing” us.
Dr. Brandenburg:
Last session’s methodology did not give us any demographic growth projections for medication clinics, or personal service coordination in the north or the south. Not one psychiatrist or nurse was added for either of the mental health clinics to provide increased services. The direct result is one has a caseload of over 800 individuals. This year we are using the Caseload Evaluation Organization (CLEO) package to predict demographic growth, and show areas where service expansion will be required. I would like to distribute a handout entitled “The Effects and Benefits of New Generation Psychiatric Medications in Nevada” (Exhibit D Original is on file in the Research Library.).
Senator Rawson:
With a yearly growth of about 80,000 people, our State adds about 4000 SMI annually.
We have disclosures to hear at this point.
Senator Cegavske:
For the record, I work for WestCare. I will be involved in all the conversations. If any vote represents a conflict of interest, I will abstain from the vote.
Assemblywoman Leslie:
For the record, I work for the Washoe County district court, specifically in the area of specialty courts and the mental health court. The funding package under discussion, if approved, will go to the mental health division, not to the courts. I will abstain from talking about that part, but otherwise I will be voting.
Senator Rawson:
We need to hear the disclosures, but we also want access to your expertise on the issues that are important and pertinent. Are there any other disclosures?
We want to start with the rate study changes.
Dr. Brandenburg:
I believe you are referring to enhancement unit 350 (E-350) Service at Level Closest to People.
HR, Northern NV Adult Mental Health – Budget Page MHDS-12 (Volume 2)
Budget Account 101-3162
E-350 Service at Level Closest to People – Page MHDS-12
The Department of Human Resources (DHR) received a letter of intent from the 71st Session of the Legislature directing it to develop a strategic plan for the department. We developed four specific strategic planning groups. They are: the strategic plan for the disabled, the strategic plan for the providers, the strategic plan for the elderly, and the strategic plan for rural health.
I call your attention to the strategic plan for the providers. The particular recommendation made, from the independent contractor who was brought in, was to provide a 37-percent payment increase for our Supportive Living Arrangement (SLA) providers. We subcontract with these providers to give residential treatment in our community. It is an extremely important component of our budget because it gives us the ability to provide housing and residential support for individuals in the community by using group homes, SLA, Intensive Supportive Living Arrangements (ISLA), and special need beds. With the 37‑percent increase, the rate should go from $15.18 to $20.75 per hour for our SLA providers. For our community treatment center (CTC) providers, the rate should go from $5.37 to $7.16 per hour, which is a 33-percent increase.
The budget before you is based on a 15-percent biennial increase. Our CTC providers felt the rate of 7 percent, the first year effective January 1, 2004, and 8 percent the second year of the biennium, showed a good-faith effort on the part of the State to provide them with the resources they desperately need to continue to provide services to our clients.
All these providers are contractors who are providing treatment for us in the least restrictive environment. They provide a continuity of care in the communities they service.
Edward Guthrie, Executive Director, Opportunity Village, Las Vegas:
Opportunity Village is the largest community-training center in Nevada. We provide vocational training and employment services to over 600 people with severe intellectual disabilities. Last year, we paid over $1.5 million in wages to folks that most people consider unemployable. I was the chairperson of the rates task force, so I had a chance to work with the outside consultant to come up with the recommendations before you.
The CTC and SLA have not received a rate adjustment in 7 of the last 10 years. In the last 8 years, they have received a grand total of 3-percent rate adjustment. Looking at caseload growth, which is required by the strategic plan, and the growth of our population, we have to consider an equitable rate adjustment. Providers who are already subsidizing existing services simply cannot afford to subsidize the additional expense of growth without some relief.
I could go into more detail, but I would rather introduce two of the parents of people we serve. They are Patti Roberts and Ed Schumacher from Las Vegas.
Ed Schumacher, Member, Board of Directors, Opportunity Village, Las Vegas:
I am proud to be the father of my intellectually disabled daughter, Anne, who was adopted at birth 42 years ago. She works at the Opportunity Village campus in Henderson. I am 86 years old, and the services provided by Opportunity Village help us make a better life for Anne. She loves her job at the Opportunity Village work center and is proud to bring home a small but regular paycheck. Like all of us, she is happy to have a productive, meaningful life and to make a contribution to our community.
As a board member, I know that Opportunity Village saves Nevada taxpayers millions of dollars yearly in providing employment for the mentally and physically handicapped members of our society. As a parent, I know that if Opportunity Village did not exist to provide job training, contract work, and social events for Anne, she would probably be at home bored and frustrated. Without the daily work routine, her condition would gradually deteriorate. I am here to urge your support for the modest rate adjustment proposed by Governor Guinn. The proposed rate increase will help Opportunity Village serve more handicapped people like my daughter. It will also make it possible for Opportunity Village to make salary adjustments to the staff members who are dedicated to the welfare of their clients. I appreciate your support on this issue, and I will answer any questions you may have.
Patti A. Roberts, Las Vegas:
My husband, Mike, and our son, Blake, are in the audience this morning. I have worked for 26 years as a registered nurse with the Clark County School District. Blake is now 21 years old. When he was 2 years old, he developed an illness that left him intellectually disabled. It made me realize we are all just one accident or one illness away from being disabled ourselves and in need of the services that we are discussing here today. Blake will soon graduate from the Clark County School District and hopefully find a place in the work-training program like those offered by Opportunity Village.
Of course, this assumes that Opportunity Village will have the money to provide services to more people like Blake. Fortunately for us, Blake got a head start by participating in the new job discovery program, which is an innovative partnership between the school district and Opportunity Village. Blake is learning valuable job skills and gaining real experience working in culinary, janitorial, grounds maintenance, retail, and factory assembly jobs.
As parents of a disabled child, my husband, Mike, and I want the same things for Blake that we want for his non-disabled sister. Blake simply wants to live and work as independently as he can, and have the opportunity to lead a happy and productive life. We know these programs need and deserve your support. If not, Nevada taxpayers may certainly pay more in the long run. We hope you will follow Governor Guinn’s recommendation and approve this rate increase so that organizations like Opportunity Village can serve our son and many more like him.
The Honorable Peter I. Breen, District Judge, Second Judicial District, Washoe County:
I preside over the various drug courts in our judicial district and preside over our mental health court. David Spitzer, Attorney at Law, is with me today. He is the attorney for the clients of the court. We are here to express our support in general for the budget, but in particular, for those aspects that relate to our mental health court.
People who are in mental health court are not incompetent to stand trial in the criminal courts, but through their illness as they continuously churn through the system. They go from the streets, to the jail, to the courts, and back to the streets again. Eventually this becomes a never-ending cycle, in which they alienate themselves from their friends and their family. This cycle frustrates the courts. These people lose contact, often intentionally, with the very government and private services that are there to help them.
We have provided you with a handout entitled “Mental Health Court” (Exhibit E) that summarizes some of its activities.
Our pilot program is irrevocably proving that use of the mental health court dramatically reduces jail time. Further, it connects these people through the power of the court to the needed services that are there for them, and keeps them connected throughout the time they are with the court. Doing the right thing appeals to and satisfies our spirit of justice, and it alleviates burdens on our pocketbook as well. We have been operating for 15 months, and the numbers of the people served are in the handout. The mental health community, Dr. Brandenburg’s agency in particular, has been contributing their services to us. It is now time to take the next step.
The next step is a bill to provide critical housing and some case management service. It is difficult for a criminal court judge to have a defendant before him, who has just been released from jail, and direct that person to his first psychiatric appointment knowing the appointment is 6 weeks away. I know they have to go back to a place on Fourth Street, which is not safe for them.
Senator Rawson:
We appreciate the time you have put into the court and in being here today. Your comments will be a part of the record.
Dr. Brandenburg:
I refer you to maintenance unit 501(M‑501), for HIPAA, which stands for Health Insurance Portability and Accountability Act of 1997.
M-501 HIPAA – Health Insurance Portability – Page MHDS-3
This decision unit provides for a privacy officer who oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures.
Senator Rawson:
We note originally there was a request for eight positions in the department and the request has been cut to five positions. Is this the amount you really need?
