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Joint Committee on Public Health, Welfare, and Labor
February 1, 2023
Rep L Johnson: Members, if you have questions, I think even if you’re not on the Committee, at this point if you’re in the room and you have a question, just press a button, we’ll try to recognize you. We talked about whether to hold questions to the end or just have them as they go. I think for the flow of conversation having them as they go is fine with us and fine with DHS. So if you do have a question as we’re going along press the button, let me know. We’ll recognize you, and when it’s appropriate we’ll let you ask the question. So with that, we’ll go ahead and recognize everyone. If you can announce your names and introduce yourselves, and we’ll go from there.
Mann (DHS): Thank you. Good afternoon, I’m Janet Mann. I’m the deputy of health and the Medicaid director for DHS.
Weatherton (DDS): Hi, Melissa Weatherton, I’m the division director for Developmental Disability Services.
Stone (AABH): Hi, I’m Paula Stone. I work for DHS for both the Division of Medical Services and the Division of Aging Adult, and Behavioral Health Services, focusing on children’s behavioral health.
Gann (AABH): And I’m Trish Gann, I’m the deputy director of Division of Aging Adult, and Behavioral Health Services, focusing on behavioral health for adults.
Mann (DHS): Just a quick note or the change on the agenda, Guidehouse was going to be here and help us present and they’ve been one of our partners on this journey but due to weather– and we think they got out, otherwise, they’re sitting at the airport listening to us. So we’re going to do the presentation for y’all.
Weatherton (DDS): So before we dive into the PowerPoint we just wanted to give a little background on kind of what population we’re talking about, why we’re here presenting this, and where the funding came from to actually do this analysis. So the who in this presentation. So we are trying to build a system that will be available to every Arkansan, those who are on Medicaid, those who are on Medicare, those who are on private insurance. So regardless of whether you’re a child, you have intellectual disability, you have behavioral health only needs. If you’re having a behavior-acute crisis episode out in the community, which could be your home or your school, or anywhere else in the community, this would be the system that would connect you to a mobile crisis team.
So the what. It’s mobile crisis response teams that we’re trying to build but we’ll go to all of these places. And the why is because we have learned over the last several years, and it’s become really transparent that we don’t have what we need in place to assess and stabilize people in their homes. We have 9-1-1, people go to jail, people are taken to emergency rooms. And then once those two things occur they’re stuck. So we are not providing the appropriate treatment for them. And then the how is what we’re going to show you in this presentation.
So before we jump right in to what we’re thinking and get your feedback on it, I want to tell you that there’s two types, and y’all probably know this. But just to be clear, there’s two types of American Rescue Plan funding. So we call it internally, and this is not the word, but we call it the big ARP, okay? And that’s the money that the state of Arkansas gets. That’s the money that Governor Sanders now is going to give out under her control.
We have another funding source within Medicaid, and it was available to us through the Center for Medicare and Medicaid where states could apply. We applied for this funding back in 2021. And we had to send in a really detailed proposal on what we would use the funding for. We refer to that as ARP 9817, because that’s the federal statute that this falls under. And it’s very specific on how we can use the money. So we can’t use it for renovations. We can’t use it for construction. We couldn’t raise rates with it. It’s one-time funding and it can only be used to expand or enhance home and community based services here in Arkansas.
So we have a lot of initiatives that we are building with about $151 million we were awarded. And I think I’ve talked to you guys before. Out of that $151 million, we gave $115 million directly to providers so they could recruit and retain their staff. So the remainder of the money we are using to build a variety of programs. And this today is just one of those initiatives where we are utilizing that federal funding stream under the 9817 funds. So any questions there? If not, I’ll start the presentation.
Rep L Johnson: Okay. We do have some questions or a question. We do or don’t? I pressed a button, we don’t have a question. I’m going to let Missy come over here, Senator Irvin, and run this thing. And she’ll look over my shoulder, make sure I’ll know when there’s somebody lighting up. All right, proceed.
Weatherton (DDS): Okay. So you guys can read that on the screen but for those of you that don’t have in front of you what we’re planning to do today is we want to go through kind of the goals of what we’re doing and a background of how we got here. And then an open discussion and get y’all’s feedback on what we’ve done so far.
So the background on this, so as deputy– what is your title? What Janet– sorry, what Ms. Mann mentioned earlier, we have been utilizing Guidehouse as a vendor to help us build a prototype essentially, best practices from other states. So we’re going to review our access that they’ve uncovered through many, many stakeholder interviews that we’re going to talk about the deployment of these crisis teams, funding sources, our population needs, and provider capacity. And I’m going to turn it over to Ms. Stone.
Stone (AABH): So we started the project with a vision. And I think Melissa’s covered that, that vision being community based crisis. So services delivered in communities to stabilize people as much as possible. And having those services, those community response services coordinated. And that’s coordinated across first responders, social service professionals, and clinical staff. So we can have everybody responding to make sure that we’re getting people to the right place.
To do that we wanted to make sure that we have a centralized system to connect everyone with that mental health intervention and treatment once they’re stabilized to build that capacity amongst providers to assess and then triage and stabilize. Triage is a word that we use a lot in the emergency department when people come in. Also on the battlefield we use triage. But definitely in community settings, triage means what do they need immediately? What do we do to keep everyone safe? And then hopefully stabilizing people, the more people we can stabilize in their home or in their school or in a community setting, the fewer people we have that are moving into higher levels of care.
