The 6th meeting of the Interim Joint Committee on Health and Welfare was held on Monday, December 11, 2006, at 1:00 PM, in Room 154 of the Capitol Annex. Senator Julie Denton, Co-Chair, called the meeting to order at 1:12 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, Tom Buford, Perry B. Clark, Denise Harper Angel, Joey Pendleton, Richard "Dick" Roeding, Ernesto Scorsone, Dan Seum, and Johnny Ray Turner; Representatives Scott W. Brinkman, James R. Comer Jr., Robert R. Damron, Bob M. DeWeese, David Floyd, Joni L. Jenkins, Mary Lou Marzian, Stephen R. Nunn, Darryl T. Owens, Ruth Ann Palumbo, Jon David Reinhardt, Ancel Smith, Kathy W. Stein, and Addia Wuchner.
Guests: Dr. Dan Kenady, M.D., University of Kentucky, Chair of the Cancer Consortium Steering Committee, American College of Surgeons; Dr. Tom Tucker, Ph.D., Kentucky Cancer Registry; Rob Sprang, Director, Kentucky TeleCare Program, University of Kentucky College of Medicine; Judy Levey, Executive Director, Homeless and Housing Coalition of Kentucky; Rick McQuady, Chief Officer, Kentucky Housing Corporation; Dr. Edgar Wallace, LCSW, LCAS, MAC; Marty White and Bill Doll, Kentucky Medical Association; Rob Sprang, Kentucky Telehealth Network; James Cecil, Kentucky Department for Public Health, Cabinet for Health and Family Services; Elizabeth Caywood and Bobbie Walters, Department for Community Based Services, Cabinet for Health and Family Services; Patty Dempsey, The Arc of Kentucky; Marlene Gordon, Executive Director, The Coalition for the Homeless; Doreen Miller, Ph.D., Executive Director, Renee Brusie, Jan Buchanan, Heather Marcus, CSW, Chad Liner, Ron Ashton, Mary Singleton, Arthur Hensley, Ronnie Cross, Carol Carr, Robert Booth, and Doug Crowdus, Kentucky Consumer Advocate Network; Diane Robertson, Kentucky Department of Kentucky; Clyde Caudill, Jefferson County Public Schools; Yolonda Kelsor, Kentucky Consumer Advocate Network and National Alliance on Mental Illness; Jim Kimbrough, Protection and Advocacy; Russell Harper, Christian Care Communities; and Sarah S. Nicholson, Kentucky Hospital Association.
LRC Staff: Murray Wood, CSA; Barbara Baker, Miriam Fordham, DeeAnn Mansfield, Ben Payne, Gina Rigsby, and Michelle Woods.
Senator Denton and Representative Burch recognized Representatives Steve Nunn and Jon David Reinhardt for their service to the citizens of the Commonwealth of Kentucky with dedication and integrity throughout their tenure as members of the Kentucky House of Representatives and the Interim Joint Committee on Health and Welfare of the Legislative Research Commission.
A motion to adopt the minutes of the November 15, 2006 meeting was made by Senator Buford, seconded by Senator Roeding, and adopted by voice vote.
A motion to amend 922 KAR 2:170 & E that establishes criteria for implementation of the voluntary quality rating system for Type I licensed childcare centers, and establishes the amount of each monetary incentive awarded to a participant in the STARS for KIDS NOW program, was made by Senator Buford, seconded by Senator Roeding, and adopted by voice vote. A motion to accept 201 KAR 28:090 - establishes procedures for annual renewal of licenses for occupational therapists and occupational therapist assistants, 201 KAR 28:220 - specifies the per diem amount for members of the Kentucky Board for Occupational Therapy for the performance of their duties, 900 KAR 6:030 - provides for the adjustment of expenditure minimums for capital expenditures and major medical equipment, 921 KAR 1:420 - establishes procedures for distribution of child support payments, 922 KAR 2:170 & E - establishes criteria for implementation of the voluntary quality rating system for Type I licensed childcare centers, and establishes the amount of each monetary incentive awarded to a participant in the STARS for KIDS NOW Program, 922 KAR 2:210 & E - establishes criteria for implementation of the voluntary quality rating system for Type II licensed child care centers and certified family child care homes and establishes the amount of each monetary incentive awarded to a participant in the STARS for KIDS NOW program, as amended was made by Senator Buford, seconded by Senator Roeding, and accepted by voice vote.