Dr. Brandenburg:
I have two hospitals, forensic facilities, and 19 clinics. There is no way I can be in compliance with the HIPAA standards by assigning these duties to a person with duties already assigned. I need this minimum number of positions to be in compliance with the privacy law.
E-225 Reward More Efficient Operations – Page MHDS-3
This decision unit allows the MHDS central office to continue use of additional office space and work area used primarily by consumers, contracted professional, and support and performance improvement staff. I have three staff members sharing one office, and this precludes having any type of supervision, privacy, or dialogue. The Department of Information Technology (DoIT) was able to give us office space they vacated on the sixth floor of the Kinkead Building. This is a request for $1.05 per square foot for the additional 900 square feet we need.
E-600 Budget Reductions – Page MHDS-4
In order to stay within the 3-percent budget cuts, funding allocated to the Psychiatric Resident Program with University of Nevada, Reno (UNR) had to be eliminated.
Senator Rawson:
You know that is going to raise a red flag.
Dr. Brandenburg:
I know you are a very strong advocate and proponent for the resident program, and I assure you I have been working with Dr. MacFarlane. He is approaching UNR to see if there is any way it can come up with the $143,969 resident program costs. Between Dr. MacFarlane and us, we will try to continue the resident program. Dr. Cook was able to take a vacant part-time contract position and turn the monies into the resident program. We are exploring all our options to try to maintain this program.
Senator Rawson:
One of the problems you have in recruiting and keeping faculty comes when residency positions figure prominently in budget cuts. How do you have serious residents look at an area if they know there may be cuts? We need to find stability in our resident programs. We have fewer resident programs than any other state comparable in size, but we know our service needs are greater. Reversing our direction on this program is not a sensible alternative.
Assemblywoman Leslie:
Have we been able to document any increased length in the waiting time since we eliminated the resident program? What impact does it have on the clients?
Dr. Brandenburg:
It definitely has an impact. We had to take a part-time contract psychiatrist position we would normally use to provide services and use the funds for the resident program. The waiting time has increased, but we are committed to maintaining the resident program. Ideally we need both the contract psychiatrist and the resident program. The decision came down to eliminating the resident program or cutting two of my staff from the central office.
Assemblywoman Leslie:
Are you saying the university might come up with some of the money to reinstate the program?
Dr. Brandenburg:
Dr. MacFarlane will be talking to the chancellor to see whether there is any way they can come up with the additional funding.
Assemblywoman Leslie:
We will flag this to keep watching, and hopefully we will get a good resolution before the end of the session.
Senator Rawson:
At one time, the university would have used its trust funds, but they are currently over-committed. I think there is a sense that we do not want to reverse 10 years of work here. Cutting the budget funding for the resident program also seriously affects other programs.
Dr. Brandenburg:
It is hurtful. As indicated, it affects the waiting list, recruitment, and retention of staff. Many of the staff who come to work for us want to be associated with the university as part of the teaching program.
Senator Raggio:
How many residents does this affect?
Dr. Brandenburg:
Four are affected. Two are second-year residents and two are third-year.
Senator Raggio:
How is service going to be provided? If you do not have the residents, what does that mean for the rest of your staff?
Dr. Brandenburg:
It does have an affect, which is why Dr. Cook, the director of the Northern Nevada Adult Mental Health Services (NNAMHS), took the funds from the vacant contract position to keep the resident program in operation. Without the program, I would probably have difficulties recruiting staff who want to work in a university teaching facility. One of the attractive features of NNAMHS is the fact we are a Joint Commission on Accreditation of Health Care Organizations (JCAHO) facility.
Senator Raggio:
This program should not be eliminated. We will have to find some solution for the funding problem.
E-710 Replacement Equipment – Page MHDS-4
Dr. Brandenburg:
The software and hardware computer equipment and printers requested in this decision unit represent bare necessities.
Senator Rawson:
Desktop computers are in this request. I believe there is also another Capital Improvement Program (CIP) request for Advanced Information Management System (AIMS). Is there some duplication of computer equipment in these requests?
Dr. Brandenburg:
I believe we have done a very conscientious job avoiding any form of duplication. This request is for five desktops and one printer.
E-903 Transfer Out To Lakes Crossing Center (B/A) 3645 – Page MHDS-4
This decision unit moves 0.75-licensed psychologist from the central office to Lakes Crossing Center with a request to increase this position to a 1.0 full-time employee (FTE). This position helps coordinate services between Lakes Crossing Center and the Department of Corrections (DOC) for the sex offender panel by evaluating inmates and providing mental health treatment per Nevada Revised Statutes (NRS) 213.1214.
Before the parole board sees inmates, they have to be evaluated as to whether or not they continue to pose a danger to the health and safety of others. The panel consists of the administrator or designee, the director of DOC or designee, and a psychiatrist from the DOC. Moving the position to the Lakes Crossing Center will permit Dr. Elizabeth Neighbors to supervise and monitor the position. We will also develop a standardized way to evaluate the inmates and provide standardized supervision that I cannot personally give from the central office.
You will see in the Lakes Crossing budget this position being transferred with a 0.25 position enhancement to create a full-time psychologist position.
Senator Rawson:
I believe they currently have a half-time FTE at Lakes Crossing, and with the 0.75 and 0.25 it looks like you are going from half-time to full-time.
Dr. Brandenburg:
We are going from three-quarter-time to full-time.
Senator Rawson:
Is a psychologist position what you require at Lakes Crossing versus a psychiatrist?
Dr. Brandenburg:
We need to have a psychologist because it gives me greater flexibility and it is cost-effective.
HR, Mental Health Information System (MIS) – Budget Page MHDS-78
(Volume 2) Budget Account 101-3164
This is the AIMS conversion that would provide us with uninterrupted maintenance and warranty support for migrating to a new Avatar system. Creative Socio-Medics Corporation (CSM) has bought out the current AIMS product. AIMS will no longer be able to assist us with the billing system or any type of support that we would need. The transition costs for MHDS total $3.2 million over the 3-year period fiscal year (FY) 2003-04 to FY 2005-06. The new software system will provide us with an integrated approach to tracking and to billing.
Senator Rawson:
Have you looked at other potential vendors? Are you satisfied you have selected the one that is best?
Dr. Brandenburg:
This particular system is currently being used in 23 other states and provides them with their mental health data needs. It is a HIPAA compliance system and is “state-of-the-art.” I feel very comfortable and confident this system will give us the data we require. Right now, I have to make data inquiries manually. It is very time-consuming, and I am unable to track patient information. I do not have the type of accountability required.
Senator Rawson:
Unfortunately, a “state-of-the-art” system means 10 years behind when we get it in place. I hope you are looking ahead.
Dr. Brandenburg:
This company is “state-of-the-art.” It is looking at JCAHO and performance indicators on a national scale. Medicare and Medicaid services have contracted for this system to do their tracking on performance indicators. We will be part of a system the federal government uses.
Senator Rawson:
Would you get together with staff and discuss the 3-day CSM user-group workshops in New York? You are asking for four people to go for 5 nights in a hotel. If it is necessary for such a large group to go, it will be acceptable. If a smaller number can go and come back to train our group, it would be more desirable.
Dr. Brandenburg:
This decision unit does not have any out-of-state travel request. We were able to secure the out-of-state travel with a large grant the division received specifically to fund the travel in this decision unit.
All 23 system-user states get together throughout the nation and talk about issues such as HIPAA, confidentiality, and billing software up-grade. We may have one or two people attending the New York workshop, but I do not believe we have five scheduled to go. I will be more than happy to work with Mr. Chapman to make sure no more than two people go.
Senator Rawson:
We wanted to make sure the workshop is appropriate and useful.
Senator Cegavske:
Do you have a contract that we can give to the fiscal staff to review?
Dr. Brandenburg:
I was very sensitive to that issue based on our prior involvements with other systems. This particular software up-grade is not in my budget. It is in Mr. Comeaux’s budget account 1325. I believe Mr. Comeaux put the request for funds there to provide the oversight and the flexibility he needs to monitor the system.