We want to have that centralized hub because we have a lot of these kinds of services going on around the state with different providers and different funding sources. And we wanted to centralize that. One, to collect the data to see exactly who needs these services, where people are going but also to get that cooperation across the stakeholders.
We also need to build technology solutions to support that. And then those closed loop notifications, so ensuring that once somebody makes a call and then someone goes out, that they’re going out and that the situation is resolved, as well as what’s needed the next day. So a lot of times, people get stabilized even if they don’t go to an emergency department or another location. And then they don’t get that follow-up care the next day. So we really want to make sure the warm handoff.
And then that crisis response teams. And so teams means not just professionals with a clinical background but also paraprofessionals or peers sometimes are used, particularly for adults with mental illness but also the individuals that can be trained to address all of the needs. So Melissa mentioned that we have people with behavioral health needs that also are either young children or they may be adults with serious mental illness but they also may be individuals with intellectual disability.
So there needs to be a little bit different approach. And so if we train these teams to address all of those issues or be able to assess for all those issues and say what’s going on here? So from young children to elderly individuals in communities, that we want to make sure that we have those teams ready for that. And then as with any project, is to look for the sustainable funding. So we want to start the project, we want to build that infrastructure but we look towards a number of different funders to sustain that funding across.
Rep L Johnson: Representative Ladyman, do you have a question?
Rep Ladyman: Yeah. I hope it’s the appropriate time. Thank you, Mr. Chairman– to ask this question but in developing the vision, goals, and objectives, what input or involvement did the providers have in this?
Stone (AABH): So we did many levels. Our partners, Guidehouse went out and did many levels of interviews and so we wanted to make sure. So we started with internal interviews at DHS because we, from our different perspectives, we all have a perspective on our population that we work with closely. And so we know that even like the Division of Children and Family Services. So people who have– working with those children in foster care, our Division of Youth Services. And I know this is sad, but our Division of Child Care and Early Childhood Education. I mean, there’s lots of things that go on with four-year-olds and it is.
And so we started there, interviewed our own staff, said from your perspective. Adult Protective Services, so we interviewed everybody. And then we took it to like state-level partners. So Department of Health, big providers like UAMS, people that are running call centers. And then we also met with groups of providers down at that level as well. So we tried to interview providers that are providing these types of services or treating individuals who need those services. So we tried to make sure across all that we did a pretty lengthy set of interviews. I think it took probably three or four months for Guidehouse to get all of them.
Rep Ladyman: So you tried to involve certain individuals or groups from each type of service provider?
Weatherton (DDS): Well, I would say on mostly – and the next slideshow shows this, but it was really trying to figure out which providers, which entities are touching people while they’re in crisis, right? So it’s a little bit different than what you’re asking. So there was certain provider types that maybe weren’t interviewed during this phase because they don’t go out when someone’s having a behavioral health crisis or they don’t get calls on those people.
Rep Ladyman: All right. Thank you.
Stone (AABH): Other questions? So this is our current crisis landscape. And you can see all of the entities involved in this. And so we started out with who gets called when there’s a crisis? And that’s where we started our interviews and started mapping this. And you can see that a lot of people call 9-1-1. The National Association for– is that for Mental illness, NAMI? Also has a support line that we support through DAABH. There’s the mental health – I have to put on my glasses – Mental Health Addiction Support line. There is UAMS had a grant to do AR-Connect, and so they built a call line. 988 is the Suicide Prevention call line, and it’s the mental health call line that was instituted federally for people to call there directly instead of calling 9-1-1 if they’re aware of that. And the Department of Health runs that.
We also have the 12 Community Mental Health Centers, and part of their contracts are to provide that kind of assessment and be on call 24/7. So we have all of that group in the crisis contact. And then we have services that are being delivered in the community. And again we tried to talk to each of them and look at that. So we have obviously the EMTs and the first responders. Again, the community mental health centers. We have behavioral health providers we have PASSE. So PASSE have pilot programs for this population or for the population that they serve. The local police departments do a lot of this. So we have all of those crisis services, people that are going out.
And then we also put together who’s actually stabilizing the crisis and providing an intervention or a service. So we know that general hospitals with adult psychiatric units within those hospitals, we have some of those across the state. We have our four crisis stabilization units. We have psychiatric hospitals, freestanding psychiatric hospitals that accept people that are in crisis. And then we added– Medicaid added something called acute crisis unit beds for hospitals and allowed that to be a billable service. And so we have two of those that have begun. And those both have been for children. And so those are our places where we can stabilize services.
And so as you can see, there’s a lot of activity and a lot of things going on out in the community with lots of different people that are involved in that. And around the bottom, along the bottom, you see all of those different outside stakeholder groups that are interacting with people that have a crisis.
Rep L Johnson: Representative Ladyman, you’re recognized for another question.
Rep Ladyman: I’m sorry but I have another question. Can you expand on that, what is the PASSEs pilot programs? Can you expand on that a little bit?
