MINUTES OF THE MEETING OF JOINT SUBCOMMITTEE ON HUMAN RESOURCES/K-12 ASSEMBLY COMMITTEE ON WAYS AND MEANS AND SENATE COMMITTEE ON FINANCE Sixty-eighth Session March 2, 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 7:30 a.m., on Thursday, March 2, 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: Mrs. Jan Evans, Chairman Mr. Lynn Hettrick, Chairman Mr. Dennis Allard Mrs. Vonne Chowning Mr. Joseph E. Dini, Jr. Ms. Sandra Tiffany SENATE SUBCOMMITTEE MEMBERS PRESENT: Senator Raymond D. Rawson, Chairman Senator Dean A. Rhoads Senator Bob Coffin COMMITTEE MEMBERS ABSENT: Senator William J. Raggio, excused GUEST LEGISLATORS PRESENT: Assemblyman Thomas Batten STAFF MEMBERS PRESENT: Gary Ghiggeri, Deputy Fiscal Analyst Robert Guernsey, Deputy Fiscal Analyst Chairman Evans began by focusing on major issues which cross over several budget areas. Chairman Evans stated the committee was concerned about the Title XIX match and the placing of Title XIX Medicaid dollars in the Mental Health budget areas rather than the previous practice of putting it in welfare and drawing down the funds. She requested Dr. Carlos Brandenburg, Acting Administrator of the Department of Human Services to respond to the necessity of keeping Title XIX dollars in the Administrative budget area. Ms. Jean Laird, Chief Administrative Services Officer of the Division of Mental Health and Mental Retardation, responded to Chairman Evans' inquiry stating that prior to this biennium, Medicaid match (General Fund) dollars were placed in the Medicaid budget. Beginning with this biennium, the general fund Medicaid federal match dollars were placed in the Administrative budget area. The federal (Title XIX) revenue dollars remained in the Medicaid budget. Ms. Laird noted that during this biennium, more increases in federal revenues have been made than in any other biennium. Ms. Laird stated that the reason for increases was because the Medicaid match was placed in the Administrative budget area. Welfare staff is more interested in augmenting federal revenues for the state and not having to come up with the federal match dollars from their budgets. If they are able to increase their federal revenue, it is not necessary to come up with the general fund match; therefore, there is not reluctance, on their part, to submit state planning changes to the federal government for approval for payment of services that are not previously budgeted. If they move it back, Ms. Laird feels there may again be some resistance to increasing the amount of federal revenue they can draw in because the Medicaid budget would have to come up with the match. Chairman Evans referred to a spreadsheet submitted by Ms. Laird (Exhibit C) showing Title XIX dollars in each of their budget areas. Chairman Evans stated that it appeared on the spreadsheet that there was an overmatch (referring to Column 3) of $447,000 in the budget. Ms. Laird stated that there was an overmatch because they were able to increase the federal revenue; if they had not been able to increase federal revenue they would not have used general fund match to match the federal revenue. The state would not have been able to drawn in $447,000 in federal dollars. Chairman Evans asked Ms. Laird to respond to what looked like extra money in their budgets and that they may have been doing other things with the money than was intended by the Legislature such as starting new programs. Ms. Laird responded that all services using the general fund match to match federal dollars have been approved by the Legislature and instead of using 100% general fund dollars, they used 50% federal and 50% state. They were able to revert approximately $3 million; had they not used the additional $447,000 to bring in an equal amount of federal dollars, they would not have been able to revert the $3 million. Mr. Hettrick asked if Eagle Pines had been approved by the Legislature. Ms. Laird stated Eagle Pines was not; however, Eagle Pines was not involved in this particular match money. Mr. Hettrick asked, "Where did the money come from for Eagle Pines if it was not approved by the Legislature and was not involved in this money?" Dr. Brandenburg responded that Eagle Pines, a patient ward for the chronically, severally, mentally ill (patients who would already be in the in-patient unit) was opened using existing staff from the in-patient unit. Dr. Brandenburg agreed that opening of the Eagle Pines patient ward was not approved by the Legislature. He further stated that he has requested staff to look at options, i.e., to continue what is presently being done, to request additional funding for the Eagle Pines, or to move Eagle Pines off- campus and try to put the project under contract monies. Dr. Brandenburg expects to receive staff recommendations in the near future which he hoped to share with the committee. In conclusion, Dr. Brandenburg reiterated that Eagle Pines did not interface with Title XIX funds. Mr. Hettrick continued, "The fact that Eagle Pines was done on-campus, wasn't it entitled to Title XIX and how do we offset the $447,000 to benefit us?" Ms. Jean Laird stated that no Medicaid money is involved with in-patient services because Medicaid does not reimburse for anyone age 21-65 (most of their clients fall within this age group), so in-patient positions that were used for Eagle Pines rather than in-patient services were not reimbursable anyway. So in either location or for either service, no Medicaid dollars would be involved. Mr. Hettrick asked if Eagle Pines were placed off-campus, how would in-patient staff be replaced and is this being considered within the budget. Dr. Brandenburg stated that they were setting up the budget for this purpose and reiterated that staff would be looking at the various options stated before. He also stated that he wanted the Legislature to revisit the Eagle Pines issue and they would present the options at that time to the committee. Dr. Brandenburg stated with regard to whether in-patient staff replacements were in the budget that he would get back to the committee with the information. Ms. Laird made a follow-up statement saying the Eagle Pines Group Home is not Medicaid eligible because it is on-campus and if it were moved off-campus