MINUTES OF THE JOINT SUBCOMMITTEE MEETING OF SENATE COMMITTEE ON FINANCE AND ASSEMBLY COMMITTEE ON WAYS AND MEANS Sixty-eighth Session February 24, 1995 The joint subcommittee meeting on Human Resources/K-12 of the Senate Committee on Finance and the Assembly Committee on Ways and Means was called to order by Chairman Raymond D. Rawson at 8:00 a.m., on Friday, February 24, 1995, in Room 352 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. SENATE COMMITTEE MEMBERS PRESENT: Senator Raymond D. Rawson, Chairman Senator William J. Raggio Senator Bob Coffin Senator Dean A. Rhoads ASSEMBLY COMMITTEE MEMBERS PRESENT: Mrs. Jan Evans, Co-Chairman Mrs. Vonne Chowning Mr. Joseph E. Dini, Jr. Ms. Sandra Tiffany Mr. Lynn Hettrick ASSEMBLY COMMITTEE MEMBERS ABSENT: Mr. Dennis L. Allard (Excused) STAFF MEMBERS PRESENT: Bob Guernsey, Principal Deputy Fiscal Analyst Gary Ghiggeri, Principal Deputy Fiscal Analyst Steve Abba, Program Analyst Marion Entrekin, Committee Secretary OTHERS PRESENT: Suzanne Ernst, Administrator, Aging Services Division, Department of Human Resources Bonnie Pillaro, Deputy Administrator, Aging Services Division, Department of Human Resources Charlotte Crawford, Acting Director, Department of Human Resources Carlos Brandenburg, Ph.D., Acting Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources Joseph L. Lamarca, Clinic Director, Southern Nevada Adult Mental Health Services, Mental Hygiene and Mental Retardation Division, Department of Human Resources Aging Services - Page 1259 Senior Services Program - Page 1267 Suzanne Ernst, Administrator, Aging Services Division, Department of Human Resources, distributed Exhibit C to the subcommittee members containing a series of graphs used for her testimony today. She said the mission of the Aging Services Division is to develop, coordinate and deliver support services to Nevada's senior citizens and assist the elderly population in maintaining their independence. Ms. Ernst stated there has been tremendous growth in the State of Nevada in the senior population, which includes individuals 60 years of age or older. She called attention to graph charts on pages 1 - 4 of Exhibit C, and said commencing in 1990, Nevada's senior population grew faster than in any other state in the union. Due to the rapid growth the state has experienced, the division has requested funding of an additional $140,000 to be used to provide senior services throughout the state. She explained 83 percent of the division's budget is from federal grants, and the funding formula used will transfer most of the federal revenue to Clark County where the majority of the senior population resides. Ms. Ernst said the division is interested in providing services to the state as a whole, and reviewed the bar graphs contained in Exhibit C to illustrate her point. As the Aging Services budget is discussed, Ms. Tiffany reminded Ms. Ernst to advise the committee of changes that have occurred at the federal level. Ms. Ernst stated the division was concerned because the United States (U.S.) Congress had considered placing federal funds used for the Nutrition Program into a block grant with the Food Stamp and School Lunch Programs. On February 13, 1995, the U. S. Congress ruled against the action since the Nutrition Program is the only service that has not been means tested, and many senior citizens close to the poverty level would no longer be eligible for services. According to a survey the division conducted, Ms. Ernst said 34 percent of Nevada's senior citizens would have been discontinued from services provided by the Nutrition Program. Ms. Tiffany asked if the division expects to be impacted in any manner during the current biennium. Ms. Ernst responded, "Anything can happen." Mrs. Evans stated the committee is pleased to hear the Nutrition Program appears to be secure for the present time, but asked for the division to continue monitoring federal activity involving senior programs. Mrs. Evans suggested: In behalf of the committee it may be well for us to ask staff to contact all of our human service agencies, and certainly the Department of Education as well, between now and the end of session to monitor changes at the federal level to determine if any of the things that are pending...if they go through...when those items might take effect. If they take effect before the 1997 session, we would need a skeleton contingency plan for how we would operate...block grants or any other changes...to avoid a special session....If there were some major changes we would want to be able to respond very quickly. Ms. Ernst said there is a Title V Senior Employment Program the U. S. Congress may place into an employment or job training block grant. However, the division is most concerned about the Nutrition Program because it is critical to