MINUTES OF THE MEETING OF THE JOINT SUBCOMMITTEE ON HUMAN RESOURCES/K-12 ASSEMBLY COMMITTEE ON WAYS AND MEANS AND SENATE COMMITTEE ON FINANCE Sixty-eighth Session April 6, 1995 The meeting of the Joint Subcommittee on Human Resources/K-12 of the Assembly Committee on Ways and Means and the Senate Committee on Finance was called to order at 8:07 a.m., on Thursday, April 6, 1995, Chairman Jan Evans presiding in Room 352 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. ASSEMBLY SUBCOMMITTEE MEMBERS PRESENT: Mr. Dennis L. Allard Mrs. Vonne Chowning Mr. Joseph E. Dini, Jr. Ms. Sandra Tiffany Mr. Lynn Hettrick Mrs. Jan Evans, Chairman ASSEMBLY SUBCOMMITTEE MEMBERS ABSENT: None SENATE COMMITTEE MEMBERS PRESENT: Senator Raymond D. Rawson Senator William J. Raggio Senator Dean A. Rhoads SENATE SUBCOMMITTEE MEMBERS ABSENT: Senator Bob Coffin (Excused) STAFF MEMBERS PRESENT: Mr. Mark Stevens, Fiscal Analyst Mr. Bob Guernsey, Deputy Fiscal Analyst PRESENTATION ON CONTINUUM OF CARE FOR JUVENILE SEX OFFENDERS Chairman Evans announced that earlier in the session when the Child and Family Services budgets were heard there had not been enough time for public testimony so those wishing to speak were scheduled for today's hearing. Ian Curley, Juvenile Probation Officer for Carson City and Storey County, testified he has been associated with the Nevada Network for Juvenile Sex Offenders since 1989. The Network believes juvenile sex offenders can be adjudicated and some can be helped if they receive sex offense specific treatment and appropriate placement. Mr. Curley distributed a document entitled "Presentation on Continuum of Care for Juvenile Sex Offenders" (Exhibit C) and a graph (Exhibit D) indicating numbers of referrals of juvenile sex offenders decreasing after the Legislature appropriated funding for sex offense specific evaluations. Mr. Curley reported in 1991 there were 364 victims of juvenile sex offenses and in 1992 there were 435 victims. Mr. Curley said in 1994, 900 incarcerated sex offenders cost the state approximately $13 million. He expressed the belief that early treatment could be effective in reducing this number. Robert Stuyvesant, a clinical social worker practicing in Reno, said nationwide studies have demonstrated early treatment of juvenile sex offenders to be effective, especially when a solid continuum of care is in place. Mr. Stuyvesant said from January of 1991 through May of 1993, he evaluated 67 juvenile sex offenders who reported a total number of 112 victims and a total number of nearly 4,500 sexual crimes. Mr. Stuyvesant distributed a sheet entitled "Treatment Follow-Up Information" (Exhibit E) which showed that of 75 adolescents receiving treatment, 35 completed the program and none of those 35 are known to have reoffended. Diane Crow, State Deputy Public Defender, reported she deals with juvenile offenders in court on a regular basis and is concerned that those individuals do not turn into adult offenders. Providing treatment in Nevada would allow the offenders to receive family support during the treatment process. Devere Carlson, Deputy Chief of Churchill County Juvenile Probation, expressed frustration at her inability to access proper treatment programs for the increasing number of juvenile offenders. Trina Dahlin, Carson City Deputy District Attorney, expressed concern about the lack of facilities for juvenile sex offenders. Many times offenders cannot return home because the offense was against a sibling or a neighbor and must remain in detention until space in an appropriate facility is available. Senator Rawson indicated the Legislature has attempted to respond to this need many times and asked what Ms. Dahlin's recommendation would be. Ms. Dahlin recommended in-state treatment be made available. Senator Rawson asked for specific information regarding the number of beds needed and where they should be placed. Mr. Curley answered Caliente's budget requested additional staff to become part of the continuum of care; this staff was removed from the budget and needs to be added back into the budget request. A legislative study two years ago recommended establishment of a residential 40 bed unit in Las Vegas with 20 beds designated for sex offenders; that recommendation needs to be implemented. Senator Rawson requested staff determine where this facility appeared in the budget. Mr. Curley noted funding of outpatient treatment for offenders who do not have insurance would be a great benefit. Tom Metscher of the Nye County Juvenile Probation Department spoke on behalf of the rural counties and the need for specific treatment which is not readily available in the more rural areas. Brian Link, Director of Specialized Alternatives for Families and Youth of Nevada, reported the organization recruits and trains foster families from the community to work specifically with adolescent sex offenders. He noted that juvenile sex offenders have been successfully treated in family based settings. Byron Parks, an individual family therapist with Willow Springs Center, a residential treatment center in Reno, testified residential treatment can be very effective for juvenile sex offenders. Mr. Stuyvesant reiterated that studies across the country have shown positive results from treatment of the adolescent sex offender and have shown recidivism rates for those untreated to be two or three times higher. Chairman Evans asked if success was defined by whether an offender reoffended after treatment. Mr. Stuyvesant responded affirmatively but