The 6th meeting of the Interim Joint Committee on Health and Welfare was held on Monday, December 17, 2007, at 1:00 PM, in Room 149 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:10 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, Alice Forgy Kerr, Joey Pendleton, Dick Roeding, Ernesto Scorsone, Dan Seum, and Katie Stine; Representatives James R. Comer, Jr., Robert R. Damron, Bob M. DeWeese, David Floyd, Joni L. Jenkins, Mary Lou Marzian, Reginald Meeks, Darryl T. Owens, Ruth Ann Palumbo, Kathy W. Stein, Susan Westrom, and Addia Wuchner.
Guest Legislator: Representative Carl Rollins.
Guests: John Tarrant, Department of Corrections, and Rob Sprang, Director, Kentucky Telecare, University of Kentucky, Co-Chairs of the Telehealth Board; Steven Davis, Inspector General, Sandra Brock, Office of the Ombudsman, and Jackie Strader, RN, BSN, State Long-Term Care Ombudsman, Cabinet for Health and Family Services; Deputy Undersecretary Tom Emberton, Cabinet for Health and Family Services; Terry Brooks, Executive Director, Kentucky Youth Advocates; Tim Lucas, Kentucky State Police; Susan Hunt, Community Hospice; Ann Hollen and Angeleta Hendrickson, Kentucky Long-Term Care Ombudsman Program; Jan Gould, Kentucky Retail Federation; Nancy M. McKee, Wyeth; Pam Jenkins, Kentucky Blood Center; Elizabeth Caywood, Department for Community Based Services, Cabinet for Health and Family Services; Ron Ashton and Ed Heimbrock, Kentucky Consumer Advocate Network; Marnie Mountjoy, Department for Aging and Independent Living, Cabinet for Health and Family Services; Gene Huff, Marymount. Medical Center; Virginia Sturgeon, Kentucky Adoption Coalition; David Ruhes, NUYF; Wayne Johnson, Kentucky Association of Health Care Facilities; Steve Davis, Inspector General, Office of the Inspector General, Cabinet for Health and Family Services; Patty Dempsey, the Arc of Kentucky; Shane O'Donley, Certificate of Need Office, Cabinet for Health and Family Services; Cindy Heine, Prichard Committee; Jim Kimbrough, Protection and Advocacy; Sarah S. Nicholson, Kentucky Hospital Association; and Anne Joseph, Kentucky Kids and Families and Kentucky Task Force on Hunger.
LRC Staff: Murray Wood, CSA; Barbara Baker, Miriam Fordham, DeeAnn Mansfield, Ben Payne, and Gina Rigsby.
A motion to adopt the minutes of the November 19, 2007 meeting was made by Senator Pendleton, seconded by Senator Denton, and adopted by voice vote.
Terry Brooks, Executive Director, Lacey McNary, and Makeda Harris, Kentucky Youth Advocates, gave a presentation on the Blueprint for Children. Mr. Brooks said that for the last twelve months approximately 60 groups worked to draft a six-year strategic plan for Kentucky's children. The first part of the Blueprint is focused on "fair deal for working parents". The most shocking data point from the 2007 Kentucky KIDS COUNT Data Book was that the percentage of Kentucky children where neither parent has secure full-time employment is only one percentage better than post-Katrina. Until Kentucky tackles the economic well-being of families, we cannot tackle the well-being of children. Two recommendations to help families are creating a state earned income tax credit and curbing predatory practices in the state.
The second focus of the Blueprint is a "fair opportunity for every child". The main focus continues to be on early childhood. The third focus is "safe and healthy families". He said that according to a working paper from the Annie E. Casey Foundation entitled "States Ranked on the Basis of Child Well-Being for Children in Low-income Families", in some states the health status of low-income children and the health status of middle and upper income children is about the same. In the western part of the U.S., low-income children's health status fairs better than middle and upper income children because these states have very aggressive and innovative health insurance programs for low-income children. The report cites five states with the biggest gap in health status between low-income and middle to upper income children, and Kentucky is one of them. He said that the report states that in a number of areas in Kentucky, low-income children are in the top 20 in the nation in family, neighborhood and community supports; cognitive development and educational achievement, Kentucky's low-income children are rank 28th or 30th; in both mental health and physical health, Kentucky ranks 48th in the nation.
He said that the first priority has to be on simplification of K-CHIP before K-CHIP can ever be expanded because there will be more children who should qualify but are not participating. In 2007, Kentucky is one of only two states that require a face-to face interview for enrollment. Another priority is better access to dental health. He said that only one in three K-CHIP children receive any dental services.