Also, in his budget is the request for one contract person to assist me with the software up-grade. Mr. Troy Williams, my program evaluator, will be in charge of this project, but I need to have a contract person back-filling his position so his regular duties and responsibilities will continue to be done.
Senator Cegavske:
Are you looking for guarantees in the contract?
Dr. Brandenburg:
Absolutely. I looked for HIPAA guarantees. We have to be HIPAA compliant. I have spoken to many of my colleagues in the 23 other states that are using the system. I have personally seen the software and a demonstration.
Senator Cegavske:
How many years has it been in place in other states? Can we confer with them to obtain some feedback?
Senator Rawson:
Please give staff a list of user states and length of time they have used the system.
Dr. Brandenburg:
The vendor is willing to come talk to staff about the software up-grade. I can arrange for a thorough orientation for members of this committee or with staff. My goal is to acquire a reliable system although there are no guarantees.
Senator Cegavske:
We need some accountability for the system.
Elizabeth O’Brien, Administrative Services Officer III, Division of Mental Health and Developmental Services, Department of Human Resources:
There is out-of-state travel for four staff to attend the user-group for the Creative Socio-Medics Corporation workshop. Our plan was to send one person from each region, which would be north, south, rural, and one person from central office. These people would come back and train the trainers.
HR, Northern NV Adult Mental Health – Budget Page MHDS-7 (Volume 2) Budget Account 101-3162
Harold Cook, Ph.D., Agency Director, Northern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources:
I have distributed a handout entitled “Northern Nevada Adult Mental Health Services, Budget #3162” (Exhibit F). It includes a summary of my testimony, tables, and performance indicators.
Table I of the handout shows the 3-percent cut this agency made in October 2002. These cuts total more than $500,000 for FY 2003 and included the residential treatment program, free bus passes for clients, campus security contract, medication, staff training, psychology internship program, and one psychiatric caseworker. In FY 2003, we pared our equipment request as much as possible and reverted more than half of the equipment budget authorized in 2001.
In cutting our budget, we cut services, lost positions, and reduced support for staff. We need this budget request for FY2004 in part to recoup some of these losses. Page 1 of the handout outlines past budget initiatives. The current budget is in sharp contrast to previous budgets, which focused on hospital‑based services with minimal growth in community-based programs. In 1997 funding was authorized for the Dini-Townsend Inpatient Facility, which opened on September 12, 2001.
In 1999, funding was authorized for psychiatric emergency service (PES). In 2001, we obtained Legislative approval to transfer inpatient resources to the PES. Implementation and growth of the PES was a trade-off for a reduction in inpatient beds from 52 in 1999 to 40 in 2001. Currently, we have a 40-bed hospital with ten additional observation beds in northern Nevada. During the past 6 years, growth in outpatient community-based programs such as residential support, medication clinic, and outpatient counseling was minimal or none.
The lack of funding growth in outpatient services has meant additional caseload growth of 637 clients in the medication clinic and 155 clients in outpatient counseling. We accommodated these increases using resources based on 1997 funding levels. Demand for services has far out-stripped the ability of staff and budget to continue to squeeze in new clients and serve ongoing ones. With budget cuts and increased demand, agency staff has been continually asked to do more with less. This places the staff at risk for burnout, which results in turnover and increased risk of medical errors. This also places the health and lives of our clients at risk.
The Governor’s recommended budget provides the necessary resources and increased staffing to allow the agency to provide an adequate level of care. We are not asking for more very expensive hospital beds. In fact, all of the recommendations of this budget, including the maintenance and enhancement packages, will reduce the use of hospital beds and delay the need for expanding hospital resources in northern Nevada for years to come.
For too long, NNAMHS has been known as the State hospital or the institute. This is graphically displayed in Table II of the handout, which shows the relative expenditures for community and institutional programs from 1996 through the next biennium. With the FY 2004 and FY 2005 budgets, NNAMHS truly becomes a regional mental health center with a complete array of community and outpatient services.
The Dini-Townsend facility has been a great success while remaining an integral component of the service array. The hospital will be used to support the community programs only when clients need acute care and stabilization. The focus will be on maintaining clients in community-based settings free of the restrictions and stigma of institutional care. These decision units address the community-treatment issues raised in the Olmstead decision, which is outlined in Table III.
M-101 Inflation & Per Unit Adjustments – Page MHDS-9
This maintenance package provides funding for pharmacy cost inflation. The inflation factor for pharmacy is based on projections by the Center for Medicare and Medicaid (CMM). The rate is estimated at approximately 15 percent annually for the coming biennium. We are asking for medical inflation increases over FY 2002 in funding of 26.7 percent in FY 2004 and 41.6 percent in FY 2005.
Senator Rawson:
Does this funding increase address both pharmaceutical inflation and the increased caseload?
Dr. Cook:
M-101 addresses only inflation. Increased caseload is addressed in M-200.
Senator Rawson:
You indicated you have estimates of a 15-percent inflation rate, but we are raising the funding increase over 20 percent.
Dr. Cook:
It is 15 percent per year of the biennium, but we are annualizing that over the FY 2002 budget. Therefore, in FY 2004 we have a compounded interest of 26.7 percent, which is 2-years worth of inflation, and in FY 2005, we have 3‑years worth of inflation.
Senator Rawson:
I have had inquiries about possible restrictions in the formulary and a limitation on the use of some of the more modern psychiatric drugs. These drugs are more expensive, but I understand they are more effective. Have restrictions been made on these drugs?
Dr. Ira Pauly, Medical Director, Northern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources:
We have had considerable discussion about a change in the formulary, and we have a program that will address the problem to the satisfaction of the psychiatrists who work there. We call the program a decision matrix in which we are recommending to the doctors that they use the less expensive new medications first to see whether they will be suitable. Our psychiatrists have been cooperative and feel they can maintain their standard of care.
Senator Rawson:
Are there restrictions that would prevent the doctors from using a different and perhaps more expensive drug?
Dr. Pauly:
We are using the new medications, but we are simply starting with effective ones that are less expensive. This procedure seems to be working, and in the last few months since we have initiated this program we have begun to see a reduction in the monthly pharmacy cost.
Senator Rawson:
We will have our staff go over the inflation figures with you just to make sure we are in agreement.
Dr. Cook:
We also have an active and growing program to get sample medications and assistance from the indigent drug program, which saves us a considerable amount of money.
M-200 Demographics/Caseload Changes – Page MHDS-10
This maintenance package funds demographic growth for FY 2004 and FY 2005 in the medication clinic. We are also requesting 1 FTE psychiatrist and 1.5 FTE advanced practice nurses to handle the increased caseload. Advanced practice nurses have advanced training in psychiatry, and under the supervision of a psychiatrist, can prescribe medication and do psychiatric assessments. The advantage of hiring advanced practice nurses is they are less costly than psychiatrists.
In addition to the prescribing staff, we are requesting 3.5 FTE psychiatric nurses for the medication clinic to do nursing assessments, treatment planning, review, treatment consents, releases, and patient education.
Senator Rawson:
How have you been able to serve the additional medication clinic patients during the existing biennium in light of cuts and without additional staffing?
Dr. Cook:
In part, we have been able to stretch our services. We have extended waiting times for new clients from 8 to 10 weeks. Ongoing clients have the time between their regularly scheduled appointments lengthened, so we are not seeing them as frequently. We have not been able to maintain an adequate level of service.
Senator Rawson:
Do you have estimates on what your waiting list will be if this budget is approved?
Dr. Cook:
If this budget is approved, we anticipate we would see new clients within 2 weeks of admission, and the ongoing patients would be served within the parameters determined by their physicians.
M-201 Demographics/Caseload Changes – Page MHDS-10
This unit requests five additional Supportive Living Arrangements (SLA) for the biennium to handle demographic growth. We currently provide residential support for more than 130 individuals. Homelessness is a major problem for the mentally ill. In the absence of this funding, we would have more people homeless, in jail, or in hospitals. This decision unit is also integral to our Olmstead efforts to provide non-institutional care for our clients.
