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2 COMMONWEALTH OF PENNSYLVANIA HOUSE OF REPRESENTATIVES 3 HUMAN SERVICES COMMITTEE
4 STATE CAPITOL 5 HARRISBURG, PA
6 MAIN CAPITOL BUILDING 7 ROOM 60 EAST WING
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9 TUESDAY, OCTOBER 15, 2013 9:02 A.M. 10
11 PUBLIC HEARING ON 12 MENTAL HEALTH INVOLUNTARY COMMITMENT LAW
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14 BEFORE 15 HONORABLE GENE DIGIROLAMO, MAJORITY CHAIRMAN 16 HONORABLE MINDY FEE HONORABLE DOYLE HEFFLEY 17 HONORABLE LEE JAMES HONORABLE STEVEN MENTZER 18 HONORABLE TOM MURT HONORABLE BRAD ROAE 19 HONORABLE MADELEINE DEAN HONORABLE PATTY KIM 20 HONORABLE STEPHEN KINSEY HONORABLE MARK PAINTER 21
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23 BRENDA J. PARDUN, RPR 24 P. O. BOX 278 MAYTOWN, PA 17550 25 717-426-1596 PHONE/FAX 2
1 ALSO PRESENT:
2 Elizabeth Yarnell, Majority Research Analyst Pamela Huss, Majority Legislative 3 Administratie Assistant Ashley McCahan, Minority Executive Director 4 Lynette Mhangami, Minority Research Analyst
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7 BRENDA J. PARDUN, RPR 8 REPORTER - NOTARY PUBLIC
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1 INDEX
2 NAME PAGE
3 OPENING REMARKS AND INTRODUCTIONS 4
4 DENNIS MARION, DEPUTY SECRETARY 7 OFFICE OF MENTAL HEALTH AND SUBSTANCE 5 ABUSE SERVICES, DEPT. OF PUBLIC WELFARE
6 LLOYD G. WERTZ, VICE PRESIDENT 23 POLICY AND PROGRAM DEVELOPMENT 7 FAMILY TRAINING AND ADVOCACY CENTER
8 SHELIA WOODS-SKIPPER, JUDGE 29 COURT OF COMMON PLEAS, PHILADELPHIA CO. 9 LUNA PATELLA, ASSISTANT CHIEF 35 10 MENTAL HEALTH UNIT, PHILADELPHIA DEFENDER ASSOCIATION 11 JACOB BOWLING, DIRECTOR OF ADVOCACY AND 37 12 POLICY, MENTAL HEALTH ASSOCIATION OF SOUTHEASTERN PA 13 MARK Z. ZACHARIA, ESQUIRE 44 14 ASSISTANT COUNSEL, CORPORATE LEGAL DEPT. WESTERN PSYCHIATRIC INSTITUTE AND CLINIC 15 K.N. ROY CHENGAPPA, M.D. 52 16 PROFESSOR OF PSYCHIATRY, UNIV. OF PITTSBURGH WESTERN PSYCHIATRIC INSTITUTE AND CLINIC 17 CAROL HOROWITZ, ESQUIRE 57 18 DISABILITY RIGHTS NETWORK
19 ALYSSA GOODIN, ASSOCIATE DIRECTOR 68 THE PHILADELPHIA ALLIANCE 20 CHRISTOPHER WYSOCKI, ADMINISTRATOR 81 21 JUNIATA VALLEY BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES 22 EDWARD MICHALIK, ADMINISTRATOR 86 23 BERKS CO. MENTAL HEALTH/DEVELOPMENTAL DISABILITIES PROGRAM 24 REBECCA MAY-COLE 91 25 BEHAVIORAL HEALTH AND AGING COALITION 4
1 P R O C E E D I N G S
2 ~k ~k ~k
3 MAJORITY CHAIRMAN DIGIROLAMO: Good
4 morning, everyone. Good to see everybody here
5 today on a -- nice and early on a Monday morning -
6 no, Tuesday morning, right? Feels like a Monday,
7 feels like a Monday morning, though, also. So, I’d
8 like to have this meeting of the Human Services
9 Committee called to order.
10 And if I might ask everyone to rise for
11 the Pledge of Allegiance.
12 (Whereupon, the Pledge of Allegiance
13 was recited.)
14 MAJORITY CHAIRMAN DIGIROLAMO: Okay.
15 With that, I know many of the members are going to
16 be here. Some of them are going to be a little bit
17 late, but there are a few members that are here and
18 I would just -- might ask them to say hello and let
19 everybody know who they are and where they come
20 from, and we'll start with Rep. Roae.
21 REP. ROAE: Thank you, Mr. Chairman.
22 I'm Brad Roae, and I represent Crawford
23 County.
24 REP. JAMES: Lee James, Venango County
25 and part of Butler County. 5
1 REP. KIM: Good morning. My name is
2 Patty Kim, and I represent parts of Dauphin County,
3 including Harrisburg.
4 MAJORITY CHAIRMAN DIGIROLAMO: Gene
5 DiGirolamo, from Bucks County, majority chairman of
6 the committee.
7 REP. MURT: Tom Murt, Montgomery County
8 and Philadelphia County.
9 MAJORITY CHAIRMAN DIGIROLAMO: Okay.
10 It is my intention this morning, I'm going to let
11 Rep. Tom Murt chair the hearing this morning. It
12 was his idea for the hearing, and he is also the
13 subcommittee chairman of the Committee on Mental
14 Health. So, I’m going to let Tom take charge of
15 the committee.
16 But, before I do, just a couple opening
17 remarks. This is, I think, an extremely critically
18 important issue to everybody around the state of
19 PA, this issue of involuntary commitment. And
20 since I’ve been chairman of the committee for the
21 last three years, I’ve heard a number of
22 heartbreaking stories from families around the
23 state of PA who were desperately trying to get help
24 for their loved ones and they knew that they were a
25 danger to themselves or to society in general, and 6
1 they were not able to get them help, and stories
2 where they, unfortunately, ended up dead and, also,
3 unfortunately, ended up in the criminal justice
4 system.
5 I kno w o ur s tate hospitals, I think for
6 the most part, have been closed around the state of
7 PA, and maybe with this committee hearing, might be
8 a -- we can start by conversation. Maybe we need
9 to start opening up some of the state hospitals
10 again. I’m not sure. That certainly might be
11 something we can have a conversation about.
12 But I know it’s an important issue.
13 And also would like to hear how this law is being
14 applied. Is it being applied uniformly around the
15 state? How each county is applying these laws, the
16 involuntary commitment. So, it’s a really
17 important hearing this morning.
18 So, with that, I’m going to turn it
19 over to Rep. Tom Murt.
20 I’d also like to recognize Rep. Mark
21 Painter, from Montgomery County, who’s joined us.
22 Good morning, Mark.
23 With that, I’m going to turn it over to
24 Rep. Murt. Thank you.
25 REP. MURT: Thank you, Mr. Chairman. 7
1 I’d like to ask our first testifier to
2 come forward, Secretary Marion, from the Office of
3 Mental Health and Substance Abuse Services in the
4 Department of Public Welfare.
5 Welcome, Mr. Secretary.
6 DEPUTY SECRETARY MARION: Good
7 morning. Thank you for allowing us to be here this
8 morning to speak —
9 REP. MURT: Thank you for joining us.
10 DEPUTY SECRETARY MARION: We have
11 submitted written testimony, and my comments will
12 follow along with that, and I will more than
13 welcome any questions as we go along.
14 It is excellent timing for us. The
15 Office of Mental Health and Substance Abuse
16 Services is in the process of looking ahead over
17 the next three to five years in terms of the
18 important aspects of mental health services and
19 supports across the commonwealth. And towards that
20 end, we've been engaged around the commonwealth,
21 having public forums and focus groups, to talk
22 about perceptions, about what's working and what's
23 not working within the system. Knowing that there
24 has been attention to the issue of our emergency
25 response capacity as a commonwealth as well as the 8
1 commitment process across the commonwealth, we
2 spent particular attention looking into this issue
3 and have convened four separate focus groups which
4 involve stakeholders from different geographic
5 regions around the commonwealth, to come together
6 and work with us and talk through how the
7 commitment process works.
8 We do identify that there is some
9 misunderstanding of how the process works. And
10 I'll be glad to address any questions you have this
11 morning.
12 Again, as deputy secretary, I work with
13 an office that has responsibilities for planning
14 services and supports to meet the needs of six
15 hundred and fifty thousand people a year in the
16 commonwealth. That’s the average number of
17 individuals who receive services through funding
18 managed by the Office of Mental Health and
19 Substance Abuse Services.
20 I want to acknowledge that in our
21 planning, we are working with the Commissioners
22 Association of PA, its affiliate, which involves
23 the administrative county-based mental health
24 programs across the commonwealth and others.
25 I want to pay particular note to our 9
1 community support programs, which is a forum that
2 is -- substantially involves individuals who have
3 been the recipients of services through the mental
4 health system. And we particularly value the
5 contributions they've given us. We've talked about
6 emergency response and commitment process.
7 The Mental Health and Mental
8 Retardation Act of '66 and the Mental Health
9 Procedures Act established the current framework
10 for the delivery system. The act also established
11 the requirement for emergency services and the
12 standards and procedures for voluntary and
13 involuntary commitment.