Stone (AABH): The PASSEs have community investment dollars that they can use to build out some community investments and so several of them built out specific programs. I know one of them built out a program to address– and brought in a company from out of state that specializes in treating individuals with intellectual and developmental disabilities and also have behavioral health conditions. And so they started a project there where they had teams just like we’re talking about, that could go out and either go into an IDD setting where somebody is being treated and having some crisis. They could go into hospitals. They could go into any place that would allow them. And so it’s been a really great project.
It’s ended very well. If we talk about sustainability, that provider became an enrolled Arkansas Medicaid provider, last week I think. And so now they’re going to be able to use Medicaid funds and pay them directly. So that’s one. Is there another one that I’m missing, the big one I remember?
Weatherton (DDS): Representative Ladyman might recognize the name. The one she’s talking about, and the company’s called Benchmark. And we’ve had really good success with our clients going in and helping waiver providers. And they just enrolled, so we were really excited about that.
Sen Irvin: Can I ask a quick question? Just if you don’t mind. I think it’s important for us to discuss exactly the different types of behavioral things that we’re seeing that constitute a crisis. So if we could just– yeah, go back to that slide because you have– this encompasses so much. So if you can just try to, let’s just talk about exactly who these people are. Exactly what is happening, and what we’re experiencing. And different examples of this type of crisis behavioral health, how this has occurred. I mean, we know some of the things, right? That are something that would come to the top of the head, like suicide and things like that but there’s a lot of others. So can we just take a second and just kind of talk about what we are experiencing in the State of Arkansas and it relates to crisis behavioral health? And that’s going to be different for children. It’s going to be different for teenagers and for adults.
Stone (AABH): Yeah. So we have so many calls that come our way that, where we see where the crisis started and then we probably get in on this and we do case staffing. And so I think about the ones that are most recent that we’re still working on the cases. And it can be– so one that we talked about actually on the phone today when we were preparing for this, a five-year-old who came into DCFS custody and was having some pretty significant behavior problems. And I don’t want to give a lot of identifying information but had been exposed– had had some I think neonatal exposure to substances but then had gone back to the family. And then there’s some additional exposure. And had gone into foster care and really was having some extreme behaviors.
Once we found out about it and it was identified as a mental health crisis, we also then looked in and saw what was her developmental age. Developmentally she was– her receptive and expressive language was about on a two-year-old level. But what we did is identified her with a behavioral health issue because her behaviors were so extreme. But our approach shouldn’t really just be at looking and saying okay, she has a mental health condition and we need to treat that looking at that whole person.
And so because we didn’t have any sort of cross-trained crisis response, somebody did what they needed to do, which is take her to the psychiatric hospital where she got admitted. So we’ve got that with young children. And that happens a lot with children that have experienced trauma, go into foster care. Sometimes it’s, I cannot tell you how many calls we get from grandmothers who are raising grandchildren. The parents are not there and they’re doing their best. And those children just have some significant anger and those kinds of behaviors.
With adolescents, it can range anywhere from self-harming behaviors that is identified at school or they come to school and they talk about what’s happened to them. Or they get into fights and they become very aggressive. And so for a lot of those also as you start digging down, you see it’s been labeled a mental health condition. But there’s also some underlying delays because they may have moved 10 times through their elementary school years and just not gotten some consistent education. And then they get to junior high, they’ve missed so much school. They’re angry. They are probably bored and not understanding what’s going on in the classroom. And they really act out.
And so we get those calls all the time for children, again as young as four. Our Division of Child Care and Early Childhood Education actually has a hotline for daycare centers to call for children that are acting out that are three, four, and five years old. So pretty extreme behaviors, and we’re trying to approach that in a specific way. But when parents or foster parents or grandparents or whoever or school officials see some pretty frightening behaviors, what they’re going to do generally is call the police, call an ambulance, or put them in the car and take them to a hospital. And so we have a lot of that. And where we’ve even gotten those children where they’ve been in an emergency room and have been there for days because there’s no place for them to be transported to. So I would say that’s a big piece of the children.
Sen Irvin: Okay. And then adults. I know my big– we’ve just seen such a rise in domestic violence and incidents as it relates to domestic violence. And so I just know in speaking with sheriff, local officials that is incredibly dangerous. Those calls are incredibly dangerous for all law enforcement officers to take and respond to. But I can imagine– they have just seen a dramatic increase in those types of calls. And so that is really a whole level of training that I’m not sure everybody’s equipped to have or that they have it to be able to keep themselves safe and all the people involved in that situation safe. So just quickly talk about the adults.
Gann (AABH): Sure. Thank you. Of course, what you talked about is those individuals who are experiencing suicidality or they are experiencing homicidal ideations due to either part of their mental illness or for whatever reason. And we have a group of individuals that are just grossly disabled. They’re psychotic. They suffer from schizophrenia or a psychotic disorder. In some of those that’s controlled somewhat with medications, if they take those medications as directed. But for some, even with medications they still continue to experience some pretty serious mental health symptoms including psychosis.