the Aging Services budget. Because of discussion occurring at the federal level, Ms. Ernst still fears the U.S. Congress may decide to take portions of the Nutrition Program and place them into a block grant. Senator Rawson asked the Fiscal Analysis Division to develop a list of the agencies most likely to run into funding problems should changes occur at the federal level. He stated the committee could then seek proper authority from the Interim Finance Committee to deal with the issues as they surface. Referring to the bar graph on page 9 of Exhibit C, Mrs. Chowning asked for an explanation regarding the annotation, "Treatment Hours." Ms. Ernst responded Treatment Hours includes time rendered for health care, such as prescriptions written and physicals rendered within a facility. She stressed physical therapy given in the home, or mental health care, is not included in the 1439 hours reflected for the item. Mrs. Chowning said she has a constituent, age 57, who receives health care services on an out-patient basis within the Cannon Senior Center. She asked how the division is able to provide such service. Ms. Ernst answered there is a Community Health Center within the Cannon Senior Center that receives community health funds for those most in need. Senator Coffin noted although there has been a reprieve granted for aging senior services in the U. S. Congress regarding the placement of federal funds into block grants, he believes the reprieve is only temporary, and the U. S. Congress will eventually turn senior services over to the states. Assuming this will occur within the next year, he suggested it might be useful to consider the Aging Services budget as one of two budgets the committee would have to consider. The other being a block grant allocation from which new numbers would be derived. Senator Coffin asked Ms. Ernst if she had given much thought to how the division would make funding decisions should this occur. Ms. Ernst replied the funding the division is currently providing to all of Nevada's counties except Clark County is at a 1989 level. If the counties are forced to take additional cuts due to federal action that may take place, the burden will have to be placed upon Clark County. The division would have to update their demographic figures to determine where those most in need reside. Senator Coffin asked if the funding formula is calculated on a per capita basis. Ms. Ernst answered the funding formula contains many factors such as the number of minority, poor, and elderly individuals who are involved. Senator Coffin asked how the geography of the distribution would affect the actual outcome of the funding formula, if it is calculated on a per capita basis. He understands revenue would have to be taken from Clark County because it has a higher number of senior citizens. Ms. Ernst answered the rural counties have not received additional federal revenue for several years since the funding formula designation has been primarily used for Clark County. The state has allocated state funds to make up the difference. Ms. Ernst indicated the division is expending its resources on federally mandated reports and paperwork, and suggested the resources could be better used to provide services for its constituents. Senator Coffin asked Ms. Ernst to quantify her suggestion. Senator Rawson asked the difference between the activities of the Community Ombudsman located in Las Vegas and the long-term care Ombudsmen. Ms. Ernst said the division's major budget request pertains to community Ombudsman positions. Currently, the division is staffed with five long-term care Ombudsmen who are assigned the primary responsibility for advocating needs of institutionalized seniors; and, one community Ombudsman located in Las Vegas who responds to at-risk seniors in the community who are home-bound. Ms. Ernst stated the community Ombudsman has become very important to the division due to the vast services provided by the position. Ms. Ernst said the charts on pages 10 and 11 of Exhibit C graphically reflect the increase in the number of complaints the division investigated in Fiscal Years 1993 and 1994 in group care facilities and other areas. She explained many of the complaints were handled by Ombudsmen. By statutory authority, the division was given the ability to utilize the community Ombudsman and the long-term care Ombudsmen interchangeably where necessary. Although in concept, the community and long-term care Ombudsmen provide advocacy services to seniors in quite different living arrangements and for different needs, there does exist a great deal of crossover. For this reason, the division limited the number of new Ombudsman positions requested to three to be placed in Las Vegas, Reno, and Elko. The division has also requested one Information Systems