HUMAN SERVICES RESTRUCTURING TASK FORCE

Institutions and Facilities Subcommittee
MINUTES

October 23, 1997 - Fourth Meeting of Five

MEMBERS PRESENT

In addition, Representative Joe Kremer attended the meeting at Independence MHI and Representative Bill Brand attended the meeting at the Iowa Juvenile Home at Toledo.

MEETING IN BRIEF

Minutes prepared by Nicole Haatvedt, Legal Editor, and Rick Nelson, Legal Counsel
Organizational staffing by John Pollak, Committee Services Administrator

  1. Procedural Business.
  2. MHI Tour.
  3. Correctional Facility Tour.
  4. Presentations by MHI and Correctional Facility Staff.
  5. Presentations by Directors of Department of Corrections and Human Services.
  6. Presentations on Dual Diagnosis Mental Health and Corrections Sex Offender Treatment Programs.
  7. Next Meeting.
  8. Written Materials and Documents Filed With the Legislative Service Bureau.

SUBCOMMITTEE BUSINESS

1. Procedural Business.
Convening. The meeting convened in the auditorium at the administration building of the Independence Mental Health Institute at 9:50 a.m. with a welcome from Chairperson Houser, Representative Kremer, Senator Rehberg, and Superintendent Dr. Bhasker Dave. A brief video tour of the MHI was presented, followed by a tour of the campus and facilities.
Independence Tour. Tour stops included both open and locked wards for treatment of up to 128 adults with serious mental illness, a residential program for up to 20 adjudicated delinquent boys operated in leased space by Four Oaks, Inc., an adolescent psychiatry unit for up to 20 males and females in a locked ward, and the Cromwell Children's Unit for up to 33 children ages seven through 14.
Luncheon. The meeting continued with a working lunch in the auditorium of the MHI. Dr. Dave spoke about the history of the Independence MHI, current operation of the MHI, and clinical needs of consumers. He also introduced speakers from the community.
Recess and Reconvening. The meeting recessed at 12:55 p.m. and reconvened at the Iowa Juvenile Home (IJH) at Toledo at 3:10 p.m.
Toledo Tour. Tour stops included the school building operated year-round by DHS, locked and open residential cottages, and special program areas.
Toledo Presentations. Superintendent Robert Eppler gave an overview of the operations at IJH and introduced speakers from the community, IJH, and other programs on the campus.
Adjournment. The meeting was adjourned from the Toledo Juvenile Home at 5:45 p.m. 2. Independence Presentations.
Superintendent and Clinical Director, Dr. Bhasker Dave. Dr. Dave gave an overview of the operations at the MHI. He stated that the MHI is composed of a team of 340 staff and that the mission of the MHI is to serve persons with mental illness in the most effective, cost-effective, and technologically advanced ways. The MHI serves a 28-county catchment area in northeast Iowa and other counties upon referral from other MHIs.
Historical Changes. Dr. Dave provided an overview of historical changes at the MHI. The MHI was established in 1873 and housed about 1,800 patients until the mid-1940s. During that time patients were essentially warehoused with no prospect of returning to society. By the mid-1950s the MHI was adequately staffed by professionals who were educated and prepared to care for persons with mental illness. In addition, antipsychotic medications were developed which revolutionized the treatment for these persons so that many could be discharged. By the mid-1960s, there was a move toward community mental health centers and the patient population at the MHI shrunk to about 300 patients. In 1991, the Department of Human Services reorganized mental health services. The Independence MHI no longer provided substance abuse and geriatric services, but the psychiatric ward was expanded, and the average daily census remained at about 170 until 1995. Around 1995, a second generation of medications was developed. The new medications allowed many patients to become responsive and be discharged. Since 1995 the average daily census has dropped to about 139. The decrease in the average daily census is due primarily to a reduction in the average length of stay rather than a decrease in admissions. In fact, total annual admissions have remained at about 1,000. Most patients admitted to the MHI have been in multiple placements and have arrived at the MHI after county central point of coordination (CPC) screening, local mental health center screening, civil commitment, or through the court system. These patients are more difficult to treat. They require more intensive treatment and close attention. This is reflected in the percentage of patients on locked wards in 1988 (46 percent) compared to the percentage of patients on locked wards in 1997 (72 percent).
Available Space and Private Users at the MHI. As a result of the decline in the average daily census the MHI has some available space and is looking for users for that space. Four Oaks, Inc. of Iowa, based out of Cedar Rapids, operates a 30-bed residential treatment program for delinquent adolescent boys in the Reynolds Building. The Division of Vocational Rehabilitation Services has its field office serving Buchanan, Fayette, and Chickasaw counties located on the campus. The MHI Independence Employees Credit Union, the DHS State-County Assistance Team (SCAT) liaison, the Buchanan County Emergency Management Office, the Buchanan County Firemen's Association, and Iowa Prison Industries also make use of space on the MHI campus.