And then that’s often complicated by substance use and substance use disorders. And so you’re going to have those two things together. And they’re often going to be homeless. There’s some homelessness. In individuals with homelessness are suffering that they’re not getting good access to care. They’re not getting good access to treatment. And they tend to come into contact with law enforcement quite frequently. Like I said, those individuals who are not medication compliant, they don’t take their meds or they are not able to get access to or go and get their injectables, if they’re on injectables for those disorders.
We really get a lot of phone calls around traumatic brain injuries and situations that occur due to traumatic brain injuries and the behaviors that come from that. In our veterans experiencing PTSD and experiencing other disorders related to veteran services.
And just going to speak briefly before I turn it over to Melissa about the dual diagnosis. And those are individuals who have a serious mental illness but they also have some intellectual disabilities, developmental delays. And so those individuals have a very unique kind of need where there’s an understanding. And I think Paula talked about that earlier, there really needs to be a good understanding of where those two come together and the specific interventions that need to happen with that population.
Weatherton (DDS): And I think we’ve talked about this before. I mean, it’s just more and more prevalent. We’re seeing people with intellectual disabilities or developmental delays have some significant behavioral health problems. And there’s really nowhere for them to go. And I mean, we’re trying to build out those programs in addition to this. I mean, those are whole other initiatives we’re working on is setting up, hopefully, specific wings in acute hospitals for IDD. And then setting up step down programs.
Because right now, I mean, you guys know this, I get referrals to the Booneville Human Development Center, the Warren Human Development Center for kids, the Conway Human Development Center. Because there’s really no other game in town right now that will take clients with intellectual disabilities who have behavioral health crises. And we really weren’t designed for that type of dual care.
And so we’ve been having to pivot and make sure my staff are trained but they still need more training. I mean, we just– we’re not equipped for that. We’re getting there but we need some other options because those are institutions. And then once we get them it’s really hard sometimes if they want to go back out in the community, to go back out in the community. So we’re trying to build community based. But I mean, I’m sure y’all have– I mean there was a lot on social media about a young man who we ended up taking at Booneville. And I know Representative Mayberry and I talked about him. And I talk to his mom now all the time. He’s done really well at Booneville.
But he was put in an ER room. I mean, how long was that? For weeks on a mattress without a sheet and I mean, it was awful. And we were trying really hard to get someone to take him while I waited on an opening at the Booneville HDC but I only have so many beds and they’re always full. And that’s where he needed to go and again, he’s doing really well there. But he is definitely– he’s intellectually disabled but he has some really significant behavioral health needs. So it’s not that it’s hard to mix sometimes a peer group with my facilities because we can’t put him in a house where people are vulnerable. We can’t put him next to people that aren’t as savvy because he’s very savvy.
But that mother has been a big advocate of how Booneville has really saved her and saved. And he was on the waiver program and they had built him a home and he lived next door to them and had staff coming in, but he was really aggressive and dangerous to the staff. And again her only option was to call 9-1-1 every time that would happen. Well, in the area of town she lived in, the ambulance quit going. They turned around when they knew what house they were going to because there was no place once they got him to the hospital that was appropriate to take care of him. So they just quit picking him up.
So I mean, we definitely are seeing this overwhelming need on a weekly basis where we are at a loss. And like Paula said, like with this little five-year-old, who we said today we’re going to go get her ourselves. I mean, it breaks my heart. My child has learning disabilities, the exact same ones, and some more. And it’s horrendous but we’re treating her for mental Illness. But that all being said– I lost my train of thought because I got worked up on that little girl.
Sen Irvin: I mean, y’all go back to your slide presentation. And I would so much appreciate it. I just think it’s so important to share that because we have to humanize this. And a lot of times we’ll look at these slides and we’ll talk about their needs, and I love this, and I love what we’re doing. But it’s so important for us to really humanize this and understand the real impact that’s happening right now to these people in our state. So thank you. Y’all can go back to– but I appreciate your passion for this and sharing that with us. It’s very important.
Rep Ladyman: Before you go back to your program let me make a comment here. And I think what y’all are talking about here shows. And I know I hear all the time people say well, we want to put everybody out in the community. And that’s great. I want everybody to be at their level that they’re capable of functioning at. That’s what the goal is. But sometimes certain people, they don’t see the need for some of these people, like the ones you’re just talking about. They may not be able to go to a community or go to the family. Or when they do go to the family you made a good example there. I mean, the family tries but it just don’t work. So everybody cannot go into a community or a waiver program. We have to have other levels of service for some people. And I think you all have shown that right there. So I’ll stop and let you get back to your program.
Weatherton (DDS): Well, Representative Ladyman, I mean, of course, we’re huge supporters of the HTCs, and we keep them full. But like in the case we were talking about, what was so sad is if we had something like this in place then we could have sent out a mobile team to help stabilize that young man while he waited to get into Booneville because it probably was at the point where he probably needed something more regardless. But the sad thing was is that he was in an ER room for that long not getting appropriate care. So even if eventually, the end result is you need a higher level, this would be a stopgap to not take people to jail and hospitals while we try to stabilize them at their houses.
Sen Irvin: Just one note on this slide right here. PCPs are stakeholders and so much of this is happening in clinics and identified in clinics, particularly with children and adolescents and adults. Especially Adult Protective Services sometimes has to be called in if it’s an adult schizophrenic that’s beating up a family member or relative. So a lot of those things, they are dealt with at the PCP levels. And so that’s a huge stakeholder that needs to be included. I realize Guidehouse did this and not y’all. So that’s on them.