indicated that long term studies need to be done. Chairman Evans indicated today's testimony would be taken into account when the children's division budgets are heard again. Senator Rawson referred to CIP number 95C-2, the Juvenile Treatment Facility for Las Vegas and asked whether this facility would benefit treatment of juvenile sex offenders. Mr. Curley responded affirmatively because the proposed facility will have 20 beds designated for offenders. Senator Rawson asked what was recommended for Caliente. Mr. Curley said the Caliente program had requested staff positions for the sex offender cottage but those positions had been removed from the budget. Mr. Stuyvesant added that a "step down program" is currently being developed by the Benchmark Hospital program from Salt Lake City to provide transition for adolescents coming out of residential treatment centers. Senator Rawson asked whether those juveniles sent to Tennessee are primarily sex offenders. Mr. Curley responded of 129 youth being treated out of state, 26 are identified as sex offenders. Susan Vander Plas, Director of the Briarwood Group Home in Reno, indicated efforts are being made to bring those juveniles back into the state; however, at this time there are no comparable in-state programs. A request for proposal to provide contract services in-state is in process. DEPARTMENT OF HUMAN RESOURCES Chairman Evans expressed her intent to first discuss major issues affecting several budgets and then to discuss each budget account separately. She invited Dr. Carlos Brandenburg, Acting Administrator of the Mental Hygiene and Mental Retardation Division, to make opening remarks concerning Mental Hygiene/Mental Retardation Administration. Dr. Brandenburg testified the Division is attempting to centralize quality assurance functions and has requested that the approved quality assurance positions in the Nevada Mental Health Institute budget and the Southern Nevada Adult Mental Health budget enhancement package be transferred to the Division Administration account so those functions can be coordinated. The Medical Director's position is also being moved into the Division Administration account. Chairman Evans confirmed two quality assurance positions are to be placed in the administration budget and requested an explanation for the request. Dr. Brandenburg said quality assurance and utilization reviews are important functions; the best way to ensure systematic and orderly performance is to place them at the Division level and make the Division Administrator and the Deputy Administrator responsible for developing, implementing and reporting quality assurance and utilization review. This will allow standardization of policy and procedure for those areas. Dr. Brandenburg indicated outpatient services for northern, southern and rural Nevada and inpatient services for the institute in southern Nevada and Lake's Crossing Center would be included. Chairman Evans asked what is planned relative to utilization review at the Mojave Center. Dr. Brandenburg responded the two positions will assist in developing a utilization review plan for Mojave. Funding has been received for software that will allow performance of a project study in Las Vegas focusing on utilization review in Mojave. This will be part of the Advanced Information Management System (AIMS). Chairman Evans asked if the $12,000 utilization review package included in AIMS is for the Mojave Center. Dr. Brandenburg responded affirmatively. Ms. Tiffany asked whether utilization review and quality assurance would be better handled by a consultant or the private sector rather than hiring staff. Dr. Brandenburg said it is hoped to hire someone with appropriate expertise. He agreed the function could be handled by a contract with an outside firm, but with the variety of programs in the Division it is advantageous for staff to develop and coordinate the programs. Ms. Tiffany requested consideration be given to having the private sector develop the program rather than adding additional personnel. Jean Laird, Administrative Services Officer for the Division of Mental Hygiene and Mental Retardation, explained the Division is currently recruiting for a vacant position with one of the criteria being experience in developing and implementing utilization review and quality assurance systems. Senator Rawson requested discussion regarding any difficulties in recruiting staff psychiatrists, arrangements with the Medical School, and whether salaries paid are adequate. Dr. Brandenburg said Dr. Barry Cole, Medical Director of Southern Nevada Adult Mental Health and Acting Director of the Nevada Mental Health Institute, has been involved in recruiting a medical director for the institute. The interview process is underway and a decision should be made the first part of May. Dr. Brandenburg stressed the importance of working in concert with the Medical School because it enhanced both the recruitment and retention processes. Dr. Brandenburg reported a salary survey revealed salaries in Nevada are comparable to those received by psychiatrists in other western states; however, they are not competitive with psychiatrists working on the east coast or in the southern United States. Senator Rawson asked whether the difference was in the salary itself, fringe benefits or the ability to work in private practice. Dr. Brandenburg responded the main discrepancy seemed to be in salary and fringe benefits. Chairman Evans invited Dr. Cole's comments regarding salaries for