The 1st meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, June 20, 2007, at 1:00 p.m., in Ballroom B, Second Floor of the Northern Kentucky Convention Center, Covington, Kentucky. Representative Tom Burch, Co-Chair, called the meeting to order at 1:05 p.m., and the secretary called the roll.
Present were:
Members: Representative Tom Burch, Co-Chair; Senators Perry B. Clark, Denise Harper Angel, Alice Forgy Kerr, Joey Pendleton, Dick Roeding, Dan Seum, Katie Stine, 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, Ruth Ann Palumbo, Brandon Spencer, David Watkins, Susan Westrom, and Addia Wuchner.
Guest Legislators: Senator David Williams and Representatives Rocky Adkins and Jimmie Lee.
Guests: Mark D. Birdwhistell, Secretary, and Tom Emberton, Jr., Deputy Secretary, Cabinet for Health and Family Services; Glenn Jennings, Commissioner, Department for Medicaid Services, Debbie Anderson, Commissioner, Department for Aging and Independent Living, Cabinet for Health and Family Services; Joel Griffith, Service Region Administrator, and Kate Goodenough Hackett, Northern Bluegrass Service Region, Department for Community Based Services, Cabinet for Health and Family Services; Dawn Denham, Executive Director, Boone County Success by 6; Dr. Kim Townley, Outgoing Director, Kentucky Early Childhood Initiative; David Allgood, Darla Bailey, and Mary Hass, Advocates for Restoring Medicaid Services; Ronnie Coleman, Schering-Plough; Naomi R. Miller and Carol Marck, Northern Kentucky Area Development District; Ron Ashten and Robert Booth, KYCAN; Rob Underhill, Dorcas Peach, and Pam Von Handorf, Cabinet for Health and Family Services; Sheila Hardy, Legislative Research Commission; Chris Goddard, Ph.D., Chief Executive Officer, HealthPoint Family Care; Ed Davis, Kentucky State Fraternal Order of Police; Gary Goetz and Ed Muntel, NorthKey Community Care; Ellen Kershaw, Alzheimer's Association; Rich Seckel, Office of Kentucky Legal Services; Leshia Zyman, United Way; Heather Nelson, Senior Services of Northern Kentucky; Emily Prabell, Tim McPrewitt, and Rosanne Nields, St. Elizabeth Medical Center; Bill Doll and Marty White, Kentucky Medical Association; Phyllis Culp, Department of Aging and Independent Living, Cabinet for Health and Family Services; Jim and Gary Beatrice, Business Benefits, Inc.; Anne Joseph, Kentucky Task Force on Hunger Covering Kentucky Kids and Families; Jan Gould, Kentucky Retail Federation; Karen Lentz, Johnson & Johnson; Judith Warren, Health Foundation of Greater Cincinnati; Lisa Ross, Dellisa Ford-Edwards, and Denise Goran, Brighton Center; Michelle Sexton, Children's Alliance; Jennifer Johnson, Kentucky Home Health Association; Becky Orsburn, Center for Independent Living; Makeda Harris, Kentucky Youth Advocates; Evelyn Tinker and Molly Dobson, KIPDA; Donna Brown, Kentucky Association of Health Care Facilities and Kentucky Association of Chiropractors; Linda Magee, Allen & Associates; Prentice Harvey; Katheryn Cook, St. Luke Hospitals; and Katie Nienaber.
LRC Staff: Murray Wood, CSA, Barbara Baker, Miriam Fordham, DeeAnn Mansfield, Ben Payne, Gina Rigsby, and Cindy Smith.
Representative Burch announced the Kentucky Court of Justice's Summit on Children to be held August 27-29, 2007 at the Louisville Marriott Downtown. Senator Stine read a resolution in memory of Senator Denton's sister, Cheri Lynnette Carman Sorley. A motion to adopt the resolution was made by Senator Stine, seconded by Senator Roeding, and adopted by voice vote.
Next a presentation on KyHealth Choices, Consumer Directed Options, and Money Follows the Person grant was given by Secretary Mark D. Birdwhistell and Commissioner Glenn Jennings, Department for Medicaid Services, Cabinet for Health and Family Services. Secretary Birdwhistell stated that the cabinet envisioned KyHealth Choices would: 1) improve the health status of Kentuckians enrolled in the program; 2) ensure people receive the right care, in the right setting, at the right time; 3) ensure the solvency of Kentucky Medicaid for future generations of Kentuckians; and 4) transform Kentucky Medicaid into a 21st century health care system. He said that technology, care management, and benefit design are tools that have helped departments within the cabinet be able to communicate with each other. The technology component is web-based with real-time eligibility verification, claims submission, adjudication, prior authorization, tracks controlled substances and will change e-health statewide. The benefit design component has improved access to services, and care management has improved the quality of care by moving from an illness model to a prevention model. KyHealth Choices changed from an 1115 waiver to a state plan amendment which gives the cabinet more flexibility. Kentucky Resource Market, a single point of entry for information for seniors and individuals with disabilities to access services, has been created in the Department of Aging and Independent Living.
