Call to Order and Roll Call
The fourth meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, September 21, 2016, at 10:00 a.m., in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 10:05 a.m., and the secretary called the roll.
Present were:
Members: Representative Tom Burch, Co-Chair; Senators Ralph Alvarado, Danny Carroll, Denise Harper Angel, Jimmy Higdon, Alice Forgy Kerr, Reginald Thomas, and Max Wise; Representatives Robert Benvenuti III, George Brown Jr., Joni L. Jenkins, Mary Lou Marzian, Reginald Meeks, Phil Moffett, Tim Moore, Darryl T. Owens, Ruth Ann Palumbo, David Watkins, Russell Webber, Susan Westrom, and Addia Wuchner.
Guests: Don Stacy, M.D., Radiation Oncologist, dABR, cBioethics, Medical Liaison, Alliance for Innovative Medicine; Tim Feeley, Deputy Secretary, Cabinet for Health and Family Services; Adria Johnson, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services; Brandon Carlson, Cabinet for Health and Family Services; Judge Paula F. Sherlock, Jefferson Circuit Court, Family Trial Division 10; Katie Ann Lester, mother; Eric B. Durbin, DrPH, MS, Director, Cancer Research Informatics, Kentucky Cancer Registry; Lars Wagner, MD, Chief, Division of Pediatric Hematology/Oncology, Kentucky Children’s Hospital, Professor of Pediatrics, Children’s Miracle Network Research Chair in Pediatrics, University of Kentucky; Katie Bathje, MA, LPCC, Kentucky Cancer Consortium; Lynette Ponder, Personnel Associate, Lisa Payne, Social Service Supervisor, Susan Howard, Eastern Mountain Service Region, Jeff Culver, Katy Coleman, Rebecca Goggin, CPS investigator, Amy Preston, frontline worker, Fayette County, Department for Community Based Services, Cabinet for Health and Family Services; Vivian Hurt, retired social worker; Brenda Rosen, Executive Director, National Association of Social Workers; Gretchen Marshall, Assistant Director of the Division of Protection and Permanency, DCBS, Cabinet for Health and Family Services; Brandon Carlson, Executive Advisor, Office of the Secretary, Cabinet for Health and Family Services; Debbie and Ed August, parents; Jenny Glass; and Sarah S. Nicholson.
LRC Staff: DeeAnn Wenk, Ben Payne, Jonathan Scott, and Gina Rigsby.
Medical Marijuana
Don Stacy, M.D., Radiation Oncologist, dABR, cBioethics, Medical Liaison, Alliance for Innovative Medicine, stated that, as a cancer doctor, he treats patients who are dying or suffering from severe treatment or cancer-related side effects such as severe pain, nerve pain, nausea, loss of appetite and extreme weight loss, and mental disorders. Current standard medical therapy for these debilitating symptoms is not very effective and may cause severe side effects. After standard therapy has failed, cannabis has been highly effective for patients in treating these conditions. Some research shows that cannabis is an exit drug not a gateway drug and teen use decreases in states that have legalized marijuana.
The Alliance for Innovative Medicine (AIM) consists of physicians, medical professionals, law enforcement, and business professionals and serves as the voice for professionals who believe that medical cannabis should be legalized in the Commonwealth of Kentucky. Articles in JAMA Internal Medicine, Christian Science Monitor, The American Journal of Public Health, IDrugs, Health Affairs, and Cancer Epidemiology, Biomarks, and Prevention show that medical cannabis decreases opioid overdose deaths by 25 percent because it is a safer alternative to many of the prescriptions used now. It is virtually impossible for someone to overdose from cannabis. The opioid epidemic is a national problem. The NIH Medicinal Marijuana Expert Group, National Institutes of Health, and Trends in Pharmacological Sciences reports that medical cannabis acts faster with significantly fewer and less severe side effects versus Marinol, the synthetic version of THC. Dr. Vivek Murthy, United States Surgeon General, reported that since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased substantially. Nearly two million people in America have a prescription opioid use disorder contributing to increased heroin use and the spread of HIV and hepatitis C.
In response to questions by Senator Alvarado, Dr. Stacy stated that he agrees there needs to be more research and three-phase studies conducted, but his patients do not have the luxury of waiting years for results of the studies. Many oncology trials are switching to patient self-reported data. Because each patient is different, there needs to be a variety of options available such as capsules, creams, oils, and edibles. Because cannabis is still illegal on the federal level, providers are afraid of losing funds for services already being provided for terminally ill patients. Senator Alvarado said that he is keeping an open mind on the topic and wants to see more clinical trials on medical marijuana. Groups like the American Medical Association and the Kentucky Medical Association have also said additional trials are needed.