there may be a potential for additional Medicaid revenue that could be earned. Chairman Evans said that the committee was interested in knowing what would be the best way to handle this situation and asked Dr. Brandenburg when could the committee get the information. Dr. Brandenburg stated he hoped he could get back to the committee in about 2 weeks. Chairman Evans questioned the status of AIMS (Advanced Institutional Management Software) Tracking Program and, given a one-shot appropriation is nearing, when they anticipated the completion of the project. David Miller, Program Evaluator, Mental Health-Mental Hygiene, responded that the project should be complete within the next biennium, specifically on-line within fiscal year 1996 for the Nevada Health Institute and in fiscal year 1997 the tieing in of rural clinics and remaining parts of the state. Ms. Tiffany asked, relative to the completion of the project, if "tie-in" or "on-line" meant that the network needed to be created. Mr. Miller responded that the tie-in or wiring is currently being done. In conjunction with the Department of Information Services, the infrastructure is being developed. Multi-drop lines are currently being considered to bring rural clinics and offices on-line. Mr. Miller indicated the department's preference was to use personal computers rather than a mainframe system because personal computers allow for more flexibility. Ms. Tiffany asked about additional software development. Mr. Miller stated that there is no software, per se. The AIMS software is about 1/3 or 36% of the budget for the one-shot. Modules were set up to fit Nevada's specific needs; therefore, they do not anticipate the need for the development of additional software. Much of the cost will be allocated to data conversion and training. Ms. Tiffany questioned if the data conversion would be automated or would data entry have to be done. Mr. Miller said that some parts of the conversion process is automated, but some data entry would be required; additionally, some training would be necessary. Ms. Tiffany asked if there was enough money budgeted for training costs. Mr. Miller stated he was confident that there is enough money budgeted. He stated with the completion of the Las Vegas portion of the project, they were now more able to accurately project the cost. In the area of training, Mr. Miller stated he expected training costs to be minimal due to cross training capabilities. Ms. Tiffany summarized that the Legislature would be keeping a watchful eye on this project because data cap/conversion within these two environments has not been seen before. Ms. Evans reported the subcommittee was concerned with the advisability of having psychiatrists on staff who may have other duties such as teaching responsibilities and outside practices. Dr. Brandenburg felt the department could have the best of both worlds. He described the department's "draft of understanding" prospective psychiatrists will sign. Dr. Brandenburg indicated if they provided staff psychiatrists with parameters and guidelines they would be able to have good physicians working for them and continue the relationship with the medical school. He noted there was some misunderstanding between the facilities and the medical school. The facilities felt it was up to the medical school to recruit. Dr. Brandenburg felt the facility could recruit the physicians, make the list available to the medical school and work in cooperation with them to hire the psychiatrists. Mr. Hettrick noted there were eight vacancies and asked whether the salaries were adequate. Dr. Barry Cole, Acting Medical Director of NMHI and Medical Director of Southern Nevada Adult Mental Health Services, testified he was not aware of eight vacancies in the psychiatric system. He stated they were looking for a medical director in the north and there were five vacancies and staff positions which totaled to six. He indicated most physicians in private practice work 48 to 60 hour work weeks. The medical school requires a 40 hour work week with the university retirement match option allowing the psychiatrist to apply $11,000 of tax deferred money on their own matched by $11,000 more from the university. The compensation package includes malpractice, disability, medical, dental, life insurance, tuition credits and the ability to buy personal computer equipment on a zero interest loan. The department costs the package at $125,000 and Dr. Cole indicated most physicians are very impressed with the sick leave, vacation time, and benefits although the $109,000 base salary does not match private practice salaries. Mr. Hettrick asked if the salary was adequate, why were there five vacancies. Dr. Brandenburg explained the psychiatrists on staff felt their responsibilities were skewed towards academia and less towards patient care. The doctors felt uncomfortable with the restructuring done by the medical school and decided to leave. Referring to the new 32 hour week, Mr. Hettrick asked how many clients would be served. Dr. Cole replied the 32 hours of direct clinical time will translate into four eight-hour days. In terms of outpatients for the medication clinic physicians, the division is asking the physicians to see approximately twenty patients a day (three or four new patients, the rest will be follow-ups). In terms of inpatients, caseloads are anticipated to be fifteen patients to one psychiatrist. Each psychiatrist presently has a second year resident assigned to them; the resident has eight additional patients. The psychiatrists will be carrying loads on paper that will approximate twenty-three to twenty-five patients at a time with the resident carrying a block of those patients and doing most of the work. The attending psychiatrist would supervise the resident who is technically still in training. Mrs. Evans asked Dr. Cole if the caseload was congruent with standards elsewhere. Dr. Cole stated fifteen to one was a reasonable workload. Mrs. Evans asked whether there were vacancies in southern Nevada. Dr. Cole replied there were none. Ms. Tiffany asked how the caseload would be impacted if the state was in a managed care situation and the staff was at its ideal level. Dr. Cole felt the state was presently