M-203 Demographics/Caseload Changes – Page MHDS-11
This maintenance package funds the demographic growth for FY 2004 and FY 2005 in outpatient counseling. The graph in Table V of the handout dramatically shows caseload growth in this program. We have been trying to deal with the increase by going from individual therapy to more group therapy, but that approach has its limitations. We are requesting two FTE mental health counselor IV positions that will be post-doctoral psychology interns.
Psychologists are also crucial to the Family Psychoeducation Program (FPP). In January 2002 Ms. Rosetta Johnson, through her non-profit organization Human Potential Development, Inc., funded a $10,000 training grant program for agency staff, which allowed us to implement this nationally recognized evidence-based program. It is the only program of its kind in the State, and it is extremely effective in assisting families to deal with the consequences of their family member’s mental illness and to reduce the rate of hospital use. Psychologists are a crucial component of this program. To date, 47 families with their mentally ill loved ones are participating in the program. Agency staff volunteered to implement this program and are maintaining the program in addition to their other duties.
M-300 Fringe Benefit Changes – Page MHDS-11
This decision unit provides for the increased cost of fringe benefits, primarily employee health insurance.
M-303 Occupational Studies – Page MHDS-11
This decision unit recommends funding totaling $9694 in the FY 2003‑05 biennium. The funds will be used to support reclassification of two employment counselor positions to vocational rehabilitation trainers as a result of a Department of Personnel occupational study.
E-350 Service At Level Closest To People – Page MHDS-12
This decision unit includes a 7-percent provider rate increase for FY 2004, and an additional 8-percent rate increase for FY 2005.
E-351 Service At Level Closest To People – Page MHDS-12
The Governor recommends funding to support the Washoe County mental health court. While the 2001 Legislature authorized the mental health court no resources were allocated for operation. Judge Breen and Assemblywoman Leslie created this first mental health court in the State on their own time with no dedicated resources.
Utilizing existing resources, NNAMHS has provided clinical services to court clients and contracts with Project Restart, a private provider, for intensive case management services for a few mental health court clients. To date, the court has served 41 clients of whom 32 are still being served. The preliminary data, presented to the Legislature by Dr. Brandenburg, indicates the court is proving effective in de-institutionalizing people.
Senator Rawson:
Is 45 additional clients a realistic number?
Dr. Cook:
We based the figure on the anticipated ability of the court to provide services. If we did not contract for all 45 clients, we would not spend the entire funding. The contract is tiered so we would encumber approximately one-third of the contract for up to 15 clients, and two-thirds of the contract for the next 15.
Senator Rawson:
Have you developed performance indicators for this program?
Dr. Cook:
We are in the process of developing the performance indicators. We look at the recidivism rate, new incarceration time, hospital time, and participation in outpatient services.
Senator Rawson:
The mental health court will represent a tremendous savings to the State. Those performance indicators can be very helpful to you, and I suggest you move ahead developing them.
E-600 Budget Reductions – Page MHDS-13
Dr. Cook:
We cut five FTE positions from the program. The Residential Treatment Program (RTP) funding cut in FY 2003 is recommended for restoration in FY 2004 and FY 2005. However, the Governor is recommending we use the funds for 15 SLA instead of an 8-bed RTP. The SLA program has better outcomes and offers more flexibility than the RTP. In addition, we will have 15 SLA of varying intensity at a lesser cost than the 8 RTP.
E-710 Replacement Equipment – Page MHDS-14
Senator Rawson:
Is this where I saw the 44 desktop computers scheduled for replacement? We are not questioning the need for the funding if the equipment is failing. We just want to make sure there is no duplication with the AIMS.
Dr. Cook:
There is no duplication. These are computers on a 5-year replacement schedule.
Dr. Cook:
We have many staff who do not have computers and the new system will require more staff to be online.
E-805 Major Reclassifications – Page MHDS-15
Since the State has had difficulty hiring and retaining pharmacists, the Department of Personnel is recommending a salary increase based on an in‑State salary survey they completed. The request is that pharmacists I, II and III be moved to the classified medical pay schedule. We will be able to increase the salaries and complete more frequent reviews. Pharmacists are an essential component of our service.
Senator Rawson:
This reclassification would give authority to make some substantial changes in salary. We need the assurance that these up-grades will be made at a reasonable level and not at the maximum authority.
Dr. Brandenburg:
We will be more than happy to work with Mr. Chapman on those up-grades, and we should be able to have the exact numbers available before the end of the session.
HR, Facility for the Mental Offender – Budget Page MHDS-18 (Volume 2)
Budget Account 101-3645
Elizabeth Neighbors, Ph.D., Director, Lakes Crossing Center, Division of Mental Health and Developmental Services, Department of Human Resources:
I am distributing to the committee a “Budget Overview” (Exhibit G). The Lakes Crossing Center facility provides statewide forensic mental health services in a secure facility to mentally disordered offenders. They are referred from the court system so their competency can be restored, and are re-referred back to the court system to stand trial.
These offenders require a high level of treatment. We also have individuals referred to us strictly for evaluation from the rural counties. If they are found to be incompetent, we treat them prior to sending them back to the court of their original venue.
In addition to our inpatient program, we have also developed an outpatient program of considerable size. The graph on page 2 of the handout shows the three services we provide. Our inpatient services have remained relatively flat. Our outpatient jail services represent our evaluation program, and those services have dramatically increased. We are operating this program in an effort to meet national and community standards to provide treatment in the least restrictive environment.
We recognize not all individuals who are in the criminal justice system need to be incarcerated in a maximum facility. We have increased our outpatient evaluations for the rural counties, but we have maintained our population under the 48 individuals cap. Consequently, we are not requesting any additional beds.
Currently, Lakes Crossing Center has a staff of 75, reduced from 80 positions. The five positions provided mental health services to the Clark County Detention Center and Las Vegas city jails. Services to these facilities were terminated in October 2002 as part of the 3-percent budget reductions. In the absence of these five positions, the local entities have enlisted the services of the University and Community College System of Nevada (UCCSN) Medical School.
I refer you to the handout entitled “Current Service Programs Provided By Lakes Crossing Center” (Exhibit H).
M-100 Inflation & Per Unit Adjustments – Page MHDS-19
The budget division calculated the inflation costs in this maintenance unit.
M-101 Inflation – Page MHDS-19
This maintenance package includes an inflation factor for pharmacy costs based on projections by the Center for Medicare and Medicaid office of the actuary.
M-300 – Fringe Benefit Changes – Page MHDS-20
This decision unit represents fringe benefit changes in health insurance for employees.
E-279 Working Environment & Wage – Page MHDS-20
The agency is requesting a 0.25 FTE psychologist along with the transfer of a 0.75 position from B/A 101-3168 decision unit E-903 for transfer. This full-time psychologist’s position will serve on the sex offender panel. The panels have increased in numbers and the Department of Corrections is requesting a single evaluator be assigned to all panels. Preparation time will also increase due to the increased number of cases.
E-280 Working Environment & Wage – Page MHDS-21
The 2002 needs assessment of the Division of Mental Health and Developmental Services cites additional and ongoing training funds are needed for professional staff in assessing and treating sex offenders. Funds are needed for the training of the professional staff in the use of assessment tools for determining competency, and the potential for attaining competency. This training would also be a retention benefit, especially for nurses and the forensic specialists. Few of the new staff hired have specialized training in providing forensic services.
Lakes Crossing Center has implemented a study to develop methods for reducing the incidence of seclusion and restraint. This effort will require significant training for all staff in evidence-based practices for dealing with difficult clients. The training has been discussed with consultants at the UNR. Funds are needed to provide materials for the staff and costs for trainers from outside the institution. Our forensic specialists are all trained as peace officers III and mental health technicians. State law mandates this training.
Senator Rawson:
Who will do the training?
Dr. Neighbors:
We have been dialoguing with UNR about their Dialectic and Behavioral Therapy Program. There is a forensic unit in Colorado that uses this particular program, and they have found it very successful in their reduction of seclusion and restraint.
Senator Rawson:
Will you be able to complete this training with the funding you have available?
Dr. Neighbors:
Yes.
Senator Rawson:
Have you decided on the program you are going to use?
Dr. Neighbors:
We have not chosen the program, but we have a staff committee investigating training sources.
