IV. Examples of Current Initiatives, Projects, and Activities That Fill Service Gaps
DHSS Priority Area: Health Care Reform
Bring the Kids Home is an initiative to return children with severe emotional disturbances (SED) from out-of-state residential facilities to treatment in Alaska and to keep new children from moving into out-of-state care. Three primary goals guide the initiative:
- Significantly reduce the number of children and youth in out-of-state care and ensure that the future use of out-of-state facilities is kept to a minimum.
- Build the capacity within Alaska to serve children with all intensities of need.
- Develop an integrated, seamless system that will serve children in the most culturally competent and least restrictive setting as close to home as possible.
A primary BTKH goal is to increase access to home and community-based services within Alaska. Several strategies have been successful:
- New grants for in-state community-based services expanded services to 519 youth in FY2008 and 944 youth in FY2009. Of the FY2009 youth receiving services, 41 were accepted from out-of-state RPTC, 129 were diverted from out-of-state RPTC and 219 were diverted from more restrictive in-state care.
- Individualized Service Agreements (ISA) paid for services to stabilize a child at risk of movement into residential treatment in a community setting. For SFY 2009 less than 1% of ISA recipients were subsequently admitted to an RPTC (5 out of 506).
- Peer navigation provided support, parenting classes, and resource facilitation for families. For SFY 2008 and 2009, over 90% of the youth served who were at risk of out-of-home placement were able to remain in their own communities.
BTKH performance measures show the impact of these strategies:
- Between FY08 and FY09, admissions to out-of-state residential psychiatric treatment centers (RPTC) decreased by 45.5% (from 202 children to 110 children). The total decrease between FY04 (the high year for admissions) and FY09 was 85.4% (from 752 children to 110 children).
- Despite this decrease in admissions, the recidivism rate to RPTC decreased between FY08 and FY09 from 8.4% to 4%. This rate is significantly lower than the 20% recidivism rate during FY04 (the high year for recidivism).
- BTKH accomplishments impacted Medicaid expenditures:
- Medicaid expenditures for out-of-state RPTC decreased by 51.3% between SFY 2006 (the high year for expenditures) and SFY 2009 ($40 M to $19.48 M).
- Medicaid expenditures for in-state RPTC increased by 739% from SFY 1998 to SFY 2009 ($2.82 M - $20.87M).
- Building sufficient in-home and community-based services and supports for children with severe emotional disturbances and their families remains a priority.
- Enhancing school-based services to support mental wellness and support youth working on recovery while remaining in school.
- Developing early intervention services and treatment services that are accessible and appropriate for young children and their families to reduce the need for higher levels of care at a later age.
- Ensuring adequate services for transition age youth with behavioral health challenges aging out of the children’s system of care.
- Improving access to behavioral health services in rural areas and through tribal providers.
Beneficiaries of the Alaska Mental Health Trust are at increased risk of involvement with the criminal justice system both as defendants and as victims. Limitations and deficiencies in the community emergency response, treatment, and support systems make criminal justice intervention the default emergency response to the conditions and resulting actions of many Trust beneficiaries.
The Trust’s Justice for Persons with Disabilities Initiative began in 2004. A collaborative group, including The Trust, advisory boards, state and local government agencies, the court system, law enforcement, consumers, advocacy groups, community behavioral health providers, and others, has developed and is implementing the following strategies: (1) increase training for criminal justice personnel; (2) sustain and expand therapeutic court models and practices; (3) improve continuity of care for beneficiaries involved with the criminal justice system; (4) increase capacity to meet the needs of beneficiary offenders with cognitive impairments; (5) develop mechanisms to address the needs of Trust beneficiaries who are victims; (6) develop community-based alternatives to incarceration for beneficiaries; (7) develop a range of housing options to provide for varying needs of beneficiaries involved at different stages of criminal justice system; and (8) evaluate the initiative’s impact to improve justice for beneficiaries.
- The proven success of the Alaska Adult Guardianship Mediation pilot project led the legislature in 2009 to include funding in the court system’s FY2010 budget to continue the program. The Alaska Adult Guardianship Mediation project was created by the Alaska Court System in 2006 with the support of the Mental Health Trust Authority, to provide mediation in appropriate adult guardianship and conservatorship cases.
- Alaska’s first juvenile therapeutic court accepted its first participant in September 2008. The Fairbanks Juvenile Treatment Center (FJTC) is a voluntary therapeutic court, targeting juvenile offenders whose mental illness likely contributed to the commission of their offense.
- FY2009 marked the second year the Department of Corrections (DOC) operated a re-entry pilot project focused on Trust beneficiaries. The project is being piloted in Anchorage, Fairbanks, Juneau and the Mat-Su Valley. It is patterned after the evidenced-based practice Assess, Plan, Identify, and Coordinate (APIC).
- Access to comprehensive community based mental health and substance abuse treatment.
- Access to safe, sober, and affordable housing with comprehensive wrap-around case management support.