The MHI is best-suited to deal with human services programs. Some possibilities for users are psychogeriatric services, a forensic mental health unit, services for elderly persons and persons who are chronically mentally ill (but do not pose a security risk) from the Department of Corrections, and a boot camp for juveniles or other juvenile programs.
Of the four unused buildings on the campus, two should be torn down and one could be renovated for office space at a cost of about $1 million. In the Reynolds Building there is space available for 24 to 30 patients on one ward. In the Witte Building there is space available for 24 to 30 patients on each of two floors.
Buchanan County Attorney, Allan VanderHart. Mr. VanderHart spoke as a member of the Board of Corrections, which has been looking at using space at the MHI due to prison overcrowding. He suggested there are possibilities for corrections programs which may be compatible with MHI resources. The Board of Corrections has considered creation of a 100-bed unit for female inmates with chemical dependency which would be separate from the Mitchellville facility. The board would also like to create two transition units for inmates due to be paroled for special skills development such as anger management and life skills development. The units would also serve a second purpose related to a "zero tolerance" policy for drug and alcohol use among inmates in work release or on parole.
Director of the Buchanan County Economic Development Commission, Tim Fox. The Commission was created two years ago and became involved with the MHI immediately, primarily in response to a 1994 state report to the Governor which stated that there was little communication between the Independence community and the MHI. The Commission has been involved with two proposed major projects concerning the MHI, an RFP for a medium-security prison and a regional juvenile detention facility. The Commission supports a relationship between the MHI and the Department of Corrections.
3. Questions to Independence Staff.
Representative Foege asked Mr. VanderHart whether there has been any discussion by the Board of Corrections about collaboration with the MHI for the treatment of sexual predators. Mr. VanderHart responded that there is a sexual offender unit at Mt. Pleasant and at most of the community correctional facilities, and that he was not aware of any expansion of those programs. Mr. Harold Templeman, DHS Division Administrator, responded that there have been discussions between DHS, the Department of Corrections, and the Department of Justice on this issue. He noted that the U. S. Supreme Court had recently upheld a Kansas law similar to an Iowa law which had been repealed due to constitutional questions and cost concerns. If Iowa reinstates the sexual predator law, these agencies are looking at implementation of new treatment programs.
Senator Rehberg asked Dr. Evans from the Cromwell Children's Unit whether there have been any concerns with managed care. Dr. Evans responded that from July 1, 1996, to June 30, 1997, a child admitted to the unit has had an average of 5.94 admissions to treatment programs outside the home and an average of 10.83 agencies have been involved with the child prior to admission to the MHI. Children admitted to the unit require a serious level of care. The unit has an acute and subacute care license as required by the managed care agreement. Medicaid only pays for acute and subacute care, but most of the children treated need continued treatment after they fall out of those classification levels. The average stay paid for by Medicaid is 38.62 days; however, the average length of stay is actually 77.9 days. Merit Behavioral Care Corp. (MBC), the state's managed care contractor, is often unable to find placement for the children after treatment at the MHI. The child may remain at the MHI after losing certification for treatment by Medicaid, at which point the county becomes responsible for the cost. Recidivism for children treated at the MHI is going up. Dr. Evans asked that funding be provided for continued care after payment by Medicaid until the child is stabilized and is able to move to a less intensive level of treatment. Representative Brauns asked Dr. Evans how much this would cost. Mr. Templeman responded that a review process was recently implemented for these types of cases to determine who is the appropriate payer for services_the managed care contractor, the county, or the state. Medicaid has paid for a lot of services in this state that, in many states, would be treated as child welfare services. Merit has a "keep kids safe" policy which allows the continuation of services to a child if there is no safe alternative. Managed care has really just raised issues that have been there for years.
Senator Tinsman asked Mr. Templeman about the recidivism increase at the Cromwell Children's Unit. She stated that that is not the intended effect of managed care and it does not reduce costs. Senator Tinsman commented that this should be brought to the attention of Merit. Senator Tinsman also commented that the per diem cost of $344 reflects the same number of staff even though the number of patients had decreased. She asked whether there is any way to have a more flexible staff. Dr. Dave responded that the MHI already moves staff from ward to ward and that if patient numbers increased, the MHI would be understaffed. The MHI is trying to manage this by merging internally. A number of staff members have left recently and have not been replaced. Dr. Dave emphasized that if different disciplines such as sexual predators were to be treated at the MHI, more staff would be needed.