E-281 Psychiatric Residency Program – Page MHDS-21
This decision unit requests the formalization of the Psychiatric Resident Program at our facility. Within our existing funds under the cap, we were able to develop a contract with the UNR Medical School for a Psychiatric Resident Program. In the course of their training, the residents provide help to the full‑time psychiatrist. They also will provide coverage with the assistance of back-up doctors from NNAMHS during leave periods for the agency psychiatrist.
Senator Rawson:
Is this a different training program than the one we were talking about cutting from the NNAMHS?
Dr. Neighbors:
Yes, it is. This program is from a different funding source. I have already discussed E-600 budget cuts we made to meet the 3-percent reduction requested by the Governor.
Senator Rawson:
You indicated you are giving service to the entire State. Is it correct that you have eliminated services to the Clark County Juvenile Detention Center and Las Vegas jails?
Dr. Neighbors:
Yes, that is correct.
Senator Rawson:
Are you seeing an increase in travel and assessments from southern Nevada as a result of the program elimination?
Dr. Neighbors:
No, travel and assessments are increasing. The services we provided there were quite different from our usual mission of doing competency assessments. We were providing actual treatment and crisis intervention. We still have a significant population from Las Vegas at our facility for competency assessment. We are still the only inpatient facility in the State. Probably 50 percent of our clients come from southern Nevada. We work with the courts in Las Vegas, and our staff goes to Las Vegas to testify for court hearings.
Senator Rawson:
This protective equipment request permits safe responses to combative and aggressive clients, and represents a small amount of funding. How are your officers protected now? How can they get help in a hurry?
Dr. Neighbors:
We have upgraded our alarm system, and we have a very sophisticated observation camera system. From anywhere in the facility, if an incidence begins to evolve, the staff has a sensor scan alarm that triggers a ceiling and control room alarm, which sends other staff immediately to the location.
Senator Rawson:
Do you still have a high injury rate compared to other State employees?
Dr. Neighbors:
I do not believe our injury rate is significantly higher. The protective equipment requested in E-720 is padding and shields that diminish the amount of contact between the staff and the client.
Senator Rawson:
I understand you have interns in association with UNR. Are we an accredited facility?
Dr. Neighbors:
The facility is not accredited. We have been looking at acquiring accreditation, but since it is an elective course, accreditation is not mandatory. The interns’ core courses have to be completed at accredited institutions.
Dr. Brandenburg:
I have directed all our agencies to seek and secure national accreditation. We are hoping to get JCAHO accreditation at the Southern Nevada Adult Mental Health Services (SNAMHS) by January. Since the Lakes Crossing Center is a forensic facility, it is a hybrid, and accreditation is difficult to obtain. We are exploring three options. We know it is extremely important for us to meet national standards, and obtaining accreditation has a high priority.
Dr. Neighbors:
Over the last 6 months the Lakes Crossing Center has been fully staffed with nurses that will allow us to go forward with acquiring accreditation there.
HR, Rural Clinics – Budget Page MHDS-25 (Volume 2)
Budget Account 101-3648
Larry Buel, Ph.D., Agency Director, Rural Clinics, Division of Mental Health and Developmental Services, Department of Human Resources:
I have distributed a handout to you entitled Rural Clinics Community Health Center (Exhibit I. Original is on file in the Research Library.). It gives specific details about the allocation of staff positions.
Senator Rawson:
Is this funding request sufficient to cover costs? Each year we have a shortfall requiring a supplemental appropriation. What can we do to create a more stable and predictable funding for this budget?
Dr. Buel:
Your questions focus on the heart of the issues in rural mental health. We usually have a high vacancy rate of clinical physicians. We have calculated that each clinical position brings in about $40,000 annually in revenue. The vacancy factor accounts for the $400,000 shortfall last year.
Senator Rawson:
Is the vacancy created because you cannot find qualified personnel to hire?
Dr. Buel:
Under the Recruitment section of Exhibit I you will see that in FY 2002 we interviewed 100 prospective candidates and only hired 25. In FY 2003 we have conducted 63 interviews and hired 15. The most difficult to fill positions are licensed clinical social workers (LCSW) because of short supply and under payment. We have worked to reclassify several clinical social workers (CSW) II positions to mental health counselor (MHC) II positions, which would permit us to recruit not only social workers, but also marriage and family therapists for these openings.
Senator Rawson:
We want you to recruit the appropriate personnel. What communities in particular have a shortage of personnel or difficulty in recruitment?
Dr. Buel:
We are fairly selective in our recruitment efforts. We do not fill positions just because someone appears to have the necessary credentials. Elko, Ely, and Pahrump represent chronic recruitment problems. We have offered prospective employees interview expenses and moving expenses up to a certain percentage.
Senator Rawson:
Do you perceive the problem exists because of the isolation of the area, or is it salary scale?
Dr. Buel:
I believe it is a combination. There should be a rural differential pay scale.
Senator Rawson:
Elko has the Great Basin College, and you could explore joint faculty positions. Ely participates in some distance learning, but recruitment there might be more difficult. Pahrump is becoming a bedroom community for Las Vegas, and it should become increasingly less difficult to recruit there. If you can see some approaches we can take to help you solve these problems, we welcome your comments. We need to find resolution rather than let the problems continue to fester from year to year.
Dr. Brandenburg:
Difficult recruitment and retention of staff in rural frontier population areas is a national phenomenon.
On a national level recommendations are being made to increase stipends to encourage people to work in rural areas. We are currently working with the Western Interstate Commission for Higher Education (WICHE) to see if we can develop a system to recruit social workers with a salary stipend. It is a long‑term process that we just started 2 years ago, and it will probably take another 4 or 5 years before we see any results.
Senator Rawson:
Would you prepare a report for us on how much a rural stipend would be, and what would be the budget implications?
Dr. Buel:
Yes. We have a group working on rural recruitment, which includes WICHE, people from personnel, the Legislative Counsel Bureau, the Department of Human Resources, and the UCCSN to attempt to find long-term solutions.
Senator Rawson:
Let us know when you are meeting and we will have some staff there.
Dr. Buel:
The mission to provide rural mental health clinics in Nevada appears to be pedestrian until you consider we are trying to cover 100,000 sparsely populated square miles. We serve persons of all age groups, with young people representing 25 to 30 percent of our caseload. While vacancies seem to be prominent, many of our contractor providers and staff have been with us for over 20 years. These people are very dedicated to the rural mission.
The services we provide are listed under the Introduction of the handout. We have a rural Nevada emergency services program. Emergency service is provided 24-hours a day, 7 days a week by clinicians and nursing staff who work the regular 40-hour week. One person in each of the nine main areas carries a pager or cell phone and responds to emergency calls as they come in. The emergency service accounts for an additional 1900 hours annual workload that has been hidden in the budget for some time. The map in this section shows the geographical spread of our offices.
In FY 2002 and FY 2003, the Legislature funded an additional 11.5 clinical FTE positions. All but two of those positions have been filled. One opening is a three-quarter-time position in South Lake Tahoe. The other two vacancies are a quarter-time nurse in Lyon County and a full-time service coordinator. Both positions were frozen until January 2003, so we are currently unable to recruit for these positions.
Senator Rawson:
Would you provide a list of the locales with the heaviest caseloads and patient waiting lists?
It looks like we might have a double-up issue on E-358. We had some contract revision negotiations, and $47,000 was added to the budget to reflect the increases. This budget appears have a total amount that may include this appropriation. We are not talking about cutting the amount if it is accurate, but if there is a mechanical problem we want staff to address it.
Dr. Buel:
I encourage you to look at the attached tables in the handout that indicate where new positions will be assigned in M-200 and E-356. Our medication budget for the rural clinics is meager. You will note in each county for FY 2001 and FY 2002 donated medications are valued at $500,000 to $600,000 annually.
Senator Rawson:
Who donates these medications?
Dr. Buel:
The medications are donated by a variety of pharmaceutical companies throughout the nation.
Senator Rawson:
Would it be beneficial if unused blister pack medications were donated from our nursing homes? The packaging assures the sterility of the medications.
Dr. Buel:
I defer the answer to that question to Dr. Rosin.