- Cross system coordination for discharge planning for Trust Beneficiaries being released from the Alaska Department of Corrections and the Alaska Psychiatric Institution into Alaska’s communities.
Outcome Data - Alaska Adult Guardianship Mediation project
- Program participants reached agreement on some or all of the issues in 87 percent of the cases mediated.
- Ninety-one percent of the participants were satisfied with their agreements.
- As a result of mediation, the court system avoided as many as 90 contested hearings over the pilot period, reducing the number of superior court cases and associated costs required to determine guardianship appointments.
The full evaluation report can be found at:
Alaska Judicial Council website http://www.ajc.state.ak.us/reports/adultguard.pdf
In 2003 the Division of Juvenile Justice launched an effort to ensure that Alaska’s juvenile justice system uses data and research-based practices effectively to inform its decisions—whether to ensure quality case management of individual juveniles or to help determine how to best allocate resources statewide. This effort continues on a variety of fronts:
To address the high incidence of behavioral health issues among system-involved youth, the Division hired more mental health clinicians at youth facilities; each of the Division’s eight secure youth facilities has at least one clinician on staff, with additional clinicians at larger facilities. A mental health clinician position in Anchorage will also assist probation officers in working effectively with youth who are not in youth facilities but living at home or other community-based settings.
Also through its participation in the Bring the Kids Home Initiative, the Division is facilitating community-based behavioral health services for youth and their families, enabling them to receive treatment and services close to home. For example, by using Bring the Kids Home funding and partnering with other Division is introducing the Parenting with Love and Limits program to Alaska. This evidence-based family coaching and therapy program will provide families with the tools they need to better manage their children’s behavior.
Due to a steady increase in the recidivism rate among youth released from the Division’s secure treatment facilities, thee Division is looking more closely at the characteristics of these youth and the services received to determine how to better serve them. The Division has formed two work groups that have made recommendations on working better with Alaska Natives and standardizing services for youth transitioning from institutions to their home communities.
The Division has developed and implemented a comprehensive Suicide Prevention Policy and Procedure for all secure juvenile facilities statewide. Suicide prevention training was developed by Juvenile Justice mental health clinicians and is provided for all Juvenile Justice officers and facility nurses.
A group of behavioral health specialists completed an analysis of alcohol and other drug services provided in our youth facilities at the Division’s request. Their recently completed report has been presented to senior Division managers who will determine how to better direct substance abuse services to improve outcomes for youth in Division facilities.
Recognizing the role of substance abuse as a factor contributing to delinquent behavior, the Division has implemented a screening instrument, the CRAFFT, to help identify potential substance abuse problems among youth when they first enter the juvenile justice system. This six-question screen is performed by probation officers, who can then make referrals based on responses to the questions.
- Step Up Program: This collaboration among the Anchorage School District, Nine Star Education and Employment Service, and the Division of Juvenile Justice, ,will provide educational services for youth who have been expelled from school or have otherwise exhausted all their educational options. The Step-Up Program opened in Fall 2009 with a small group of students and expects to expand in the coming years.
- The Division received three awards of financial support from the U.S. Office of Juvenile Justice and Delinquency Prevention to examine critical areas of agency operations: workloads of juvenile probation staff; training of all Division staff; and quality assurance. The awards enabled the Division to have experts nationally recognized in these subject areas examine Alaska’s strengths and challenges in meeting workload demands, training needs, and quality assurance, and will result in recommendations that will help guide Division operations and management in the coming years.
- Interstate Compact for Juveniles: The Division assisted the Alaska Legislature and Governor’s Office in passing House Bill 141 into law in 2009. The bill adopts a new agreement, developed by the U.S. Council of State Governments, that guides and facilitates the movement of adjudicated juveniles across state lines. Alaska now joins a majority of other states and territories that have adopted the new compact, enhancing the ability to track and monitor juveniles under court supervision that leave and enter Alaska.
- Culinary Arts Program: By partnering with the Alaska Department of Labor’s Workforce Investment Act program, and a local cooking school and catering business, the Johnson Youth Center in Juneau launched a culinary arts program for youth in the facility. In FY2009, thirteen youth received a certificate of completion from the culinary program, and the program is on course to continue in FY2010. During the 8-week class, students learn not just how to prepare and cook meals but also master techniques in managing kitchen and developing a budget. The students contributed culinary services to several community organizations and events.
- There is a continuing need for adequate assessment and community-based services for juvenile-justice youth, particularly those with mental health, substance abuse, and sexually offending behavior. In addition, community-based options such as crisis respite services are needed for youths with (or at risk of) severe emotional disorders, as they are sometimes are placed in secure detention due to a lack of community-based options.
- The need for crisis intervention and treatment options for families is critical. Two particular groups with needs are families with youth who have behavioral health disorders, and those in homes where family crises result in domestic violence. Services for families are resource-intensive, as needs range from training staff to work with and advocate for these families to implementing models that touch on various service systems. Yet meeting such needs is necessary if the state is going to interrupt the cycles of abuse, violence, and despair these families face.