14 The emergency services can include
15 procedures for initiating involuntary examination
16 and emergency treatment under the Procedures Act of
17 '76. And that was one of the items we identified
18 in our conversations. That folks didn't recognize
19 that from the time somebody might make an overture
20 through the system, say through crisis, and they
21 move to filing a petition which would seek to have
22 someone admitted involuntarily for care,
23 recognizing that this process goes through the -
24 what we call the delegate. The delegate works
25 under the authority of the county administrator, 10
1 who has the authority to approve a warrant, which
2 would then allow authorities to take an individual
3 who's perceived as posing a threat to self or
4 others to an emergency room for an evaluation.
5 And, then, in the emergency room, that review, that
6 assessment is completed by a medical professional,
7 a doctor, sometimes a psychiatrist, other times the
8 attending physician in the emergency room.
9 At that point is when the decision is
10 made to involuntarily admit or not to an acute care
11 unit, which is a community-based resource, not the
12 state hospitals.
13 So, those are the basic introductory
14 steps in the emergency response process, typically
15 crisis, and, then, along the way, a petition, a
16 review by a delegate of the administrator of the
17 county MR developmental disabilities program. And,
18 then, that would authorize an individual to be
19 brought in to an emergency room for evaluation, at
20 which point in time, the doctor makes the
21 determination whether a commitment to an acute care
22 unit might be necessary or warranted.
23 And, this crisis -- counties across the
24 commonwealth, under the act, have responsibility
25 for the emergency service provisions, including 11
1 crisis. So, we do have some level of crisis
2 services in every county, every joinder. Some
3 counties work in concert with one another. And,
4 so, there's forty-seven entities out there which
5 are county-based programs, and each one of them has
6 responsibility for having a crisis response
7 capacity.
8 We do recognize that there are some
9 differences among the counties, but there's a
10 generalized rule base that governs both basic
11 crisis services and certainly the procedures needed
12 to be followed in the commitment process.
13 Based on information we received from
14 the PA State Police, we are estimating
15 approximately thirty-six thousand commitments per
16 year. One limitation as a system and as a
17 commonwealth is we don't have a common information
18 base to track the number of petitions filed and
19 then the number of commitments that occur.
20 Counties submit their information about
21 commitments to -- directly to the state police to
22 satisfy state and federal reporting requirements.
23 That information does not flow through the Office
24 of Mental Health and Substance Abuse Services.
25 I want to credit the state police, the 12
1 county Commissioners Association, and the
2 Commission on Crime and Delinquency. We’ve been
3 meeting and discussing, over the past few months,
4 since my movement into the role of deputy, about
5 how to improve that information flow.
6 So, one of the things we don’t know is
7 how many petitions get submitted versus the number
8 that are approved. But we are talking with
9 counties now and seeking their local information so
10 we can get a better handle on it. For instance, in
11 Allegheny County, if I might, we can just give you
12 a sense of -- in 2012, Allegheny County had over
13 fifty-seven hundred petitions filed, of which
14 forty-three hundred and ninety were approved. So,
15 we’re looking at 75 percent, 76 percent rate for
16 Allegheny County. I cannot say that that is the
17 same rate of approval throughout the other
18 counties, but we are gathering that information
19 now.
20 So, the first sampling shows that
21 that’s a reasonable estimate, but, again, we are
22 engaged with conversations with counties, trying to
23 pull together the best information we have as to
24 how often the process is utilized across the
25 commonwealth. 13
1 As I mentioned at the beginning, we’re
2 in focus groups. And our goal, then, is to be in
3 the room with what we consider to be our
4 stakeholders, particularly folks that are -- have
5 responsibility for managing the local emergency
6 response system throughout the commonwealth as well
7 as folks who have experienced treatment services.
8 We’re particularly interested in hearing from them,
9 along with families and other individuals that have
10 a particular interest.
11 It is very interesting, as we’ve gone
12 through this. We have been attempting to identify
13 whether or not -- there is consensus on
14 circumstances when everybody generally agrees that
15 an emergency response is warranted and potentially
16 a commitment process is necessary. I think there
17 is general consensus, from the sessions we’ve held
18 so far, which has involved -- just to give you an
19 idea, of the sessions we’ve had, we’ve had some
20 generalized planning sessions as well as specific
21 meetings with community support program personnel
22 where there’s a substantial number of individuals
23 who have been in service.
24 We have now crossed the three hundred
25 mark in terms of number of people we engaged with. 14
1 Our goal is to reach five hundred.
2 And the way we have engaged in the
3 conversation is, working with counties, we've
4 generated a number of sample scenarios that reflect
5 the kinds of situations that local crisis programs
6 and local delegates will face. And then we've just
7 been asking, under those circumstances, if people
8 would concur that a response is warranted.
9 And it's interesting that in every
10 single session, there's differences of opinion.
11 So, what we're looking at is a well-established
12 base of law and procedure, policy, governing crisis
13 and commitment process. But, even amongst
14 professionals, we recognize that there's
15 differences of opinion regarding when this kind of
16 step should be taken.
17 One thing we have noted is we've heard
18 profound stories from individuals who went through
19 the commitment process during the course of the
20 their illness, and in their -- in the public
21 forums, we've heard examples of troubling memories
22 of what that process was like to have gone
23 through.
24 One of the most intriguing responses,
25 and one I quite honestly had not though of 15
1 previously, occurred in our first CSP session,
2 where a member who had gone through a commitment
3 process described the difference in terms of having
4 an emergency response to a health issue. When an
5 ambulance arrives, friends, neighbors, family
6 members, the ambulance coming evokes concern and
7 empathy and concern for the welfare of the
8 individual.
9 In the commitment process, it’s likely
10 the emergency response will come in the form of a
11 police car, and juxtaposing that, the different
12 emotional response and reactions you get when the
13 police car pulls up, and that rather than empathy
14 and concern, it might be a different kind of
15 concern about what is going on there and not a
16 recognition that this is a medical emergency.
17 So, this is one of those unique medical
18 conditions that warrants or brings out a different
19 kind of response.
20 And one of the other things that was
21 mentioned is that, as a medical emergency, it’s the
22 one scenario where, when an individual, if a
23 warrant’s been signed to have someone brought in
24 for evaluation, it may well be that that individual
25 will be handcuffed and placed in a police car on 16
1 the way to the hospital, just as a precaution,
2 which is very different and part of that memory
3 that some individuals report, that being shackled
4 was something that stuck with them long after the
5 original event. It just is another subtle element
6 or not-so-subtle element within the broad complex,
7 that there's competing interests in the whole
8 conversation of how best to handle emergencies.
9 The other piece we did hear is that
10 general recognition by all stakeholders that an
11 earlier response, such as mobile crisis, where
12 there's an attempt to engage before pulling out the
13 commitment process as the response, and an attempt
14 to do a softer intervention I think is something
15 that we received very broad support for in all of
16 our conversations.
17 We do know there are significant
18 variations in how warrants are processed. In one
19 county, we know that there's a specialized response
20 unit, which included an ambulance and specially
21 dedicated, trained personnel who serve a warrant,
22 but in other counties, it may be, particularly
23 rural areas, it may be the responsibility of the
24 state police to fulfill that role.
25 There is a general sense that in 17
1 psychiatric emergency or crisis situation has a
2 potential to traumatize the individual who may be
3 subjected to forcible removal for his or her home
4 and then taken into custody and then brought to the
5 emergency room for evaluation by a medical
6 professional.
7 So, at any time during the involuntary
8 commitment process, there's the prospect that
9 physical restraints, seclusion, involuntary
10 medication, or other restrictive interventions may
11 occur. So, there’s just the sense of really trying
12 to hold this back as the avenue of last recourse.
13 And what we heard even from the consumers that
14 participated with this is -- when we did these
15 scenarios, is what earlier interventions were
16 attempted? Was mobile crisis invoked? Were there
17 other attempts to do this so that we did not have
18 to get to a commitment process?
19 What we do have is, fortunately, the
20 work of the Commissioners Association and the
21 county MH administrators. They had been looking
22 into these issues back in 2010 and compiled a
23 report and put forward a number of recommendations,
24 and I’ve included those in my testimonies, such as
25 the statewide assessment should be conducted to 18
1 determine what crisis intervention services are
2 funded by each county.
3 We’ve begun to compile that information
4 and update it. We have a look that’s dated in
5 2010. We really real do need to bring it up to the
6 current time, and we’re beginning that process.
7 An emphasis on timely accessing to
8 supports and services, which can reduce the
9 likelihood of relying a heavier interventions,
10 more -- more late-stage interventions. And the
11 idea that diversions should be part of the whole
12 continuum of intervention work.
13 There’s an interesting part coming out
14 now, some counties have -- have identified that
15 they’ve begun to integrate peers in their crisis
16 response. So, having an individual in the response
17 community that has prior experience from their own
18 intervention.
19 I started my career in the drug and
20 alcohol system, and it was typical to have folks in
21 recovery as part of an outreach or a sponsor coming
22 out and attempting an earlier intervention. We’re
23 still looking at how that emerges in the mental
24 health services delivery system.
25 There is a recommendation that we, as a 19
1 department, we -- and as county programs continue
2 to promote and utilize mental health advance
3 directives, where, when folks are stable in their
4 recovery, that decisions are made of what
5 happens -- what to do if a problem emerges.
6 And there are three items that also
7 further down in my testimony on page four, that
8 really were consensus items. One thing we have
9 identified is that there’s not a standard training
10 process for folks who fulfill the delegate
11 function. Remember, that’s the first step in a
12 commitment process, the individual who refused the
13 petition, and we do not have a standard set of
14 qualifications and/or training required. Each
15 county makes decisions to do that.