Representative Owens asked if the face-to-face interview requirement could be eliminated through amendments to an administrative regulation from the cabinet, and Mr. Brooks said yes. Representative Owens asked about why fewer children are getting dental care. He also asked about loan forgiveness as a way to attract more dentists. Ms. McNary stated that they are waiting on data to see if more children received dental care because of the recent increase in dental reimbursement rates. Ms. Harris said that one major issue is the shortage of dentists and the lack of availability of services in some areas. Mr. Brooks said that a school loan forgiveness program for dentists graduating from the University of Kentucky or University of Louisville dental programs, it could be a way to draw dentists from other states to serve in underserved areas.
Senator Harper Angel said Governor Fletcher's recent press release attributed the graduated driver's license (GDL) to Kentucky's improved teen death rate, and asked what can be done legislatively to affect the high death rate of young children. Mr. Brooks said that the data indicates that since the GDL has gone into effect, there has been a 33 percent decline in 16-year old fatalities. Nationally, the child mortality is improving by nine percent, but Kentucky's child mortality rate is getting worse by five percent. He said that national research indicates that booster seat legislation will help decrease the death rate of four- to eight-year old children.
Representative Stein stated that one way to track and retain dentists is to encourage and recruit students in high school. He said that the federal Rural Health Policy Office in Washington, DC, said that the time to attract rural dentist ten years from now is today in high schools. She asked why the free and reduced lunch information collected from schools could not be sent to the cabinet to help them find children who would qualify for K-CHIP.
Senator Roeding stated that if only 25 percent of dental graduates remain in Kentucky, how can we attract out-of-state dentists. Ms. McNary stated that is part of the thinking behind the loan forgiveness program. Mr. Brooks said that student loans forgiveness programs are most effective when someone has to practice in Kentucky for a set period of time.
Representative Owens asked how many children are enrolled in K-CHIP. He also asked how many more children are eligible but are not enrolled, and why. Ms. Harris stated that according to the data, an estimated 50,000 uninsured children are currently eligible but not enrolled in K-CHIP. She stated that there has been a decrease in outreach since K-CHIP began. She said that studies show that a face-to-face requirement and lack of continuous eligibility hinder enrollment. Mr. Brooks stated that it is hard for working parents to leave work and go through the enrollment process.
Senator Denton stated that Kentucky needs to look at other states to see how they verify eligibility without a face-to-face interview requirement. Mr. Brooks said that there are different ways to verify information. Ms. Harris said that the process would not change verification if face-to-face interviews were eliminated.
Representative Burch suggested that services could be more user friendly such as having more convenient office hours.
Representative DeWeese asked what data was used to arrive at 50,000 uninsured, unenrolled children. Ms. Harris said that the figures in the Kentucky KIDS COUNT 2007 County Data Book were from the 2005 U.S. census data. The Department for Medicaid Services data reports estimates there are approximately 65,000 uninsured Kentucky children. The location of the children by county can be found in the Data Book.
Representative Marzian asked that a letter be sent requesting the cabinet to make enrollment more accessible and to not require a face-to-face interview. Deputy Secretary Emberton stated that for the past eight months, the cabinet has been developing a web-based application where individuals can enroll. He said that they would be glad to come back to the next meeting and give more details.
Senator Buford stated that while a web-based program is a good idea, many people may not have access to a computer and we enrollment may only serve a small amount of people. Deputy Secretary Emberton said that people could access the website in a public library. Senator Buford said that transportation could also be a problem for many individuals. Senator Buford stated that one solution is to expand the dental programs at the University of Kentucky and the University of Louisville, but another is to offer free tuition and/or room and board to out-of-state dental students who sign a contract to serve a number of years in Kentucky. Senator Buford said that a few complaints he has heard from dentists is that half of the Medicaid patients do not show up for appointments, there is detailed paperwork, and low reimbursement rates.
Representative Jenkins asked if the cabinet could coordinate with public schools on eligibility for free and reduced lunch programs. Deputy Secretary Emberton said that the cabinet is working with Representative Owens on a project in Jefferson County that does this.