Dr. David A. Rosin, Medical Director, Southern Nevada Adult Mental Health Services, Division of Mental Health and Developmental Services, Department of Human Resources:
The pharmacy services we provide for the rural clinics are mailed from NNAMHS and SNAMHS. We would have to develop a new protocol to accept medications from nursing homes. Our proposed new system would have the capacity to track items like expiration dates and recalls. Until we get this new system in place the tracking must be done manually, which is very time‑consuming.
Senator Rawson:
We would require an opinion whether actual savings could be generated using medications from nursing homes.
Dr. Buel:
I would like to direct your attention to Table 7C in the handout. It shows the existing positions in our agency. The existing allocation of clinical positions results in significant imbalances in the ratio of clinician to population. Our allocation of new positions is designed to improve parity across the counties. The new position allocation I am recommending greatly diminishes those discrepancies.
Dr. Brandenburg:
I have distributed a handout entitled “Facts About The New State Psychiatric Hospital in the Las Vegas Valley”(Exhibit J). This new hospital is the Governor’s priority Capital Improvement Project (CIP). Nevada has fewer psychiatric beds per capita than the surrounding states. In 2001, the national per capita average of public mental health funding for inpatient psychiatric hospitals was $25.62. Nevada ranked forty-third with a per capita spending for inpatient psychiatric hospitals of only $15.49.
The number of psychiatric patients is overwhelming the emergency rooms in Las Vegas Valley. The patients are being held for extended times in emergency room facilities because there are insufficient psychiatric emergency beds and psychiatric acute care beds at SNAMHS. This decreases the ability of the emergency rooms to handle life-threatening acute trauma cases and medical emergencies like heart attacks.
For the past 6 months there has been a daily average of 14.3 seriously mentally ill patients in the Clark County emergency rooms on legal hold. Today 35 individuals are waiting in the emergency rooms to be transferred to the hospital at SNAMHS.
Senator Rawson:
We are talking about a 48-hour stay at the hospital with no change in treatment. This waiting period places the family in absolute turmoil.
Dr. Brandenburg:
That is the issue currently in the greater Las Vegas valley.
Senator Cegavske:
How many people on the waiting lists have insurance or sources of payment? Do we make referrals to outside providers?
Dr. Brandenburg:
The emergency rooms are very conscientious about triaging those people who have third party payments. Most of the people who are waiting have no form of insurance or means to pay. Medicaid patients go to Monte Vista or East Lake Mead hospital.
The total number of available psychiatric beds in the private community has dropped dramatically since 2000. Ninety private beds have been lost in Las Vegas. Currently, there are only 58 acute private adult psychiatric beds and 12 geriatric beds in Clark County. There has been a drop of 44 percent in available private adult psychiatric beds.
As the number of private psychiatric beds decreases, tremendous pressure is placed on the public system to try to absorb the patients. We also have an extreme shortage of public psychiatric beds. The national Center for Mental Health Services (CMHS) has determined the national average of state hospital psychiatric beds is 33 per 100,000 population. We have 4.5 psychiatric beds per 100,000 in Nevada. We actually need 511 beds to come up to the national average. This new hospital will only provide 150 beds, which is 47 more than what we have available this biennium.
The current hospital has operated at capacity for many years and is incapable of meeting the demands for acute psychiatric care in the Las Vegas valley with the continued major population growth.
Since FY 2000, bed utilization at SNAMHS has averaged 96 percent. The average length of stay is approximately 17.7 days. Over the same time period, hospital inpatient admissions have dramatically increased. The staff has been trying to keep up with the additional mentally ill population by trying to bring in more help, and trying to stabilize the patients in a shorter length of stay.
SNAMHS has a strong, continuing commitment to fund community-based services over the next biennium. Seventy percent of the funds allocated will go to community programs, and 30 percent will go to the hospital. We are trying to be very sensitive and conscious of providing treatment in the least restrictive environment.
HR, Southern Nevada Adult Mental Health Services – Budget Page MHDS-34 (Volume 2) Budget Account 101-3161
Jonna Triggs, Ed.D., Agency Director, Southern Nevada Adult Mental Health Services, Division on Mental Health and Developmental Services, Department of Human Resources:
Many of the issues I planned on covering in my introduction have already been discussed. I refer you to my complete testimony (Exhibit K).
M-100 Inflation – Budget Page MHDS-35
This decision unit is an inflation package for insurance and technology.
M-101 Inflation & Per Unit Adjustments – Budget Page MHDS-36
This maintenance package includes an inflation factor for pharmacy cost based on projections by the CMM office of the actuary.
I refer you to my handout entitled “Legislative Handouts” (Exhibit L Original is on file in the Research Library.). I have included comparable national health expenditure amounts in this handout.
M-200 Demographics/Caseload Changes – Budget Page MHDS-36
This request will add positions to provide essential services to the rapidly increasing caseloads at the medication clinics at all four sites. The division utilizes linear regression in determining the caseload growth through its Caseload Evaluation Organization (CLEO). Our waiting list is shown on page 7. We have added about 1000 patients during this last fiscal year to our medications clinics. We have requested no additional doctors or other resources to service this increased caseload.
Senator Rawson:
What was the time period you gave?
Dr. Triggs:
The time period was over the past year. All our medication clinics are currently scheduled through May. Without funding for projected consumer growth, clients with serious mental illnesses will experience even longer delays in seeing psychiatrists and nurses. They will also represent an increased risk of decompensation for suicide attempts and high-cost hospitalization. Right now the average wait time in any of four medication clinics is 3 months. This is substandard health care.
Our budgets are built on a standard ratio of medication clinic psychiatrists to patients, which is now 1 to 345. Our current caseload of 6674 patients divided by our current number of psychiatrists and one advanced practice nurse results in a doctor/patient ratio of 1 to 808. Each psychiatrist in our medication clinic carries 46 SMI patients over accepted community standards.
In the next 2 years, CLEO projections predict an increase of 412 clients in FY 2003-04, and 411 in FY 2004-05. This package will provide for an addition of 8.6 FTE positions including 2 senior psychiatrists, 4 psychiatric nurses, 1.6 administrative assistants, and I pharmacy technician.
M-201 Demographics/Caseload Changes – Page MHDS-37
This decision unit uses CLEO data, which projects an increase in caseload for residential services of 91 clients, phased in over the FY 2003-05 biennium. Supported housing services are focused on the indigent seriously mentally ill. Priority is given to the psychiatric patients recently discharged from the inpatient psychiatric hospital. Placements are determined by patient need, with the goal of achieving maximum client independence.
Residential programs currently serve 584 clients. The current waiting list for residential programs is 55. This wait list does not include those individuals who are already in more restrictive care, like group homes, who are waiting for transfer to a less restrictive placement, like a Supportive Living Arrangement (SLA). This list is maintained internally and currently stands at 20.
This decision unit requests a 0.5 FTE administrative assistant I in FY 2004 and a 0.5 FTE in FY 2005. We also are requesting 1 FTE accounting assistant III to augment billing, receivables, and client check processing.
M-204 Demographics/Caseload Changes – Page MHDS-37
Psychiatric emergency services (PES) consist of two separate components: psychiatric ambulatory services (PAS) and psychiatric observation unit (POU). PAS is a 24-hour emergency walk-in center for clients in psychiatric crisis. POU is a 72-hour observation unit for clients needing short-term observation, stabilization, and treatment in a secure environment. Both of these services meet the intent of the Olmstead decision by maintaining clients in the least restrictive environment. In this fiscal year to date, POU has averaged 24.7 patients per day in 20 beds, which gives an average length of stay of 22.5 hours each.
The needs of the clients requiring emergency walk-in psychiatric services are no longer being adequately met by the current staffing. Of concern is the number of seriously mentally ill individuals who leave without being seen because of staffing shortages. Each client who leaves without an evaluation and treatment poses an increased risk of self-harm as well as an increased risk to community safety.