16 I’m comfortable in responding that, in
17 conversation with counties, they do not -- they
18 look for folks who have skill sets to fulfill that
19 role, but I do think there was general acceptance
20 from all the stakeholder groups, whether it be
21 families or individual assistants or
22 county representatives, crisis representatives,
23 that there is room for us to step forward and try
24 to standardize the minimum training and experience
25 required and also to provide guidance, because we 20
1 do know there are ranges of interpretation.
2 In my own observation, it's not much
3 different than what happens in sort of the criminal
4 justice system, where you've got standard sets of
5 criminal procedures. But counties do, in local
6 courts, you will see them used somewhat
7 differently.
8 I think we have the same thing going on
9 in the mental health system. We have the Mental
10 Health Procedures Act, and that there are some
11 basic rules to be followed, but among those rules,
12 there's room for variation and practice.
13 So, what we want to do is identify the
14 outer edges, so that there is a consistency, that
15 everybody should expect a relative simpler
16 response, regardless of which county an issue may
17 emerge in.
18 And then there is an -- an emerging
19 practice that is also being recommended, which is
20 promoting the goal that every individual in
21 services has a Wellness Recovery Action Plan.
22 Again, a preventative tool that helps have a
23 predetermined response as a problem begins to
24 emerge.
25 So, my remainder of my testimony is 21
1 before you. I think the one thing that I would
2 like to leave with you is the goal of the effective
3 crisis intervention services should be to ensure
4 the individual receives -- during a crisis, gets
5 the right service in the right way at the right
6 time to avoid escalation. So, our goal would be
7 really to try to build out the system and enhance
8 our ability to get involved as the -- at the
9 earlier stage of the crisis emerging, so that we
10 are not left with trying to use what can be termed
11 -- identified as a blunt instrument in terms of the
12 commitment process, you know, later-stage
13 intervention.
14 If you look at our health innovation
15 planning across the commonwealth, you will hear the
16 language of "better and earlier interventions.”
17 Whether it's a heart attack, you want to get there
18 as the symptoms begin to emerge, not after a
19 full-blown heart. If it's a psychiatric emergency,
20 we want to get in earlier, as symptoms emerge, and
21 not late into a break.
22 So, at this point, our goal is to move
23 from a reactive approach to mental health crisis
24 that relies on restrictive, late-stage
25 interventions such as involuntary commitment to a 22
1 more proactive approach that provides effective
2 crisis response and reduces the likelihood of
3 future emergency situations.
4 So, I do thank you for the opportunity
5 to speak with you this morning in this committee
6 meeting and would welcome any questions.
7 REP. MURT: Thank you, Mr. Secretary.
8 As the chairman mentioned at the
9 outset, we are going to ask our members to please
10 hold their questions to the end.
11 Mr. Secretary, if you can stay, we’d be
12 grateful. If you cannot stay, we will be getting
13 our questions to Melanie Brown and we will be
14 submitting them in writing to you for follow up.
15 DEPUTY SECRETARY MARION: Thank you
16 very much.
17 REP. MURT: Thank you for your
18 testimony.
19 Before we have our second testifier,
20 just want to recognize some of our members who have
21 joined us. Rep. Doyle Heffley, Rep. Steve Kinsey,
22 Rep. Mindy Fee, Ashley McCahan, Rep. Lynette
23 Mhangami, Rep. Steve Mentzer, and Rep. Madeleine
24 Dean.
25 Thank you very much for being with us. 23
1 Our next testifier is Lloyd Wertz, the
2 vice president of Policy and Program Development
3 for Family Training and the Advocacy Center.
4 Mr. Wertz, thank you for joining us
5 this morning. Good to see you again.
6 MR. WERTZ: Good to be seen. Thank
7 you.
8 And thank you so much for holding this
9 hearing to further discuss the potential benefits
10 and costs of proposed changes to the commonwealth's
11 Mental Health Procedures Act of 1976 as amended in
12 1978.
13 This opportunity to provide testimony
14 is greatly appreciated. And feel free to ask
15 questions during my testimony or follow the
16 direction of your coach here and wait until the
17 end.
18 I do want to note that the last time I
19 testified to you folks, there was a middle school
20 oom-pah band out front, and I do greatly appreciate
21 having an opportunity to speak to you without that
22 interference.
23 I do have over thirty-six years of
24 experience in community and residential services,
25 primarily devoted to serve individuals with serious 24
1 mental illnesses, intellectual disabilities,
2 addictions, and folks who are aged. I've also
3 served as a county mental health/intellectual
4 disabilities administrator in my home county and
5 currently work with Family Training and Advocacy,
6 as you've heard.
7 We offer assistance to programs across
8 the commonwealth to help them more effectively
9 engage families and others in the treatment
10 processes for persons in recovery. Probably more
11 importantly, I had a father who suffered from
12 mental illness for years before his premature death
13 in 1981.
14 On several occasions, as a young adult
15 and maybe a little before I was an adult, I was
16 placed into the position of having to act as
17 petitioner in forcing my father to have an
18 examination for involuntary mental health
19 treatment, as provided under Section 302 of this
20 act. On some of those occasions, he was admitted
21 involuntarily into the acute inpatient unit of the
22 local psychiatric unit in our local general
23 hospital. On others, he signed into that treatment
24 facility voluntarily. On no occasion was the
25 petition denied, nor was he determined not to be 25
1 mentally ill and in need of treatment.
2 I suppose an observer could say that
3 the current law worked for him and our family
4 during those difficult and challenging times. It
5 was only later, as I chose a career path in the
6 field, that I learn that statewide law might not
7 work as well across the commonwealth. In fact,
8 even as I assumed the role of county administrator,
9 I remained largely unaware of this current reality.
10 In addition, there are portions of the
11 Mental Health Procedures Act which allow for the
12 involuntary examination and treatment to be
13 delivered on an outpatient basis for those who are
14 not so impacted by their illness as to require
15 treatment in a locked inpatient facility, but no
16 illness aspect of his or her limit insight to the
17 point where the treatment may be only accepted if
18 required by a commitment order under this act.
19 I have learned through experience in
20 working in the mental health crisis response system
21 and in serving as program director of several
22 inpatient acute psychiatric units, that the use and
23 application of the Mental Health Procedures Act in
24 both the areas of inpatient and outpatient
25 commitment for mental health treatment has wide 26
1 variability across our state.
2 I also have learned that the
3 application of the Mental Health Procedures Act in
4 any given county is significantly impacted by the
5 understanding of the Mental Health Procedures Act
6 by existing members of the judiciary in that given
7 county. The president judge appoints individuals
8 to serve as the mental health review officer, and,
9 thus, when questions as to interpretation of the
10 Mental Health Procedures Act in specific cases,
11 it’s my understanding that these are the
12 individuals who study and specialize in this law
13 and establish courses of action and routine
14 findings in each county or county program.
15 A few years ago, there was an effort
16 which offered training sessions in several
17 locations to those involved in the application of
18 the act. Individuals went to those county
19 programs, and they went to those trainings. And I
20 was fortunate to be able to attend two of these
21 sessions in two different regions.
22 I was struck by two phenomena.
23 Individuals from counties with very different
24 interpretations of the Mental Health Procedures Act
25 all reported that their approaches had been 27
1 verified as being correct, based on what they heard
2 or what they thought they heard. There were very
3 few, if any, members of the judiciary in attendance
4 at the two sessions for which I was present.
5 This brings me to the point of my
6 testimony. Most agree that there is need for the
7 effective application of the current, or re-worded,
8 Mental Health Procedures Act to safely maintain our
9 communities and properly deliver services to those
10 who are significantly impacted by serious mental
11 disability.
12 The act under which we currently
13 operate is over twenty-five years old in its
14 amended version. There may be better ways of
15 wording the Mental Health Procedures Act which
16 could improve its application in the context of
17 today's updated treatment and recovery-oriented
18 resources.
19 However, if changes are to be adopted
20 by the legislature at this point or any future
21 point, they simply must be applied with consistency
22 across the commonwealth to gain the optimal level
23 of benefit from those changes.
24 Additionally, the local policy setting
25 entity of local judicial systems should be engaged 28
1 at the outset of any changes, and all efforts must
2 be made to assure that those regional resources are
3 well educated and prepared at the outset of
4 implementation of any changes and consistently
5 updated along the way.
6 Finally, there needs to be recognition
7 that any changes in the behavioral health system
8 will require additional resources to properly
9 effect and sustain those changes. In our now
10 grossly underfunded community mental health
11 systems, the issue of lack of treatment resources,
12 especially at the outpatient level, has to be
13 addressed as part of any changes which will
14 increase demand for those services.
15 Access and availability are the keys
16 and will require increased funding to properly
17 serve this population. Absent those, any changes
18 in the Mental Health Procedures Act will have
19 short-term and certainly limited effects, at best.
20 Thank you.
21 REP. MURT: Thank you, Lloyd, for your
22 testimony.
23 Our next testifier is Judge Shelia
24 Woods-Skipper.
25 Your Honor, thank you for joining us 29
1 this morning.
2 Judge Woods-Skipper joins us from
3 common pleas court in Philadelphia.
4 JUDGE WOODS-SKIPPER: Good morning and
5 thank you for this opportunity.
6 I’m going to apologize in advance for
7 my voice. I’m a little bit under the weather, but
8 hopefully we will get through this very quickly.
9 As indicated, I am the supervising
10 judge for the criminal trial division in the Court
11 of Common Pleas in Philadelphia. I also serve as
12 the presiding judge of our mental health court.