psychiatrists. Dr. Cole said generally psychiatrists around the country feel Nevada's benefit package is very good; however psychiatrists in smaller communities feel the salary is good while those in larger metropolitan areas feel it is low. Chairman Evans said this was good news because salaries had been an issue in hiring and retaining psychiatrists. Dr. Cole indicated that salaries probably would become an issue in the future. Senator Rawson asked whether the requirement for board certification made recruitment more difficult. Dr. Cole answered the requirement for board certification has actually been a positive factor in recruitment. Board eligible psychiatrists are allowed to work for up to five years before becoming board certified so residents who are just finishing and want to become board certified are likely to apply. Chairman Evans asked what responsibilities the Deputy Administrator position will have relative to Mental Hygiene/Mental Retardation and what level of staffing will be required. Dr. Brandenburg said the Deputy Administrator would oversee Mental Health; an Associate Administrator oversees Mental Retardation. The Deputy Administrator for Mental Health will be located in Carson City and will be responsible for policy development and planning relative to quality assurance, utilization review, the Nevada Mental Health Institute study, new programs including the North Las Vegas Clinic, and satellite clinics in rural Nevada. Chairman Evans asked the status of recruitment of five staff psychiatrists. Dr. Cole responded recruiting a Medical Director was the first priority. Review of 22 applications for the position of staff psychiatrist is proceeding; and recruitment will also be done at the American Psychiatric Association meeting in May. Dr. Brandenburg indicated it is hoped the Medical Director will be hired in time to assist in recruiting staff psychiatrists. The Medical Director will assist the Division in developing policies and procedures relating to psychiatry and medicine. Dr. Cole will be in charge of psychiatry within the Division and will work with staff at the Medical School, with the new Medical Director at the Institute, with staff psychiatrists at Lake's Crossing and with psychiatrists in the rural clinics to develop a cohesive plan for psychiatry and medicine throughout the Division. Chairman Evans confirmed that Dr. Cole's position will have statewide responsibilities, that there is additional compensation for that position and that both positions are to be placed in the Division Administration budget. Senator Raggio asked whether the psychiatric residents program for the Nevada Mental Health Institute would be funded. Dr. Brandenburg responded that program is not currently in the budget; any funding could be in the Division's budget or in the Medical School's budget. Dr. Brandenburg expressed his preference for placing funding in the Medical School's budget. If the program is funded in either budget, a residency program will be in place at the Institute. Dr. Cole said conversations have taken place with Dr. David Johnson, residency coordinator for the Department of Psychiatry at the Medical School regarding possible staffing levels and scheduling of residents. Chairman Evans questioned the status of accreditation at the Institute. Dr. Brandenburg said the accreditation review team was expected during the next week. He noted that considering the current situation, continuation of JCAHO (Joint Commission on the Accreditation of Health Care Organizations) accreditation for the next three years was unlikely. It was hoped conditional accreditation would be granted which allowed six months to one year to correct the identified deficiencies. Chairman Evans asked whether a residency program would be allowed in an institution that is not accredited. Dr. Cole responded negatively but added conditional accreditation would allow continuation of the residency program. Chairman Evans inquired what corrective measures would be necessary to ensure accreditation. Dr. Cole said the Institute is a year behind in the accreditation process. In October 1993, JCAHO instituted new guidelines to take effect in January 1995. One year's worth of data should have been compiled; however, the guidelines were not reviewed by Institute staff until October 1994. The process of forming the required leadership teams began in 1995. Chairman Evans expressed concern regarding psychiatrists who terminated their employment and left behind incomplete patient records. Dr. Cole indicated it was necessary to close approximately 150 incomplete charts; however, the Joint Commission more closely evaluates process and safety issues. The Bureau of Licensure and the Health Care Financing Administration will perform the annual Medicare survey in May or June and will focus on charts. Chairman Evans requested updates as the accreditation process moves forward. Chairman Evans requested the committee be updated regarding the AIMS (Advanced Institutional Management Software) program and its projected completion. Dr. Brandenburg responded the system should be in place by 1997. Chairman Evans noted the caseload at the Nevada Mental Health Institute and the Las Vegas Mental Health Center is 15 inpatients to one psychiatrist and inquired whether those psychiatrists will also see outpatients. Dr. Brandenburg said the ratio had been negotiated jointly by the Division, the Budget Office and the Legislative Counsel Bureau. He deferred to Dr. Cole who explained physicians are given