Specialist, for a total of four new positions. Ms. Ernst stated the new positions will significantly enhance the division's ability to target home-bound and at-risk seniors who live in Las Vegas, and will establish a presence in the Reno area and rural Nevada. Senator Rawson asked why it is necessary to separate the titles since the work of the Ombudsman is generic or can be crossed-over. He pointed out if the roles are segregated, two different funding mechanisms may be involved. There have been instances when federal funds could have been used rather than revenue from the General Fund, he maintained. Ms. Ernst replied although the work can be interchangeable the community Ombudsman also staffs the Elder Care Help Line and leverages resources, and this is not a function of the long-term care Ombudsmen who primarily investigate difficult nursing home cases. Senator Rawson suggested the division provide the committee with documentationdescribing the job related differences between a community Ombudsman and long-term care Ombudsmen. Ms. Ernst pointed out at the request of Assemblywoman Chris Giunchigliani, the division did provide new Performance Indicators for the community Ombudsman reflecting community consultation and assistance services for at-risk seniors that are not institutionalized. She said the aforementioned Performance Indicators can be found on page 16 of Exhibit C. Senator Rawson questioned the methodology used in decision unit M-200 regarding the medical inflation increases in the Purchase of Service funding request, which were applied to the June 1994 average monthly client costs rather than the Fiscal Year Actual of $294 per month. He said the result is an increase of over 100 percent in the total level of funding in the Executive Budget, from $1.72 million (the Fiscal Year 1994 Actual) to $3.46 million for Fiscal Year 1997. Senator Rawson also voiced concern the methodology used for this budget item, which does not follow standard budgeting practice, could be considered precedent setting. He said it is necessary to find an appropriate way to address the needs in this budget category. Ms. Ernst responded she thought he was referring to the Community Home-Based Initiatives Program (CHIP). She referred the committee members to the last three graphs shown on pages 17 - 19 of Exhibit C from which she continued her testimony. Senator Rawson said if the committee selects a high month for a trend the budget will be overstated. If an average month is selected and the Consumer Price Index (CPI) is then factored in, the same figure could be arrived at by a more reliable method. Ms. Ernst explained the division operates the program very conservatively. For example, the average client is currently receiving just under 7 hours of service per week, at an average cost of $10.80 per hour, thereby avoiding the ne cessity of entering a nursing home. In April 1994, a Medicaid review indicated the division was not increasing services unless the client requested more service. As a result of reevaluating the amount of service being provided to avoid the nursing home option, the cost of service was determined to be dramatically higher than what was previously thought. Beginning in July 1994, the average cost per month, per client, were: July, $308; August, $329; September, $322; October, $323; November, $329, and December, $332. Ms. Ernst pointed out although the average cost for the previous year was $294, the costs were determined to be higher subsequent to the Medicaid review. Mrs. Evans suggested in the future the division should develop Performance Indicators which measure the Governor's goal, as well as Performance Indicators which measure other program activities. She stated the information just provided would make excellent Performance Indicators. She also suggested Performance Indicators prepared in the future for the Ombudsman position should include the total number of investigations performed and the number of complaints investigated that were satisfactorily resolved. Ms. Ernst concluded her testimony of the Aging Services budget by reviewing the remaining charts contained in Exhibit C. Ms. Ernst pointed out effective July 1, 1995, the division will be losing approximately $30,000 in funding previously provided by the Department of Transportation through a matching grant. As a result of the funding cut, she said senior transportation or vehicle services will no longer be provided to Esmeralda and Storey Counties. The Nye County Nutrition Services, Hawthorne's Senior Care and Share Program, the Elko Indian Council, the Battle Mountain Band, Southern Nevada Sightless, and the Salvation Army Adult Day Care Center in Henderson, Nevada will no longer have senior transportation. Senator Rawson asked if the division will request additional