13 But, to be clear, I do not preside or handle the
14 matters that specifically involve the provisions of
15 the Mental Health Procedures Act that you are
16 seeking to amend at this time. However, I have
17 solicited comments from those directly involved
18 with its use and these are the comments that I have
19 incorporated into my testimony today.
20 Additionally, I am joined by Luna
21 Patella, who is the assistant chief of the Mental
22 Health Unit of the Philadelphia Defender
23 Association, because I do think it is important
24 that you get a practical implication of what some
25 of these changes may mean from those who are 30
1 handling them on a day-to-day basis. This office
2 is the primary defender of individuals who are
3 impacted by provisions of the Mental Health
4 Procedures Act and specifically the section we are
5 addressing today.
6 I strongly recommend that you seek
7 their specific comments regarding the proposed
8 amendments.
9 I should also say that hearings under
10 this section are conducted by hearing masters, not
11 judges, who then make recommendations that are
12 finalized by the president judge.
13 I have asked the district attorney's
14 office, public defender's office, and the
15 Department of Behavioral Health to comment on the
16 proposed changes to this section. And I will be
17 specifically addressing really more of the language
18 that is contained in this section, because that
19 seems to be the key as to what the concerns are
20 about from the lawyers and from the Department of
21 Behavioral Health.
22 In summary, the concerns surround
23 several basic categories. One big concern is when
24 charges that should have been avoided are filed
25 because the police are called hopefully to make a 31
1 commitment, and because of assaultive behavior that
2 the individual demonstrates, the charges are not
3 filed. Then, at some point, it's determined that
4 this defendant is not committable, and twenty-four
5 hours later, the defendant is now charged with
6 criminal crimes committed as a result of their
7 decompensation due to some psychotic episode.
8 We, in Philadelphia, have instituted a
9 CIT, which is Comprehensive Intensive Training, for
10 our police department, so that they can handle
11 these individuals, that they can recognize the
12 signs, call in specific officers who have been
13 trained to handle these situations, and, hopefully,
14 avoid the criminal charges being filed, because
15 they are then sent to hospitals or emergency rooms
16 for treatment.
17 The amended language appears to address
18 this issue but fails to give proper definition and
19 guidance. For instance, "reasonableness" is used
20 as an undefined benchmark. It seems to permit
21 someone to be committed based on verbal threats of
22 harm. And it further fails to define "substantial
23 bodily harm," a term that is prominently used
24 throughout the proposal, although we know that it
25 is defined throughout relevant case law on this 32
1 issue.
2 Also, the "could" language that is
3 utilized in the proposal leaves the door open for
4 any mentally ill defendant going through a
5 psychotic episode to be committed, since, in
6 quotes, it is reasonable to believe that they could
7 act on the threat, end of quote.
8 Concerns have been raised regarding the
9 language that permits someone to be committed for
10 communicating an intent or desire to harm himself
11 or others on his or her word alone without the need
12 for an act in furtherance. It allows the person to
13 be committed for expressing those thoughts alone.
14 Moreover, those thoughts can be shared outside of
15 the confidential relationship with their
16 psychiatric providers, like an endangered
17 individual or a law enforcement agency.
18 It is believed that this would have a
19 chilling effect on those seeking treatment if the
20 content of their conversation could be shared and
21 disseminated to law enforcement.
22 Additionally, stating that information
23 may be disclosed to an endangered individual or law
24 enforcement does not address whether a treating
25 psychologist or psychiatrist has a duty to report 33
1 information where the public is in danger. Also,
2 taking into account that certain information would
3 not be revealed under the HIPAA requirements -- and
4 this is covered under the previous lines nine
5 through eleven -- only reasonable, necessary
6 information would be disclosed. Where it states
7 that this subsection does not impose an obligation
8 or duty to release information, it is unclear how
9 it relates to the duties to report, which is on the
10 last page, on lines eleven through fourteen.
11 The standard of the threats can
12 reasonably be attributed to the individual’s mental
13 illness is vague and is subjective as there’s no
14 legal psychiatric definition or standard is
15 provided in the amendment.
16 The provisions regarding incompetent or
17 acquitted by lack of criminal responsibility
18 totally eviscerates the intent of the act by
19 seeking to address behavior in a timely fashion and
20 as it relates to an individual’s current mental
21 state by circumventing the thirty-day rule and by
22 slashing the objective standards for establishing
23 the need for involuntary commitment and the due
24 process requirements for deprivation of their
25 liberty. 34
1 Generally speaking, there's some
2 commissions who HAVE identified advantages to the
3 proposed changes in the form of increased latitude
4 and making a commitment determination earlier in
5 the course of someone's symptoms of behavior, like
6 if a doctor feels that, based on a totality of the
7 clinical presentation, that the individual is at
8 risk for harming self or others, rather than
9 waiting for evidence of an act of in furtherance.
10 But with that being said, there is a
11 very real risk that an overly liberal application
12 of a re-defined Mental Health Procedure Act that
13 would encroach on individual liberties and possibly
14 allow for abuses by third parties with a secondary
15 gain, for instance, someone who is wishing to
16 obtain control of a relative's finances.
17 So, really, I think -- and I think from
18 the conversations I've had, the most prudent
19 measure would be, in terms of looking at this
20 amendment, would be to continue a course of
21 training and education for the community and the
22 behavioral health system about the appropriate
23 interpretation and application of the standards set
24 forth in the act, and that's whether it's the
25 current act or any amended act. 35
1 However, if the standards are broadened
2 in any way, that would mean that more people would
3 be committed, that means we need more beds -- and I
4 was glad to hear that there is some consideration
5 to opening more beds -- and then, given that, comes
6 with the need for more funding, which is always the
7 bottom line. If you can’t fund, you don’t have the
8 resources to treat these individuals, it leaves us
9 in the same place no matter what the act says.
10 Luna, are there any things you wanted
11 to add?
12 MS. PATELLA: I’ve had the advantage,
13 as a public defender for eighteen years, to see all
14 sides of this issue. I’ve represented clients at
15 the civil involuntary commitment hearing, and I’ve
16 also represented them in court. Some of them have
17 gone on to state prison. And I see the issues all
18 along the way.
19 And I do have to say that funding is
20 going to be the biggest issue. Even under the
21 current civil commitment act, when an individual,
22 at a 303 hearing -- and that is first judicial
23 intervention that happens after somebody’s
24 involuntarily committed after five days or a
25 hundred twenty hours of being in the hospital -- we 36
1 have seen our review officers commit people for
2 twenty days or less, but I think what is at issue
3 is the average length of stay is considerably less
4 than twenty days, and like anything that's
5 health-care driven, funding is always going to be
6 an issue.
7 And I do think I've seen, even at the
8 statewide level, our state institutions are closing
9 beds and downsizing, and our population is only
10 growing, and this issues is just, you know,
11 becoming more of an issue, and it's important.
12 JUDGE WOODS-SKIPPER: And I think,
13 generally, just that there is more awareness and
14 recognition of issues automatically indicate
15 there's going to be a need for increased beds.
16 So, I do thank you for the opportunity
17 to speak with you this morning. And,
18 unfortunately, I will not be able to stay for the
19 conclusion of the hearing as I do have a full court
20 list waiting for me in Philadelphia, so I'll be
21 heading back, but thank you.
22 REP. MURT: Thank you, Your Honor.
23 Thank you for your testimony. Thank you.
24 Our next testifier is Jacob Bowling,
25 director of advocacy and policy from the Mental 37
1 Health Association of Southeastern PA.
2 Mr. Bowling, thank you for joining us
3 this morning.
4 MR. BOWLING: Good morning.
5 REP. MURT: Good to see you.
6 MR. BOWLING: You, as well.
7 First of all, I’d like to thank the
8 committee for convening this hearing, and I’d like
9 to thank Melanie for pulling all the pieces
10 together. This is a really important topic for us
11 at the Mental Health Association of Southeastern
12 PA.
13 I’m the director of advocacy and policy
14 there. I’m also a mental health consumer, and I
15 just wanted to bring to your attention some of
16 recommendations that we have.
17 First, I also want to draw attention to
18 the pin that I’m wearing, and I think you all were
19 each given a pin, and it says "26 percent." And
20 what this figure represents is the number of people
21 in any given year who have a diagnosis of a mental
22 health condition. So, what that means for me is
23 that this isn’t a fringe issue. This is a huge
24 public health issue in PA and in America, and it
25 also represents that it’s not like an "us and them" 38
1 issue. It's an issue that affects very many of us
2 and many families across the commonwealth.
3 And despite the variability of opinions
4 here today, I'm sure there are a few things that we
5 can agree on. First, no individual or family
6 should have to experience a mental health crisis
7 without getting the help that they need from the
8 system.
9 Second, people with mental health
10 conditions, which are the 26 percent, should be
11 able to get the support they need to live full
12 lives in their communities, like everyone else.
13 Thirdly, no individual or family should
14 have to experience a mental health crisis if there
15 is some way we could have intervened sooner in the
16 mental health system to prevent that crisis from
17 occurring.
18 And, finally, if people can get the
19 help they need without force, coercion, without
20 court orders, then, obviously, they should be able
21 to get it, and forced treatment should be the last
22 resort that we have in our system.
23 So, our three recommendations here
24 today are to ensure that the implementation that -
25 we would join with the various testifiers so far to 39
1 say that we need to look at the consistent
2 implementation and application of the Mental Health
3 Procedures Act across the state; also, to ensure
4 sufficient investment in our behavioral health
5 system; and expand — we have an opportunity this
6 year to expand mental health coverage for many of
7 the working poor across the state.