the choice of seeing only inpatients, only outpatients or a mix. The ratio of 15:1 applies to those physicians seeing only inpatients. He noted the issue is not so much the number of patients a physician has but rather the velocity at which the patients move through the hospital. Dr. Brandenburg pointed out caseloads at Lake's Crossing and the Institute are not truly comparable. At Lake's Crossing the ratio is one psychiatrist for 36 patients; however, the turnover at Lake's Crossing is not as high and averages 126 admissions per year. The Institute's physicians actually see more patients. He noted a formula had been developed which clarified the issue. Chairman Evans indicated the information would be helpful. Chairman Evans requested the Division work with staff regarding revenue collections for the Rehab Option. Chairman Evans requested explanation of how the budget was built in regard to the inpatient census. Dr. Brandenburg said the Las Vegas Mental Health Center budget was built on 79 beds; the Institute budget was built on 52 beds. Staff in southern Nevada has been directed to close the group care home and Dr. Cole has been directed to seek licensure for the group care facility so bed capacity can be increased to 79. Staffing is available for 79 beds and when licensure is secured, staff and clients can move into the facility. The Institute has staffing for 52 beds and no changes are expected in the near future. Dr. Brandenburg indicated over the last two years the census has been artificially low. The number of admissions at both facilities has increased and it is not known if that trend will continue. Chairman Evans noted at an earlier hearing the rising census had been related to re-evaluation of admissions procedures. Dr. Brandenburg said there had been a propensity to deflect potential Medicaid and Medicare clients to other facilities. Dr. Cole has developed an improved deflection policy which provides Medicaid and Medicare clients are not deflected out until occupancy reaches 80-90 percent. Chairman Evans inquired whether any other budget adjustments would be made to compensate for the anticipated higher inpatient census. Ms. Laird said although the facilities are staffed for 79 beds in the south and 52 beds in the north, food services and other operating costs were built for 40 and 41 beds for each year of the biennium and would need to be adjusted. She indicated she would work with staff on the required adjustments. Chairman Evans requested explanation regarding closure of the Eagle Pines facility. Dr. Brandenburg said the group care home was developed as a program without legislative approval to receive chronically severely mentally ill patients from inpatient hospitals to allow those individuals to be introduced gradually back into the community. Because the program was created without legislative approval, the Division converted it to an inpatient facility to help with the increasing inpatient caseload. Chairman Evans observed that it might be important to track funding drawn in the Medicaid budget. Last biennium Medicaid money was put in the Mental Hygiene/Mental Retardation budget; possibly those funds should be returned to the Medicaid budget. Ms. Laird responded the Division would prefer that the matched funds be retained in the Mental Hygiene/Mental Retardation budget because federal dollars have been maximized to a greater extent when the matching funds are in the Division budget. Medicaid is a separate division and if Medicaid matching funds are obligated for other services they are less likely to draw federal dollars. With the match in the Mental Hygiene/Mental Retardation budget, Medicaid draws the federal share and MH/MR finds the match. Chairman Evans expressed concern with putting General Fund match in the MH/MR budget because if the funds are not used, there is an opportunity for General Fund to be used in other ways. Ms. Laird concurred but explained a legislative letter of intent indicated if the match could be handled in this way and would provide better service, it was acceptable to do so. Chairman Evans asked what the agency planned concerning the mentally ill homeless. Dr. Brandenburg explained an enhancement package in the Nevada Mental Health Institute budget would allow the Division and the Institute to contract for services for the mentally ill homeless being released from the jails. The Division is working closely with the Washoe County Sheriff to facilitate the triage of individuals in custody who need either inpatient or outpatient treatment. Those individuals are referred directly to inpatient facilities by staff at the county jails and a Case Manager spends approximately 20 hours per week interviewing and evaluating mentally ill offenders in the jails to determine appropriate services. Chairman Evans noted a concern had been expressed regarding the timeliness of services. Dr. Brandenburg said the Division has worked very diligently to improve timeliness of service through Case Managers. Chairman Evans referred to decision unit E125 in the Lake's Crossing budget and inquired where the Case Manager was based. Dr. Brandenburg said the Case Manager works with the Institute to triage offenders into treatment. Decision unit E125 in Lake's Crossing budget provides staff to perform competency evaluations. Mrs. Chowning referred to page 1050 of the Lake's Crossing budget and noted Clark County has a growing homeless population of individuals released from jails. Dr. Brandenburg responded the two positions