revenue from the state to be used for matching funds for the senior transportation services program with the Department of Transportation. He stated federal funding cannot be used towards a match, but by changing some of the budget categories it might be possible to provide state revenue. Ms. Ernst said this would be helpful since senior transportation service is a major concern to many of the states'elderly population. Mrs. Evans asked the amount of funding the state provided for care-giver training under the CHIP. Ms. Ernst replied, "$50,000 annually, but the amount was reduced to $10,000 after the last budget cut then increased again due to legislative action to $20,000 annually." Ms. Evans noted the division trained 250 care givers in Fiscal Year 1995 to date. She asked if care-giver training is a good investment. Ms. Ernst provided examples of care-giver services provided on a daily basis to elderly individuals who are home-bound. She emphatically believes care- giver training is a good investment for the state to make as it allows many elderly people to stay in their homes and not be placed into long-term care. Mrs. Evans requested Ms. Ernst to provide the subcommittee with actual figures reflecting the cost to the state to train 250 care givers, and how many additional care givers can be trained with the remaining revenue allocated for this purpose. She asked for the information to contain the actual per unit cost for the training. Mr. Hettrick referred to the budget summary reflected on page 1265 of the Governor's Executive Budget and noted the percentage basis for the item Information Services has risen. He asked if the expenditures are used for ongoing concerns. He stated the amounts do not concern him as much as the percentage increase. Ms. Ernst said some of the costs relate to major computer changes in the division's Carson City office to allow them to accommodate tracking required under CHIP. She said this would be a one-time process. The division also has computers purchased in 1987 and 1988 that require updating. Mr. Hettrick said he does not have a problem with the division acquiring new computers, but he is concerned agencies are placing $400 annual maintenance contracts on new computer equipment that already carries 1 to 3-year warranties, causing unnecessary ongoing costs. Bonnie Pillaro, Deputy Administrator, Aging Services Division, Department of Human Resources, remarked when the division prepared the budget for their computers an analysis was done to determine if maintenance contracts would be needed. She stated the division does not have any maintenance contracts budgeted for their computers at this time. Mental Hygiene - Mental Retardation - Page 1013 Charlotte Crawford, Acting Director, Department of Human Resources, testified that after 1992 and 1993 budget cuts, the Southern Nevada Adult Mental Health Services (Las Vegas Mental Health Center) budget had a General Fund reduction of $1.8 million in Fiscal Year 1992 and was required to save approximately $2.5 million in Fiscal Year 1993. The Department of Human Resources and the Mental Hygiene and Mental Retardation Division (MH/MR) are concerned about the demand on the diminished staffing and resources available to the agency and how clients will continue to receive services. Ms. Crawford pointed out the Southern Nevada Adult Mental Health Services had to close five satellite outpatient clinics and retained only one central site. The agency also eliminated day treatment services and outpatient counseling, and case management services were reduced. Ms. Crawford said as a result of the cuts, an analysis was performed and it was determined there were approximately 1,700 individuals whose services are being eliminated in southern Nevada, of which approximately 32 percent are Medicaid enrollees. The division has a serious concern for this group because while MH/MR balanced their budget problem by reducing services, Medicaid continued to maintain liability for services to those individuals entitled to mental health services under the state's Medicaid plan. Additionally, Ms. Crawford explained the division is dealing with individuals that are seriously mentally ill who rely on outpatient services previously provided by the public mental health system. Ms. Crawford remarked, "The individuals also rely heavily on case management, a key component with the mentally ill of keeping services coordinated and the individuals in the community on their required medication." Continuing her testimony, Ms. Crawford said to solve the problems associated with the loss of services, a number of former employees of the MH/MR Division started a nonprofit corporation known as "Mojave" to service clients who would be eligible for Medicaid funding. The Mojave group soon began working with the