8 So, first, we think that before making
9 changes to the language in the Mental Health
10 Procedures Act, OMHSAS needs to review whether it’s
11 being implemented consistently statewide.
12 We agree with the recommendations of
13 other testifiers here, and I’m going to reference
14 that in this section of the testimony.
15 We also need to collect data on how
16 many people in our system are experiencing
17 commitment, and -- so that we know what we’re
18 dealing with here.
19 In addition, a study should take place
20 to see how counties are interpreting, and, thus,
21 implementing the Mental Health Procedures Act.
22 Inconsistent application of the Mental Health
23 Procedures Act means that, in some places in PA,
24 even if someone maybe meets the commitment
25 threshold, he or she is not getting the help that 40
1 they need. Therefore, it make sense that if the
2 interpretation and the application of the statute
3 is inconsistent across the state, causing people to
4 not get the help they need, that this inconsistency
5 should be addressed before any language is changed
6 in the statute.
7 In addition, we would support more
8 training for those responsible for deciding whether
9 people can experience commitment. People -- the
10 mental health review officers should be well
11 trained on the interpretation and application of
12 the Mental Health Procedures Act and best practices
13 when dealing with individuals and families in
14 crisis.
15 And they should also be trained about
16 alternatives. If people don’t meet the involuntary
17 commitment threshold, what are alternatives in the
18 community that prevent them from reaching crisis
19 again or get them engaged in mental health
20 services.
21 Secondly, we suggest that we need an
22 adequate investment in mental health services,
23 which I think we’re all -- most folks are in
24 agreement about. Mental health advocate and former
25 congressman Patrick Kennedy says that if we treated 41
1 diabetes like we treat mental health, we would wait
2 until someone had an amputated leg or was blind
3 before we initiated treatment.
4 Unfortunately, the more underfunded our
5 system becomes, the more dependent on crisis
6 services we become. The dearth of services in the
7 community, like peer support, Assertive Community
8 Treatment, and outpatient services, which we know
9 work, can create a situation where people must
10 reach a crisis point before they can gain entry
11 into our mental health system, or, worse, our
12 criminal justice system.
13 So, instead of a revolving and
14 expensive door of crisis services, people should
15 get services in the community.
16 Also, studies suggest that the
17 accessibility of services in the community and
18 Assertive Community Treatment is what can help
19 prevent mental health crisis from occurring in the
20 first place. And this is even for the folks with
21 the most severe mental health conditions and severe
22 functional impairments.
23 Studies also demonstrate that these
24 services are shown most effective when they’re not
25 coercive and don’t rely on compulsory orders. 42
1 Thus, force and coercion aren't necessary
2 ingredients to helping people in crisis. Assertive
3 community treatment, peer support, and other
4 services can be effective, and forced treatment and
5 hospitalization should remain a last resort.
6 Services should be committed to people
7 before people are committed to services in our
8 system. And, so, tinkering with the Mental Health
9 Procedures Act, after many years and millions of
10 dollars of devastating cuts to the mental health
11 system in PA, won't solve the issue at hand.
12 Instead, mental health services in the community
13 that could help prevent people from reaching crisis
14 and help them during crisis and in a less expensive
15 way would be an alternative.
16 Finally, every Pennsylvanian should
17 have access to mental health services. And this
18 year, we have an unprecedented opportunity to
19 expand coverage through Medicaid expansion.
20 Currently, people who have insurance through their
21 employers and people who are on Medicaid can get
22 mental health services covered by their insurance,
23 but there are -- there's still a cohort of people
24 in PA that don't get coverage through their
25 employers, hard-working PA families who don't have 43
1 access to that mental health benefit. So, Medicaid
2 expansion will enable that these folks can now get
3 the coverage that they need.
4 In addition, when we talk about
5 potential changes to our Medicaid system, we should
6 remember that what we have in our mental health
7 system that really works can largely be -- can
8 somewhat be attributed to our HealthChoices
9 program, the behavioral health carve-out in our
10 counties. HealthChoices has increased the number
11 of people served by our system. It's improved
12 quality, managed costs, created local
13 decision-making ability, developed a larger array
14 of services, and even garnered savings that could
15 be reinvested into the system, like Mental Health
16 First Aid, which is being used to advocate
17 community members about mental health conditions
18 and reduce stigma.
19 So, I would ask that you all would be
20 champions, this committee champions for us around
21 our various recommendations on behalf of the 26
22 percent.
23 And thanks for the opportunity to
24 testify today. We share your belief that every
25 person in every family, no matter where they are in 44
1 recovery or where they live in PA, should get the
2 help they need in the mental health system.
3 We also believe that research
4 demonstrates that we can prevent and mitigate
5 crises through services in the community and that
6 every person should have access to those services.
7 In addition, we echo recommendations from other
8 that we should streamline the
9 interpretation and application of the Mental Health
10 Procedures Act to ensure that people of every
11 county across the commonwealth get the help they
12 need.
13 Thanks so much.
14 REP. MURT: Thanks, Jacob, for your
15 testimony.
16 Our next are Dr. Roy
17 Chengappa, from the University of Pittsburgh,
18 Western Psychiatric Institute and Clinic, and also
19 Mark Zacharia, Esquire, also from the Western
20 Psychiatric Institute and Clinic.
21 Gentlemen, thank you for joining us
22 today. Appreciate you giving testimony.
23 MR. ZACHARIA: Hello. And thank you
24 for inviting us here today.
25 I'm Mark Zacharia, and he's Dr. Roy 45
1 Chengappa, on behalf of the Western Psychiatric
2 Institute and Clinic
3 On March 14th, 2013, Dr. David Lewis,
4 the medical director of the Western Psych,
5 previously testified before the Human Services
6 Committee of the House of PA. In his testimony,
7 Taking Steps to Balance the Risk of Violence by
8 Mentally Ill Persons, Dr. Lewis made three major
9 points.
10 One, access to needed services for
11 mentally ill persons in the community should be
12 expanded. Public health concerns regarding access
13 to weapons needs to be addressed. And PA’s Mental
14 Health Procedures Act of 1976 is outdated.
15 We’re here today to address the third
16 of his points, updating the Mental Health
17 Procedures Act of 1976.
18 The Mental Health Procedures Act is out
19 of date. This thirty-seven-year-old statute was
20 drafted in response to a very different set of
21 circumstances that were prevalent in mental health
22 treatment many years ago. The law was a response
23 to the lack of due process afforded to individuals
24 who are diagnosed with a mental illness and
25 subsequently warehoused for years following the 46
1 diagnosis.
2 In addition to the protection
3 originally provided in the MHPA, today’s budget
4 cuts, state hospital closings, and state
5 supported -- supportive of the recovery model add
6 to the prevention of that same level of
7 institutionalization or warehousing of individuals
8 with mental illness.
9 Unfortunately, the protections
10 originally provided MHPA have also developed
11 barriers to treatment.
12 The MHPA needs to be updated to reflect
13 the standards of modern medicine. The MHPA is
14 focused on the need for dangerous conduct and
15 excessive confidentiality severely hampers the
16 mental health clinician, families, and law
17 enforcement professionals from obtaining treatment
18 for individuals who are in need.
19 We recommend that the following part of
20 the 1976 law be changed, specifically, the MHPA’s
21 definition of "dangerousness" for purposes of a
22 patient’s civil commitment that focuses on whether
23 a patient has committed an act of furtherance. We
24 also comment here upon issues and formulations
25 within the 1976 law that can strongly affect 47
1 patient, families, physicians’ patterns of
2 communication, information sharing, and truth
3 telling.
4 There’s irony, always I’ve heard here
5 today among many people, in our discussion about
6 violence in mental health that occurs here in PA
7 and across the nation. In many states, the current
8 legal standard for involuntary civil commitment is
9 dangerous conduct. It stipulates that an
10 individual is required either to commit acts of
11 violence or at least to attempt an act of violence
12 to him or herself or other before treatment can be
13 provided.
14 The standards for involuntary civil
15 commitments vary among states. Some states have a
16 "need for treatment” standard. Others, like PA,
17 base commitment on dangerous conduct,
18 dangerousness.
19 Simply put, the standard requires two
20 things. One, that an individual have a mental
21 illness. And, two, that that individual has done
22 something dangerous because of his or her mental
23 illness.
24 Dangerous conduct is the act of harming
25 or attempting to harm yourself or another 48
1 individual. Threats alone are not enough.
2 The current statutory language requires
3 more than just a threat. It requires a step in
4 furtherance of that threat. Without that step in
5 furtherance, an individual cannot be involuntarily
6 committed, no matter how symptomatic he or she may
7 be .
8 Under the current standard, what’s
9 necessary to obtain a 302 is a diagnosis of mental
10 illness and dangerous conduct. A patient’s
11 behavioral history or medical history is
12 irrelevant. Input from family, friends, or even
13 providers who are familiar with the patient and can
14 recognize the signs of a decompensating individual
15 or loved one is not relevant.
16 The MHPA does not allowed consideration
17 be given to the fact that when this individual
18 exhibits these signs and symptoms that are
19 typically of his mental illness and extended
20 hospitalization typically follows. Instead, it
21 focuses on whether the individual is mentally ill
22 and whether he or she has exhibited dangerous
23 conduct in the last thirty days. What matters
24 under PA law is that the person has a mental
25 illness and has tried to harm him or herself or 49
1 another person.