working in managed care situations. Ms. Tiffany asked the doctor to use HMO's as an example. He was not sure what the current numbers of psychiatrists or social workers to clients would be at any of the existing HMO's in Las Vegas. He remarked the patients they saw in these situations were much more difficult as they were homeless, totally resourceless with a great deal of history of not following through in terms of medication or keeping their appointments. Dr. Cole noted the division had not made any particular plans to move into a true HMO as they did not have the medical component to add on. He saw an HMO as an umbrella of which psychiatry would be one part of the whole process; he could not attend to someone's mind and neglect their body. Dr. Cole recommended there be a bridge with some other existing medical structure, whether it be the Family Medicine Department in Las Vegas or the Department of Internal Medicine. He added more medical backup to the one general physician on his staff would be needed both in the north and south. Ms. Tiffany stated they would take this into consideration when they examined the staffing ratios and caseload. Dr. Cole said the division used a variety of health care practitioners (psychologists, social workers, nurses) in the north and south to work with the patients; the program was not a psychiatrically driven model. Mr. Allard asked whether the division's psychiatrists conducted group therapy. Dr. Cole replied groups are handled in northern Nevada by psychologists, mental health nurses and social workers. All patients are seen individually on a monthly basis by the psychiatrist so they can focus on specific medication management issues. Mrs. Evans directed the committee to refer to a memorandum dated February 20, 1995 to Dr. Brandenburg from Mr. Guernsey regarding Joint Committee Questions (Exhibit D). Mr. Hettrick asked for more information regarding staffing ratios in other states for all levels of care including psychiatrists, psychologists, social workers, case managers, psych nurses and forensic specialists. Dr. Brandenburg replied the division was in the process of finalizing the ratio by discipline question. They were not aware the committee wanted a comparison with other states. They based their figures on the staffing ratio for each of the major agencies. Mr. Hettrick said the committee was trying to devise a measurement indicator of some type in order to determine whether the program was running efficiently in comparison to other states. Mr. Hettrick asked the division to indicate whether the ratios were different for MH compared to MR and were there different ratios for the rural areas compared to the urban locations. He mentioned the committee was concerned with the status of rural clinics and how they could be staffed to provide the same service as that in urban areas. Dr. Brandenburg stated this information would be provided. Referring to question three which addressed waiting lists, Mr. Hettrick asked Dr. Brandenburg to supply comparative information by program. Dr. Brandenburg agreed to provide the information. Mr. Hettrick asked for projections regarding Rehab options and whether the state would be able to reduce the General Fund obligation. Ms. Laird replied she could not give an answer in terms of dollars, however, her staff was working on the calculations. The division has submitted some billings to Medicaid for a retroactive period for the Rehab option and when payments are received the projections can be made. She added the figures would be ready within the next week or two. Mrs. Evans asked whether the division had submitted a recent Stale Claim. Ms. Laird assumed Mrs. Evans was referring to the claim for Sierra Regional Center amounting to $420,000. She explained the division as only one single provider number with Medicaid. Medicaid made large errors in paying the division for FY 94 services and did not correct the overpayment until the division's books were closed. Medicaid deducted the money from the division's 1995 payments and put them $420,000 short for the present year. The division is requesting to obtain some of the money that was reverted from FY 94 and transfer it to FY 95 to be available. Mr. Ghiggeri asked what impact this had on the division's FY96 and FY97 budgets and whether the expectations for federal revenue in these years was overstated by that amount of money; was the base built on that level? Ms. Laird replied their federal revenues were projected from a zero base and did not overstate their anticipated revenue from Medicaid. Mr. Ghiggeri asked whether the division was anticipating approximately $300,000 more in FY 96 and approximately $400,000 in FY 97 than what they actually earned. Ms. Laird said that was a good estimate. Mr. Ghiggeri asked whether the 1994 revenue figure was overstated by $400,000. Ms. Laird said the reason was the division greatly increased their home and community based waiver revenue. Mr. Ghiggeri asked whether the committee was looking at a $700,000 increase. Ms. Laird said that was correct. Referring to medication costs, Mrs. Evans asked whether there was adequate funding in the division's budget for the new types of drugs. Dr. Cole reported he had met with southern Nevadan physicians and asked them to look strategically at the medications that each patient was receiving and how they were being prescribed. He said they are trying to do everything they can to improve compliance and lower the risks to patients. The department has asked physicians to prescribe medications that would not afford people an option for suicide. By taking that direction, Dr. Cole stated they have had to switch to the more expensive medications (Prozac, Zoloft) which have fewer side effects and if there is an inadvertent ingestion it doesn't have a lethal outcome. The department is attempting to balance cost against safety and against efficacy at the same time. Dr. Brandenburg remarked the central office is monitoring carefully that particular line item, notifying Dr. Cole when the budget has become overexpended so he can take the necessary administrative action with his physicians. Mrs. Evans asked the doctors to address the adequacy of their budget for meds. Dr. Cole