The following administrative regulations were referred to the committee for consideration: 201 KAR 21:032 - repeals 201 KAR 21:031 because it is unnecessary and repetitive of law set forth in statute; 201 KAR 21:060 - establishes professional standards for chiropractic offices and chiropractic clinics; 201 KAR 21:065 - defines the forms of solicitation or advertising that may be false, misleading, or deceptive and grants the responding consumer a seventy-two hour rescission period; 900 KAR 5:020 - establishes the State Health Plan for facilities and services; 902 KAR 20:009 - establishes licensure requirements for plan submission and the structural specifications and plan requirements for new construction, renovation, and maintenance of hospital facilities; 910 KAR 1:260 - establishes the Kentucky Family Caregiver Program; 920 KAR 2:040 & E - establishes staff qualifications and program standards for children's advocacy centers; 922 KAR 1:050 & E - establishes guidelines for the implementation of state-funded adoption assistance and federal Title IV-E adoption assistance; and 922 KAR 1:360 & E - establishes: (a) 5 levels of care based upon the needs of a child for whom the cabinet has legal responsibility; (b) a payment rate for each level; (c) gatekeeper responsibilities; (d) provider requirements; (e) procedures for classification at the appropriate level of care; and (f) procedures for determination of components of the model program cost analysis. A motion to accept the technical amendment for 900 KAR 5:020 was made by Senator Roeding, seconded by Senator Harper Angel, and approved by voice vote. Senator Borders asked for clarification about the comment "no longer required to consider the impact of open heart programs in bordering states on the need for additional program in Kentucky". Shane O'Donley, Director, Division of Certificate of Need, Cabinet for Health and Family Services, stated that the requirement was removed from the administrative regulation because Kentucky does not have the ability or capacity to validate information or survey data that is provided from hospital providers in other states to their state regulatory agencies. In 902 KAR 20:009, Senator Stine requested that considerations be made about energy efficiency when recommending new state construction. A motion to accept the administrative regulations as amended was made by Representative Damron, seconded by Representative Palumbo, and approved by voice vote.
The following prefiled bills were before the committee for consideration by House members: The first bill to be considered was Bill Request 24, AN ACT relating to the Kentucky Family Trust Program, sponsored by Representative Carl Rollins. Representative Rollins testified on the bill request. A motion to recommend passage as prefiled was made by Representative Stein, and seconded by Representative Jenkins. After a roll call vote of 12 yes votes, 0 no votes, and 0 pass votes, Bill Request 24 was recommended for passage as prefiled. The next bill to be considered was Bill Request 117, AN ACT relating to booster seats, sponsored by Representative Tom Burch. Representative Burch and Captain Tim Lucas, Commander of the Highway Safety Branch, Kentucky State Police, testified on the bill request. A motion to recommend passage as prefiled was made by Representative Owens, and seconded by Representative Marzian. After a roll call vote of 10 yes votes, 0 no votes, and 3 pass votes, Bill Request 117 was recommended for passage as prefiled. The last bill to be considered was Bill Request 118, AN ACT relating to health data collection, sponsored by Representative Tom Burch. Representative Burch explained the bill request. A motion to recommend passage as prefiled was made by Representative Owens, and seconded by Representative Stein. After a roll call vote of 9 yes votes, 0 no votes, and 4 pass votes, Bill Request 118 was recommended for passage as prefiled.
Senator Stine, Co-Chair, Families and Children Subcommittee, reported that the subcommittee met that morning and heard a report on outcomes of the HANDS program from Dr. Steve Davis, Deputy Commissioner, Department for Public Health and Brenda Chandler, Coordinator of the HANDS program. Cindy Heine, Associate Executive Director, Prichard Committee for Academic Excellence and Ed Monahan, Executive Director, Catholic Conference of Kentucky, testified in support of the HANDS program and its expansion to include three-year olds and all births, not just first births. T.J. Delahanty, Youth Development Specialist, University of Kentucky, presented the report required by 2006 SJR 184 which established the Kentucky Youth Development Council. Also testifying were Commissioner Mark Washington, who served as chair of the council, and Jessica Amburgy, staff for the council. Sandra Brock, Executive Director, The Office of the Ombudsman, Cabinet for Health and Family Services, presented the report required by 2007 HJR 137, which directed the cabinet to track and report on trends in the receipt, review, and resolution of citizen complaints about child protection programs and services. A motion to accept the report was made by Senator Buford, seconded by Representative Stein, and approved by voice vote.