University of Nevada Medical School and became a division of the Nevada Family Residency Program, Incorporated, a primary-care, case management provider under the Medicaid system. In fact, Ms. Crawford remarked, it was the original provider with a number of years experience in the area of trying to coordinate medical services to reduce inpatient utilization and keep medical costs down. The Nevada Family Residency Program, Incorporated, agreed to accept the program and set it up in Las Vegas. This was done under a provider agreement with Medicaid and with a Memorandum of Understanding with the Department of Human Resources and the MH/MR Division. According to Ms. Crawford, the documents were written so that the MH/MR Division retained control of the type of individuals referred to Mojave, the type and scope of services provided and the number of services that could be delivered. Ms. Crawford stated the Mojave group receives referrals from the MH/MR Division and provides data to the division using the Administrators in Medicine (AIMS) Client Tracking Computer System. The agency bills directly to Medicaid and funding does not flow through the MH/MR Division. Part of the agreement with the MH/MR Division indicates the billing shall reflect that portion of the Medicaid payment earned by the Mojave program and the portion earned by the MH/MR Division. Ms. Crawford concluded her testimony by stating she believes the Mojave program has been a tremendous success to date. Senator Rawson advised the subcommittee due to the complexity of the Mojave program, additional details will have to be discussed at a later date. He stated a utilization review of the division's referral patterns will be required by the agency in order to have a clear understanding of what is happening. Mrs. Chowning asked for information regarding the new outpatient treatment facility scheduled to open in Las Vegas. She said the proposed facility is a Catholic center that will provide services to homeless families under the jurisdiction of the Southern Nevada Adult Mental Health Services. She specifically requested information regarding when the facility will open, what services will be offered, and the status of tenant services and remodeling efforts currently underway. Carlos Brandenburg, Ph.D., Acting Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources, stated the division is proposing a site in North Las Vegas to provide outpatient counseling. He deferred to Mr. Joseph Lamarca, Clinic Director, Southern Nevada Adult Mental Health Services, to provide specific details regarding the clients that will be served in the proposed facility. Joseph L. Lamarca, Clinic Director, Southern Nevada Adult Mental Health Services, Mental Hygiene and Mental Retardation Division, Department of Human Resources, commented work is underway to redesign the existing building at the proposed site to make it functional to house the outpatient clinic. He said both the City of Las Vegas and the Catholic Community Services are involved in planning efforts currently underway, and it is anticipated a plan will be ready within the next 30 days. Mrs. Chowning asked when the clinic will be operational. Mr. Lamarca responded the agency's budget request provides for the funding necessary to accommodate staffing the clinic to open on a small scale within the next 7 to 8 months in the North Las Vegas area. By the end of the next fiscal year, Mr. Lamarca said the clinic will be fully operational with all of the different components requested by the agency. Mrs. Chowning asked if services provided by the new clinic will duplicate or complement services now offered by the city and the county. Mr. Lamarca said the treatment the outpatient clinic will provide should enhance current services, and will certainly not duplicate constituency assistance now underway in other facilities in the area. He pointed out the clients for the new clinic will be determined by zip code designation. Mrs. Chowning said she is concerned about parking and security for the employees of the clinic. Mr. Lamarca responded security is a big issue, and all of the division's planning efforts will be designed to provide a safe and secure environment for the employees and clients. Because of the security issue, the division plans to operate the clinic during daylight hours commencing at about 7:00 a.m. and ending at 4:00 p.m. Mrs. Evans asked how many clients the clinic will serve in the North Las Vegas area. Mr. Lamarca said the clinic should serve all of the clients presently being treated at the division's West Charleston Street facility who come from two or three surrounding zip codes, which is approximately 60 percent of the patients presently served in the division's medication clinic. In addition, they hope to provide services to the homeless