Call to Order and Roll Call
The third meeting of the Interim Joint Committee on Health and Welfare was held on Monday, August 4, 2014, at 11:00 a.m., in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order 11:12 a.m., and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Julian M. Carroll, Perry B. Clark, Denise Harper Angel, Alice Forgy Kerr, and Reginald Thomas; Representatives Bob M. DeWeese, Kelly Flood, Joni L. Jenkins, Mary Lou Marzian, Reginald Meeks, Tim Moore, Darryl T. Owens, Ruth Ann Palumbo, Russell Webber, Susan Westrom, and Addia Wuchner.
Guests: Beth Jurek, Executive Director, Office of Policy and Budget, Cabinet for Health and Family Services; Teresa James, Commissioner, Department for Community Based Services, and J.P. Hamm, Executive Director, Office of Human Resource Management, Cabinet for Health and Family Services; Mary Begley, Commissioner, and Beth Jordan, Branch Manager, Children’s Services, Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services; Bill Doll, Kentucky Medical Association; Eric Clark, Kentucky Association of Health Care Facilities; Mark Brengelman, Hazelrigg & Cox LLP; Sarah S. Nicholson, Kentucky Hospital Association; and Marylee Underwood, Commonwealth Council on Developmental Disabilities.
LRC Staff: DeeAnn Wenk, Ben Payne, Jonathan Scott, Sarah Kidder, Gina Rigsby, and Cindy Smith.
Approval of the Minutes
A motion to adopt the minutes of the July 16, 2014 meeting was made by Senator Buford, seconded by Senator Clark, and adopted by voice vote.
Child Protective Services Staffing Caseload
J.P. Hamm, Executive Director, Office of Human Resource Management (OHRM), Cabinet for Health and Family Services, stated that the way personnel is recruited and retained is the foundation of how casework is done. DCBS is OHRM’s largest and most diverse client with 4,500 employees. Because DCBS and the cabinet are the only entity that employs workers in all 120 counties, recruitment and retention of employees varies within rural and urban communities. The commissioner and division directors are constantly looking at each of the counties, both in family support and social work areas, to see how employees can be transferred, recruited or moved to ensure quality outcomes. DCBS is always subject to turnovers. Family support workers begin at $24,000 per year and are not required to have a college degree, and social workers begin at $32,000 per year but are required to have a college degree. In the past several years the lack of raises, retirements, job burnout, and family reasons has cause the number of workers to decline. Some problems in recruiting and retaining employees are that the cabinet competes with the private sector and other government agencies that offer higher salaries. There are over 100 employees on some form of family medical leave, and their cases have to be given to other workers, causing caseloads to increase. In the past six months, DCBS has averaged 200 interested registrants per month. The DCBS commissioner works with the 11 colleges of social work, state and private institutions, to help improve the quality of the candidates that graduate. Since 2012, DCBS has either maintained or increased the number of staff while staying within its budget. In 2012, there were 3,153 field staff employees; currently, DCBS has 3,240 employees.
Teresa James, Commissioner, Department for Community Based Services, stated that child protective services and adult abuse caseloads are managed by employees classified as Social Worker I & II and Clinicians I & II. Caseloads are divided by the number of cases by the number of staff. Since July 2012, the past due cases have been reduced by 2,500 cases. DCBS continues to make aggressive efforts not to just close cases, but address the past due issues by safely and appropriately intervening. DCBS is looking for ways to keep cases from going beyond what is a reasonable timeframe and what is required in the administrative regulations. In July 2012 and July 2013, the APS caseload was 40.2 and 36 in July 2014. The CPS caseload for 2012 was 18.5, 2013 was 17.5, and 2014 was 17.7. Calls to the abuse registry in July 2012 were 12,500; July 2013 was 13,600; and July 2014 was 18,000. During this timeframe, calls that met the criteria and were investigated increased from 7,500 to 8,500. Out-of-home care cases went from 6,900 cases to 7,800 and back down to 7,600 currently. As long as there is substance abuse in Kentucky, children will have to be taken into care to ensure their safety. The number of high acuity level cases continues to rise because of mental health issues, substance abuse, and poverty. An increase in the number of children in care increases the number in caseloads and the number of investigations. There is a list of all the cases and who is covering them available daily.