2 For clarity, unless an individual has
3 some insight and voluntarily agrees to treatment,
4 he or she will have to decompensate to the point of
5 actually trying to harm him or herself or someone
6 else before anyone can step in and provide the care
7 needed.
8 One small change is needed to remove
9 the barrier to treatment. That change is to remove
10 the need for a step in furtherance. Without a need
11 to act upon a threat, symptomatic individuals can
12 be engaged in treatment earlier. Opponents of this
13 change may argue that with the absence an attempt
14 to harm an individual, due process rights would be
15 violated.
16 I would like to point out that a change
17 like this would only allow an examination by a
18 physician, and that is not a guarantee that an
19 individual would be admitted to a psychiatric
20 facility. Further, it would not change the hearing
21 process or an individual's right to
22 representation.
23 Another significant change that should
24 be made is the need to allow treatment providers to
25 disclose limited information, based upon threats 50
1 made by an individual, that lead the provider to
2 believe that the disclosure is necessary to protect
3 someone from -- from or prevent harm from
4 occurring. The MHPA generally does not allow
5 disclosure of patient information without the
6 patient's consent.
7 The duty-to-warn exception that does
8 exist in PA is based upon case law. That creates a
9 duty to warn where it's a specific threat of
10 immediate harm to an identifiable victim. That's
11 Emerich v. Philadelphia Center for Human
12 Development.
13 This narrow exception should be
14 expanded to allow treatment providers discretion to
15 disclose limited information where, based upon
16 their professional judgement, they believe, in good
17 faith, that is necessary to prevent harm to their
18 patient or someone else more in line with federal
19 the standard, as in HIPAA.
20 Treatment providers are often faced
21 with situations that are extraordinarily concerning
22 and yet fall short of the Emerich standard of duty
23 to warn or even the 302 standard for commitment.
24 There are situations that are
25 concerning, based upon professional judgment, 51
1 experience, and history. Mental health providers
2 in PA should be able to disclose limited
3 information more in line with the privacy rules
4 exceptions of the Health Insurance Portability and
5 Accountability Act. In such situations, as
6 expressed by Leon Rodriguez, director of the Office
7 of Civil Rights of the Department of Health and
8 Human Services, letter dated January 15th, 2013, to
9 the nation’s health care providers.
10 Mental health providers should be
11 allowed to exercise their professional judgment in
12 good faith with immunity. Though it has been
13 omitted from Dr. Lewis’s testimony, we would also
14 support statutory exceptions to nondisclosure to
15 law enforcement, as are available under HIPAA.
16 If a crime is committed in a mental
17 health facility by a patient, a provider should be
18 able to release limited information to the police.
19 If law enforcement is looking for a missing person
20 or a fugitive, a mental health facility should be
21 able to confirm whether that person is in their
22 facility.
23 Currently, the law in that scenario
24 would only allow this disclosure if a person has
25 involuntarily committed themself to the facility. 52
1 While our experiences may be different
2 than most providers, given the volume of patients
3 and the severity of the illnesses we see, we are
4 often challenged to find ways to resolve concerning
5 situations in creative ways, due to the
6 restrictions of the MHPA.
7 Thank you again for this opportunity.
8 MR. CHENGAPPA: Good morning. And
9 thank you for this opportunity.
10 I work as a psychiatrist at Western
11 Psychiatric Institute in Pittsburgh. And in my
12 administrative role, I run one of our service lines
13 which oversees a three-center clinic of roughly two
14 thousand five hundred patients, with mostly a
15 diagnosis of schizophrenia or related spectrum
16 disorder. And seventy of the inpatient beds at
17 Western Psychiatric Institute’s three hundred beds
18 are devoted to serving this population.
19 So, we have had the opportunity to talk
20 to the twenty-four doctors that I work with and
21 come up with two cases I thought I’d try and bring
22 to light in front of this audience. And I quite
23 agree, in fact, with the before me about
24 uniform training, uniform application of the law,
25 more budgets, perhaps more beds, long-term beds. 53
1 But this brings into question, I think,
2 what Secretary Marion brought up as one statistic
3 for Allegheny County, interestingly is where I
4 work. That is, there is a roughly 75 percent rate
5 from petitions to commitments. And maybe these two
6 case studies, a little anonymized for the sake of
7 privacy, do reflect maybe the 25 percent that did
8 easily make to till the act in furtherance.
9 So, this gentleman, in his late
10 forties, with married children, had a late break,
11 not an early break, somewhat late break in his
12 thirties, huge problems at work, fired from his
13 job, and then began to suspect his wife of
14 infidelity. And, at that point, he began to slowly
15 utter threats, verbal mostly, began to be concerned
16 that the children were covering for his wife. And
17 before long, there were threats with a knife, at
18 which point he was hospitalized, diagnosed with
19 paranoid schizophrenia, treated, released, looking
20 golden, to put it, you know, in one of the treating
21 's words.
22 Promptly stopped the medicines. The
23 pattern recurred. And the next time, he had, in
24 fact, invited his wife to a desolate rural road,
25 and the wife knew he had not been taking his 54
1 medicines, managed to get a family friend, a state
2 trooper, to convince her husband to come in
3 involuntarily — voluntarily into the hospital.
4 Again, treated and released.
5 So, this pattern continued, stopping
6 medicine, threats, not getting committed until the
7 act of furtherance.
8 The final incident occurred when the
9 threats would escalate to holes in the wall, broken
10 windows, knife. And, then, eventually, the grown
11 son had to come in the middle, between his mother
12 and his father, to prevent what would have been a
13 very disastrous assault on his wife. At that
14 point, the police tasered him, and at that point,
15 he was recommitted and treated.
16 So, I’m sure, you know, that the
17 testifiers behind me in the audience perhaps have
18 similar stories in the national news, and so we
19 feel this application of acts of furtherance in
20 people who have clearcut diagnosed mental illness,
21 ten- to twelve-year histories of a recurrent
22 hospitalizations, is sometimes discounted because
23 in the last thirty days -- the thirty-day rule that
24 the honorable judge mentioned doesn’t happen.
25 So, this type of interpretation, I 55
1 think, leads to very serious consequences for us to
2 assess and then treat.
3 You know, I fully understand where this
4 could be abused. In fact, the judge mentioned how
5 a family member, wanting to get ahold of moneys,
6 might abuse such a system. That is possible.
7 But, I think, from our perspective,
8 mostly, the first case and the second is even more
9 telling, because unlike the first, the second
10 person has had old-fashioned schizophrenia, with a
11 break early in his twenties, twenty-five years of
12 illness, and the only way he seems to come to the
13 hospital is to hit someone, in fact often the legal
14 authority.
15 So, the hospitalist, the psychiatrist,
16 managed to convince him to go on to injectable,
17 long-acting medications, which most of them with a
18 diagnosis of schizophrenia do not want to take, but
19 a few do, and he does, interestingly. He gets a
20 whole lot better, and then when he’s released from
21 the hospital, he’s on an outpatient commitment for
22 which he counts the days to one hundred eighty
23 days, and at that point he starts refusing his
24 monthly injection. Typically doesn’t decompensate.
25 You know, I spoke to the doctor who’s 56
1 looking after him currently. As of yesterday, he
2 is about three months post the six-month
3 commitment. He has been refusing his injections.
4 He's issuing verbal threats at this point. The
5 housing that he's in in Pittsburgh, the manager
6 just doesn't want to testify. He's afraid for his
7 own life. And I think we will have a situation
8 before he's committed again. He's had at least
9 somewhere between fifteen and twenty
10 hospitalizations.
11 So, yet again, I think these
12 interpretations of what an act of furtherance is in
13 people who have clearcut mental illness, known
14 histories, is often discounted by the county
15 delegates.
16 So, it's my recommendation and request
17 to this group to consider this seriously in light
18 of what can be done much sooner. I think an
19 example was given of Patrick Kennedy's saying, in
20 diabetes, we would not allow someone to go on to be
21 amputed (sic) or have blindness in the eye before
22 treating their diabetes. Likewise, I agree with
23 him fully, if one in four people in this country
24 have a diagnosable mental illnesses, they are no
25 longer the fringe. They are very much part and 57
1 parcel of our lives, of our families and people
2 around us.
3 And, so, this would be my testimony,
4 but thank you for this opportunity.
5 REP. MURT: Thank you, Mr. Zacharia.
6 Thank you, Dr. Chengappa.
7 Also, I'd like to make note and accept
8 into the record the testimony of Dr. David Lewis,
9 also from the Western Psychiatric Institute and
10 Clinic. I don't believe Dr. Lewis is here today.
11 Is that correct?
12 Okay. Our next testifier is Carol
13 Horowitz, from the Disability Rights Network.
14 Thank you, Carol, for being with us
15 this morning.
16 MS. HOROWITZ: Good morning. I
17 appreciate this opportunity.
18 I'm the managing attorney of the
19 Disability Rights Network of PA. We are the
20 organization that is federally mandated and
21 appointed by the state to advocate and protect the
22 civil rights of people with mental illness.
23 I am also a family member of an
24 individual with mental illness. So, on behalf of
25 the DRN and myself, I'm offering this testimony to 58
1 address the draft of legislation that proposes
2 changes to the criteria for involuntary
3 commitment.
4 I really appreciate your interest in
5 this subject. It’s a very important problem.