In response to questions by Representative Benvenuti, Dr. Stacy stated that some of his patients already use cannabis for pain because they do not have the luxury of waiting years for the results of the research. There are no documented cases of overdose of someone using cannabis.
In response to a question by Representative Benvenuti and Senator Wise, Dr. Stacy stated that he wants a legal, safe way to help his patients.
Senator Higdon read from a recent Politico article on South Carolina Senator Lindsey Graham’s evolution on the subject of legalizing marijuana. Senator Higdon stated that he is still on the fence about medical cannabis. One important factor will be how it is defined in legislation. He stated that he could support a bill like Senate Bill 304 from the 2016 Regular Session sponsored by Senator McGarvey that deals with end-of-life issues for Hospice patients.
In response to a question by Representative Owens, Dr. Stacy stated that each state has chosen a list of medical conditions where it is legal to use cannabis.
In response to questions by Representative Moore, Dr. Stacy stated that he does not conduct studies, but his information comes from treating his patients. He helped create AIM approximately six months ago. Since each patient is different, the effective dosage of cannabis would be different. It is not impossible to conduct research unless there is a change in state laws. Cannabis needs to change from a Schedule I narcotic to a Schedule II narcotic.
Representative Burch stated that lawmakers will continue to grapple with the subject in upcoming sessions until something is done.
Approval of the Minutes
A motion to approve the minutes of the August 17, 2016 minutes was made by Representative Watkins, seconded by Representative Meeks, and approved by voice vote.
Consideration of Referred Administrative Regulations
The following referred administrative regulations were on the agenda for consideration: 201 KAR 23:055 – establishes the requirements relating to inactive licenses, extension of inactive status, return to active status, and reinstatement by the Kentucky Board of Social Work; and 922 KAR 5:081 – repeal of 922 KAR 5:080, certification of assisted living residences. A motion to accept the referred administrative regulations was made by Representative Marzian, seconded by Representative Jenkins, and accepted by voice vote.
Childhood Cancer Awareness
Katie Ann Lester, mother of Bennett, stated that her daughter, Bennett, was born in 2013 and died in October 2015. At the age of two, Bennett was diagnosed with an aggressive brain tumor with a zero percent survival rate. Bennett never had a chance, because not enough research has been conducted on pediatric cancers. More funds are needed on the state and federal levels for pediatric cancer research.
Eric B. Durbin, DrPH, MS, Director of Cancer Informatics, Kentucky Cancer Registry, stated that cancer incidence rates are the number of new cases diagnosed in the population at risk over a specific time period. During 1999-2013, there were approximately 3,000 children diagnosed with childhood cancer in Kentucky, and of these children the highest prevalence was children between the ages of 15 and 19 years of age. There is a higher rate of childhood cancer incidence in Kentucky, especially in the Appalachian region, than anywhere in the United States. Survival has improved in Kentucky since 1994. Mutations in Predisposition Genes in Pediatric Cancer, reported that germline mutations in cancer-predisposing genes were identified in 8.5 percent of 1,120 pediatric cancer patients tested.
Katie Bathje, MA, LPCC, Program Director, Kentucky Cancer Registry, stated that the Kentucky Cancer Action Plan (CAP) is the state’s comprehensive cancer control plan to reduce the burden of cancer and maintained by the Kentucky Cancer Consortium. The Kentucky Cancer Consortium is federally funded and meets quarterly. The plan is a blueprint for action that addresses prevention, screening and early detection, treatment and care, and quality of life. The CAP uses the latest cancer data from sources such as the Kentucky Cancer Registry to identify priority cancers and formulate measurable objectives towards reducing the burden for each.
One of the 2016 CAP’s goals is to promote overall health of Kentucky cancer survivors from diagnosis onward to increase quality of life. Measurable objectives include the percentage of Kentucky pediatric oncology patients seen at Children’s Oncology Group at Kosair Children Hospital and the University of Kentucky, five-year survival rate of Kentucky childhood cancer patients, and the number of Kentucky-specific resource guides available to pediatric cancer patients and their families or caregivers. Children should not be treated the same as adults.
In 2016 in the U.S., approximately 10,380 new cases of cancer will be diagnosed among children from birth to 14 years of age, and about 1,250 of those children are expected to die. In Kentucky, approximately 200 children are diagnosed with invasive cancer each year according to the National Cancer Institute. The Kentucky Cancer Registry reports that although pediatric cancer death rates have declined by nearly 70 percent of the past four decades, cancer remains the leading cause of death from disease among children.
Senator Wise stated that more needs to be done at the federal level on pediatric cancers.
