Call to Order and Roll Call
The 3rd meeting of the SB 192 Implementation Oversight Committee was held on Monday, August 10, 2015, at 10:00 AM, at the University of Kentucky HealthCare Albert B. Chandler Hospital, Pavilion A Auditorium in Lexington, Kentucky. Representative Denver Butler, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Christian McDaniel, Co-Chair; Representative Denver Butler, Co-Chair; Senators Morgan McGarvey and Whitney Westerfield; Representatives Joni L. Jenkins, and John Tilley.
Guests: Lisa Lee, Department for Medicaid Services; Mary Burnette, Independence House; Stephanie Barnett and Kate Barnett, Choosewell Communities; Kevin Pangburn, Desi Brooks, Kirstie Willard, Paula Hellard, Kentucky Department of Corrections; Barry Brady, Marion County Department of Corrections; Jim Thaxdon, HIRT; Sharon Perkins, Kentucky Hospital Association; Mark Bolton, Louisville Metro Corrections; Jason Halligan, Harvard Kennedy School Social Impact Bond Lab; Tracy Burch, Ashel Kruzenkamp, and Stacie Nance, St. Elizabeth Healthcare; Dr. Paul Kensick, WellCare, Jim Beiting, Transitions, Inc.; Diana Frankenburgers, UK Childbirth Education Coordinator; Kristi Lopez, UK Public Relations; Core Burckman, SAS, Laurie Conkright, St. Elizabeth Healthcare; Anne Peak, KIPDA; J. Michael Brown, Justice and Public Safety Cabinet; Mark Mangeot, Kentucky Department of Corrections; Paula Chipko, Strategy UK; Steve Shannon, KARP; and G. Scott Colvin, Deputy Chief, Lexington-Fayette Detention Center.
LRC Staff: Jon Grate, Sarah Kidder, Alice Lyon, Jonathan Scott, and Cindy Smith.
The Minutes of the July 13, 2015 meeting were approved without objection.
Pre-Natal/Post-Partum Substance Use Treatment and Neonatal Abstinence Syndrome (NAS)
Dawn Forbes, MD, MS, FAAP, Neonatologist, Kosair Children's Hospital, Neonatal Specialists Founder and Director HARPS, (Helping At-Risk Pregnancies Succeed)/Effects, Inc., Lon R. Hays, MD, MBA, Chair, Department of Psychiatry, UK HealthCare, Henrietta S. Bada, MD, MPH, Professor, Department of Pediatrics, Vice Chair, Academic Affairs, UK College of Medicine, Professor, Department of Health Behavior, UK College of Public Health, and Mary Burnett, MA, CADC, CSS, Director & Clinical Services Supervisor, Independence House Corbin, spoke on substance use treatment and NAS.
Dr. Forbes’ presentation discussed opportunities to improve outcomes for infants and families that are affected by addiction. She said that health care providers and legislators have an obligation to provide short-term and immediate solutions for the families and to focus on long-term sustainable solutions that will decrease the incidence of this reoccurring in future generations. The three things she has focused on are: (1) decreasing the incidence of adverse childhood events (ACE) for infants and children; (2) improving fetal and newborn care and decreasing costs, lengths of stay, and opiate exposure for infants at risk for neonatal abstinence syndrome (NAS); and (3) improving access to and utilization of existing programs and services. As infants are exposed to abuse, neglect, and household dysfunction of which substance abuse is one of those dysfunctions, then these infants are affected emotionally, cognitively, and are at risk of having long-term adverse outcomes. ACE scores greater than 2 are the beginning of the high-risk population. Nationally, 12 percent of children have ACE scores that are two or greater. In Kentucky, 20 percent of children have ACE scores greater than two. Kids that are proven to have been exposed to abuse cost the state $65,000 per child annually. That relates to about $37 billion annually across all the children.
In 2001, HARPS began putting together a comprehensive program with three core concepts: (1) early intervention; (2) education; and (3) family-centered care. This was done through a multi-model longitudinal approach by intervening with mothers early in the pregnancy and following the children through their first three years of life, supplemented with long-term developmental follow-up. In addition to this approach, they also have multiple on-going NAS projects and they have a huge NAS multi-centered data base.