6 First, I would like to speak to our
7 concerns with the draft. And, then, second, I
8 would like to make recommendations that ensure
9 better, more consistent application of the current
10 Mental Health Procedures Act.
11 First, our concerns. The problem with
12 the Mental Health Procedures Act has not been
13 clearly defined. The constitution requires that we
14 tread very carefully as we walk through the process
15 of taking away liberty. It is impossible to
16 address a problem that does not have a clear
17 definition.
18 Before coming to a conclusion that the
19 current criteria are not broad enough, we need to
20 know if many people are regularly prevented from
21 accessing inpatient or outpatient treatment. As
22 Secretary Marion testified earlier, the Department
23 of Public Welfare does not track the number of
24 involuntary commitments in each county. There is
25 occasional anecdotal evidence that the current 59
1 criteria are inadequate, and, yet, we have no idea
2 about the total number of people that are committed
3 or the services that they're offered for either
4 inpatient or outpatient treatment.
5 Presumably, the involuntary inpatient
6 commitments are reported to state police, as
7 required by law, but that information makes it back
8 to the Department of Public Welfare only if it is
9 requested. And as I understand it, it is not
10 counted by county or is it -- is the registry an
11 unduplicated list.
12 We've heard testimony that there are
13 great differences between counties and how they
14 apply and implement the Mental Health Procedures
15 Act. That's not surprising, since there is no
16 standardized training for mental health review
17 officers or clear guidance at this point in time
18 from the department.
19 Similarly, we do not have a clear
20 picture of the differences in the implementation of
21 the outpatient commitment provisions throughout the
22 state. At least some counties, if not all, do not
23 have a system of knowing exactly where people
24 reside or monitor the delivery of the outpatient
25 treatment services that people actually receive. 60
1 It is impossible to determine how outpatient
2 commitment is used without better data collection.
3 For example, are more people on an
4 involuntary outpatient commitment as a diversion
5 from inpatient because it’s a least restrictive
6 alternative? Are some counties successfully using
7 the current outpatient commitment provisions to
8 assure access to treatment? Are some people using
9 it as a step-down from inpatient treatment for a
10 long period of time, possibly indefinitely?
11 We have not yet determined the flaws
12 that exist in our current outpatient applications
13 or the differences between counties. I suspect
14 that some counties use it quite effectively and
15 others do not.
16 Recent tragedies have caused renewed
17 interest in making changes to the Mental Health
18 Procedures Act in an effort to prevent future
19 horrific events. We should not rush to change the
20 current statute until we can clearly define the
21 problems we seek to solve.
22 More broad criteria will not
23 necessarily prevent violent acts. The draft
24 legislation allows a finding of clear and present
25 danger if, quote, the threat can reasonably be 61
1 attributed to the individual’s mental illness and
2 it is reasonable to believe that the individual
3 could act on the threat if evaluation and treatment
4 is not immediately forthcoming, end quote. This
5 language relies heavily on speculation by mental
6 health review officers, delegates, clinicians.
7 Recent tragedies will almost certainly push mental
8 health review officers to attribute any threat to a
9 person’s mental illness if the person has any
10 history at all of mental health treatment.
11 Broad language such as this seems to
12 rest on the assumption that if we can cast the net
13 widely enough, we will be sure to capture anyone
14 with violent intentions. This is an unsound
15 premise.
16 Given the imprecise standard, we expect
17 that many more people will, indeed, be committed.
18 However, the end result of more commitments is a
19 concern from both of civil rights and a funding
20 perspective. The law requires that people receive
21 mental health treatment in the least restrictive
22 environment appropriate for their needs.
23 Constitutionally, we cannot detain people in
24 inpatient settings simply because they need
25 treatment without also having a finding of 62
1 dangerousness. Threats do not necessarily equal
2 dangerousness, nor does a diagnosis of mental
3 illness.
4 We believe that programs in the
5 community that are designed to identify and engage
6 individuals are a much more effective way of
7 finding and serving at-risk individuals. The
8 Mental Health First Aid program is one example of
9 these programs.
10 Funding is also an issue, and not just
11 because more people committed equals more dollars
12 for inpatient treatment and the commitment
13 process. The much more important funding issue is
14 that casting the net too wide means diverting
15 resources from the community treatment that we
16 need. This is not a wise use of resources.
17 In addition, the proposed criteria do
18 not pass constitutional muster. It is important to
19 note that the current MHPA meets the constitutional
20 requirement to protect individual liberty as
21 defined by the Supreme Court of the United States.
22 When a mental health review officer is
23 making the determination to involuntarily commit a
24 person, there must be a finding that the person is
25 a danger to himself or others before the loss of 63
1 liberty can occur. We take it very seriously when
2 we lock people up.
3 That means that the criteria used to
4 measure whether a person is in need of such an
5 extreme deprivation of liberty become pivotal in
6 preventing a violation of the person's civil
7 rights.
8 The constitutional "void for vagueness”
9 doctrine requires that the standards used in
10 statutes must be clear enough that the average
11 citizen has fair notice of what conduct the law
12 compels or precludes. The third circuit has stated
13 that: It always operates when a statute's
14 vagueness creates the possibility that it can be
15 applied in an arbitrary manner that infringes on
16 such fundamental interests as First Amendment
17 rights of speech and assembly or the right of
18 physical liberty.
19 The proposed standard relies too
20 heavily on the judgement of mental health review
21 officers and delegates, creating the possibility of
22 inconsistent and arbitrary application.
23 On what basis do they determine if a
24 treat made is attributable to anger or mental
25 illness? When is it reasonable to believe that a 64
1 person could act on the threat? How far into the
2 future is the officer supposed to look when
3 determining whether the person could act on a
4 threat?
5 Criteria for commitment must provide a
6 better, more consistent way to measure the need for
7 emergency examination and loss of liberty than that
8 proposed if it is going to pass constitutional
9 muster.
10 The current Mental Health Procedures
11 Act already allows the combination of a threat and
12 an act in furtherance to serve as one way to show
13 clear and present danger. When applied
14 consistently, this is a better standard because
15 there is more reliance on actual evidence and less
16 reliance on beliefs and predictions.
17 The problem is not that we cannot
18 commit enough people. Rather, we are unable to
19 provide them with the services and supports they
20 need to maintain their health in their
21 communities. This is largely because we do not
22 require and fund the types of specialized services
23 that are needed to keep people well.
24 While DRN does not support the proposed
25 language, we are very concerned that the current 65
1 MHPA is being implemented in an arbitrary way.
2 Therefore, we have the following recommendations.
3 First, as you've heard before,
4 understand the differences in how counties apply
5 the criteria in the existing statute. As you
6 heard, OMHSAS is attempting to collect some of this
7 data at this point in time.
8 We believe that minimum qualifications
9 should be set for mental health review officers.
10 As Mr. Wertz told you in his testimony, mental
11 health review officers aren't actually often the
12 people who are setting the policy for how an act in
13 furtherance, the criteria for emergency evaluation
14 and commitment, are understood within that county.
15 So, it's very important that these people have some
16 idea about the mental health system.
17 We would expect that they would have to
18 know something about the potential alternatives to
19 inpatient or outpatient commitment.
20 OMHSAS must develop a mandatory
21 training for the mental health review officers to
22 ensure consistent statewide application, and, then,
23 those mental health review officers need to be sure
24 that they are training within their counties so the
25 consistency remains throughout. 66
1 That training must clearly and
2 consistently develop an understanding of the
3 commitment criteria.
4 OMHSAS must put a monitoring system in
5 place to collect and track the county data related
6 to commitments. And, indeed, related to the crisis
7 and medication management policies in each county.
8 It’s very important that we deliver crisis services
9 if we’re going to divert people from the need for
10 crisis services, for acute inpatient or outpatient
11 care. What we really want is for people to stay
12 well in the community.
13 We also should be reviewing the Joint
14 State Government Commission study before
15 recommending new language. Through House
16 Resolution 226, the Joint State Government
17 Commission has been charged with conducting a study
18 of all aspects of PA’s mental health system and
19 then to report back with specific areas for
20 amendments and improvement. Along with the
21 specific county data referenced above, the Joint
22 State Government Commission study must be reviewed
23 to determine if new language is necessary.
24 And, most importantly, we need to fund
25 community services. Resources must be allocated to 67
1 assure that crisis services, Assertive Community
2 Treatment teams, mobile medication services, peer
3 support services, psychiatric rehabilitation
4 services, and adequate housing exists in every
5 county.
6 I understand I ’ve heard some talk
7 about the need to keep institutions open. In the
8 west, we closed Mayview. The five counties had
9 every intention of not using any more state
10 hospitals. And they were being very successful at
11 that until their funding was cut by 10 percent.
12 Once the funding that funded those people and those
13 new services that had been developed had been cut
14 so drastically, they began to struggle. But until
15 that time, they were very successful at living
16 without a state hospital.
17 Programs such as Mental Health First
18 Aid and case management are important for
19 and engagement. Mental
20 health courts and training for police officers and
21 crisis intervention are important components of
22 communities that support recovery. A strong
23 community mental health system is, by far, the most
24 effective way to assure safety and recovery.
25 It is imperative that stigma and false 68
1 assumptions about the potential for violence from
2 individuals with mental illness do not drive our
3 mental health system. We must develop the needed
4 services and supports in every county and require
5 that DPW monitor the mental health system for which
6 it is responsible. It is very premature to change
7 the Mental Health Procedures Act language until we
8 can clearly define what we are trying to address.
9 Thank you very much.
10 REP. MURT: Thank you, Carol, for your
11 testimony.
12 Our next testifier’s Alyssa Goodin,
13 associate director of The Philadelphia Alliance.