The first presentation was by the Dr. Dan Kenady, M.D., University of Kentucky, Chair of the Cancer Consortium Steering Committee, American College of Surgeons, and Dr. Tom Tucker, Ph.D., Kentucky Cancer Registry, on Kentucky's comprehensive cancer control. Cancer control is "the use of proven prevention, early detection, diagnosis, treatment and continuing care intervention strategies to reduce cancer incidence, morbidity and mortality in defined populations." The Kentucky Cancer Action Plan was published in 2001. The Kentucky Cancer Program received a five-year grant from the Centers for Disease Control and Prevention (CDC) for planning and implementation of a statewide comprehensive cancer control plan. Kentucky is one of 49 states to receive a grant.
To implement the state plan, the Kentucky Cancer Program, the Department for Public Health, and the American Cancer Society established the Kentucky Cancer Consortium, a broad-based coalition of stakeholders that include medical and public health officials, insurers, educators, employers, survivors, policymakers, advocates, and volunteers. The KCC consists of a steering committee and four work groups, one for each priority area, to implement state-level goals and strategies. All 15 Area Development Districts have a regional cancer partnership that carry out programs at the regional and local levels. The Kentucky Cancer Action Plan, updated in 2004, serves as a blueprint for statewide coordination of public and private cancer control resources and efforts. The plan includes 12 objectives and 28 strategies in four priority areas: prevention, early detection, treatment, and quality of life. The KCC devoted its first three years to identifying gaps in the continuum of cancer care in the state and to building a cancer control infrastructure that represents a broad spectrum of integrated disciplines. KCC members have backgrounds in such diverse fields as public health, education, business, nutrition, and smoking cessation.
Representative Stein asked if the KCC had an opinion about the effectiveness of the HPV vaccine, and Dr. Tucker stated a KCC task force is focusing directing on this issue. They are in favor of the vaccine to lower the incidence of primary cervical cancer.
Representative Marzian asked if the breast and cervical cancer screening funding was reauthorized in the federal budget, and Dr. Tucker stated that it had passed the U.S. House of Representative and is pending in the United States Senate. Representative Marzian asked about the 446 women in the study diagnosed with early stage breast cancer. Dr. Tucker said they were age 65 and approximately three-quarters of them were on Medicare.
Senator Seum asked where are we in terms of an "all purpose cancer screening with today's technology." Dr. Kenady stated that the problem is cancer is 500 to 600 diseases, and different groups would be screened for different things.
Representative Owens asked if the project's focus is regional data. Dr. Tucker said data is collected both regionally and by other characteristics of person such as age, gender, and race that may have higher risk factors for specific types of cancer. Representative Owens asked if specific regions have particular types of cancer, and Dr. Tucker said that cancer does vary greatly by region. For each cancer that has a proven intervention strategy, each region is reviewed and then groups at high risk are identified within the regions. Dr. Tucker stated that a web site to help locate the data is www.kcr.uky.edu.
Representative Burch asked how communities receive and deal with information that identify areas where high degrees of cancer exists. Dr. Tucker stated the regional cancer partnerships involve local communities and district cancer councils in all 15 Area Development Districts. Representative Burch asked if the HPV vaccine should be mandated. Dr. Kenady stated that there are many factors against mandating the vaccine, but it is important that the public is educated about the advantages of the vaccine as soon as possible.
Senator Denton asked if there had been a push back on immunization to see if there would be side affects, and Dr. Tucker said no. He cautioned that even though someone has received the vaccine, they still need to have regular pap smears.
Senator Harper Angel asked that the KCC provide information to legislators for community meetings held in their districts to help get information out about Gardasil, the HPV vaccine.
Representative Burch, Co-Chair of the Families and Children Subcommittee, presented the subcommittee report. They met that morning and heard testimony from Ms. Kathy Adams, Assistant Director, Mr. Jim Grace, Assistant Director, and Mr. Mike Grimes, Adoption Branch Manager, Division of Protection and Permanency, Department for Community Based Services (DCBS), Cabinet for Health and Family Services, about the activities and research of the cabinet on services related to relative placement and adoption of foster children by relatives. They indicated that there are several different types of arrangements for children not living with their parents including: independent adoptions which do not involve DCBS, relative custody of children with DCBS involvement, cabinet custody and placement in kinship care with a relative, cabinet custody and placed in foster care with relative or other foster parent, and, relative foster parent adoption.
They indicated that there are different benefits and barriers to these arrangements. Currently, there are about 6,900 children in the custody of the cabinet who are in foster care placements and an additional 7,911 children in the kinship care program. Few services or assistance are available from the cabinet unless DCBS is involved. They indicated that the lack of resources is sometimes a barrier to relative adoptions because after adoption, most assistance ceases.