In response to questions by Representative Wuchner, Lars Wagner, MD, Chief, Division of Pediatric Hematology/Oncology, Kentucky Children’s Hospital, Professor of Pediatrics, Children’s Miracle Network Research Chair in Pediatrics, University of Kentucky, stated that brain tumors are the leading cause of death in children and are more prevalent in eastern Kentucky. More research needs to be conducted to identify causes of childhood cancers and the best cure for each.
In response to questions by Senator Alvarado, Dr. Durbin stated that there is a correlation between smoking and lung cancer. It is difficult to capture data on the correlation between a smoking mother and childhood cancer.
In response to questions by Senator Higdon, Dr. Durbin stated that 19 years of age is when an individual would still be seen by a pediatric oncologist. Dr. Wagner stated that some adults get cancers more prevalent in children, so if a pediatric oncologist is comfortable seeing these adults, there could be better outcomes.
In response to a question by Senator Thomas, Dr. Durbin stated that poverty is a major factor in poor outcomes in cancer patients.
In response to a question by Representative Marzian, Dr. Durbin stated that symptoms of exposure to toxins can take many years to develop in children.
State Social Service Workers
Tim Feeley, Deputy Secretary, Cabinet for Health and Family Services (CHFS), stated that the cabinet is trying to build an environment conducive for long-term employment. The cabinet is visiting schools and universities to recruit new social workers.
Adria Johnson, Commissioner, Department for Community Based Services (DCBS), Cabinet for Health and Family Services, stated that the DCBS has six divisions: Service Regions, Child Care, Administration and Financial Management, Protection and Permanency, Family Support, and Program Performance. There are nine protection and permanency service regions and four family support regions. Some of the programs that the DCBS administers are the Supplemental Nutrition Assistance Program (SNAP), the Temporary Assistance for Needy Family Block Grant that includes K-TAP, Kentucky Works, and supportive services, the Child Care Assistance Program, foster care and public agency adoption, the Community Services Block Grant and standards for Kentucky’s Community Action Network, eligibility determinations for Medicaid and health insurance affordability options, and regulations of state-funded domestic violence shelters, day care, private child care, and domestic violence batterer intervention providers.
From January to July 2016, of the 443 statewide staff turnovers, 294 were from resignations. Prior agency reporting did not reflect past due cases, request cases, and staff that is not at capacity. Effective August 2016, these variables have been incorporated within staffing and caseload reporting. An Adult Protective Services (APS) caseload ranges from 40 to 46 cases. Currently, 117 APS staff have 4,623 open cases. A CPS caseload ranges from 20 to 30 cases. Currently, there are 8,801 Child Protective Services (CPS) cases being handled by 1,134 CPS staff. KRS 199.461(3) sets the monthly statewide caseload average for social service workers in foster care, child protection, juvenile services, and adult protection at 25 active cases. In accordance with KRS 199.461(4), if the monthly statewide caseload average exceeds 25 active cases for 90 consecutive days, the DCBS is to report the fact, a description of the factors contributing thereto, and recommendations related thereto.
Statewide efforts to recruit and retain staff include salary increases for all frontline DCBS staff, continued enhancements to the Assessment and Documentation Tool (ADT) used during investigations, review of existing organizational and management structures, greater presence of leadership in local offices, and exploration of other quality improvements to recruit and retain staff. Some focused efforts in Jefferson County include temporary intensive leadership team, aggressive recruitment efforts and priority filling of frontline vacancies, improved work culture and environment, and development of a plan to address intake numbers to avoid future backlogs.
Lynette Ponder, Personnel Associate in Jefferson County, stated that DCBS social service staff is committed to work to serve Kentucky’s families.
Lisa Payne, Social Service Clinician, stated that, since she was hired with the cabinet almost nine years ago, things have drastically changed for the worse.
Susan Howard, Eastern Mountain DCBS service region, stated that she has worked with DCBS for 41 years. A challenge is to know the exact needs of clients and what is needed to help meet those needs. Another challenge is how to meet the total number of past due cases. Abuse and neglect does not always happen between 8:00 a.m. and 4:30 p.m. Workers are committed and advocate for families.
Judge Paula F. Sherlock, Jefferson Circuit Court, Family Trial Division 10, stated that in 2005, she became a family court judge in Jefferson County. There are 1,820 active cases in the ten Jefferson County trial divisions. Resources for family courts have diminished. More children are in foster care than ever before because of increased addiction issues, increased gun violence, and crime. There is a disproportionate number of African-American children in state care. Judges depend on social service workers when hearing court cases. There is an enormous turnover rate of social workers which make cases harder to adjudicate. Recruitment and retention of social workers is crucial. There needs to be better communication between the cabinet administration and DCBS social workers.