Representative Stein, Co-Chair, Aging, Disabilities, Independent Living, and Long-Term Care Subcommittee, reported that the subcommittee met that morning and heard a presentation by Dr. Julie McKee on issues concerning oral health for the elderly and disabled. Lisa Lee testified about Medicaid Works the new Medicaid buy-in program for the disabled. Pat Dressman and Barbara Gordon gave a presentation on the state's home delivered meals programs for seniors. A motion to accept the report was made by Representative Stein, seconded by Representative Owens, and approved by voice vote.
An update on the Telehealth Network was given by the co-chairs of the Telehealth Board, John Tarrant, Department of Corrections, and Rob Sprang, Director, Kentucky Telecare, University of Kentucky. Dr. Tarrant and Mr. Sprang stated that Kentucky is a national leader in the development and utilization of telehealth technology and is becoming a national model. The 25-member Kentucky TeleHealth Network (KTHN) has been so successful, that there are now over 100 telehealth sites in Kentucky. State funds support the four telehealth training centers and the administrative costs for the Telehealth Board. The KTHN will conduct approximately 7,000 clinical encounters in 2007 and conduct over 30,000 contact hours of healthcare education. Telehealth technology helps provide clinical support in the home, as well as other services such as family visits for hospitalized patients. Telehealth is used to connect physicians and inmates, thus reducing the number of expensive, and possibly dangerous trips to receive medical care. The KTHN is also used to connect families with soldiers overseas. One important way telehealth is used is for emergency preparedness and public health disasters.
Deputy Secretary Tom Emberton, Cabinet for Health and Family Services, presented recommendations from the Blue Ribbon Panel on Adoption. He stated that the panel was established to evaluate and review the processes and protocols in the termination of parental rights leading to adoption as well as provide an assessment of the strengths and weaknesses of the child welfare system. The panel heard testimony about the child welfare system from parents, judges, practicing guardian ad litems and court appointed counsel for parents (GAL/CAC), child development specialists, foster care review board members, foster parents, and advocates. The Policy workgroup researched the development of a voluntary paternity registry, the need to enhance existing policies and the provision of additional supports for birth parents and children involved in the child welfare system. The GAL/CAC workgroup addressed issues related to the provision of counsel for children and biological parents and an appropriate fee schedule for attorneys serving in this capacity. The Transparency workgroup addressed the complex issues surrounding opening judicial proceedings for child abuse, neglect, and dependency cases to the public.
Deputy Secretary Emberton said that Representative Owens has prefiled legislation with recommendations from the GAL/CAC and Policy workgroups such as attorney training requirements, greater reimbursement for guardian ad litems, and cabinet staff training. The Transparency workgroup determined that additional information and research is required before a recommendation could be made on opening judicial proceedings for child abuse, neglect, and dependency cases.
Representative Floyd asked if there was any dissension in the workgroups that developed the legislation, and Deputy Secretary Emberton said he was not aware of any dissension from panel members.
Senator Roeding stated that he will have legislation during the 2008 Regular Session that directs the cabinet establish a punitive father registry to be called "The Fatherhood Information System of Kentucky". The purpose of the legislation is to ease the process of locating and notifying a man of his parental rights before an adoption of a child. He said that children under 12 who have been physically abused should not to have to testify in open court.
Senator Kerr stated that a large number of pregnant women are physically abused. Representative Stein said that more pregnant women are killed by homicide than any other death.
Commissioner Mark Washington, Department for Community Based Services, Cabinet for Health and Family Services, gave an update on the Boni Bill (2007 SB 59). Commissioner Washington stated that 638 incidents of safety concerns have been reported since the Critical Incident Reporting System (CIRS) became operational in November, 2006. Seven of the nine DCBS regions have hired full-time safety officers. The central office safety officer duties are being managed by a contract employee from Eastern Kentucky University until a full-time position is filled. He said that a thorough safety analysis has been conducted at each of the leased properties occupied by DCBS staff, and requests have been submitted to the Finance and Administration Cabinet to relocate and to renovate offices.
The department continues to work on suggestions from the Worker Safety Study Group to identify actual changes needed to policies, procedures, and related training. The final report recommendations include the creation of a Safety Oversight Committee to monitor, assess, and make recommendations regarding worker safety. The additional funding provided for frontline staff has enabled the department to increase the number of frontline protection and permanency staff by over 100 positions. The department learned of several recently developed GPS/satellite technologies at its National Safety Forum held this past October. The information will be incorporated into the next Request for Proposal that will be posted through the Finance and Administration Cabinet. The Study Group has made recommendations on the layout and setup for all future visitation rooms. The recommendations will also be incorporated into building renovations, space requests, and RFPs for neutral visitation sites.