Stone (AABH): And completely agree. I think we’ve been having some of those side conversations. So when we went out and started talking about the acute crisis unit beds in hospitals, one of the things that the hospitals said or actually talked to the pediatricians at the pediatrician group, is they said if we can bring in clinicians and we can provide those counseling services we’re still going to need somebody to call or someplace to send them when they’re coming in because we feel like we’re at loose ends.
And we’re willing to treat but we need some support. And they even said, Children’s Hospital said, and we’ll take them back into our PCP clinics and treat them – which is one of the things we want to happen, if there’s a place for them to go and somebody to help us stabilize. Because we’re not equipped for like crisis stabilization we can do some small stuff. So yes, you’re exactly right.
And I think that’s also the goal, I think this is that whole continuum because the more people we catch on that front end as we’re doing behavioral health screenings, which we’re now Medicaid pays for. So when we’re doing that kind of stuff then our system is not getting clogged with all of those people waiting and waiting and waiting for services. And then they can’t do home and community based services because it’s too far. We’ve let it go way too far. And then we don’t have as many beds in human development centers and other places where people need to go.
And so I think a lot of this is trying to catch people early because it’s amazing how many people. And I didn’t know this happened until like probably this last two years but people who’ve been managing somebody with a pretty significant issue at home. That they may have been removed from school and they may have been homeschooling them and then they get really large. They’re large young strong young men and the family has not had anyone to reach out to really. They haven’t really been keeping up. And so they show up at the emergency department say I can’t do this any longer. And if we had caught them much earlier, and then our only choices in the family is like I cannot do this. This is too much, they’re too large. And so if we caught them earlier. So I think it’s trying to come back in that on that front end.
Weatherton (DDS): Well, and just to add. So we talk about this all the time, it’s like we say where did they come from, right? Like they were never on our radar. We didn’t have any case file on them. We look at all of our systems, where do they come from? And she’s right, they’re showing up oftentimes 14, 15, 16. We’ve never served them. And we’re trying to put a deck together that like we’re catching them too late. And just trying to back that up. And like Paula said, backing it up by passing the rules to put clinicians under the supervision of PCPs and doctors, where you can supervise them. And then this would back it up significantly. They never get to one of those places where we have to wrestle them out of. Because once they’re labeled at some of these places then their file starts building.
Gann (AABH): And just to talk a little bit about first episode psychosis because we have some set-aside funding that comes from our federal partners around first episode psychosis. And those are our young individuals who are beginning to have those first signs of a psychotic disorder such as schizophrenia. And the earlier that we can catch them and the earlier we can get them on appropriate medications in an appropriate treatment, the better the outcome is for those individuals.
So it’s really, really important as part of this integrated crisis system that we’re grabbing them. And sometimes those are the individuals that have private insurance, and if you look, we’re taking this across everything. They have private insurance and that’s why we don’t get them. We don’t get them until it’s gotten to the point where they are very, very ill. And the chances of that really good recovery outcome has gone down somewhat. And I’m up.
Rep L Johnson: Representative Ladyman?
Rep Ladyman: Let me just make a comment real quick about what you just said about you don’t know where they come from. I felt for many, many, many years that we don’t know how big this problem is. And I’ve often wondered how many people do we have in the State of Arkansas that needs these type of services. I know there’s a whole broad range of services but because we took our son to ball games or things. And I never can forget this. We would take him to his brother’s ball games. Do you know that after about three games, another family showed up that had a child like ours and talked to him, and they said well we saw you all bring your son here so we thought we’d bring ours.
They weren’t on any kind of program. They didn’t know. They had no idea that there were programs like that. And I’ve seen that over and over and over again. I don’t know how you find those people, I really don’t. But they are out there like you said. And it’s people trying to take care of their adults or their– it may not be their sons or daughters, it might be a niece or somebody. And they’re trying to do the best they can. And they do it until it gets to the point where they just can’t do it. And they wind up holding them down and calling the police and that’s where it goes.
Weatherton (DDS): Well, and I will say briefly and before she starts slide six. With some of this money, with this 9817, one of the build-outs we’re doing is a huge educational campaign. And by no means, I don’t want y’all to think we’re out trying to get more people on Medicaid. But for some of these clients, we’re going to get them eventually, and we need to catch them earlier. Because if we could do more prevention type services and then get them back out off of Medicaid, we would be a lot better off. And they would as well.
So we are using some of this funds to do a big educational campaign on the Medicaid services and what we have to offer. Because we agree with you. We’re not doing a good job of even on our website of showing what’s available. Working with community partners so they can help tell people what’s available. So unless it’s one of you guys who knows what we do, and knows to tell them to call me or call one of them, I think a lot of people are at a loss.
Gann (AABH): So I think this was a great lead-in because I think we can identify individuals and I think that we can do early intervention and early treatment and that we can get individuals into the appropriate levels of care and we can get them what’s needed. But in order to do that, then I really think that where we need to go is this community based crisis response system.