Ms. Arlene Dayhoff requested that there be a report of the study on decertification for children and adolescents from Mr. Templeman. Ms. Dayhoff also questioned whether there could be an arrangement for children who need long-term treatment in the new managed care contract. Mr. Templeman commented that the continued discussion of including rehabilitative treatment services (RTS) for children in the managed care contract along with mental health and substance abuse services may address this issue.
4. Toledo Presentations.
Superintendent, Robert Eppler. Mr. Eppler provided an overview of the programs and facilities at IJH. The IJH was first established as an orphanage in 1920. Today it serves up to 92 adolescents ages 12 to 17 years, up to 30 of whom are females adjudicated as committing a delinquent act and the remainder, males and females adjudicated as children in need of assistance (CINA).
President of Local Iowa Juvenile Home Foundation, Bill Skow. Mr. Skow distributed copies of the Iowa Juvenile Home newsletter and commented that the IJH is an integral part of the community. The foundation has a goal of becoming a "children and family research and resource center" via private foundation funding.
School Principal, Mike Sawyer. Mr. Sawyer commented that the average student at the IJH is two or three grade levels behind and the school works with students to catch up on educational programs. The school is developing its vocational department and finding ways to participate in the community. Mr. Sawyer distributed a handout outlining the various community involvement programs, including Children of Change, Salvage Santa, Clothes Closet, HIV/AIDS presentations, the Hy-Vee Program, the Nurse's Aide Class, Toledo Clean-up, the Service Learning Class, on-the-job training, South Tama Community Schools and IJH school sharing, and the Toddler Program.
Toddler Program (Circle in Life). Ms. Barb Thompson, a speech-language pathologist with AEA 6, explained that the Toddler Program couples toddlers with special needs and adolescents with different skill levels in a program centered on the IJH campus. Ms. Cindy Skopec, an early childhood special education teacher, commented that, while the program benefits the toddlers, it also benefits the adolescents by providing them with vocational and parenting skills and influencing their parenting decisions. The classroom at IJH is also used for adolescent-parent and child or sibling interaction.
Clinical Director, Deb Hanus. Ms. Hanus stated that medical services provided to youth at IJH include psychiatric evaluation, psychological evaluation, dental services, and medications. The treatment process involves the school, the cottages, and sometimes the community. An individualized treatment plan is developed for each youth. Group work focuses on anger management, social skills training, abuse therapy, friendship development, and grief and loss issues. The community outreach includes the Teddy Bear project with the sheriff's and fire departments and the Adopt a Highway Program.
Tama County DART Program Manager, Kim Johnson. The DART (Delinquency Alternatives to Residential Treatment) Program leases space at the IJH. Ms. Johnson stated that the program was created in 1995 as a day treatment program to reduce the need for out-of-home placement of delinquent youth. The program is very structured with physical training, anger management programs, study hours, and school involvement. The program provides strict guidelines and emotional support for the youth. Arturro, a participant in the program, also spoke to the Subcommittee about his experience with DART.
5. Questions to Toledo Staff.
Cause of Problems. Representative Houser asked Mr. Eppler what the one thing is that attributes to most of the problems of the juveniles at IJH. Mr. Eppler responded that the primary cause of the problems is the breakup of the family. He opined that children need stability, whether that is with one or two parents. Mr. Eppler appealed to the legislators in attendance for more services at the front end to prevent or lessen juvenile problems and maintenance of services at the back end to address problems after they develop.
MHI Placements. Mr. Eppler was asked about the proportion of children who are referred for placement at IJH before, during, or after a placement at the Independence MHI. Mr. Eppler conjectured the proportion has increased in recent years and agreed to provide more specific information following the meeting.
The meeting continued with a discussion of the upcoming NCSL meeting at the Willow Creek Conference Facility in Des Moines, the Subcommittee meeting at Mt. Pleasant on November 6, and a suggested date of December 11 for a wrap-up meeting of the Subcommittee.
6. Next Meeting.
The next meeting of the Subcommittee is scheduled for Thursday, November 6, at Mt. Pleasant Treatment Center. Agenda items include tours, an overview of the dual diagnosis mental health and substance abuse treatment program, and presentations by the Directors of the Departments of Human Services and Corrections.
7. Written Materials and Documents Filed With the Legislative Service Bureau.
1. An overview of Independence MHI prepared by Dr. Bhasker Dave, Superintendent.
2. A history of Independence MHI, general overview, and brochure.
3. A memorandum prepared by Mr. Timothy Fox, Buchanan County Economic Development Commission.
4. An orientation brochure for parents and for students placed at the Iowa Juvenile Home at Toledo.
5. A description of the Iowa Juvenile Home Education Department.
6. A description of the Toddler Program provided at the Iowa Juvenile Home.
7. A newsletter from the Iowa Juvenile Home.

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