replied for the next two years it would be quite a good match. Mrs. Evans asked for clarification regarding contract pharmacy services. Dr. Brandenburg said once they had contracted with Albertson's pharmacies some of their clients became more compliant as they had better accessibility to the medication. The department has renegotiated the contract with Albertson's to lower the cost. Dr. Cole stated although the cost per prescription has been decreasing, the success of their East Las Vegas office has overwhelmed the department. Ms. Tiffany asked whether the department had utilization review (UR). Dr. Cole said both NMHI and Southern Nevada Adult Mental Health have utilization review committees. The committees have a primary medical physician, a psychiatrist and a utilization review nurse that look specifically at bed resources and x-rays and in coordination with infection control, making sure labs are being ordered before antibiotics are being started and that there is appropriate follow-up. Ms. Tiffany asked whether the data is tracked by computer. Dr. Brandenburg stated the department does not have that type of sophistication. The department has requested two QA positions (one in the institute and the other in the southern Nevada budget) to be centralized in the division administrative budget in order to provide division-wide QA and UR services with appropriate software for tracking. Ms. Laird added without the AIMS one-shot, the department would not be able to track QA and UR in the north. Mrs. Evans asked about plans for utilization review at Mohave. Dr. Brandenburg said he planned to do this with the two QA individuals centralized within the division's administrative budget. He stated the division plans to provide the QA and UL services for Mohave as well as for the inpatient and outpatient programs. In regard to staffing at Henderson, Mrs. Evans asked whether the division will know their needs before budgets are closed. Dr. Brandenburg said he would not; he hoped the committee would give him flexibility to move staff from the West Charleston office to the Henderson office where there are more clients. Mrs. Evans asked the committee to turn to page 23C in their packet of information from Bob Guernsey to Ms. Laird dated January 25, 1995 (Exhibit E - exhibit on file in Legislative Counsel Bureau Research Library). Mrs. Evans asked whether the design was drawn by architects familiar with professionals working with mental health patients. Dr. Brandenburg said the architect had extenstive experience with designing in-patient facilities and maximum security forensic facilities. He noted his participation in the design of the 12-bed addition. Mr. Hettrick questioned the practicality of monitoring the day room doors. Dr. Brandenburg said the area will be a free standing acute unit. The staffing pattern for the unit will be separate from the rest of the unit. Staff will be stationed in the unit around the clock. Dr. Brandenburg indicated there would be no offices in the acute unit; it will be a direct custody unit where the staff and clients intermix and are constantly on the floor with each other. Referring to page 23A, Mrs. Evans asked for clarification regarding the division's CIP at Lakes Crossing. Dr. Brandenburg stated the institute study was not completed when the division first presented the budget. When he became aware the project was being considered, the Public Works Board was meeting that day and declined to include it. The division is asking for an addendum to the CIP for Lakes Crossing of approximately $572,000 to take into consideration the issues that were brought up in the institute study. Mrs. Evans asked whether the request had been discussed with the Public Works Board. Dr. Brandenburg said he discussed it with Tom Stevens and Richard Knapp (author of the addendum). Mrs. Evans advised Dr. Brandenburg to work with the legislative CIP subcommittee. Mrs. Evans requested more information on the institute study. Dr. Brandenburg reported he had received the final draft of the institute study and would have copies for the Legislature and advocacy groups within two to three weeks after finalization. He hoped to schedule a meeting with the architect who proposed the report and the Public Works Board so they could present the plan to the Legislature in great detail. In terms of the CIP, Dr. Brandenburg stated he wanted to continue with the request as submitted for the institute as it will provide the division and Legislature with a good framework for the 1997 session. Mrs. Evans questioned the operating budgets and staffing for Southern Nevada Mental Health and the Institute. Mr. Guernsey reported the staffing at Las Vegas Mental Health Center Inpatient was approved last session for 79 beds and 72 beds at the Institute. The inpatient bed count at both facilities has been significantly lower than the staffing. He noted there has been a change over the past few months in admission procedures at both facilities and stated the committee needed to know the updated projections for the inpatient census for each of the coming two fiscal years and what budget adjustments are required. Dr. Brandenburg believed the inpatient census was artificially low during the post biennium and the division needed to make sure they had sufficient staffing for the inpatient facilities in the north and south. He hoped to meet with Dr. Cole to provide the committee with projections. Senator Raggio requested an explanation of "artificially low." Dr. Brandenburg explained his theory that some individuals might have been deflected away from the inpatient unit in southern Nevada and referred to other facilities. Senator Raggio asked why Nevada Mental Health Institute was artificially low. Dr. Brandenburg replied they had developed a protocol with the municipal and district courts that will allow them to refer more homeless mentally ill to the division. The HUD grant will identify more homeless mentally ill and as a result through the case finding, the division will have more patients being referred to their inpatient unit. Senator Raggio asked what level of staffing was required to meet accreditation and standard of care requirements during the biennium. Dr. Brandenburg said