HARPS has put together a program in three hospitals. Since 2012 when the average length of stay of NAS babies was 45 days, it is now down to under 13 days at the hospital that is fully integrated, and that number has been sustained for 18 months. This has been a continuum of improved care over the past four years. Dr. Forbes said there are two more challenges to overcome. One is how to share the experience and the evidence-based knowledge to make that hospital’s success more widely available. HARPS is actively moving forward with that and packaging the care model so it can be distributed more widely. The second challenge is to continue to reduce the exposure to adverse events beyond the first four months of life.
HARPS has been able to partner with ChooseWell Communities, a program focused on working with and improving the outcomes of women-led families in recovery. This is done in collaboration with other resources by providing a supportive community made up of volunteers who have expertise in the areas that these families need as they are dealing with being a new mom and being newly sober. The program uses care managers to coordinate a health plan and focus for these families. It also utilizes peer coaches who are paired with other women who have already navigated the system. Putting this all together, ChooseWell has targeted outcomes.
Dr. Forbes said that, for the future of the families, she encouraged the legislators to challenge programs to anticipate and address barriers to access. She believes programs that commit to prevent/reduce incidence of ACEs, reward collaboration, and break the cycle of addiction should be a legislative priority.
In response to a question by Senator Westerfield, Dr. Forbes said slots for women and their children in Kentucky to get help and resources are very limited. There are very few programs that will specifically take in pregnant women who also suffer from addiction. Senator Westerfield said he believes there are only three facilities statewide that offer these services, and they are maxed out.
In response to a question by Senator Westerfield, Dr. Forbes said they see over 600 women per year delivering infants and that is a very small part of the population. Over 1,000 women in her community are pregnant and suffering from addiction.
In response to a question by Senator Westerfield, Dr. Forbes said the barriers that are found at certain hospitals against the program are at an administration level, not at the nursing level.
In response to a question by Representative Butler, Dr. Forbes said infants in the programs are monitored for years after their length of stay in the hospital.
In response to a question by Representative Jenkins, Dr. Forbes said opiate exposure is a huge problem and has reasonably good protocols. There is systematic support and some medicines can be beneficial. Infants exposed to cocaine or SSRIs or marijuana or amphetamines do not have great treatment protocols. The next area her practice will be working on is how to address the more common poly-substance exposure. Dr. Forbes said that alcohol is a completely different topic. Alcohol disturbs fetal development in the first trimester. These infants are born with many birth defects and fetal alcohol syndrome.
In response to a question by Senator McDaniel, Dr. Forbes said there is not a lot of data relative to the impact of opiate exposure. It is hard to look at developmental outcomes because it is so convoluted. The infant is exposed to opiates in utero but that is not where the exposure stops. The infants go to homes that are dysfunctional and broken with continued opiate exposure and risk factors. So it is hard to tease out what the actual in utero exposure is compared to what the home environment impact is.
Dr. Hays discussed the history of treatment of opioid dependent pregnant women on UK inpatient psychiatric service. In the early 1990s, these women were admitted and treated with methadone, maintained on methadone, and placed into a methadone maintenance program until delivery. Within two years it was realized that this treatment of maintaining women on methadone was breaking the bank. The entire budget for the program was used within the first two months of the year. From that point forward, Dr. Hays and his group took the option to detox some women if it was appropriate. They looked at each case individually. It was obvious that treatment was necessary but methadone maintenance was not. Each would come through OB triage before they were admitted to their service. More often than not they are then admitted to the psychiatry service. The options for treatment are either (1) methadone stabilization followed by maintenance; (2) methadone stabilization followed by detox; or (3) Subutex treatment. The factors involved in treatment decision are (1) patient choice; proximity to a methadone maintenance program; or (3) availability of Subutex providers. He added that the ideal time for detox is during the second trimester. The average length of detox stay is 5-7 days, but can be longer due to availability of a follow-up. The number of women treated in the program is greater than 600. The current breakdown is 75 percent detox, and 25 percent medication assisted treatment, which is largely dictated by proximity to other forms of treatment. He believes the ideal situation would be inpatient treatment followed by residential treatment such as Shwartz Center/Independence House or a Subutex provider with OB experience. New issues being seen include an increase in cases of Hepatitis C. He hopes to see more coordinated follow-up and increased use of Subutex with qualified providers.