The criteria for home evaluations, the kinship care program, and relative foster parent training were presented. They also presented research conducted by the cabinet on randomly selected cases to determine the use of best practices. The study asked questions related to case quality. Data was presented that showed an increase in relative placements since May 2005. The data show that children exiting to relatives leave foster care two to five times faster than other children. The data also indicated that improvements are needed in case worker monthly visits to the homes of children placed with relatives.
Data from the 2003 Kentucky Foster Care Census was presented on the needs of relative foster care providers. As many as 90 percent of relatives caring for children indicated that they did not have training to deal with special needs of the child in their care. Many indicated that they needed additional supports for their child and several indicated problems with the birth parent not visiting the child. The cabinet is currently planning several strategies for facilitating relative placement where appropriate.
The subcommittee heard a presentation by Mr. Paul McElwain, Director, Division of Nutrition and Health Services, Department of Education. The department administers several programs that promote quality nutrition and nutrition education to Kentucky students and encourages and facilitates physical activity opportunities in schools. Mr. McElwain indicated that schools in Kentucky have taken a variety of approaches to integrating physical activity into the school day. He indicated that as required under KRS 160.345(11), the department collected and reported to LRC on how the schools are providing physical activities in schools. The department is not required to collect and report information on reducing obesity in schools. A motion by the co-chair to accept the report was approved.
Representative Stein and Senator Roeding, Co-Chairs of the Aging, Disabilities, Independent Living, and Long-Term Care Subcommittee reported the subcommittee had met that morning and heard testimony about the University of Kentucky's Council on Aging in the College of Public Health. The Donovan's Program provides life-long educational opportunities for senior citizens with tuition waivers and enrollment assistance. The program serves about 100 citizens per year, and approximately 48 participants have earned 50 college degrees, including five doctorates. Enrichment classes for wellness and arts have about 1,000 enrollees each year. The subcommittee also heard about the Ohio Valley Appalachian Regional Geriatric Educational Center that provides continuing education in geriatrics for health professionals through a consortium involving University of Kentucky, University of Louisville, University of Cincinnati, and Eastern Tennessee State University. Federal funding for this center has been cut and they are seeking additional funding to keep the center operational. The Council provided a brochure for the 23rd Annual Summer Series on Aging, scheduled to take place in Lexington on June 12-14, 2007.
The subcommittee then heard from the Acting Commissioner of the Department of Aging and Independent Living, advocates, parents of children with disabilities, and a consumer about problems with the implementation of the Consumer Directed Option (CDO) for non-medical services that is available for Medicaid recipients in certain waiver programs. The cabinet is working with advocates and consumers to address problems in the administration of the program that include: eligibility and assessment for the program, the paperwork processes, training for people responsible for case plans and financial activities, how budgets are to be developed, and workman's compensation issues. The cabinet is developing a technical assistance team to meet on December 19 to work through all the issues identified. Additional staff are on loan to the Department of Aging and Independent Living to assist with program implementation. The subcommittee requested an update on progress at its next meeting. A motion to accept the report by the co-chairs was approved.
Next, Representative Nunn and Rob Sprang, MBA, Director, Kentucky TeleCare Program, University of Kentucky College of Medicine, gave an update on the Kentucky TeleHealth Network (KTHN). Representative Nunn stated that House Bill 177 from the 2000 Regular Session created a Telehealth Board and Kentucky TeleHealth Network (KTHN). The network is a work in progress and has a tremendous amount of potential. Mr. Sprang reported that many health problems result from poor access to healthcare resources and economic and geographical barriers contribute to access problems. Using communications technology to extend healthcare resources to all Kentuckians gets the right care to the right people at the right time in the right place. KTHN now includes over 70 sites and is a model for other states. Kentucky's PROACT disaster preparedness and response network is a national model. Mr. Sprang said that healthcare is the greatest challenge. Telehealth is a cost-efficient way to bring patients and clinical resources together and strengthens rural economies.
Senator Buford asked if there would be a savings to Medicaid if they would pay for primary care consultations. Representative Nunn stated there could be savings from not having to transport patients to and from doctor appointments and clinics. Primary access can save money because a condition can be treated before it requires emergency room use and/or hospitalization. Senator Buford asked if the University of Kentucky has an obstetrician is available through the TeleHealth Network. Mr. Sprang said yes. Mr. Sprang said that one of the challenges faced by the network is that the legislation is permissive, and, physicians are reluctant to participate if they are not assured of reimbursement. Senator Buford asked about cost for Medicaid to pay for primary care. Representative Nunn stated that Medicaid is required to reimburse for specialty care now, but not for primary care.