A crisis response system is an organized set of structures and processes and services that are in place to address those urgent and emergent behavioral health crisis. And that is whether it’s substance use. That’s whether it’s mental health. That’s whether it’s an intellectual– someone with behaviors related to an intellectual disability or developmental delay. And this is a defined population, and we need to act as soon as possible, and we need to act as long as necessary in order to stabilize that situation.
So the components of that system can be 24-hour crisis call centers or call lines. Crisis response teams, which have as Paula said, a variety of individuals who participate in those teams who have special training. Crisis stabilization units and acute crisis beds. We’ve already got a few acute crisis beds for children but we certainly need more acute crisis beds where individuals are getting that care, behavioral health urgent care. So those are kind of the systems and the system goals that we want to look at over time.
And so the models of mobile crisis team deployment include a mobile crisis response team deployment option, such as statewide call centers, regionally-based call centers, or provider-specific call centers. So those are some of the models around which mobile crisis teams are deployed.
Weatherton (DDS): What we’ve been asking Guidehouse to do, because we’ve talked about this before as well, but the PASSE model was really our highest needs clients within Medicaid. And of course, this model is for all Arkansans, but if we’re just looking at our PASSE clientele with behavioral health and IDD, we have how many children, we have 35,000 children. So we’re really serving the hardest of the hard in terms of kids under the PASSE model. And we need to build a model that this would work for children because that’s what we’re seeing over and over. And we also had to build it for clients with intellectual disability because that’s what we’re seeing as well time and time again each week.
So Guidehouse really researched two states who were doing that type of mobile crisis for specifically those populations are included in their mobile crisis. And so two really good models they’ve been looking at are the Georgia model and the Arizona model.
And then we also were trying to figure out the working with them on background, is how they tie in their 9-8-8 systems and then how they tie in their 9-1-1. I think we all probably are on the same page of we don’t want another phone number out there. There’s too many phone numbers. So we need a way where regardless of where it comes through we can connect it to this statewide hub and mobilize teams.
So on slide nine, this is just talking about the difference between kind of what we’re trying to do versus what Georgia and the Arizona models are doing. And again in the essence of time, we picked some key things that we liked as you can see like Georgia has this centralized hub model which we really like. We think that would work well here in Arkansas. We think we need one hub that can do local deployment and keep up with all of our data so that we can utilize our data to see what’s going on.
And then Arizona does this cool thing, like we’re talking about where they link all of these lines together. So we’re taking pieces, or what we’re presenting or are hoping to move forward with, is taking pieces, the best pieces we think from the Georgia and the Arizona model to make our own.
Stone (AABH): These are design key considerations. And so we talked about this. Thank you, Senator Irvin, for asking us about the overall population. So who needs this? What areas of the state are we having significant need? Are some areas facing more challenges than others? What’s our current provider capacity and do we have workforce gaps? As so we’ve talked a lot about that. I know with our behavioral health task force that we’ve been working with, there’s been a lot of conversations about capacity, workforce capacity. What’s the technology necessary to operate this? And then who’s going to be on that mobile crisis team because we’re asking a lot of those mobile crisis teams if we want them to serve all populations, all the populations in need.
And then the last is, what is our sustainable funding? So we know that we’re expending funding from Medicaid, from some of our state general revenue in our different divisions, some of our block grant dollars. And how do we bring all of that together and look at sustainable funding across? And as Melissa mentioned earlier, also if we’re going to talk about all Arkansans, then we are talking about commercial insurances as well.
Mann (DHS): And so part of what we can do is look at an example of a crisis resource need calculator and that’s the ability to feed information in. And then it provides estimates of community based crisis response system capacity and associated funding that’s needed based on that data input. So this is kind of an example. We don’t yet have the Arkansas numbers, so it’s an example of this tool and how we would gauge population needs.
Rep L Johnson: When you say we don’t have the numbers, do we have the ability to get the numbers to put the data in? Sometimes I just wonder what we’re tracking, if we’re tracking that?
Weatherton (DDS): We definitely have the capacity to look at our own claims and what we’re paying. Where we’re struggling to just be honest, is we’re struggling to identify who’s sitting in local jails that we don’t know. And what their diagnosis was or is. That’s where we’re really struggling.
Sen Irvin: Yeah, we had somebody in the Searcy County jail for how long was that, over a year? I think it was over a year awaiting a bed at the state hospital. I mean, just and finally we got him moved but there’s no real-time tracking system which is why we need the technology.
Gann (AABH): And then again just based on this is a kind of just an example of potential cost savings based on this model or the models that we are looking at. And that’s diverting away from inpatient emergency rooms and there’s some significant cost savings when we actually get people the care they need in the community rather than the more high cost alternatives to this.
Mann (DHS): May I just add that once we get the data and some additional data to run the model on the example on 12. Then we can complete a more reasonable cost savings just because I can’t guarantee that we’re going to save this amount of money yet I said so.
Weatherton (DDS): No, I agree. Jane, is like oh, I thought you were taking those numbers off of 13? I think I meant to. This is just an example. So no, this is just them putting into this national type calculator on what other states have achieved in savings when they’ve diverted people out of these high cost settings. But again we’re working to get our claims. And if anybody has any ideas about how we get local jail figures, okay good, then we can add that in. Because I think that is a significant cost that we’re not capturing on our side of the house at all.