According to CLEO projections, the number of clients seen in the PAS clinic will increase from 9398 at the beginning of FY 2004 to 11,534 over the course of the biennium. This will increase the need for both psychiatric observation beds and hospital beds at a significantly higher cost. Nationally our State ranks second in per capita suicides. This request is for a 0.5 FTE psychologist and a 0.5 FTE registered nurse II, and 2 FTE administrative assistants in the first year of the biennium. The second part of the biennium will add 0.5 FTE psychologist and a 0.5 FTE registered nurse II.
M-205 Demographics/Caseload Changes – Page MHDS-38
The projected growth of clients in residential support programs has a direct impact on service coordination. Every client in a transitional living arrangement must have a service coordinator. Service Coordination is an outpatient program that assists individuals in procuring services necessary to live independently in the community. Services include needs assessment, referrals to other programs, monitoring of medications, and other support services as necessary.
The current caseload ratio is 35 clients per service coordinator. Using CLEO, the projected growth of 91 clients in FY 2004 and another 91 clients in FY 2005 will require 5 additional service coordinators. Two administrative assistant II positions were eliminated from the agency request in place of eliminating positions vacant for more than 6 months.
E-451 Reward Self-Sufficiency – Page MHDSA-39
This request will provide staffing to increase the number of psychiatric beds available in the POU from 10 to 16. This increase in POU beds has been necessitated by the enormous growth experience in Clark County. This has resulted in overcrowding of local hospital emergency rooms with psychiatric patients awaiting admission into the SNAMHS POU. Bed capacity was increased in May 2002 from 10 to 20 beds with no additional staff. Positions were temporarily transferred from the hospital to meet staffing requirements in the POU.
The direct result was that 17-inpatient hospital beds had to be temporarily closed. This package requests two consumer service assistants who would perform consumer surveys, schedule and verify appointments, confirm follow-up appointment attendance, and maintain and continue assessments of clients’ stability in the community.
Senator Rawson:
Last year the emergency room of the University Medical Center (UMC), our highest level trauma center, was gridlocked trying to deal with chronic inebriates and mental health patients.
Dr. Triggs:
You are absolutely right. When we were putting this budget together, I received a call that UMC had 15 patients and 7 ambulances in the driveway waiting to unload.
Senator Rawson:
Private ambulance companies are paying their staff for 2 additional ambulance waiting hours because there are not enough nurses in the hospital to admit the new patients.
Dr. Triggs:
A temporary expansion of beds was attempted, increasing POU from 10 to 20 beds, while temporarily decreasing the capacity of the inpatient hospital from 68 to 60. This procedure was in place from May to September when the inpatient hospital beds returned to 68. The staffing ratio for the POU is one staff to three clients. The staffing ratio of the inpatient hospital is one staff to five clients.
The differences in staff ratio are attributable to the difference in patient acuity. The SMI individuals admitted to the POU are in acute distress, usually highly agitated, dangerous, and suicidal. In order to guarantee their safety, they are put on one-to-one supervision or at a minimum 15-minute watch. In order to serve 20 patients in POU, the total direct care staff should be 34.65, but we have been operating with only 27. We have seen an increase in staff injury and an increase in the use of seclusion and restraint. After 72 hours in the POU, patients are more stable than they were on admission, and no longer in need of the extremely close supervision initially required. Thus, the lower staff to patient ratio in the inpatient hospital.
In order to adequately care for 68 patients in the inpatient unit, the direct care staff should total 72.6, but it is currently at 69. This staffing request would permit a return to the staffing ratio of 1 to 3 per POU, and increase bed capacity to the licensed maximum of 26. We could return “borrowed” hospital staff to enhance the POU staffing to the inpatient hospital unit, and reinstate its 77 bed availability. This decision unit requests 15.5 FTE positions.
M-453 Reward Self-Sufficiency – Page MHDS-40
This decision unit recommends expansion of the Program for Assertive Community Training (PACT). The PACT team needs to be increased to serve 23 individuals who are on a wait list, and potentially serve some of the 2600 individuals who have been identified by a University of Nevada, Las Vegas (UNLV) study as being homeless, and 260 homeless individuals released annually from the Clark County Detention Center. I have distributed a handout entitled “Homeless Outreach Pilot Evaluation (HOPE) Interim Report” (Exhibit M. Original is on file in the Research Library.). It will provide you with more comprehensive information on HOPE and the homeless problem in Clark County.
Senator Rawson:
This decision unit request would allow you to serve an additional 72 clients.
What is needed for this program?
Dr. Triggs:
I have met with city and county officials. If the PACT is approved, we would like to place it right in the homeless corridor locating them at the Crisis Intervention Center (CIC). The team would work with the 2600 severely mentally ill who are homeless to try to keep them out of the jails and hospitals.
E-458 Reward Self Sufficiency – Page MHDS-41
The request would create a mobile crisis team to provide services to mentally ill clients in the emergency rooms 24 hours a day. The demand for psychiatric evaluation, screening, and intervention in local emergency rooms has outstripped current available resources. This service would allow for rapid triage of mentally ill clients in the emergency rooms. A total of 5.6 FTE clinical social work positions are needed to provide necessary coverage.
Senator Rawson:
It looks like we need as many as 15 FTE positions to staff the mobile crisis team round-the-clock. Will the team be available 24 hours a day?
Dr. Triggs:
It will be, because the 5.6 social workers will be at our crisis unit for psychiatric emergency services. We will always have one social worker available.
E-600 Budget Reductions – Page MHDS-41
As part of the 3-percent budget cuts, the “Bruce Adams Residential Treatment” program was eliminated. This was a 10-bed step-down program for clients discharged from our inpatient unit. In addition to the residential treatment program, the overtime budget is reduced by $40,000. In place of restoring the 10-bed step-down program, this package includes a less costly and more effective residential solution. The request is for funding the phase-in of 10 SLA and 6 Intensive Supportive Living Arrangements (ISLA). This unit would restore 62 percent of the funding in FY 2004 and 76 percent in FY 2005. We would, then, serve 16 clients over 2 years with more flexibility in placement.
E-710 Replacement Equipment – Page MHDS-42
We have stripped this request to the “bare bones.” Items include office equipment, computer hardware and software, furniture, vacuum, wheelchair, and other equipment needs for the inpatient hospital such as bed frames, curtains, and janitorial cart.
E-711 Replacement Equipment – Page MHDS 42
This decision unit provides funding for replacement equipment included in the FY 2002-2003 equipment budgets, but reverted for the 3-percent cuts. Items include refrigerators, office equipment, chairs, furniture, and vacuums.
Senator Rawson:
In E-720, the request is for 10 desktop computers, but the Avatar program has 40 desktop computers designated for SNAMHS. We want to make sure there is no duplication. Eighty to ninety percent of these position increases come out of the General Fund. Is there any device we can use to gain some matching funds?
Dr. Brandenburg:
We have explored that issue, and we have tried to build our budgets based on third-party funding and Medicaid. What historically happens to us is a lot of the Medicaid patients who come to us have already exhausted their Medicaid benefits. In an attempt to draw down the federal dollars, the division has been very conscious of the General Fund, and we are willing to sit down with staff to review the figures.
Senator Rawson:
It appears that 40 new beds will not be funded. We have to look at what point we will pick those up, and what will be the funding base for them. These may be technical issues, but we want the planning in place.
Dr. Brandenburg:
As you know, it will probably take us this entire biennium to build the hospital.
Senator Rawson:
I think it will take us two bienniums to build the hospital.
Dr. Brandenburg:
I hope not. One of the things we were able to do with the Dini-Townsend facility was build it in 13 months as opposed to 24 months.
Senator Rawson:
Did you build that facility through the Department of Public Works?
Dr. Brandenburg:
Yes, we did. We want to use the same architectural plans and the same design. We are confident that public works will work with us on this hospital.
Senator Cegavske:
I had a meeting with some concerned citizens who live in the area where the new hospital is to be built. I was told they had never been contacted or told about having this facility in their community. I had a representative there to answer some of their questions, but the citizens’ main concern was that they were not informed until after the fact. We saw plans that had already been developed and drawn for the new hospital.
Dr. Brandenburg:
The plans you saw were the Dini-Townsend facility plans. We hoped to use the same plans to cut down on construction time. I do not know what public works procedures are in terms of neighborhood notification. I would be more than happy to go with you for another community meeting. We can assure the community that we are planning a very safe and secure facility. It will be a locked facility.