he was attempting to develop those figures at the present time. In response to Senator Raggio's question on cost per day, Dr. Brandenburg said Southern Nevada was $465 per day and the Institute was $390. Senator Raggio requested the figures be furnished to the committee so they could be compared to the numbers in the budget. Mrs. Evans asked whether the performance indicators were based upon base budget or enhancements. Ms. Laird said the performance indicators in the budget reflect all of the Governor's recommendations. Mrs. Evans directed the committee to turn to page 1013 for budget review. MENTAL HEALTH-MENTAL RETARDATION - PAGE 1013 Dr. Brandenburg explained his request to move enhancement package 276 and 275 (two quality assurance positions), into the division's administration budget. He stated the centralization of those enhancement packages would allow him to have QA and utilization reviews throughout the division and be in a better position to assure compliance. Referring to enhancement package 177, the division's medical director, Dr. Brandenburg asked whether the position could be centralized within the division's administration budget. Keeping the enhancement package under Southern Nevada or the Nevada Mental Health Institute basically crystallizes the division administrator to that particular position. Dr. Brandenburg stated he did not know how to put the monies under a central budget so the division could appoint a medical director either from the north or the south. Mr. Hettrick asked Dr. Brandenburg what his plans were for the Deputy Administrator position. Dr. Brandenburg said he desperately needed the position for policy development and planning, compliance, and crisis problem solving at various agencies. The deputy will also serve as an advocate with various advocacy groups making sure the division is in compliance with the QA and UR issues. The deputy will have no direct authority over the existing medical directors or clinic directors. The division is in the process of recruiting for the position. Mr. Hettrick thanked the doctor for the much needed explanation. Mr. Hettrick asked Dr. Brandenburg to address the high cost of the division's computer request. Ms. Laird replied they used the amount provided to them by the Budget Division. Mr. Hettrick noted the figure had been significantly reduced, down to $3,500 or less for the computers, and suggested the number be corrected. Mrs. Chowning asked Dr. Brandenburg to explain what items the Commission deals with, the need to expand to 12 meetings, and how many of the seven members normally attend meetings. Dr. Brandenburg replied the Commission sets policy, provides the administrator with direction, and provides direct feedback from the community to the administrator and agency directors. It was Dr. Brandenburg's understanding that most of the commissioners attend every meeting; only one commissioner was absent at the last meeting. Mrs. Chowning asked Dr. Brandenburg to put his last statement in writing. Dr. Brandenburg yielded to Mr. Bruce Adams, Chairman of the Commission on Mental Health and Mental Retardation. Mr. Adams indicated the commission met every two months; each member comes from a professional mental health background. The commission has been very involved with mental health policy and have created mental health advisory boards who meet monthly with division staff in all areas of the state to specifically address ongoing crisis issues. The commission reviewed and helped plan the division's budget. He noted the commission was very concerned about the overall continuum of care; the division needs to provide services that keep people out of the hospital (the most expensive type of care). MENTAL HYGIENE/RETARDATION-REGIONAL TRAINING - PAGE 1019 Mr. Gordy Cronenberger, Personnel Officer and Training Coordinator for the division of Mental Hygiene and Mental Retardation read from prepared text (Exhibit F) and distributed an amendment to Budget Account 3176 to the committee (Exhibit G). Mr. Cronenberger indicated the budget provides training for the certification education program, as provided for in the statutes (NRS 433.279), for Mental Health and Mental Retardation Technicians and Forensic Specialists, for the improvement of professional staff providing direct care and the division's central office and agency support staff. The division currently has 33 technicians and forensic specialists that have completed the certification training out of 142 authorized personnel. The base budget provides funds for continuing the certification program for the other 109 technicians. The program pools resources and coordinates training across agencies by scheduling training needed by divisional personnel, thereby providing the greatest benefit for specialized training and avoiding duplication of effort. Training is provided through: University system registration fees, division training classes, other registration fees, contracts with training consultants, and State Personnel training classes. The Mental Retardation agencies maintain training programs within their own budgets and are not included in this budget. E-175 adjusts training resources for inflation and for necessary training not provided in the base year due to the vacancy in the Personnel Officer position which coordinates training. E-176 provides for the additional training which will be required for training new mental health staff recommended to be added in mental health budgets. E-720 will provide for the purchase of a computer operated projector system. The equipment will allow staff to visually present medical and educational data by encoding, presenting, discussing and correcting data all in one step, thereby saving a large amount of staff time. Mr. Hettrick questioned the negative value for the central office and CTC. Mr. Cronenberger replied money was transferred in from other agencies to the central office to provide computer training for support staff which is no longer necessary thus showing a negative amount for the two upcoming fiscal years. Mr. Hettrick questioned inflation increases in the E-175 category. Mr. Cronenberger explained training was not going on during the time the personnel officer position was vacant