population in the surrounding area, Mr. Lamarca said. Mrs. Evans said rather than providing a percentage of clients served, the actual number of clients the outpatient clinic hopes to serve will be more helpful to the subcommittee. Mr. Lamarca replied there are approximately 2,500 individuals being treated in the division's medication clinic at the present time, and 60 percent of that number, or 1,500 individuals, would be transferred to the new North Las Vegas facility which he anticipates will be southern Nevada's largest outpatient facility. He remarked if the clinic treats individuals once every 30 days, and provides treatment 6 days per week for approximately 10 hours per day, 3,000 patients would be served each month in the medication clinic alone. Mrs. Evans asked what level of service is now being offered in Henderson, Nevada. Mr. Lamarca answered the outpatient counseling and medication clinical services offered on Wednesday mornings are filled to capacity. The division would like to expand the hours in Henderson, and the option is currently being reviewed with the director of the Department of Human Resources and Dr. Brandenburg to determine if there is any flexibility within the budget to expand. Mrs. Evans asked if there is a time table, or plan, underway to increase the capacity of outpatient care in Henderson. Mr. Lamarca stated the division is attempting to create a unique scheduling mechanism to provide additional hours for the Henderson clinic without increasing costs. In addition, Mr. Lamarca said another location for the outpatient clinic is being investigated by the division that will fit into budgetary constraints. At the present time, the clinic uses space in the office of a doctor who is closed on Wednesday mornings. Dr. Brandenburg said he has asked the southern Nevada clinical directors to submit suggestions to his office by March 2, 1995, regarding changes that can be made in existing programs to provide additional services in Henderson without the use of additional revenue. Dr. Brandenburg said the information provided will be given to the subcommittee for their review. Dr. Brandenburg stated he has impressed upon his administrators and directors that once the budget is closed, there will be no program or staff movement permitted. Instead, the division will provide services in the areas mandated by the Legislature, and will avoid service in the areas not yet approved; the division may be submitting proposals in the future for the unapproved services. Senator Rawson noted at the close of the 1993 session of the Legislature, the Transitional Housing Program was terminated in the Carson City area. He asked if the proposed budget provides for the reopening of any of the facilities. Dr. Brandenburg replied he did not have the information immediately available but would provide it to the subcommittee right away. Senator Rawson said he is interested in knowing what direction the division will take in providing transitional housing and mental health services in northern Nevada. Dr. Brandenburg replied the division received a $4.5 million Housing and Urban Development (HUD) grant for rent subsidy that will be partially used to provide some of the services needed in northern Nevada. In response to an inquiry by Senator Rawson regarding a Medical Director position to be filled at the Northern Nevada Adult Mental Health Services Division, Dr. Brandenburg stated the division met with members of the Department of Psychiatry and learned, as of February 23, 1995, there were four applicants for the vacant position. He advised the staff at the Department of Psychiatry he wants the position announcement to run for an additional 30 days to be certain there will be a large pool of applicants from which to draw. Mrs. Evans noted there are Psychiatrist position vacancies at the Northern Nevada Adult Mental Health Services, and asked if filling the positions is part of the division's immediate recruiting efforts. Dr. Brandenburg replied in the affirmative. He said the division is currently recruiting for one Medical Director position, and six Psychiatrist positions for the north, and two Psychiatrist positions for the Southern Nevada Adult Mental Health Services for a total of nine positions to be filled. Senator Rawson stated another meeting of the subcommittee on Human Resources/K- 12 of the Senate Committee on Finance and the Assembly Committee on Ways and Means will be scheduled to discuss additional issues. Senator Rawson adjourned the meeting at 9:40 a.m. RESPECTFULLY SUBMITTED: Marion Entrekin, Committee Secretary APPROVED BY: Senator Raymond D. Rawson, Chairman DATE: Assemblywoman Jan Evans, Chairman DATE: Senate Committee on Finance Assembly Committee on Ways and Means Joint Subcommittee on Human Resources/K-12 February 24, 1995