Secretary Birdwhistell said that the Medicaid budget was balanced without reducing enrollment, services, or harming access to care. Kentucky has significantly reduced the number of uninsured and increased employer-sponsored health insurance in the last year according to the Kaiser Family Foundation. The changes to the Medicaid program has allowed the cabinet to attract and leverage external funding to help transform systems and services. KyHealth Choices and the Long Term Living Initiative are helping consumers direct and manage their personal assistance services according to their own specific needs. KyHealth Choices offers benefits plans for specific populations and provides greater choice of care to the consumer through the Consumer Directed Option (CDO), Self Directed Option Pilot, and Money Follows the Person grant. The Consumer Directed Option (CDO) program provides consumers the option and flexibility to control their non-medical services such as personal care, homemaker services, and respite care to stay in their homes and communities. Area Agencies on Aging and Independent Living will administer the CDO through Support Brokers and Fiscal Intermediaries. The CDO and Money Follows the Person grant are signs of Kentucky's commitment to expand choice to all Medicaid beneficiaries and to promote independence. The Long Term Living Initiative and the Department for Aging and Independent Living were created as a result of the modernization of the Medicaid program. Kentucky continues to make progress on the development of a full continuum of care for elder Kentuckians and those with disabilities.
In May, 2007, Kentucky Medicaid was award a $50 million five-year grant from the Centers for Medicare and Medicaid Services for the Money Follows the Person (Rebalancing) initiative that will eliminate barriers that prevent or restrict the flexible use of Medicaid funds to enable individuals in institutions to receive support for appropriate and necessary long-term services in the settings of their choice. The first year funds will be used to transition individuals that currently reside in an intermediate care facility for the mentally retarded/developmentally disabled (ICF/MR) or nursing facilities to community settings, The second year funds will be used to transition individuals with brain injuries that reside in facilities to community settings. The grant will allow funding for services not traditionally covered by Medicaid such as transportation, medical alerts, home adaptations, housing assistance, and technology. It will encourage continued coordination of services between the departments for Medicaid Services, Aging and Independent Living, and Mental Health and Mental Retardation Services, the Kentucky Housing Corporation, and the Transportation Cabinet. The goal is to transition 47 individuals by May 1, 2008 and 471 more individuals over the next five years. Nine employees will be hired to implement and maintain the program, and a monitoring plan will be developed to ensure the health, safety, and welfare of the participants.
Senator Harper Angel asked about the number of slots and implementation date of the Self Directed Option Pilot program. Secretary Birdwhistell said that the number of participants was limited to 200 because this program's scope of flexibility is broader than the CDO. The draft state plan amendment has been submitted to CMS, and the target implementation date is October 2007.
Representative Burch asked if the facility beds will be filled after an individual moves to the community. Secretary Birdwhistell said that most of the beds will be needed to meet the needs of Kentucky's senior population that is growing older at a disproportionate rate. Representative Burch stated that more should be done to help individuals stay in their homes instead of trying to find ways to help transition individuals back into the community from institutional settings. Secretary Birdwhistell stated that the CDO helps keep individuals from ever entering into an institutional setting, and the Money Follows the Person grant will help individuals transition from institutional settings to the community. Representative Lee stated that the new initiatives will allow individuals to get services that had not been eligible for Medicaid services before. Senator Roeding asked if the beds would stay in the same geographical area, and Secretary Birdwhistell said yes. Representative Lee said that it is appropriate to limit the number participating in the CDO program in order to allow the cabinet to make necessary assessments of the program. Representative Lee said that the Medicaid reform has curtailed the rate of growth without the loss of services to individuals.
Senator Stine commended the cabinet for raising the awareness of the importance of physical activity with the Get Healthy Kentucky Program and recognizing the need of better dental care.
Senator Harper Angel asked about when the Kentucky Resource Market would be statewide. Commissioner Debbie Anderson stated that the pilot program in began in Northern Kentucky but will become available statewide in October, 2007. Phase I is a single point of entry for access to aging care services. The next phase will be eligibility Medicaid, TANF, or other needed services.