during the 1993-95 biennium. The division is presently projecting training on a continuous basis throughout the fiscal year, thus the inflation. Mr. Hettrick suggested there should have been an adjustment in the base budget to account for the vacancies. Ms. Laird explained it is adjusting the base to bring it back up to what the agency's budget was based on for the current biennium. She added it could have been done either way. Mrs. Evans asked why the Telex Magna Byte computer projection system wasn't part of the computer one-shot recommended on page A-39. Ms. Laird said it was a projector system which will be utilized with an existing computer and was one of the items that was pulled off for one-shots. Mr. Cronenberger added it was put into this budget as it was solely related to training. Mrs. Evans expressed the committee's concerns regarding the budget's absence of performance indicators. She requested the agency provide an adequate mission statement and measurement indicators in the future. Ms. Laird reported the agency made an error when the budget was prepared. The Southern Regional Training budget (under expenditures) is understated and should read $3,191 the first year and $3,554 the second year. A like amount should be reduced from the rural clinics training line so that number should be $751 the first year and $778 the second year. A memorandum with the changes was supplied to Mr. Guernsey (Exhibit G). Mrs. Evans skipped to Budget Account 101-3160, Community Training Centers, in order to accommodate guests in the audience who wished to testify. COMMUNITY TRAINING CENTER FUND - PAGE 1081 Dr. Brian Lahren, Executive Director for Washoe Association for Retarded Citizens spoke on behalf of the Nevada Association of Community Training Centers (NACTC), an association of all providers of community training center services. He distributed an NACTC fact sheet (Exhibit H), and a handout reflecting CTC funding corrected for inflation and population growth (Exhibit I). Dr. Lahren explained community training centers are reimbursed for services provided to the clients that are there. The centers provide employment training services, employment and supportive employment services (services provided to individuals who are being placed in competitive jobs in the community). He requested the staffing ratios the centers are reimbursed on for providing services to their clients be standardized at one common rate. The present 1:8 ratio generates $32,000 per year in total reimbursement of all clients who are present all the time. The 1:5 ratio generates $33,500. He suggested the ratios be standardized at the current rate of reimbursement at the 1:5 level which would allow the center to pick up the cost of the staff salaries and overhead associated with it. Dr. Lahren addressed adjusting the number of paid days per year to reflect the average absenteeism experienced by the centers. If average absenteeism is between 10 and 12 percent and there are 251 available workdays per year, at the 12 percent average absenteeism rate, the center should be able to draw in all of their money in 221 days instead of 251 days. Every day a client is absent simply subtracts money from the reimbursement rate the community training centers receive. Dr. Lahren related problems concerning CTC reimbursement payment delays. He recommended there be provision for a one time prepayment of two months average CTC reimbursement per center to cover cash-flow problems. Dr. Lahren suggested the certification process be returned to the CTC's as their responsibility. He said the agency would like to request an interim study be funded to review the whole issue of CTC services and reimbursement rates. Dr. Lahren yielded to Mr. Ed Guthrie, Executive Director of Opportunity Village. Mr. Guthrie distributed testimony in regard to Opportunity Village (Exhibit J). Addressing the waiting list problem, Mr. Guthrie said their research has shown in Clark County 259 new case management slots will be opening up over the next two years. The jobs in the training portions appear to have only 58 new slots in the recommended budget. Historically 65% of the people who have received case management services have received services through job and day training. The center is left 111 people short in terms of the necessary slots to meet the need for just those people who are receiving new case management slots. The state needs to open at least 170 new service slots in the area of jobs and day training during fiscal years 1996 and 1997. Mr. Guthrie's second issue was cash flow. Due to the center being on a post- payment mechanism (fee for service basis), it is difficult for the center to generate the money up front in order to pay their staff and to cover their costs. He also requested the state to recognize a realistic rate of absenteeism. He stated there should be a way to prepay or finance two months worth of operating for the agency so they can afford to provide the service and wait thirty days for payment from the state after the service has been provided. Ms. Claire Perigo, Executive Director of Disability Resources, Inc., a private nonprofit agency in Washoe County informed the committee there were alternative treatment facilities and alternative treatment options operating within the state that are in conjunction with the CTC's. She encouraged the committee to maintain (at the discretion of the administrators) the ability to develop individual client services on an individual basis because some of the clients do not utilize CTC services. Ms. Perigo's organization is providing community based employment for people with all disabilities. She stressed they have many success stories. Ms.Tiffany asked whether Ms. Perigo's organization ran into the same problems as the centers, i.e., the cash flow issue, staffing ratio formula. Ms. Perigo stated they have the same cash flow problem. Comparing her organization to the CTC's, Ms. Perrigo stated the CTC's are a contained environment where individuals report every day and spend most of their day doing social employment training. When a client is referred to her agency, he or she is taken into the community and given a job. Her organization's funding and pay funding is billed back