Representative Marzian asked if physicians and ARNPs would need to be credentialed or licensed to participate in the network. Mr. Sprang said a provider must be credentialed just like other healthcare. He has worked with Joint Accreditation of Health Care Organizations (JAHCO) and there is a streamlined process for credentialing that is easier than traditional privileging and credentialing. Representative Nunn said that a provider would have to be part of the network to be reimbursed. Representative Palumbo asked if there is a charge to join the network, and Mr. Sprang said no.
Next Dr. Edgar Wallace, LCSW, LCAS, MAC, and Bob Burch testified about treatment for substance abusers. Dr. Wallace stated that his hope is to open The Serenity Center, a therapeutic treatment community. (A ten-minute tape on Triangle Residential Options for Substance Abusers, Inc. - TROSA was shown.)
Representative Wuchner asked if residents in the program were court assigned or volunteers, if some had dual diagnoses of substance abuse and mental illness, and if a reduction of recidivism has been documented. Dr. Wallace said many residents were court assigned and many residents did have a dual diagnosis. He said that the program had a 100 percent employment rate, a good recovery rate, and low recidivism rate.
Representative Marzian asked about the cost of the two-year residential program and who is responsible for payment. Dr. Wallace stated there is no cost to the person. The individual works at a job the entire two years and a percentage of the resident's earnings goes into a savings account. When an individual leaves, approximately $2,000 to $3,000 has been saved. A car that has been refurbished by residents in a body, frame, and mechanic shop on campus is also given to each resident who has completed the program.
Next, Marlene Gordon, Executive Director of the Coalition for the Homeless, Judy Levey, Executive Director for the Homeless and Housing Coalition of Kentucky, and Rick McQuady, Chief Officer of the Kentucky Housing Corporation, and George Pickford, testified about homelessness in Kentucky. Ms. Gordon stated that the Coalition for the Homeless (TCH) is part of the Kentucky Interagency Council on Homelessness. The council and the Kentucky Housing Corporation developed a ten-year plan to end chronic homelessness. The plan and work of the TCH is to address the root causes of homelessness not just continue to manage homelessness. The report indicates that prevention is a better strategy to address the complex issue. Some homeless people have high school diplomas, some suffer from mental and physical illness, some are veterans and some have substance and chemical dependency issues, and approximately 28 percent of them work but make less than $10 per hour.
Mr. Pickford testified that there is no greater feeling than to have your own home. Having a place to go home to has helped keep him out of jail.
Ms. Levey stated that although agencies work together to count the number of homeless people in Kentucky annually, it is very difficult to get an accurate count. The estimated number, which is required by the U.S. Department of Housing and Urban Development (HUD) annually, is estimated to be 19,000. HUD's definition of homelessness includes people in emergency shelters and people living outside, but it does not include the thousands of people without a fixed night-time residence, people sleeping doubled or tripled up on couches and floors, or those living in severely substandard housing. In Kentucky, the urban and rural homeless are different. The most common rural homeless person is a 35 year old single woman with two children and a high school education. A typical urban homeless person is a single male in his early 40s, although the Coalition for the Homeless in Louisville's recent data shows that many of the urban homeless were part of families prior to entering homelessness. Federal policies have shifted and HUD now primarily funds housing but not services. In response to the changes, housing providers have formed new partnerships with social service providers to maximize resources. Funding for services to help people remain in stable housing is a constant and ongoing challenge.
Mr. McQuady stated that the Governor's plan to End Homelessness calls for the creation of additional supported housing units, and identifies the need for funding and coordination of support services, the need for improved discharge planning, and the need for prevention initiatives. Over the last two years, the KHC has funded 679 new permanent supported housing units in Kentucky. The Affordable Housing Trust Fund bill, passed during the 2006 Regular Session, provides additional resources to fund additional supportive housing units statewide. The KHC has focused its resources on meeting the housing needs of those who are most in need and difficult to serve. This includes those who are homeless, those at risk of becoming homeless and those who have special needs such as a physical or mental disability. Kentucky's efforts have been recognized by the United States Interagency Council on Homelessness.