In response to questions by Representative Westrom, Commissioner James stated that there are about 50 to 60 special tuition social work program students enrolled per semester with 20 to 25 graduates per semester. After students graduate, they can choose from 10 counties to work, but they agree to go anywhere statewide. Counties with the greatest need are given priority to select one of the graduates first.
In response to questions by Representative Moore, Commissioner James stated that of the 3,240 employees, 1,489 are CPS and APS workers and 1,751 are family support workers. Not included in the total are indirect employees that include specialists, supervisors, and associates. In July 2012 there were 9,664 CPS cases compared to 6,945 in July 2014. Strategies to manage cases on the front and back ends are being studied. In January 2014, workers started using the new documentation form that takes half the time to document information, is more targeted, and provides better clinical assessment of dynamics for safety and risk. One of the ways reduce caseload numbers is to provide funds to hire additional CPS and APS workers. The new healthcare benefit that provides substance abuse treatment to not only children but parents has made a huge difference and should reduce the number of children in care by stabilizing families.
In response to questions by Representative Owens, Commissioner James stated that the CPS caseload for Jefferson County was 18.78 in July 2012 and 17.3 in July 2014. The APS caseload for Jefferson County was 35.1 in July 2012 and 39.1 in July 2014. In the Jefferson County service region, 20 percent of the workers have been on the job a year or less. The national accreditation agency recommends 18 to 20 cases per worker. In Kentucky, a case is considered one case no matter the number of children in the family. If caseloads were to be measured by children and not families, the number of workers needed would double or triple. The legal statewide caseload in Kentucky cannot exceed 25 cases per worker. DCBS budget recommendations are submitted to the secretary of the cabinet who incorporates them into the cabinet’s budget recommendations to the Governor.
In response to questions by Representative Wuchner, Commissioner James stated that there is one centralized intake center in nine regions that receive calls from 8:00 a.m. to 4:30 p.m. Calls are redirected by staff to the appropriate region based on area code. From 4:30 to 12:00 p.m. there are individuals in Jefferson County that take reports. DCBS has a contract with Seven Counties in Jefferson County and only takes calls from individuals from 11:00 p.m. to 8:00 a.m., on weekends, and holidays. If an immediate response is necessary, a front-line worker is contacted. In 2012, a 24 hour/7 day per week web site was created for physicians, medical providers, and educators to report cases. The wait time for assistance is ten minutes.
In response to a question by Senator Buford, Commissioner James said that state regulations specify the types of skill sets required for front-line workers and do not recommend training someone with a two-year associate degree in healthcare to become a front-line worker because of the intensity and expertise required to do the job.
In response to a question by Representative Westrom, Commissioner James stated that there are only eight children in out-of-state placement.
Legislative Hearing on Executive Order 2014-560 relating to Reorganization of the Cabinet for Health and Family Services
Beth Jurek, Executive Director, Office of Policy and Budget, Cabinet for Health and Family Services, stated that Executive Order 2014-560 directs the Cabinet for Health and Family Services (CHFS) to reorganize the Department for Medicaid Services (DMS) and the Office of Administration and Technology Services (OATS) to improve supervision, communication, and incorporate oversight of managed care organizations (MCOs) responsible for providing Medicaid covered services to over one million Medicaid members. DMS’s administrative operations have been altered with the Commonwealth’s implementation of statewide managed care and Medicaid expansion. These major changes in Medicaid’s health care delivery and payment systems require a reorganized structure in order to accommodate the needs of the majority of Medicaid recipients now being served in a largely managed care environment. Transitioning from a primarily fee-for-service model to a primarily managed care model impacts multiple business functions such as budget and financial management activities, member and provider communication, Medicaid Management Information System (MMIS) requirements, eligibility policy and management, and MCO utilization reports, provider networks, and MCO performance monitoring.