So on slide 14, just upcoming discussion points. So what we’re really pitching here through this presentation is this statewide hub. So one entity that would operate for the entire state of Arkansas, we would link the numbers together so that it would be routed to this hub. And then they would deploy local mobile crisis response teams. We had discussed internally doing a pilot of three regions and selecting those regions, they had different types of makeup. Some that maybe have an acute capacity in their county and then some that don’t. Because we’re really trying to pilot to see what can work and what’s not going to work and then how do we tweak that before we do a statewide deployment.
And the model would include these integrated models where we would take the good things we like out of Georgia and the good things we like out of Arizona. And we would test those as well through the pilot to see if we can operationalize it and if we need to make any tweaks.
And then as far as training, technology, data analysis. Again we have no visibility on a lot of these things currently. And so trying to start gathering that centralized hub for data collection so we can see who these people are, how many times are they calling, where are they going, who’s following up. So that we actually can see some trends and then make changes to a statewide program. So we would do all of those items through these three pilots.
And then the last two pages are just if you want to learn more about a kind of deep dive into how Georgia works and then how the State of Arizona works. But as far as our presentation, we are finished and happy to answer questions.
Rep L Johnson: Representative Ladyman, you’re recognized.
Rep Ladyman: Yeah. I mean I don’t really have a question, but you talk about you don’t know how many people are out there in the jails and I understand we don’t. But I mean, I can give you personal examples. But I think a lot of times in cities and counties, these police departments and sheriff departments know things but they’re not really reported.
And I mean I can give you an example a little town where I was a mayor. There was a couple of people that would show up every day and they’d just be on the street. They weren’t really homeless, they had a home but they didn’t have adequate care. So I’d call the chief, he’d take them home. Well, you can’t put those police resources every day taking that individual home. So after a while, we had to take them to jail. Well, that’s not really recorded anywhere that I know of. But I mean, that’s the connection that we need is with these local police enforcement units to somehow report that and get it into your data system. Because I guarantee you these police chiefs, these fire chiefs, and these mayors, and judges, sheriffs, they know these numbers and they know where these people live. But how do you get that in the database? That’s the question.
Gann (AABH): Thank you. Just to kind of speak. We recently had a case where I started digging deeper into a forensics case. So we know that we get requests for forensic evaluations. So I’m a rather curious clinician, and I went back to look at the number of crisis contacts that we had in our system. And we had multiple crisis contacts that were in our system prior to this individual ending up incarcerated with a forensic evaluation.
So I think it’s really important. This to me is a continuum and it’s a system that’s going to address a lot of these issues. And part of the issue on the adult side that I would love to address is can we grab these people early on first contacts before we get to that they’re stuck in jail like Senator said. And we’re waiting for them to get into a bed at the Arkansas state hospital. So just my idea about this continuum is that we’re going to grab adults early, we’re going to intervene early, get them into appropriate treatment, and divert away from that.
Rep L Johnson: Representative Mayberry, you have a question?
Rep Mayberry: Thank you. So appreciate the information. What do you need from us? What do we need to do? What’s the next step? Is this something that you can do by rules? That you can just automatically do without legislative help? Do you need us? Tell us.
Weatherton (DDS): I mean, I think today our goal for today was just to tell you we’re working on something. Because there’s so much spinning right now, especially during legislative session and I know you all have ideas being thrown at you on things to draft and bills to run. And just maybe just hoping that you will think okay, they are working on this. If someone comes to you and it fits into what we’re doing, reach out to us so we can stay on track. We didn’t want y’all to think that there was no plan. Because we know y’all are being bombarded probably with ideas.
Rep Mayberry: If you don’t mind another question. So you don’t need anything legislatively?
Weatherton (DDS): Yet.
Rep Mayberry: Okay. So the question is when?
Weatherton (DDS): We’re working on it and working on it as fast as we can. So I can’t give you a complete timeline.
Rep Mayberry: Among all the other things that we’re asking you to do because I know I have other topics I’ve talked to you about and drinking out of a fire hose I know.
Weatherton (DDS): At least one a day.
Rep L Johnson: I don’t think any of those ladies are shy about approaching us. So I’m sure once they have information for us they’ll let us know. Representative Ladyman, you had another comment or question?
Rep Ladyman: Well, one of the things I think you’re going to have to come to us for– and I had this question when we were looking at this. These are projects, and this is an initial funding mechanism. And if this works, how do we sustainably fund it? And that funding’s not there right now that I don’t think. I hope I’m wrong, but I don’t think it’s there. So I think that’s something that we’re going to have to address. And hopefully, it’ll be a successful program and we’ll be able to fund it somewhere in the future. But as Representative said, there may be some things you need now, and if you do, come back to us.
Weatherton (DDS): I just don’t think we’re ready to ask you for anything right now. But you’re right. I mean, starting up a pilot, yes, is something that we’ve talked about money wise but I think the end goal because we are kind of spending money on behavioral health and on this population across through contract dollars, through Medicaid dollars, through Medicare dollars, through private insurance dollars. And if the savings are anything like the national model shows us, we think this will be a fully sustainable program without any further request. Maybe even, I don’t want to say save money but it might, right?