The following nine recommendations were from the Human Services Worker Safety Study Group's final report: (1) have adequate numbers of well prepared human services workers must be continuously in place to serve the needs of vulnerable children and adults in the Commonwealth; (2) establish within the DCBS a redesigned position of Social Service Aide to assist protection and permanency workers and family support workers; (3) establish a separate, safe, home-like, family friendly room or location for visitation only that promotes healing, coaching, mentoring, and evaluation of parental/child interaction for all DCBS offices; (4) establish mandatory safety training for all DCBS staff; (5) establish a system for safety information sharing and intervention in high risk case situations; (6) establish a safety sharing information system and between DCBS and community partners; (7) continue assessments of all DCBS local offices to determine levels of safety and remediate when necessary; (8) implement and utilize appropriate safety technology within DCBS; and (9) create a Human Services Worker Safety Oversight Committee to advise and oversee the total implementation of recommendations concerning worker safety. The department requested $16.6 million for FY 2008-2009 and $23.9 million for FY 2009-2010 for the initial implementation of the nine recommendations in the final report.
Steven Davis, Inspector General, Cabinet for Health and Family Services, Sandra Brock, Office of the Ombudsman, and Jackie Strader, RN, BSN, State Long-Term Care Ombudsman, Cabinet for Health and Family Services, provided the committee with information on patient safety. Mr. Davis stated that Office of Inspector General (OIG) conducts licensure, certification, and life safety code surveys of health care facilities. The OIG inspects over 2,345 health care facilities annually, that include 37 levels of care. Of the 2,345 facilities, 939 are certified as participants in the Medicare and Medicaid programs. The OIG conducts over 4,000 investigations annually by 136 staff, which include managers and surveyors. The total number of complaints and standard surveys have increased over the past several years, but staffing has remained relatively the same. He said that one of the biggest challenges is to make sure the office does its work with the highest level of integrity and applies the standards consistently to every facility that it regulates.
Mr. Davis said a major concern is staff turnover, because when someone with years of education and experience leaves the position, it takes approximately two years to get another surveyor acclimated to the process. The five top concerns of surveyors are: (1) to be treated with dignity and respect by management; (2) prompt and consistent review of documents by management in central office; (3) more and focused staff training above required federal training; (4) access to better equipment, computers and vehicles, to conduct surveys; and (5) turnover.
Representative Palumbo asked about the vehicles. Mr. Davis stated that each region has three vehicles, and they share cars with child care and health care surveyors. When there are no state cars available, surveyors are required to take their personal vehicles and then submit a travel voucher for reimbursement.
Representative Floyd asked about the major source of complaints. Mr. Davis said that he would provide that information. Representative Floyd asked if a large percentage of complaints were from disgruntled former employees of facilities. Mr. Davis said yes, and also from family members, and DCBS employees.
Ms. Brock stated that the Office of the Ombudsman and the Office of the Inspector General are independent offices within the cabinet. The Ombudsman's Office has over 90 employees, and deals with any complaint that someone has with any program offered by the cabinet. She said that they deal with approximately 32,000 contacts by letters, e-mails, phone calls, and referrals. Ms. Strader said that in 1978, the federal Older Americans Act mandated that each state have an ombudsman program to identify, investigate and resolve complaints. The office provides education to consumers and residents and works with governmental agencies when needed or required. The Long-Term Care Ombudsman Office has developed a strategic plan for 2008. The office averages approximately 5,000 complaints from residents, family members, staff members, legislators, and consumers. The top five complaints are unanswered call lights, evictions and discharge planning notice, lack of dignity and respect, staff attitude, care plans or resident assessments, accidents and improper handling.
Ms. Strader stated that there are 15 district ombudsman offices statewide that have an ombudsman who makes routine visits or conduct complaint investigations in nursing facilities. The emphasis of the Kentucky Coalition for Person-Centered Care is to take the care model back to the interest, lifestyles, and choices of the resident in the nursing home. It emphasizes care practices, workplace practices, and the environment of the nursing home. Ms. Brock said that the provider community is reluctant because they are afraid they will not be able to comply with the regulatory agency. She said that the Office of the Ombudsman has submitted a proposal that would use some of the civil monetary penalty moneys to help the provider community implement care models while staying in compliance with regulations. A director of Quality Initiatives has been hired to educate providers about implementing culture change and how to stay in compliance.
There being no further business, the meeting was adjourned at 3:36 p.m.