The cabinet proposed a reorganization plan aimed at defining key roles in a managed care environment to serve both the existing Medicaid members as well as the new individuals enrolling in the Medicaid expansion. Personnel with similar functions and expertise will be placed organizationally in the same area with distinct definition of responsibilities in order to promote the Center for Medicaid and Chip Services (CMCS) Medicaid Information Technology Infrastructure (MITA) framework, to foster business and IT transformation across the Medicaid enterprise, and to improve the administration of the Medicaid program. The cabinet is recommending that Medicaid roles and responsibilities be organized into the following six divisions within DMS: Fiscal Management, Program Quality and Outcomes, Provider and Member Services, Policy and Operations, Community Alternatives, and Program Integrity. The DMS Division of Information Systems will be abolished and its functions transferred to the OATS where the Division of Medicaid Systems will be established. These changes will align all Medicaid system functions into one centralized area for greater efficiency and oversight. There are no fiscal impacts, and all changes will be within the current CHFS budget allocations. The organizational enhancements are designed to improve efficiency and provide more effective management structure, and make the functions of the department more descriptive of the agency’s function. The cabinet has thoroughly evaluated the structure and streamlined it wherever possible. Positions will be established only as needed within the current personnel cap. Therefore, the changes will be budget neutral.
A motion to accept Executive Order 2014-560 was made by Representative Jenkins, seconded by Representative Palumbo, and approved by voice vote. A motion for a roll call vote was made by Representative Moore, seconded by Representative Wuchner, and approved by voice vote. After a roll call vote, there were 11 yes votes, 7 no votes, and 0 pass votes.
Legislative Hearing on Executive Order 2014-561 relating to Establishment and Operation of the Office of the Kentucky Health Benefit Exchange
Beth Jurek, Executive Director, Office of Policy and Budget, Cabinet for Health and Family Services, stated that Executive Order 2014-561 directs the Cabinet for Health and Family Services to establish the Kentucky Office of Health Benefit (KHBE) and Health Information Exchange (HIE). The Kentucky Health Care Improvement Authority is established under Chapter 304-17B of the Kentucky Revised Statutes as an administrative body attached to the CHFS for administrative purposes. The KHBE and HIE shall not establish procedures or rules that conflict with or prevent the application of the Affordable Care Act (ACA). The kynect Advisory Board is created and attached to the cabinet for administrative purposes. As a result of the Patient Protection and Affordable Care Act, effective January 1, 2014, individuals now have access to health coverage through the newly established KHBE. Individuals and small businesses can use the exchange to purchase affordable health insurance from a choice of products offered by qualified health plans. The exchange ensures that participating health plans meet certain standards and facilitate competition and choices by rating the quality of health plans. Individuals and families purchasing health insurance through the exchange may qualify for premium tax credits and reduce cost-sharing if their household income is between 138 and 400 percent of the federal poverty level. The exchange also coordinates eligibility and enrollment with the State Medicaid and Children’s Health Insurance Programs (CHIP) to ensure individuals eligible for those programs have affordable health coverage. The cabinet was designated the lead for the KHBE due to the large number of health-related programs housed within the cabinet. The Governor’s Office of Electronic Health Information (GOEHI), created by executive order in 2009, is also housed within the cabinet. GOEHI developed the Kentucky health information exchange and coordinates the work with health care providers through the Commonwealth in guiding implementation of electronic health information technology. The personnel impacts will be budget neutral based on existing funding. The organizational enhancements being made to the cabinet are designed to improve efficiency and appropriately satisfy the requirements of the federal grants while remaining budget neutral.