Next David Allgood, Darla Bailey, and Mary Hass, Advocates for Restoring Medicaid Services (ARMS) gave an update on the Consumer Directed Option Program.
Ms. Hass stated that stated that the following are initiatives that the Advocates for Reforming Medicaid Services (ARMS) have advocated for: 1) Money Follows the Person (MFP); 2) Consumer Directed Option (CDO); 3) Home and Community Based Services (HCBS); 4) Self Directed Option (SDO); 5) Single Point of Entry (SPOE); and 6) the Department for Aging and Independent Living (DAIL). She said that rebalancing is an equitable redistribution of Medicaid long-term care dollars. It is about choice, not closing institutions. According to the 2007 Jim Worth Financial Figures for Kentucky Survey, the average cost of private nursing home care per day is $180 per day or $65,700 per year. The CMS-64 data from the Office of State Agency Financial Management reported on July 7, 2006 that Kentucky is spending 72 percent of total Medicaid dollars on long-term care institutional services and 28 percent on community-based services. The following are Kentucky's 1915(c) waivers: 1) home and community based for individuals who are elderly and have physical disabilities; 2) supports for community living for individuals with mental retardation and developmental disabilities; 3) acquired brain injury; and 4) Model Waiver II for individuals who are ventilator dependent. There are approximately 16,000 individuals enrolled in these waivers.
ARMS has had concerns with implementation of the training, the educational efforts for consumers and providers, budget processes, policy shifts, and related administrative regulations. The SDO pilot program will allow 200 consumers to purchase services and goods with a true flexible budget based on the person's needs. The single point of entry is a pilot program in Northern Kentucky that is a one-stop shop that is a single, easily accessible and invisible entry point for aging services. ARMS would like for the Department for Aging and Independent Living to be designated as the policy and program coordination focal point for services to people with all disabilities and older Kentuckians. She said that flexibility equals choice, and choice equals independence.
Mr. Allgood stated that all Kentuckians should have a choice in where they live in the community. ARMS was established in 2003 to advocate for the Medicaid program and to prevent recipients from losing their home- and community-based services. Studies show that individuals do not want to go into nursing homes. The cost of institutionalization went from $55,000 to $65,000 over the past two years. The cost of living in the community with services is between $14,000 to $25,000. While some individuals require a higher level of care, the majority of Kentuckians could live in the community. He stated that the initiatives will not succeed unless there is an equitable redistribution of long-term care dollars. Rebalancing is not about kicking people out of nursing homes and institutions, but about diversion. As of now in Kentucky, the system is geared toward institutional settings.
Representative Floyd questioned why the ARMS' "Long-Term Care in Kentucky" November 2005, pamphlet had grouped nursing home and assisted living together. He asked if it would be considered assisted living if an individual has a choice to apply funds however they choose. Ms. Bailey stated that assisted living should be a part of the long-term care delivery system. Representative Floyd stated that the 72 percent/28 percent split is only for long-term care dollars not the entire Medicaid budget.
Senator Clark asked what the committee could do to help. Ms. Bailey stated that they would like a commitment from each committee member to move toward rebalancing the long-term care dollars being spent to reach a 60 percent institution/40 percentage community balance by 2010, increase SDO slots from 200 to 1,000, and to help them advocate for better home- and community-based services.
Representative Marzian asked what percentage of the Medicaid budget is spent on long-term care. Commissioner Jennings stated $600 million of the $4.8 billion budget is spent on long-term care annually. Representative Marzian asked if the MFP participants would come from institutions or from homes or both. Commissioner Jennings stated the MFP part of the eligibility criteria for the CDO is a person would have had to been institutionalized six months to qualify for the transition services. The SDO individuals would come from an institutional setting to a less restrictive community setting.
Representative Brinkman asked if the SDO and MFP would include transportation and job coaching. Ms. Bailey stated that it does not cover transportation. Ms. Carrie Branahan stated that a SDO draft proposal has been sent to CMS that includes transportation and employment opportunities. Representative Brinkman asked what other states were providing funds to disabled individuals who want to work. Ms. Branahan stated that Alabama is the only state that has been approved for the SDO. Jan Day, Center for Accessible Living, stated that other states have accessed these services through a Benefits Counseling Grant. The Real Choices Grant developed a postsecondary education program that trained and certified direct care givers through KCTCS but because of the lack of enrollment, the program was discontinued.