In response to a question by Representative Tilley, Dr. Hays said they frequently see patients that are HIV positive. The number of cases are increasing, but much slower than what is being seen with Hepatitis C.
Dr. Bada said that NAS will not disappear and will only increase or evolve from different opioid formulation. Since 2000 there has been a 48-fold increase in babies born with NAS in Kentucky. There are 2-3 babies per day that have NAS, and approximately 27 babies a week with NAS. Infants born exposed to opiates have low birthweight, have smaller heads, could have congenital malformations, abnormal tone may persist, seizures and abnormal EEG patterns and abnormal sleep patterns, and also have signs of withdrawal. The summary of long-term outcomes include psychomotor delay in the first two years, lower IQ scores, poor language development, and behavior and school problems.
She said interventions and outcomes should consider the balance between cumulative risk and protective index. Kids with high risk and low protective factors have behavioral problems that continue to rise between the ages of 5 to 15. To help these children, the adverse childhood experiences have to be diminished and the protective factors in the household have to be increased. Child outcomes can be changed if protective factors are increased and drug use and other risks are decreased.
Dr. Hays said the ideal treatment is residential treatment for mothers and infants together. The alternate is intensive outpatient program that focuses on the transition from pregnancy, including medicine-assisted treatment/detox, counseling, peer support, monitoring of drug use, and parenting skills.
She concluded by saying that it take a village to disentangle the world of the drug-exposed child.
In response to a comment by Dr. Bada, Senator McDaniel said the environment around the children is very important. If there is a good environment and the mothers are treated, then there will be a better outcome. It is a nature versus nurture issue.
In response to a question by Senator Westerfield, Dr. Bada said the standardized approach starts with inpatient treatment of the baby and training of the nurses who are scoring the infant because they increase or discontinue treatment based on the baby’s assessment. There has to be uniformity with how things are done.
In response to a question by Senator Westerfield, Dr. Bada said that, upon discharge, babies are left to the care providers, but the program continues case management because the babies will still be seen.
Mary Burnett shared information she has gained from over 30 years of working with addicted women. She said in 1987 there were only two women in a coed treatment as opposed to 20 men, and the primary substance abused was alcohol. Today they have at least 1000 calls per year from women seeking help. The primary drugs have changed. Her program houses pregnant women that are addicted. They send all the pregnant women to detox if they need it, depending on what they have been using. She stressed that one size does not fit all and there are many answers that could work. Her program does not do medicine assisted treatment, just abstinence at this time. When the babies are born drug free, they are kept in the house for 30 days and the mothers stay the entire time as well. The mothers need to learn skills and their behaviors need to change to not have a relapse. The biggest issue when women leave the facility is continued care and a place to go.
In response to a question by Representative Butler, Ms. Burnett said they have fifteen beds for mothers and children and they are currently full. Pregnant women have priority for a bed.
In response to a question by Senator McDaniel, Ms. Burnett said suboxone strips need to be controlled somehow. Her facility is seeing a big problem with people coming in with suboxone being their drug of choice.
Medicaid Coverage for Substance Use Treatment
Lisa Lee, Commissioner, Department for Medicaid Services, and Dr. Allen Brenzel, Medical Director, Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services, spoke regarding Medicaid coverage for substance use treatment. Dr. Lee said that 93 percent of the populations that need treatment are enrolled in the Medicaid program, which makes Medicaid a vital player in the tangled web. Prior to the Affordable Care Act (ACA), coverage for pregnant women was limited to those individuals under 185 percent of the federal poverty level. Previously, in order to enroll in Medicaid, the individual had to be either pregnant, disabled, blind, or an adult 65 or older. If an individual is pregnant with one child, she is considered a family of two because poverty levels are based on the number of individuals in the family. The income limit for a family of 2 in 2015 was $2,589 per month. After delivery, she would no longer be in one of those eligible categories, so her coverage for Medicaid would end after the 60 day post-partum period. Today the options after the 60 day post-partum are traditional Medicaid, Medicaid expansion, or coverage through Kynect. Approximately 79 percent of pregnant women re-enter Medicaid after delivery.