Safe Havens is a program that provides rapid re-housing for victims of domestic violence, homeless families with children, and homeless individuals with persistent and severe mental illness. KHC has allocated $10,000,000 over two years to provide at least 2,000 temporary housing vouchers to qualified individuals and families. In addition to rental assistance, case management, services are provided to all participants to help them move toward self sufficiency. Partnerships have been established with several organizations and government agencies to provide needed services to these populations. Availability of individual development accounts allow participants to receive a two for one federal match on any savings up to $2,000.
Recovery Kentucky is an initiative that will provide housing and recovery services to help Kentuckians recover from substance abuse that often leads to chronic homelessness. While those seeking recovery will initially be housed in one of ten transitional housing facilities located throughout the state, each recovery project is required to have a permanent housing plan that includes the continued availability of services for as long as they are needed. To date there have been groundbreakings for seven of the ten projects. The KHC and the Kentucky Interagency Council on Homelessness are working with communities throughout the state to assist them in creating their own ten-year plans. The plans will reflect many of the priorities of the state plan and will also identify needs specific to the homeless population in their communities and regions.
Representative Burch asked how many houses would be needed for the approximately 19,000 homeless people in Kentucky. Mr. McQuady said that there is a significant need for not only homes, but for affordable rental housing statewide. Representative Burch asked how many houses would be built from the Affordable Trust Fund. Mr. McQuady stated that the anticipated amount from the fund will be $5.4 million annually, and $9,500 to $10,000 will be spent per unit.
Representative Stein asked how the Affordable Housing Trust Fund is funded. Ms. Levey stated that the fee was spread across 23 recording instruments at the county clerk's office and $6 of the fee goes into the trust fund. Mr. McQuady said that collection of the fee started in August 2006, and in the first two months, $940,000 was placed into the fund. Ms. Levey stated that part of the fund pays for home repairs, and some goes to people with extremely low-income who have critical housing needs. Ms. Gordon stated that federal funds cannot be used for prevention.
Next Doreen Mills, Ph.D., Executive Director, and Heather Marcus, CSW, Volunteer, Kentucky Consumer Advocate Network (KYCAN), and Mary Singleton testified on peer support services for individuals with mental illness. Trends have shown that when the state mental health budget is cut, it impacts state hospitals, emergency rooms, law enforcement, and communities. When peer support services are included within the continuum of community care, the mental health system expands quantitatively and qualitatively. Research supports the effectiveness of peer-support services. Social support is better than isolation, mental health improves and symptoms decrease, hope and empowerment fosters independence, and communication with providers improves. There is a fundamental shift in recovery when consumers change the way they participate in treatment. Meaningful involvement can ensure that consumers lead a self-determined life in the community, rather than remaining dependent on the mental health system for a lifetime. KYCAN's mission is "To employe mental health consumers to have hope, to take personal responsibility, advocate, educate, and to represent the consumer community before public and government bodies."
The B.R.I.D.G.E.S. Program is a ten-week course with a manual with three major components: empowerment, recovery, and psycho-education. Since 2002, 430 KYCAN consumers have participated in the program. Of the 430 participants, 75 percent reported being hospitalized on average one to two times per year before taking the course. After taking the course, 97 percent reported no relapse and no hospitalization. The cost for one individual to stay 14 days at Central State Hospital is $12,500, and at a 97 percent success rate, the program has saved taxpayers $4,874,170. KYCAN helps individuals to live full lives, proving that someone with mental illness can function well in society with supports, make positive contributions to society, use experience of mental illness as a source of knowledge, learn from and teach others, and recover. Ms. Singleton told the committee about her experience with mental illness and how she found help when she entered Haven House and participated in the Building Recovery of Individuals, Dreams and Goals through Education and Support (B.R.I.D.G.E.S.) Program, one of KYCAN's Peer-Support programs. She stated that it is important to start with prevention. She said that the road to her recovery was a challenge, but she continued because she could see the light at the end of the tunnel. Ronnie Cross, Affiliate Coordinator, Bowling Green-Warren County, stated there are approximately 200 consumer community members. The B.R.I.D.G.E.S. Program will be taught at a Bowling Green consumer center opening in January.
Senator Denton asked of the 97 percent of individuals not rehospitalized or having relapses, what percentage are on Medicaid. Ms. Marcus said that most are Medicaid recipients. Ms. Mills stated that the majority of KYCAN's programs are typically offered to individuals with severe, persistent mental illness.
There being no further business, a motion to adjourn at 3:46 p.m. was made by Representative Comer, seconded by Representative Burch, and adopted by voice vote.