for Lake's Crossing will be statewide positions and will perform competency evaluations in the jails and on an outpatient basis for municipal and district courts. Chairman Evans asked where the rural clinic director and support staff would be located and whether this program will be impacted by changes at the Institute. Dr. Brandenburg responded negatively and said Dr. Bill Beck, the Director of Rural Clinics, would remain at the Nevada Mental Health Institute. Mr. Dini requested explanation of proposed staffing provided in enhancements to the rural clinics. He inquired whether the full-time counselor and half-time clerical positions would be adequate for Battle Mountain. Dr. Beck responded affirmatively. Mr. Dini then asked whether the full-time counselor and half-time clerical positions would be adequate for Lovelock with the opening of the new prison. Dr. Beck responded affirmatively. Mr. Dini inquired where the Fernley/Silver Springs office would be located. Dr. Beck said the decision to locate in either community had not been made. Mr. Dini asked if enhancements to the Yerington office would help with the heavy work load there. Dr. Beck said plans for the Yerington office include the transfer of eight positions from the Fallon Mental Health Center to Yerington and assignment of a Case Management position to the Yerington office. Mr. Dini confirmed the Case Manager would also provide services to Dayton. Mr. Allard asked if there were any plans for community based services in the north Clark County areas of Overton, Logandale or Mesquite. Dr. Beck said there are no plans to staff that area. Chairman Evans referred to information from Ed Guthrie of Opportunity Village that indicated payments for Community Training Center (CTC) clients took from 60-75 days when the Division indicated payments averaged 13 days. Ms. Laird said the Division studied payments and found payments averaged 13 days from receipt of a bill. There could be a discrepancy from when service was provided to when a bill was submitted. Mr. Hettrick referred to decision unit E128 in the Rural Clinics budget which provides funds for support staff, a Management Assistant position and operating costs for the Tonopah office. He asked how service is currently being provided in Tonopah. Dr. Beck said the staff in decision unit E128 is in addition to two clinical staff members, a psychologist and a mental health counselor currently assigned to that office. Chairman Evans requested Dr. Brandenburg discuss the impact of the Nevada Mental Health Institute Survey (a copy of which is on file in the Research Library of the Legislative Counsel Bureau). Dr. Brandenburg said the study addressed four main areas: an inventory and assessment of the actual facilities which evaluates the structural integrity of the buildings; program needs versus space availability; presentation of five options; and evaluation of whether to maintain a centralized heat plant. Dr. Brandenburg said the five options include on-campus improvements; new facilities off-campus; a public and private partnership off-campus; and off-campus contract services. On-campus improvements include remodeling; remodeling with expansion; new construction on a new site; and new construction on existing sites. Dr. Brandenburg indicated through meetings with Institute staff, the decision has been to make non-structural rehabilitations to buildings used primarily by clients. Non-structural improvements would include paint, drapes and new carpet. To address the long-term need of the recommendations, Public Works has been asked to include the Division in CIP number 95-S4 so Institute staff in conjunction with Public Works can present to the Sixty-Ninth Legislature a specific strategy and outline. Dr. Brandenburg expressed the intention to use capital improvement funding to perform non-structural remodeling. Chairman Evans confirmed that a plan for the entire campus would be presented in two years. Dr. Brandenburg said the Division would like ample time to weigh the options, discuss them with all involved parties and present to the Legislature a recommendation. Chairman Evans noted much of the work done on campus could be done in the community through private sources. The appropriate role for the state needs to be examined. She encouraged the Division to involve mental health consumers, advocates and community service providers. Dr. Brandenburg concurred with the value of involving all concerned parties in the planning. MENTAL HYGIENE/MENTAL RETARDATION - PAGE 1013 Chairman Evans indicated that since the budgets had been previously heard, this would be an opportunity for the committee to raise any additional questions and for the agency to make any additional comments. Senator Rawson questioned whether the Deputy Director position is still considered to be necessary. Dr. Brandenburg responded affirmatively. Senator Rawson inquired whether a salary increase for the Medical Director is recommended in this budget. Dr. Brandenburg said the enhancement is included in the southern Nevada budget. NEVADA MENTAL HEALTH INSTITUTE - PAGE 1039 Chairman Evans referred to page 1044 of the Executive Budget, decision unit E282, and asked whether a federal grant was available rather than using General Fund. Dr. Brandenburg explained Project Restart was able to secure $629,000 for a federal grant to assist in providing case management services to the homeless. Although it appears that services are duplicated by Project Restart's federal grant and decision unit