In response to questions by Representative Moore, Director Jurek stated that the executive order was drafted by the Governor, acting on behalf of the Commonwealth, and filed with the Secretary of State’s Office. House Bill 235, enacted in 2014 and containing the executive branch operating budget, allocated $30 million in 2015 and $26 million in 2016 for the Kentucky Health Benefit Exchange.
A motion to accept Executive Order 2014-561 was made by Senator Clark, seconded by Representative Marzian, and accepted by voice vote. A motion for a roll call vote was made by Representative Moore, seconded by Representative Wuchner, and approved by voice vote. After a roll call vote, there were 11 yes votes, 7 no votes, and 0 pass votes.
Children’s Behavioral Health Update
Mary Begley, Commissioner, and Beth Jordan, Branch Manager, Children’s Services, Department for Behavioral Health, Developmental and Intellectual Disabilities (BHDID), Cabinet for Health and Family Services, stated that 20 percent of Kentucky’s children and youth may have a diagnosable behavioral health problem, ten percent may suffer from a serious emotional disability, 66 percent report at least one traumatic event by age 16, and 14 percent do not graduate from high school on time. Suicide is the second leading cause of death among youth ages 10 to 24 years. Sixty percent have behavioral health challenges and do not receive the help needed. Before 1980, Kentucky had a single state funded children’s psychiatric facility. After 1980, Kentucky began to focus more on children, youth, and families, and by the 1990s, a System of Care (SOC) infrastructure was created. The Department for Behavioral Health, Developmental and Intellectual Disabilities (BHDID) received the first Substance Abuse and Mental Health Services Administration (SAMSHA) SOC grant that focused on integrating mental health into schools and building relationships with families. Kentucky also received a SAMHSA grant for a statewide family network and statewide youth council. Local Interagency Councils (LIACs), Regional Interagency Councils (RIACs), and State Interagency Councils (SIACs) were created in statute. Kentucky implemented a statewide Interagency Mobilization for Progress in Adolescent and Child Treatment (IMPACT) program. The Department for Juvenile Justice separated from child welfare.
In the 2000s, the Kentucky Invests in Developing Success NOW (KIDS NOW) was created to implement programs focused on family and young child well-being, including early childhood mental health. BHDID received a second SAMHSA SOC grant that focused on serving youth with co-occurring mental health and substance use challenges in school settings, also an early childhood component. BHDID also received a SAMHSA grant that focused on building the capacity of clinicians to treat youth with mental health and substance use. Kentucky received a third SAMHSA SOC grant that focused on integrating early childhood mental health program and KY IMPACT to more comprehensively service ages 0 to 5 years. The Department for Public Health received a MCHB perinatal depressions grant and the Division of Behavioral Health received a SAMSHA youth suicide prevention grant.
Systemic barriers to effective care included lack of adequate funding, limited home and community-based services and supports, reliance on overly restrictive, expensive, and ineffective services, fragmentation of the system when families and youth have multi-system needs, limited provider network, limited evidence-based interventions, disparities and disproportionality, limited engagement with families and youth, inadequate accountability, and over reliance on psychotropic medication as the sole intervention. In 2013, BHDID was awarded a SAMHSA SOC Expansion Implementation cooperative agreement that provides human and fiscal resources to support expansion and redesign efforts. The strategy to improve outcomes includes increased access, an enhanced infrastructure, and high quality services and supports.
In response to a question by Senator Thomas, Ms. Jordan stated that the Department for Public Health has received federal grants where the HANDS program can now serve more than just first-time parents in over half of Kentucky’s counties. BHDID has a perinatal depression project pilot that identifies mothers who are pregnant or shortly after post partum who meet criteria for a major depressive disorder. In seven regions, the mothers are referred to the community mental health centers (CMHCs) who have clinicians trained specifically in best practice shown to work in home for pregnant moms with depression.
Adjournment
There being no further business, the meeting was adjourned at 12:28 p.m.