on an hourly fee for service system which is somewhat different from the CTC's structure. The CTC has contained staff that have to be on duty every day. Mr. Allard asked what percentage of Ms. Perigo's clients become self-sufficient after being assigned a job and no longer need their services. Ms. Perigo said some funding sources provide ongoing support, so if the client fails they have the opportunity to obtain more training. She noted there are a variety of funding sources they access. Mr. Allard noted Ms. Perigo's organization was on the right track. Mr. Thomas Batten, Assemblyman, District 7, Reno encouraged the committee to maintain funding parameters that enable vendor agencies to competitively bid for service contracts (Exhibit K). He testified he ran a small janitorial business and that 90 percent of his employees were disabled individuals, many of which were referred by Ms. Perigo's organization. He indicated two of his employees were former substance abusers who are currently paying off their fines and treatment and are often commended for their quality of work. Mr. Batten stated he did not want the state to reduce the range of client choice or restrict the service delivery to agencies. He wanted to be able to have a broad base of service providers. Ms. Mary Winkler, Director, Ormsby Association of Retarded Citizens (OARC) in Carson City, described the functions of their community training center. She said 32 to 34 percent of the population they serve are presently employed in the community. She yielded to Mr. Dave Mercurio, Job Developer for OARC who introduced clients Mr. Sean Stanebrook and Ms. Tina Hall who explained their jobs and independent living situations. Mrs. Evans directed the committee members to return to the Community Training Center budget on page 1081. Mr. Jack Middleton, Director of Rural Mental Retardation Services for the Mental Hygiene and Mental Retardation Division, said the program between the state and private nonprofit corporations who have provided services has been very successful. He indicated the needs of the clients have changed drastically within the last decade. The waiting lists for supportive employment are extremely large. He reported 182 people are working; 70 are currently being supervised by community training centers. The remaining people have been placed by other agencies financed by funds applied to regional budgets. The 70 CTC clients are working an average of 26.7 hours a week, earning an average wage of $4.97 an hour which totals over one half million dollars a year in client earnings. Mrs. Evans asked Mr. Middleton to comment on the reconsolidation of budgets suggested earlier by Dr. Lahren. Mr. Middleton stated of the three regional budgets and $5 million CTC budget, 89 percent goes to CTC's (fiscal year 1997) in one form or another; the remaining 11 percent go to private providers buying supportive employment. In addition to the division's money, vocational rehabilitation gave his agency nearly $4.2 million of grant seed money to five of the CTC's to begin supportive employment programs. He concluded there were pros and cons to the consolidation into one budget. He agreed the issue should be decided by the Commission on Mental Health and Mental Retardation. Mrs. Evans asked whether Dr. Middleton's budget was adequate enough to chip away at the waiting lists. Dr. Middleton indicated due to the influx of money from rehab one year ago, the agency ended up with an $83,000 surplus which was divided up among the CTC's (distributed according to NRS 290). He stated 180 people are currently working that two years ago would have been in CTC's; there is a waiting list for supportive employment statewide of over 80 clients; and there are only ten people on their waiting lists for case management that require intensive CTC services. SOUTHERN NEVADA ADULT MENTAL HEALTH SERVICES - PAGE 1023 Mrs. Evans informed the agency of needed work on their performance indicators as they did not include information regarding waiting lists for services, percentage of in-patients previously admitted, average length of stay and length of time between admissions plus any client or family satisfaction data. She asked for an explanation of the drop in out-patient counseling projected in FY 95 at 1,512 hours vs the actual FY 94 of 3,413 hours; the increase projected was dramatic in FY 96 and FY 97. Mr. Joe Lamarca, Director, Southern Nevada Adult Mental Health Services (SNAMHS), reported the drop in service hours was due to the agency's move to more group therapy and contracting for services instead of using in-house therapists. Mrs. Evans instructed Mr. Lamarca to include the information in the agency's performance indicators in the future for tracking purposes. In regard to the dramatic increase of in-patient counseling in FY 96 and FY 97, Mr. Lamarca stated the budget was prepared before October when their numbers were down. Since then the agency has increased their therapy numbers and are exceeding the 3,413 hours and project more than 1,512 next year. Mr. Hettrick noted the 10,922 hours and 12,430 hours would triple the agency's actual for 1994. He asked how the agency would triple the number in FY 1996. Mr. Lamarca replied the agency was bringing on additional contract providers; without adding employees they would still be able to add services. The agency preferred contracting services as they only had to pay for actual direct client contact hours. Mr. Hettrick asked where the contract services could be found in the budget's decision modules. Mr. Lamarca replied it was under M-202 Demographic Caseload Changes, Outpatient Counseling. Mr. Gene Brown, business manager for SNAMHS, reported $308,000 for contract services was cut from the budget. When the performance indicators were put together there was $308,000 in the budget. He agreed to adjusting the performance indicators for future use. Mr. Hettrick asked for an explanation of Decision Unit M-300. Ms. Laird said due to a computer problem, a much higher amount was identified as the merit salary adjustments for the positions in the budget. The amount should have been $200,000 for the merit salary adjustments; instead the computer identified $1.2 million. The payroll amount