E282, decision unit E282 specifically addresses mentally ill individuals referred by the criminal justice system. Chairman Evans referred to a 1994 Interim Finance Committee meeting at which a five year HUD grant for 55 community beds was discussed. She questioned how many of those beds are now in place. Dr. Bill Beck, Clinic Director for Outpatient Services in Washoe County said there are currently 15 HUD beds and 8-10 beds are in the application process. It is intended to bring on a total of 24 beds by the end of the year on a 2 bed per month schedule. Chairman Evans requested this information be included in measurement indicators for the next budget cycle. Dr. Beck agreed to do so. FACILITY FOR THE MENTAL OFFENDER - PAGE 1049 Discussion regarding this budget was included in the department overview. RURAL CLINICS - PAGE 1055 Mr. Dini observed it might be better to open separate offices in Fernley and Silver Springs. Dr. Brandenburg agreed to investigate that alternative; however, establishing a combined office for Fernley and Silver Springs would provide baseline data to determine needs. Chairman Evans asked what services the agency provides for youngsters in the rural clinics. Dr. Beck said currently approximately 24 percent of the treatment population is children under the age of 18 years. He added some outpatient services are provided for juvenile sex offenders, however that is not a large percentage of the population. Chairman Evans asked whether juvenile sex offenders were referred to the rural clinics. Dr. Beck said referrals came from the courts, the juvenile justice system, concerned parents, and occasionally the problem is discovered as part of treatment for another problem. Most referrals of offending adolescents come through the juvenile justice system. Chairman Evans asked whether Dr. Beck felt his staff was sufficiently trained to work with juvenile sex offenders. Dr. Beck responded they were not and added a significant amount of specific training is necessary for a professional to be able to effectively deal with this population. Dr. Beck questioned whether an adolescent sex offender with a long history of sex offenses could be successfully treated as an outpatient. Chairman Evans requested recommendations be submitted regarding changes necessary for the rural clinics to provide effective service to this population. Dr. Beck indicated he would provide the information. Mr. Dini referred to decision unit E403 and asked where the four Clinical Social Worker positions would be based and what the caseload would be. Dr. Beck responded the four Clinical Social Workers would work as case managers with a ratio of one case manager to 35 clients. One position each will be located in Fallon, Yerington, Carson City and Douglas County. Mr. Dini confirmed sufficient travel funding was built into the budget. Senator Rawson asked how the more rural areas such as Tonopah, Caliente and Pioche access services. Dr. Beck explained the southern areas of Nye County have been typically served by Clark County. The 1992 budget reductions caused closure of a small clinic in Caliente and it is not planned to reopen that clinic because of the relatively low demand for service. NORTHERN NEVADA MENTAL RETARDATION SERVICES - PAGE 1073 Chairman Evans expressed concern regarding the waiting list and whether it could be reduced. Dr. David Luke indicated approximately 40 additional people would be served through case management. There will still be a residual waiting list, however the agency feels this level of program expansion is the maximum that can be accomplished in this biennium. Chairman Evans asked for information regarding the southern Nevada waiting list. Dr. Luke said that waiting list is much larger so new placement monies have been weighted for that part of the state as well as some of the most under served rural areas. Plans include 70 additional placements for the south as well as four or five additional case managers to provide service to another 200-300 individuals. There will be a residual waiting list. Mr. Dini asked how rural areas access the program. Dr. Luke responded Rural Mental Retardation Services are included in budget account 101-3167, Residential Placement, which is based in Carson City. During this biennium staff in the Elko office will be increased to 2.5 FTE staff members. Chairman Evans asked whether the length of time an individual is on the waiting list can be reduced in addition to reducing the number of individuals on the list. Dr. Luke said the biggest problem with moving people in and through the system has been case management so the additional case managers in the south will greatly help expedite the pace. Chairman Evans asked how long it takes individuals to access services. Dr. Luke said this is a difficult number to choose because many times parents will place their child on the waiting list because the child will turn 18 in a couple of years and families are aware of the waiting list. Chairman Evans requested performance measurements be revised so they reflect the length of time an individual waits before accessing services. Senator Rawson observed there were currently 202 individuals on the case management waiting list and asked how long they would be required to wait. Dr. Luke said probably near six months for some individuals. However, those requiring more extended services could wait as long as 2-3 years. Senator Rawson asked whether more case managers would help reduce the list. Dr. Luke said the number of case managers