Next Chris Goddard, Chief Executive Officer of HealthPoint Family Care, testified community health centers are America's safety net providers. He stated that CHCs provide a high, if not higher, quality of care as other practices, reduce the need for more expensive in-patient and specialty care services, and lower emergency room visits, thereby saving millions of taxpayer dollars each year. Studies show that community health centers save the Medicaid program approximately 30 percent in annual spending per recipient due to lower specialty care referrals, emergency room visits, hospital admissions, and prescription drug costs. HealthPoint is one of 16 statewide community health centers that provide care to approximately 224,000 patients annually.
He stated the medical navigator project is a new two-year project in Northern Kentucky designed to reduce the improper use of hospital emergency rooms. The goal is to improve health outcomes and reduce health care costs. Medical navigators will be hired to contact targeted patients to help them establish primary care medical and dental homes. He also presented legislative suggestions to increase health care cost transparency and to increase cigarette tax rates.
Representative Watkins stated that the number one health problem in the nation is the use of tobacco. Approximately 25 percent of Kentuckians smoke and 50 percent of Medicaid recipients smoke.
Representative Damron stated that there was a discussion about tying Kentucky's future cigarette tax rate to surrounding state averages. Legislators were told that it would be illegal to set tax policy based on the actions of other state legislatures.
Representative Burch asked how doctors at the CHC were reimbursed. Mr. Goddard stated HealthPoint is part of the Medicaid program and is reimbursed a set amount per visit.
A motion to adopt 201 KAR 2:260 - establishes the standards for the operation of an automated pharmacy system in a residential hospice facility (KY Bd. of Pharmacy) (AMENDED AT ARRS) and 201 KAR 36:070 - establishes the educational requirements for licensure for professional counselors (Bd. of Licensed Professional Counselors) was made by Senator Roeding, seconded by Representative Damron, and adopted by voice vote.
Next Leshia Zyman, United Way, stated that "Success by 6®" started in Minneapolis in 1988 and has become the largest network of early childhood coalitions nationwide. The goal of the project is to look at what is already available in the community and bring them together to better align the resources so children are prepared for kindergarten. The majority of brain growth occurs by the age of 3 years so it is important that children get stimulation and needed health care. The approach is wholistic, looking at every aspect of a child's life that may influence their success in school. Studies show that every dollar invested in high quality early care and education saves taxpayers up to $13 in future costs. "Success by 6®" can be successful in any county or community.
Dawn Denham, Executive Director, Boone County Success by 6® testified that children deserve to be healthy, safe, nurtured, and to succeed in school. Funding comes from equal partnerships between the United Way, the fiscal court, the local health department, the public library, and local cooperative extension. There are five focus areas: 1) data collection and analysis; 2) quality early care; 3) oral health; 4) early literacy; and 5) nutrition and physical activity. They are conducting their fifth year of kindergarten assessments for children to gauge the status of school readiness. They are also measuring trends in school readiness over time and using these findings to improve strategies of the initiative. Kindergarten assessments include cognitive ability, social-emotional health, adaptive ability, physical ability, communication ability, literacy, hearing, dental, vision, body mass index, and parent questionnaires.
Representative Burch asked if Success by 6® was available all over the county, and Ms. Denham stated that the mobile unit will visit any child care center that requests their services.
Representative Wuchner asked when a similar program would be implemented by the cabinet. Dr. Steve Davis, Deputy Commissioner, Department for Public Health, Cabinet for Health and Family Services, stated a Request for Proposal would be available soon and applications would be due back by fall. Approximately three to five counties would be chosen to develop a program similar program to Success by 6®.
Dr. Kim Townley, outgoing Director of the Kentucky Early Childhood Initiative and Division of Early Childhood Development, testified that the Revenue Forecast Group underestimated the tobacco settlement dollars and for SFY 2007, there was approximately $4.5 million one-time additional funds. These funds were used for programs that were reduced as the tobacco funds decreased. She gave an update on the Healthy Babies Campaign, Folic Acid Campaign, Substance Abuse Treatment Program for Pregnant and Postpartum Women, Universal Newborn Hearing Screening, Newborn Metabolic Blood Screening, Immunization Program for Underinsured Children, Eye Examinations for Children, Oral Health Education and Prevention Program, HANDS Voluntary Home Visiting Program, Early Childhood Mental Health Program, Children's Advocacy Centers, Access to Child Care Subsidy, STARS for KIDS Now, Scholarship Fund for Child Care Providers, Training Into Practice Project, Increased Licensing Personnel, Healthy Start in Child Care, Community Early Childhood Council Funding, First Steps: Kentucky's Early Intervention System, Early Childhood Development Authority, Business Council, Professional Development Council, and Evaluation of Initiative. She said that many of the initiatives have higher quality and have children who are having better outcomes.