in the base looks artificially low because of the error; the $1.3 total was subtracted from the base in the budget. In M-300 it adds the same amount back in; it took out too much in Category 01 in the base and puts back in the same amount. The total dollar amounts are correct; the merit salary amount was incorrectly calculated. In reference to the Merit Salary Adjustment, Mr. Jim Riggs of the Budget Office said there was a comparison made between two separate printouts of the salaries. In one printout, 9 psychiatrist salaries were left out. Their salaries impacted the amount by $1,360,000. Mr. Riggs said he would provide correct information to Mr. Guernsey. Mrs. Chowning asked about the new treatment site recommended under E-125 and whether there was need for bilingual staff and what were the anticipated client numbers. Mr. Lamarca indicated they have presently contracted with an agency to translate many of their documents into Spanish, Mandarin Chinese and other languages. The agency has contracted with outpatient counseling bureaus to provide services in languages other than English. The agency hoped to transfer many of their existing bilingual staff from their West Charleston facility to the north Las Vegas office to deal with the large Hispanic population. Mr. Lamarca explained 1,600 clients are served in the West Charleston facility; 60 percent will be moved to north Las Vegas, totaling 900 clients on opening day. Mr. Lamarca said they did not anticipate additional revenue. He reported he had discussed employee security issues with Catholic Community Services at Mrs. Chowning's suggestion and they had recommended the agency deal directly with the service's unemployed population for security guards. Referring to the agency's E-276 module (Quality Assurance Program), Mrs. Evans asked Dr. Brandenburg whether the Director's Office was being moved and what he hoped to accomplish by the move. Dr. Brandenburg said he wanted to centralize the QA services under the direction of the administrator so he can delegate staff to check the various clinics to make sure performance indicators are properly being followed. Mrs. Evans requested written information pertaining to Other Operating Expenses be given to the committee. SOUTHERN NEVADA MH/MR FOOD SERVICE - PAGE - 1035 Mrs. Evans asked for an explanation regarding why each agency paid a different rate per meal. Ms. Marjorie Pepper, Administrative Services Officer at Southern Nevada Mental Retardation Services said in order to maintain a viable food service contract, the agency developed a sliding scale based on the total number of meals served. If the number of meals served were to decrease, the cost per meals goes up. There is an internal sliding scale that has been developed to charge each agency for the actual number of meals they are served. This avoids drastic census changes or program evolution from adversely affecting the meal costs. The costs are not passed along to the other agencies, thus the reason for each agency paying a different rate. Mrs. Evans requested Ms. Pepper to provide further explanation of the sliding scale system to the legislative staff at a later time. Ms. Tiffany asked whether the budget was impacted by the federal government. Ms. Pepper said the budget was not touched by federal grants in any way. Referring to the M-100 module, Ms. Evans asked how the inflation rate was calculated. Ms. Pepper said the rate was calculated based on the inflation figures given to the agency by the Budget Division; 4 percent in the first year and 1.7 percent in the second. Mrs. Evans noted there was some disagreement with the figures and staff would check further into the matter. SOUTHERN NEVADA MENTAL RETARDATION SERVICES - PAGE 1063 Mrs. Evans said the committee's primary concerns were the adequacy of funding and waiting lists. Mr. Stan Dodd, Director of Southern Nevada Mental Retardation Services said he could address the waiting lists by program. Waiting lists for Case Management as of January was 202; waiting time for service at that time was 10 months. In the new budget the agency is budgeted for 259 new clients and the projected waiting list for June 1997 is 96 clients. The percent of needs met was 73 percent. Mrs. Evans asked whether the new budget would do anything to reduce the waiting time for those on waiting lists. Mr. Dodd said it would decrease due to the hiring of new case managers after the first quarter. The agency anticipated the waiting list to drop from 10 to 12 months to about 3 months. In the second year the agency will begin another waiting list if the intakes continue at the same rate. He reported the agency is receiving 300 new client referrals per biennium. RESIDENTIAL PLACEMENT - PAGE 1083 In regard to Residential Placement, the agency had 110 individuals on the waiting list as of January with a waiting time of 29 months. The agency is budgeted for 86 placements and anticipate a waiting list of 123 by the end of the biennium. Forty-six percent of the need will be met by the new budget. For Jobs and Day Training the agency currently has 36 individuals waiting for jobs; average waiting time is 3 months. The agency will be budgeted for 50 new jobs with a projected waiting list by the end of the biennium of 58 individuals. For Day Training the agency has a waiting list of 8 individuals; the waiting list is approximately one month. The agency anticipates a waiting list of 57 at the end of the biennium. If the Jobs and Day Training programs are combined, the agency anticipates a total waiting list of 115 individuals. Mr. Dodd added the new budget will almost eliminate the waiting list in the first year of the biennium and a waiting list will begin again in the second year of the biennium. NEVADA MENTAL HEALTH INSTITUTE - PAGE 1039 FACILITY FOR THE MENTAL OFFENDER - PAGE 1049 RURAL CLINICS - PAGE 1055 NORTHERN NEVADA MENTAL RETARDATION SERVICES - PAGE 1073 MENTAL RETARDATION HOME CARE - PAGE 1091 These budgets were not discussed. The meeting adjourned at 10:58 a.m. RESPECTFULLY SUBMITTED: ______________________________ Janine Sprout, Committee Secretary Joint Subcommittee on Human Resources/K-12 Assembly Committee on Ways and Means Senate Committee on Finance March 2, 1995 Page