would most likely be sufficient once they were fully trained. Senator Rawson asked what needs to be done to shorten the time individuals wait for service. Dr. Luke said service capacity has traditionally been too low relative to residential placement capacity; however, this biennium placement money has been increased to nearly double that of the last biennium. Dr. Luke pointed out the Title XIX match would particularly affect the Mental Retardation budget which is 90 percent Medicaid dollars. Having the match in that budget has allowed access to other match through the Home and Community Based Waiver. He added that without the match in the budget, other problems occur because the budget carries less than one month of operating capital. Although the intent is to collect and maximize all possible Title XIX dollars, all eligible individuals, whether eligible for Title XIX services or not, must be served. Funding that could be used for match must be used if an individual needs services. Chairman Evans observed that from a budgetary and accounting viewpoint, it is expected that when money is placed into a category it will be expended for that category. Dr. Luke responded the budget is spent within appropriate categories. Senator Rawson inquired whether there is any risk for being out of compliance or for being sanctioned. Dr. Luke said the quality of the programs is quite good. The biggest risk relative to compliance and sanctions is the waiting lists and the statute which indicates eligible individuals are entitled to service. Senator Rawson requested a plan be provided to address the waiting lists and eliminate the risk of sanction be supplied. Dr. Luke indicated some of that information had been submitted. Ms. Laird pointed out during this biennium the agency has not used any money set aside for Medicaid match for any other purpose. Rather, additional match was used to bring in more federal dollars. She indicated the agency would like to provide assurance this would continue and would be willing to provide ongoing reports to the Interim Finance Committee. Ms. Laird observed that if the General Fund match goes back to the Medicaid budget, the state will lose federal money. Dr. Brandenburg expressed his willingness to work with staff to devise an appropriate reporting system. Chairman Evans indicated funding would have to be tracked very carefully and actual expenditures would have to be easily identified. RESIDENTIAL PLACEMENT - PAGE 1083 Chairman Evans expressed concern whether the title of the budget reflects the actual work of the agency. Jack Middleton, Director of Rural Nevada Mental Retardation Services, indicated the budget deals with rural mental retardation services and should carry that name. He indicated two years ago, the state residential placement fund was discontinued as a centralized budget and was divided into three regions. The rural share remained in this budget, however the name of the budget was not changed. Mr. Middleton pointed out the waiting list for rural Nevada continues to grow more rapidly than existing case managers can process cases and now contains 45 individuals. Senator Rawson expressed concern with the growing waiting list and requested submission of a plan to address the problem. Mr. Dini requested the committee receive a list reflecting placements and from what counties the placements were made. Mr. Middleton said the information was available and would be provided. Mr. Hettrick referred to the M200 decision unit which provides $10,816 and $510 in Information Services the first and second years of the biennium respectively and decision unit E401 which provides $5,400 and $510 in Information Services in the first and second years of the biennium respectively. He pointed out if computers are being purchased, two year warranties should be included with the purchase. Chairman Evans observed case managers in urban areas do not face the same difficulties as case managers in rural areas and asked whether the 1 to 45 ratio is realistic. Mr. Middleton said the statewide ratio for mental retardation is 1 to 45; however, in rural Nevada a large amount of time is spent traveling from community to community so a portion of case management is done through intermediaries, families and telephone. Any time the ratio is increased, services must be reduced. Chairman Evans asked that Mr. Middleton also submit recommendations regarding the case management ratio. MENTAL RETARDATION HOME CARE - PAGE 1091 Mr. Middleton explained the name of this budget should be changed to Family Preservation which would more accurately reflect the purpose of the budget which provides assistance for families caring for a profoundly retarded individual in the home. If those families were not able to provide care, the client would require intensive institutional care. Currently 137 families receive service. The turnover in this group of recipients is fairly high because the clients are very fragile and medically involved. Money spent assisting parents and relatives to care for their families at home is less than the cost of two days of care in an institutional setting. Chairman Evans asked what determines the payment level. Mr. Middleton said the payment level is based on family size and need and ranges from a minimum of $30 to a maximum of $300. A family with a child under age 18 with moderate income may not be eligible for other federal programs but by virtue of being eligible for this program, may receive SSI in the amount of approximately $400 per