Representative Brinkman asked why funding was cut for the folic acid program by approximately 55 percent. The local health departments perform these functions because funds available from the Master Tobacco Settlement have to be reevaluated each year. Dr. Davis stated that the folic acid program provides both the vitamin supplements as well as counseling. Health departments are still providing the vitamin supplements and are providing the counseling up as part of the normal women's health visit.
Representative Burch read a resolution in honor of Dr. Kim F. Townley, Executive Director of the Governor's Office of Early Childhood Development. A motion to adopt the resolution was made by Senator Roeding, seconded by Senator Harper Angel, and adopted by voice vote.
Next Tom Emberton, Jr., Deputy Secretary, Cabinet for Health and Family Services, gave an update of the implementation of the "Boni Bill" (07 Senate Bill 59). Deputy Secretary Emberton stated that $2.5 million was appropriated for staffing and $3.5 was appropriated for technology, office improvements, and visitation services. An agreement has been reached with the Justice and Public Safety Cabinet to provide front-line staff with 24/7 access to state criminal background checks by enabling the Department for Community Based Services (DCBS) to have direct access to the Law Enforcement Information Network (LINK). The reporting of incidents involving threats or attacks against staff and the establishment of an information system to track the incidents is operational. The Central Office safety liaison position and safety liaisons for each of the regions have been advertised and are in the hiring process. The anticipated start date for the Central Office Safety Liaison is July 1. A thorough safety analysis has been conducted at each of the 30 local DCBS high-risk offices. Requests have been submitted to the Finance and Administration Cabinet to relocate 14 local offices and additional requests are being prepared to relocate two more with 14 more renovations.
The Human Services Worker Safety Study Group was appointed by the cabinet secretary's Administrative Order in May, 2007, and held its first meeting on May 9. Members of the Operations Committee of the Human Services Worker Safety Study Group and staff in the Central office are working to evaluate and redesign the Standards of Practice (SOP) in place for investigations and service delivery to support the goals of child safety, permanency and well-being while incorporating principles of worker safety. The cabinet's internal personnel approval process has been streamlined, targeted recruitment activities continue to take place statewide, DCBS has increased their training capacity for new front-line staff, and local and regional staff are actively working registers to increase the number of filled front-line positions. The cabinet did not receive any vendor responses to the Request for Information to procure emergency response technology issued on May 25, and the RFI will be reissued to obtain information on the feasibility and cost of potential solutions. Cabinet staff have determined the number an location of all existing visitation rooms in existing local DCBS offices. The Operations Committee of the Human Services Worker Safety Study Group and the Central Office staff are working to evaluate and redesign the Standards of Practice in place for family visitation to support the goals of child safety, permanency and well-being while incorporating principles of worker safety. A national safety conference sponsored by the cabinet has been scheduled for October 9-11, 2007 at the Holiday Inn Hurstbourne, Louisville, Kentucky.
Next Joel Griffith, Service Regional Administrator, and Kate Hackett, Northern Bluegrass Service Region, Department for Community Based Services, Cabinet for Health and Family Services, gave an update on the Parent Advocacy Program. The Parent Advocacy Program was developed to improve outcomes for families in crisis and is based on a national model of child welfare reform. A parent advocate is someone who has had previous involvement with the child welfare system and now helps mentor other families through the system. Parent advocates or family mentors work mainly on a volunteer or contractual basis, work collaboratively with DCBS social workers, and train with the Annie E. Casey Foundation's "Building a Better Future" curriculum, provide support to birth families to prevent removals or disruptions, and/or assist with reunification action plans, bridge gaps between the agency staff, birth parents, and foster families to achieve case closure in less time, provide other extended support and resources to birth parents, participate in team decision making processes, assist with the development of the family action plan, and courage parent participation.
Parent advocates provide the following services: 1) help families find services; 2) provide information about available services; 3) provide information about DCBS; 4) coach families on visiting with children in foster care; 5) attend team decision meeting with families; 6) attend court proceedings with families; 7) transport families to services; and 8) attend meetings with social workers. Referral criteria is based on demographic needs of the region. Regions target children who are younger because data indicates younger children are at greater risk of entry into out-of-home care and re-entry into out-of-home care. Children with families in the Parent Advocacy Program experience one less move in their foster care placement than children of families without parent advocate services. Children in this program also spend 10.8 months versus 18.2 months in out-of-home care. Parent advocates are an integral part of child protective services that fully engages the family, provide unique perspectives and support to families in need because of their experiences, and improve family outcomes resulting in safe and permanent homes for children.
There being no further business, a motion to adjourn at 4:02 p.m. was made by Senator Roeding, seconded by Representative Comer, and adopted by voice vote.