Senator Cegavske:
Is the new facility located in a residential area?
Dr. Brandenburg:
A residential area is on one side and a commercial area is on the other. We have been very sensitive to this issue, and I can guarantee you it will be a very safe hospital. If you would like to tour the Dini-Townsend facility, I will make the arrangements. The design itself is state-of-the-art community-friendly, not institutional. I believe I can relieve some of the community’s concerns by meeting with them.
Senator Rawson:
According to our budget documents, your authority to spend the $30 million on the hospital is in FY 2006. If you are planning on fast-tracking the facility, we are going to have to deal with that. It does not look like you will have the spending authority until then. The bonds could be all sold at once, but the funding does not track the budget until 2006.
Assemblyman Goldwater:
Assemblywoman Gibbons and myself, and the members on the taxation committee, want to commend you on your efforts to present this “bare-bones” budget. We are impressed that you can do so much with so little.
Senator Rawson:
We will reschedule the developmental-services issue so we can take public testimony at this time. We will rotate between Carson City and Las Vegas for those people who wish to testify.
Rosetta Johnson, President/CEO, Human Potential Development, Inc:
I support the mental health budget (Exhibit N). Governor Guinn recognizes our mental health needs, and, as a conscientious leader, has given us a budget which contains essential elements, such as newer medications, housing, and especially for Las Vegas, the PACT and new hospital, which are critical to the safety and recovery of the SMI citizen.
My organization has developed two community programs. Family Psychoeducation Program (FPP) trained 18 staff members to form two teams to meet with patients and family members and staff to discuss ways to work together for the patient’s recovery.
Systems Integration for the Seriously Mentally Ill (SISMI), our other program, is organized to address fragmentation, duplication, and gaps in mental health services. SISMI goals require five essential activities reaching across multiple systems: sharing of information, sharing of planning, sharing of clients, sharing of resources, and sharing of responsibilities.
For the record, we have a statement from the Nevada Disability Advocacy and Law Center by James. J. Vilt (Exhibit O).
Dr. Dale Carrison, Chairman, Director of Emergency Medicine, University Medical Center, Las Vegas:
If we passed this budget today we would have a crisis for the next 2 years. At a recent meeting with the Medical Advisory Board, which controls the emergency medical services for Clark County, we had to set up a mental health divert system. We also had to set up a drop-off time for ambulances in which time they will simply leave patients in the emergency department. We have one-quarter to one-third of our emergency beds being tied up by mentally ill patients. They languish in our emergency departments because the SNAMHS has neither the resources nor the facilities to be able to handle the number of mentally ill people we are seeing. These are men and women who need help and are in crisis.
This situation also seriously impacts the 911 emergency call system. You may have constituents, family members, or friends call 911. They may find an ambulance is not available because they are waiting in the Las Vegas valley’s emergency departments’ driveways. Nurses are not available to staff patients left in hallways.
What SNAMHS did not mention is the fact that when these people show up with an acute psychiatric problem they are not directly admitted to the hospital. They are sent to the local emergency departments for medical clearance. Then, they remain in our emergency department until a bed opens up in the crisis unit. The problems created by lack of resources at SNAMHS affects all who live in this community because it has a direct impact on our emergency medical services.
Senator Rawson:
I understand we have gone from a 90-percent 12-minute response time to about a 24-minute wait for an ambulance.
For the record, we have a statement from Benito and Romelia Briones (Exhibit P).
Brent Tyler, Carson City:
I am the father of a schizophrenic son. I know you would like to hear something positive for a change. My son’s case is positive. He obtained his degree from UNR in public health and then developed schizophrenia. I know the tragedy parents feel. I have paid for seven hospital admissions and numerous medications for him. Although there is no cure for schizophrenia, my son has survived.
Today, he is 90-percent recovered. Treatment can and needs to be done. The new drugs made the difference for my son. Do not hesitate to fund for the new medications because even if they are not perfect, they really do make a difference. One out of every 14 people has a treatable mental disorder.
I have a statement from my son, Joseph Tyler, President of the National Alliance for the Mentally Ill of Northern Nevada, which I submit for the record (Exhibit Q).
Vic Davis, President, National Alliance for the Mentally Ill of Nevada, Las Vegas:
Our organization represents many family members and consumers (Exhibit R). I am encouraged as I listen to the hearing today. This is the first time I have heard the State admit there really is a problem. We desperately need the paperwork management system. In Las Vegas, files are manually carried between clinics, hospitals, and emergency rooms. The records never really catch up with the patient. After 90 days of patient absence, the paperwork is archived and the staff has to start the paperwork all over again when patients reappear.
The medicine funding needs to be reinstated. When a mentally ill individual is having a psychotic episode the brain is in trauma and it needs to be treated. These are the people who end up homeless and in jail when no treatment is forthcoming.
If you are mentally ill and you voluntarily go to the hospital, there is a high probability you will not be seen. It is the legal-hold patients that are being placed in the system. The people seeking voluntary admission continue to decompensate until they become an involuntary commitment themselves.
We need a great deal more concentration and funding in the after-care programs for the mentally ill. If continuing care and treatment are unavailable or marginal, suicide rates increase.
Next week, the Clark County and Las Vegas police will graduate their first class of 33 Crisis Intervention Team (CIT) members. This number will eventually increase to 300 patrolmen. These officers will be out in the community handling crisis calls for the mentally ill and diverting them away from the jails into the mental health system. The problem is there is no mental health system for these people to be diverted to.
Two bienniums ago, the Dini-Townsend facility in Reno became a reality and now it is focusing on outpatient services. In Las Vegas, even without the growth, we are still 2 bienniums behind. We are just starting to think about adding our hospital. We are pushing outpatient services farther and farther down the road. There has to be a complete cycle for the system to work. The solution is more resources.
Elena M. Brady, President, Asian-American Republican Club of Nevada, Carson City:
I am the mother of a wonderful son who has schizophrenia. I am here to urge your support of Governor Guinn’s proposed budget for mental health (Exhibit S).
Thanks to the mental health programs, my son was able to benefit in his struggle with the illness. I believe the programs saved my son’s life. He is now a consumer of the PACT. The PACT program has allowed me to have peace of mind, take care of the rest of my family, and have time to volunteer for community services. This program empowers my son to make his own decisions. It has shown him he has a lot of potential and can still be a productive member of society.
Patricia Martinelli-Price, Homeless Advocate, Las Vegas:
Taxes need to go up. I say shame on people who are selfish and do not want to fund programs when they, themselves, or their families could end up being mentally challenged. We need to come together as a community to fund these programs.
Rachel Paxton, Carson City:
Although I may appear to you to be a vibrant and healthy person, I am mentally ill (Exhibit T). I am a “poster girl” for tax dollars well-spent. As a direct result of the services I have received in northern Nevada mental health programs, I am once again a productive member of my community. I am a contributor to our tax base instead of continuing to be a lifelong tax drain. I ask you to save the citizens of our State a fortune in future costs from an ignored problem while helping to end the ongoing and continual victimization of the mentally ill.
Senator Rawson:
Time constraints have not permitted us to give everyone who wished to testify a chance to be heard. I request you submit your testimony for the record.
(Complete testimony of Rena M. Nora is attached as Exhibit U.)
(Complete testimony of Donna M. Shibovich is attached as Exhibit V.)
(Complete testimony of Rodney Smith is attached as Exhibit W.)
(Complete testimony of David P. Ward, Commissioner, Commission of Mental Health and Developmental Services, Department of Human Resources is attached as Exhibit X.)
(Complete testimony of Nancy H. Neill is attached as Exhibit Y.)
(Complete testimony of Doreen Begley, Nurse Executive, Nevada Hospital Association is attached as Exhibit Z.)
(Complete testimony of Victoria Campe is attached as Exhibit AA.)
Chairman Rawson adjourned the meeting at 10:57 a.m.
Judy Coolbaugh,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE:
APPROVED BY:
_____________________________________________
Assemblywoman Sheila Leslie, Chairman
DATE: _______________________________________