Stone (AABH): Only a proof of concept, we can’t say that.
Rep L Johnson: Well, I think there’s some infrastructure money that we’re going to need. I mean, you’re talking about some technology to link these systems and some data tracking technology. And there’s two ways to get that, you can buy it or build it. And probably buying it is probably better most of the time. So I know there’s going to be some infrastructure issues but then yeah, hopefully, this is the kind of thing where once we get it set up, the savings results in enough cost value to allow us to run this sustainably on its own.
And I guess my question would be from the stepwise I understand stay tuned, wait. The concept of the pilot, the hub, is the hub the first step? I mean, what’s the first step in the process, is it linking the calls? Is it creating the hub? Is it creating a physical call center, and then the pilots? What’s the order y’all see that happening in?
Stone (AABH): So I think it’s almost like you have to have the infrastructure there but once you put the infrastructure in place you want to be able to roll with the mobile crisis teams very quickly. Because nobody’s going to want to send calls there unless – I mean, they can start collecting data – unless there’s somebody to launch. So ideally, what you would be doing is building out that hub with the technology pieces, while finding the teams, recruiting the teams, and training communities. Because back to what you were talking about, it’s going to be delivered in communities and it’s going to be delivered by the people that are already living in those communities and working with people.
And so I think you need to do it. It’s almost like different groups are doing this but it all has to come together. So when you launch it the teams are ready to go, we’re ready to collect the data, and we’re ready to accept phone calls from all those different call lines that we’re looking at.
Weatherton (DDS): And I would say in terms of next steps of what we were planning on doing with Guidehouse, and Paula, correct me. I mean, I think they are going to put together that strategy for us on how to implement that all at the same time. I mean because that’s what we would have to do. You can’t turn on, piecemeal it or it’s not going to work. That’s also why we want to start with three pilots and not go statewide right out of the gate.
Rep L Johnson: Any more questions? Yep.
Rep Ladyman: Thank you. I just want to say that I mean, this is great. This is something that’s been needed for many, many years. And it’s a challenge, I really, I know that it’s a big challenge and hopefully, like you say, the savings will pay for it but we don’t know that yet. But this is something I think we really needed to address for a long, long time. And I think it will go out into other areas where we’re spending money that we don’t need to. So thank you all for doing this.
Weatherton (DDS): Well, and thank you for your comment on the mayors. So we’re still doing surveys and I don’t think we had thought that through but I think that might be a good group to reach out to.
Sen Irvin: I’d just wrap up just to say thank you again. We do really have a dream team here, which I’m really proud of you guys. I mean, y’all have dug into this for a long time. I’ve been talking about this for a little bit as well because of what we’ve just personally experienced. And my husband kept saying we have a trauma call system. Why do we not have a trauma call system for people that are in need, that are dealing with mental illnesses, behavioral health issues? We can’t find beds for these individuals. And it’s not safe for their family members. It’s not safe for them. So this is something that’s just incredibly important and it’s hard when you’re an emergency room doctor and you’re faced with the situation trying to get somebody help and you cannot find a place in the entire State of Arkansas to help the person. So it’s incredibly frustrating for those folks, but I appreciate this. I’m excited about where we’re going. And we’re going to get there.
And also to the members that are here, so important that you’re here and to listen to this. Spread it amongst our colleagues. It’s very important that they understand and know we are entering into like a strategic planning phase that’s really comprehensive and statewide I would say all over DHS and Medicaid as a whole. And we’re working towards that. And that started on our journey with Representative Ladyman and Representative Johnson and Representative Michelle Gray and Cecile Bledsoe. And we’ve really been starting this a while and been working on it a while. So I just appreciate my colleagues just being passionate about this and digging into this.
I know Representative Garner with early childhood we’ve talked about this specifically. And how it’s just you have to be integrated or we’re just not going to solve the problems. So just appreciate all of my colleagues here. And Representative Johnson for setting all this up.
Rep L Johnson: Representative Mayberry, you had one more comment?
Rep Mayberry: Yes, it’s actually just a little request. I know you had the packet in printed form but can it be emailed to maybe someone that could then email it out to other members who are not here? Because this was really good information and there’s only a few of us here.
Rep L Johnson: Yeah, I think it’s good. I think it’s easy for that to be sent out. And the good news about the streaming is this will all be on video and we can encourage people to watch and get the information. And hopefully, there’s somebody watching at home right now. I know the weather made the attendance low. But the topic is really important and I think that everyone agrees.
And I’m optimistic. I think it’s great that we’re sort of on the front edge of this mobile crisis idea that we’re seeing other places in the state. And some of the things we’re doing with community paramedics and other things are sort of laying the groundwork for these frontline workers that can go and have these crises. We just have to get all the resources organized, have a good plan for mobilizing the resources. And it feels like we’re heading the right direction on that to see some change.
And so thanks again for spending the time on a snowy, icy afternoon. Everybody be safe going home. And we’ll get the information out to anybody that was here. I think we have a list of people here. We’ll make sure the other Committee members get it as well. So thank you, all. Appreciate it.