Medicaid Waiver Rates
Providers of Medicaid waiver services for seniors and individuals with disabilities have experienced significant cost increases related to energy, health coverage, and workers’ compensation in particular, as well as overall inflation. Reimbursement rates had been frozen for years until providers received a very modest (4% to 6%) increase for FY 2009, but it does not compensate them for the full range of increased costs.
Advocacy groups are seeking a formal change in DHSS policy which would provide for automatic regular reviews of waiver reimbursement rates similar to those now received by hospitals and nursing homes. Senate Bill (SB) 32 was introduced during Alaska’s 26th Legislative Session.
- For FY 2009, advocated for and received a small increase in Medicaid waiver rates.
- Regular rate reviews (Medicaid and grant funded services) included in 2009 advocacy priorities for Trust-associated boards.
- DHSS receptive to discussions on incorporating regular reviews of waiver reimbursement rates.
- Providers are having a progressively difficult time remaining solvent in the face of un-reimbursed cost increases; if services’ viability is threatened, seniors and others may suffer.
- Unclear whether provision for regular reviews should be statutory or regulatory.
- Budget restraints due to low price of oil may inhibit commitment to regular rate adjustments.
In May 2004 a summit was held to develop a strategic plan for addressing the supply of workers in Alaska with a focus on behavioral health. Policy direction from that meeting included: (1) increase the supply of workers at all degree levels; (2) improve course and program articulation across all campuses; (3) increase cultural competence skills of the workforce, and (4) ensure curriculum reflects new practice trends including integration of substance abuse and mental health practices.
Following the summit, several major entities within Alaska partnered together to address current and future demand for behavioral health professionals. The partners include the University of Alaska, the Alaska Mental Health Trust Authority, and the State of Alaska, Department of Health & Social Services, Division of Behavioral Health.
The Trust, University of Alaska and DHSS are in their second year of jointly funding a workforce development coordinator who focuses on behavioral health workforce initiatives across the partnership. Additional partners, such as WICHE (Western Interstate Commission on Higher Education) and the Annapolis Coalition have been involved in the planning and implementation of strategies to address workforce needs of the beneficiaries.
Some of the ongoing activities to increase recruitment and retention are:
- Credentialing and Quality Standards;
- Loan repayment
- Marketing and a media campaign; and
- Wages & benefits
Training and education activities include:
- Alaskan Core Competencies for Direct Care Workers in Health and Human Services - WICHE (Western Interstate Commission on Higher Education) and the Annapolis Coalition worked with the three partners and finalized the Alaskan Core Competencies for Direct Care Workers. The competencies are designed to guide skill development with direct care workers, who are also referred to as direct support workers, direct support professionals, para-professionals, or technicians.
- New loan repayment program -Supporting Access to Healthcare Repayment Program (SHARP) provides a new state-managed loan repayment opportunity for primary care and behavioral health providers working in designated health professional shortage areas. Providers include physicians, nurse practitioners, physician assistants, social workers, counselors, psychologists, dentists, and dental hygienists.
- Alaska Psychology Internship Consortium (AK-PIC) – Alaskan providers with facilitation by WICHE (Western Interstate Commission on Higher Education) have developed a consortium that will allow Ph.D. students to complete accredited internships within Alaska. The first cohort will begin in the summer 2010.
- Alaska Psychiatric Residency – A coalition of government agencies, UA, hospitals and clinicians have partnered to address the critical shortage of psychiatrists in Alaska. A feasibility study and business plan has been completed.
- Recruitment and Retention. Alaska continues to have a significant need for additional health care providers that serve Trust beneficiaries, especially in rural areas. (See 2009 Alaska Health Workforce Vacancy Study). Across the state there is an immediate need for all levels of home and community-based, long-term care and behavioral health workers, from direct care to psychiatrists. While workforce recruitment and retention efforts are underway, we have been unable to directly impact the current crisis for additional direct care service workers across the state. Additionally, with the aging of the population, it is anticipated that the future will bring more demand for providers.
- Training and Education. Alaska has quality academic training and education available across the state but what is lacking is sufficient funding to provide a uniform and regulated process. Resources are needed to assist providers, agencies, workers and institutions with paying for training that might be currently available and/or required and to develop specialty training for direct care service workers that does not exist.
- Long Range Strategic Plan for the Health Industry Workforce. The State of Alaska needs a long range strategic plan for planning, implementing and funding workforce efforts. The future roles and responsibilities of the State of Alaska (DHSS, DOLWD, EED, AWIB), The Trust and the University of Alaska regarding workforce development (recruitment, retention, training and education) and the roles of each entity in the coordination, implementation, and funding for recruitment, training, professional development and academics. Currently plans are being drafted by the Alaska Health Care Workforce Coalition and the Alaska Health Care Commission.
Outcome data – See Figure WD-1
Other Examples of Current Initiatives, Projects, and Activities That Fill Service Gaps