Dr. Brenzel said the cabinet is working to coordinate all the services that are available. The costs are staggering, and the most appropriate services need to be offered to the women that are seeking service. The best treatment programs provide a combination of therapies and other services to meet the needs of the individual patient. He noted that the cabinet does focus on how the women are cared for after delivery. That time is a high risk time for the mom to overdose if she resumes use. The infant is at high risk of abuse and neglect and cumulative adverse child events. So, continued care is important.
Dr. Brenzel said he is working the Justice Cabinet and the Cabinet for Health and Family Services to allocate the approved funding from SB 192 that will address neonatal abstinence and services. He also mentioned that the Department for Behavioral Health is working with the Department for Public Health on a $3 million grant to provide better coordination of services in the Cumberland area and the Bluegrass region of Kentucky.
In response to a question by Senator McDaniel, Dr. Brenzel said when writing the grant, they looked at where specific federal incentives could be used most effectively, so the grant targets the Cumberland and Bluegrass regions. The benefits of this grant can be incorporated into the whole system.
Representative Jenkins wanted the committee to be aware of the Department for Community Bases Services’ START Program, which is in various parts of the state. The program helps families at risk of child removal because of substance abuse. Rep. Jenkins said it is very cost effective and underfunded. This is an opportunity where Kentucky could get the most bang for the buck.
Treatment for Jail Inmates
Rodney Ballard, Director of Community Corrections, Fayette County, Mark Bolton, Director, Metro Corrections, Jefferson County, and Barry Brady, Jailer, Marion County, testified about treatment for jail inmates.
Mr. Bolton talked specifically about the Louisville jail, the biggest jail in Kentucky. The jail has 1,793 beds and processes about 36,000 people per year. The average daily population is about 1,850 inmates. The jail actively detoxes between 50 and 100 inmates every day. In 2014, about 6,200 people went through detox. Of those, 4,400 were for opiates, with almost 2,800 for heroin. The heroin numbers are on the rise. Over 1,000 of those people were detoxed multiple times over the year. Up to 20 people per day are released who have not been in jail long enough to complete detox. People coming in for low level offenses are released without detox, even if they are heroin users. The biggest challenge in Louisville is the lack of detox capacity in the community.
In response to a question by Senator Westerfield, Mr. Bolton said the individuals they are most challenged by are the individuals they do not have long enough to detox. The jail is not built or staffed to be a detox center. In terms of individuals being released daily, a strong majority of them need substance abuse treatment.
In response to a question by Senator Westerfield, Mr. Bolton said in the local Circuit Courts have just developed a heroin rocket docket which they believe will see some positive results. Individuals in jail long enough are put into a treatment program in the jail and they are then able to develop discharge planning with those individuals to continue treatment in the community.
Mr. Ballard discussed what he believes a treatment model should look like from a jail perspective. He said there should be a safe, medically-assisted detoxing system. Many of the inmates have co-occurring disorders. Finding adequate treatment facilities that will address all those needs can be difficult. There also needs to be a continuity of care when being released from jails. The goal should be to seek a continuity of care both inside and outside correctional facilities. This will take collaboration with local facilities and local treatment centers. The treatment providers used to detox inmates from their early release could also accept individuals from the general public seeking safe detoxing. Jails should assist inmates to enroll in the Affordable Care Act before they are released from custody.
Mr. Brady said that since January, 2015, the Marion County Jail has seen 615 drug charges. If they go into detox, there are 175 beds in Jefferson County, down to 16 beds in Hardin County. Priority for those beds still consist of the individual being suicidal, homicidal, IV drug user, or pregnant, to get to the front of the line for detox. There are 19,720 jail beds in Kentucky, with 9,322 prisoners, and the rest are detainees. In regard to treatment in Kentucky jails, there are 1,264 in some type of treatment bed. There are other very beneficial programs, including cogitative training that does not replace substance abuse treatment, but could go along with it. In his facility there are 297 beds, with 11 degreed counseling staff. With the 297 beds, he is running about 240 evidence-based programs in the facility.
In response to a question by Representative Butler, Mr. Brady said there is an after care plan for those inmates who complete the SAP program, but it depends on what the judge orders for the inmate.
Representative Tilley noted that there are 2 million severely mentally ill individuals serviced by jails every year. Three quarters of these individuals have addictions, which cost 2-3 times more than the average person detained. There is no return on investment because a better plan is not in place to improve recidivism rates and recovery numbers.
The meeting was adjourned at 12:00 p.m.