month and Title XIX medical payments. These three programs provide a considerable resource to help care for the profoundly retarded individual in the home. The program has less impact on adults because adults are eligible for SSI and Title XIX. Mr. Middleton said the amount of payment has fluctuated based on the number of recipients and cost of living increases granted by the Legislature. Cost of living increases of 6 percent and 3.5 percent are projected which will raise the maximum payment to $318 and $327 for the first and second years of the biennium respectively. If the number of families requiring assistance increases dramatically, the program continues to accept recipients and reduces payments accordingly. Mr. Middleton observed last year was the first time since 1982 any funding reverted. This year there will probably be approximately $16,000 reverted because last year's projections did not include the number of individuals who might leave the program. Senator Rawson asked how long efforts had been made to change the name of the budget. Mr. Middleton said since 1982. Senator Rawson said the name would be changed. Chairman Evans called for public testimony. Nancy Paolini, Executive Director of Project Restart, reported Project Restart is a private, non-profit organization that has worked in collaboration with Nevada Mental Health Institute, Haven of Hope and other agencies in Reno to present a HUD Innovative Projects Proposal. Project Restart has been unofficially notified the $625,000 two-year grant will be awarded. In the event the grant is confirmed and Project Restart can fulfill the conditions of the grant, aggressive outreach will be provided for four specific populations, one of which is the severely mentally ill. Another component of the grant is for immediate housing. Ms. Paolini stressed the grant does not duplicate services provided by Mental Hygiene/Mental Retardation. Michael Bender of Haven of Hope distributed a document (Exhibit F) which describes the agency's work. Mr. Bender reported the organization works with the jails and the courts and has found case management in the jail and providing guidance to individuals released from jail to be very effective. Mr. Bender observed case management capability needs to be greatly increased. Chairman Evans requested explanation regarding the case managers. Mr. Bender said case managers would be based with Haven of Hope on contract through the Nevada Mental Health Institute. Chairman Evans inquired whether there are currently any case managers. Mr. Bender said the Stewart B. McKinney Grant provides two full time case managers. Brian Lahren, Executive Director of the Washoe Association for Retarded Citizens, indicated he is a member of a group concerned with issues of mental health service in the city of Reno. Mr. Lahren reported there needs to be a clear distinction between the various services and that all are critical to the maintenance of adequate community health services. He testified the two community service positions in the Nevada Mental Health budget are essential to provide outreach services. In December the Division identified 862 severely mentally ill individuals in the Reno area which indicates the large amount of case management services to be provided. Chairman Evans expressed her hope that Dr. Lahren, Mr. Bender, Ms. Paolini and others would participate with Dr. Brandenburg in developing a program plan for mental health services. Senator Rawson confirmed that Dr. Lahren supported the agency's budget request as it was submitted. Ernest Nielsen, Executive Director of Washoe Legal Services, reported Washoe Legal Services represents low income individuals in Washoe County. He testified Washoe County supported the Nevada Mental Health budget. Rosetta Johnson, President of the Nevada Chapter of the National Alliance for the Mentally Ill, read the Alliance's Executive Statement, attached as Exhibit G. Ms. Johnson also distributed a document entitled "Journey of Hope," a copy of which is on file in the Research Library of the Legislative Counsel Bureau. Senator Rawson requested explanation relative to Journey of Hope. Ms. Johnson said the program trains family members about mental illness. Senator Rawson indicated staff would review the packet. Norma Brownell, president of the Northern Nevada Alliance for the Mentally Ill and member of the State Alliance for the Mentally Ill, expressed support for the Journey of Hope. She stressed it is very important for family members to be educated relative to mental illness. Brian Lahren referred to slow payment of CTC bills and said the Division processes invoices quickly, but occasions arise when invoices are delayed in the Budget Division and pre-audit because of staffing problems. Dr. Lahren indicated his hope that some sort of expedited processing could be arranged so CTC bills are not delayed in the Budget Division. Jim Riggs of the Budget Division indicated he was not aware of delays in payment but indicated he would notify Mr. Comeaux of the problem. Dr. Lahren wished the record to reflect his association is very strongly in favor of supported employment and is willing to work with the Division to put quality service mechanisms in place. With no further business to come before the committee, Chairman Evans adjourned the hearing at 11:02 a.m. RESPECTFULLY SUBMITTED: Deborah Salaber, Committee Secretary Joint Subcommittee on Human Resources/K-12 Assembly Committee on Ways and Means and Senate Committee on Finance April 6, 1995 Page