Jeff Culver, DCBS social worker, stated that $50 million has been cut from the DCBS budget over the past nine years. There is a heroin epidemic problem. Senate Bill 200 caused more investigations and more children committee to the cabinet. Social workers have stressful, low-paying, dangerous jobs. There is a huge need for more experienced staff. Areas that need to be addressed are systemic issues, funding for veteran workers, need for hazardous duty pay, and higher pay for office support staff, updating intake criteria, evaluation of administrative tasks, and looking at employee criteria. Funding has to be part of the solution.
Katy Coleman stated that she has been with the cabinet for seven years. Social workers live in fear in the past of retaliation by the cabinet for speaking out about issues that need to be addressed. She hopes that this will not happen with the current administration. Social workers need more training to be more effective in their jobs. Past due investigations have been used against workers. Areas that need to be addressed are worker safety, the need for hazardous pay, and the need for more foster parents.
Rebecca Goggin, CPS investigator, stated that she has been frustrated that while performing a high stress and hazardous job protecting children, she is unable to advance in her career. New processes of evaluation of job performance are needed. Kinship care needs to be reinstated.
Amy Preston, frontline worker in Fayette County, stated that she is a 15-year veteran social worker. Staff retention is a crisis. Staff had to take mandated furloughs, because of the $50 million cuts in the budget. Workers have been ridiculed and scorned. Kinship Care needs to be reestablished. Kentucky has 8,000 children in out-of-home care. Children and families cannot afford to wait until change comes within the cabinet. Protection of children and families is monumental for workers.
Vivian Hurt, retired social worker, stated that with the recent raises veteran workers may earn less than new hires. Secondary trauma is a huge problem for social workers. Social workers need to receive hazardous duty pay. The current cabinet is too big to effectively take care of workers. There should be a cabinet that focuses on just child protection. The Child Welfare League of America recommends that workers investigate no more than 12 cases per month. Large caseloads is a national problem not just a state problem. It is hard to retain workers. Workers need immunity from civil and criminal cases brought against them.
Representative Burch stated that he visited the Jefferson County DCBS office and talked with social workers and found that the caseloads were still too high. Some concerns from workers were the lack of pay, no recognition, and high stress levels. There is a need to solve pay inequities between new hires and veteran staff.
Deputy Secretary Feeley stated that every worker is receiving a raise. The cabinet has heard workers concerns and are working on the problems. The days of retribution to workers for speaking out is over.
Commissioner Johnson stated that evaluations will have different criteria. The cabinet wants to structure Kinship Care with long-term outcomes. There is a need to prioritize child care. Another problem that is being looked at is Guardianship Assistance. Internal and legislative review is being conducted for foster care. Worker safety is of paramount importance.
In response to questions by Senator Higdon, Deputy Secretary Feeley stated that all state workers have a 37.5 hour work week. Moving to a 40-hour work week would take most of the additional funds allotted for raises for social workers, and he did not think this would be good for the morale of staff. Family support workers were included in the raises.
Representative Benvenuti stated that if a worker has problems with retaliations, falsification of documents, or any other problem, the Office of the Inspector General is there to help. He is confident the current administration is going to be more transparent than previous administrations. There is a systemic societal issue – parents need to be responsible for their children.
In response to a question by Senator Danny Carroll, Gretchen Marshall, Assistant Director of the Division of Protection and Permanency, DCBS, stated that the only change to the intake criteria for investigations was to add human trafficking.
In response to a question by Representative Meeks, Brandon Carlson, Executive Advisor, Office of the Secretary, Cabinet for Health and Family Services, stated that the cabinet is very concerned about security for workers. The cabinet has a contract with Murray Security. The security of the L&N Building is currently under review. Judge Sherlock stated that state law requires a foster care case be adjudicated in 45 days, and federal law requires 60 days. Sixty days would give more time to prepare for cases and adjudicate cases. Commissioner Johnson stated that discussions have begun to change the timeline, because she realizes it is a challenge to meet the 45-day adjudication deadline.
In response to questions by Senator Thomas, Commissioner Johnson stated that the Child Welfare League of America (CWLA) recommends 12 active cases per month. KRS 199.461(4), mandates a monthly statewide caseload average of 25 active cases per month. Currently social workers carry 23 cases per month. Ms. Preston stated that currently she has 27 cases. Historically, her caseload was between 25 to 40 cases per month.
Representative Brown stated that he would like a detailed plan on how the cabinet plans to accomplish the goals to improve the problems addressed at today’s meeting.
Adjournment
There being no further business, the meeting was adjourned at 1:56 p.m.