14 Good morning, Alyssa. Thank you for
15 joining us.
16 MS. GOODIN: Good morning, and thank
17 you for having me to today.
18 Thank you for allowing me a speak with
19 you on a very important and complex issue of
20 involuntary treatment in PA. As Rep. Murt said, my
21 name is Alyssa Goodin, and I’m the associate
22 director of The Philadelphia Alliance.
23 The Philadelphia Alliance is a
24 nonprofit trade association of fifty-four different
25 mental health, addiction treatment, and 69
1 intellectual disability service providers in PA.
2 Our members provide services to both adults and
3 children, and although located in Philadelphia, our
4 service organizations can be found throughout the
5 state.
6 Our members have mental health services
7 along the continuum, providing everything from
8 inpatient psychiatric services to outpatient
9 community-based psychiatric rehabilitative programs
10 like peer support and other community-based
11 services. So, we have a unique perspective on this
12 issue as providers who see people at various phases
13 in their recovery.
14 In addition to being a social worker
15 and representative of the behavioral health
16 provider community, I'm also a family member of
17 someone with a mental health condition. My younger
18 sister, Katie, was diagnosed with bipolar disorder
19 when she was fifteen, when I was in the middle of
20 my college career. The next three years were a
21 flurry of suicide attempts, so we had plenty of
22 experience with involuntary commitment, although it
23 happened in Connecticut. And my family was thrown
24 in chaos for those years.
25 Katie's suicidality was so severe that 70
1 my mother had to quit her job so that someone could
2 always be home with her, making sure that she was
3 safe.
4 We spent years trying to get Katie the
5 help that she needed, and our private insurance
6 didn’t meet her needs. Luckily, she was able to
7 get onto the Medicaid program in Connecticut, and
8 it helped her to access services that she needed to
9 be well. And Katie’s now twenty-four years old,
10 and she hasn’t had a suicide attempt since she was
11 eighteen. So, she’s doing very, very well, which
12 I’m happy to report.
13 But I tell you this because I want you
14 to know that I’m here not just as a professional
15 but as someone for whom this issue is deeply
16 personal, and I understand the fear and the stress
17 and the anxiety of having a loved one who is trying
18 to harm themselves. And I understand the sleepless
19 nights. So, I just wanted you to know that I bring
20 that experience to the table as well.
21 But I’ve also seen, as a professional
22 and a family member, the tremendous potential for
23 people to get better and to lead healthy lives in
24 the community, as my sister has done, when they’re
25 able to access appropriate supports in a vibrant 71
1 service system.
2 So, it's both personally and
3 professionally important to me that we get this
4 right. This is a complex issue. It's an
5 emotionally charged issue. And, unfortunately,
6 it's not a black and white issue. That makes this
7 a difficult conversation to have, but it's
8 important that we have it.
9 Between 1999 and 2010, the CDC reports
10 that suicide rates in PA increased by 24 percent,
11 with more than nine hundred Pennsylvanians taking
12 their own lives in 2010. Suicide in PA is an
13 epidemic which needs to be addressed. And our
14 involuntary commitment laws are one important
15 component of that larger strategy.
16 So, I'd like to start by reviewing a
17 little bit about what our current law says, as
18 others have done. In your packets, you should have
19 a copy of Section 302 of the MHPA, and you should
20 also have my testimony, which highlights certain
21 sections of the law.
22 I'd like to pay particular attention to
23 the part of the law which says that examining
24 physicians should consider the probability that the
25 person would be unable, without care, supervision, 72
1 and the continued assistance of others, to satisfy
2 his need for nourishment, personal or medical care,
3 shelter or self-protection and safety in accordance
4 with Section 301B.
5 I say this because I think that this is
6 one of the sections that applies to the people that
7 we hear are falling through the cracks. And I
8 think that this language demonstrates that it does
9 allow for more than the simple standard of threat
10 of -- or for furtherance of harm to self or
11 others. It allows for the people that, you know,
12 may be experiencing, you know, acute psychosis, may
13 be unable to care for their own medical needs or
14 hygiene needs, the folks who may be wandering into
15 traffic, the people that we're hearing aren't
16 getting in but we believe, according to this
17 language in the law, they should be. And these are
18 the folks who could really benefit from crisis
19 services, to stabilize them, get them well, and
20 then get them into appropriate follow-up care so
21 that we can support them in leading healthy lives
22 in the community.
23 So, if the language is clear about
24 this, why do we keep hearing that people are not
25 getting admitted to treatment? As other testifiers 73
1 have said today, I will echo that what I hear most
2 often from our providers is that the law is not
3 being implemented uniformly in different counties.
4 In Philadelphia County, we hear that
5 there are issues with this. Despite language
6 clearly outlining the rights of physicians to admit
7 these folks, family and providers are being told
8 that they’re not a clear and present threat to
9 themselves or others. So, our task is to make this
10 law and our system work that well, as well as it’s
11 working in other counties, for all of PA. Because
12 we are hearing that some counties are doing this
13 well.
14 So, we believe that since the language
15 is here and seems appropriate and seems to cover
16 the individuals that we’re concerned about,
17 strengthening the language of a law which is
18 already implemented incorrectly will likely be
19 duplicative and ineffective.
20 Rather than considering changing the
21 language of the Mental Health Procedures Act, we
22 recommend investing in implementing the law that we
23 have as it’s worded and as it was intended. This
24 can be done by increasing training on the law for
25 appropriate personnel, releasing a bulletin, and 74
1 collecting data on how the law is being implemented
2 across counties.
3 So, our recommendation to this
4 committee is to reach out to the administration and
5 encourage and support them to implement these
6 simple but important administrative fixes.
7 But suicide prevention requires a more
8 comprehensive strategy than just fixing involuntary
9 commitment alone. People often think of inpatient
10 hospitalization as the first and last line of
11 defense in the fight to prevent suicide, but
12 hospitalization is only one small component of a
13 larger system to support people struggling with
14 mental health issues.
15 I know that there have been
16 conversations about the need to reopen hospitals,
17 but I think that it’s critically important that
18 before we start talking about investing in
19 hospitals, we look at the impact of the severe cuts
20 that we've been making year after year to our
21 community-based mental health service system and we
22 think about investing in those services first.
23 So, we know that when we invest in
24 preventive programs and can get people into
25 treatment early, before they reach this level of 75
1 acuity, we’re much more likely to prevent
2 tragedies. All the research has found that early
3 intervention leads to better outcomes.
4 Unfortunately, prevention services and
5 outpatient mental health services, which are our
6 most crucial mental health safety net services, are
7 also the most difficult services to fund, and in
8 the case of outpatient, contain burdensome and
9 unnecessary regulations.
10 Over the past few years, our mental
11 health system has suffered a number of blows,
12 including the 10 percent cut to mental health
13 services in Governor Corbett’s block grant and the
14 elimination of the General Assistance program,
15 which had previously provided a bridge for people
16 with behavioral health disabilities applying for
17 Social Security, a process which can often take two
18 years.
19 The effects of these cuts have been
20 significant. The block grant cuts have forced some
21 providers to close programs or reduce services, and
22 there’s consistently a wait list for outpatient
23 mental health treatment.
24 We saw a significant jump of more than
25 40 percent in the numbers of homeless individuals 76
1 seen in this year's Philadelphia street homeless
2 count compared to the year the count was taken
3 before the cuts were implemented.
4 Outpatient mental health treatment is
5 another important tool in the fight to prevent
6 suicide. An individual's risk of suicide is
7 significantly elevated during the week following
8 their discharge from psychiatric inpatient
9 hospitalization, but connection to community-based
10 services can mitigate this risk. Unfortunately,
11 our providers frequently report that outpatient
12 mental health treatment is the level of service
13 which has the most demand and the fewest dollars.
14 They're constantly operating at a deficit.
15 Outpatient programming is nearly
16 impossible to keep afloat without supplemental
17 funds, and the current financing and regulatory
18 structure results in service capacity which is
19 sorely inadequate to meet the need.
20 For example, in the children's system,
21 Public Citizens for Children and Youth recently
22 found that the average wait time for children's
23 outpatient behavioral health services was sixteen
24 days for an intake appointment and an additional
25 twelve days after intake to see a therapist, with 77
1 many agencies unable to accept new clients at all.
2 Anyone who has had a child with
3 significant behavioral health issues can tell you
4 that this is untenable. We must expand capacity in
5 our outpatient mental health system by implementing
6 regulatory reform and improving outpatient rates.
7 Despite the challenges facing our
8 system, there are opportunities available to invest
9 in our behavioral health infrastructure. Most
10 significant is the Medicaid expansion opportunity
11 in PA. Medicaid has long been a life-saving
12 program for people with mental health conditions
13 when commercial insurance fails. Despite having
14 passed federal parity legislation in 2008,
15 commercial insurance still provides inadequate
16 behavioral health benefits, leaving Medicaid as the
17 best option for individuals with a behavioral
18 health issue.
19 I know this firsthand, as this was the
20 case for my family. When my sister became sick,
21 despite having the best private insurance you can
22 buy, we had to get Katie on Medicaid in order to
23 meet her mental health needs. Medicaid was able to
24 get Katie to where she is today and helped her
25 where commercial insurance failed. And I know that 78
1 this is the story for many families across the
2 commonwealth.
3 Expanding Medicaid in PA is the obvious
4 choice. It will invest billions in our health
5 economy, create an estimated forty thousand jobs,
6 and provide health insurance to six hundred
7 thirteen thousand hard-working Pennsylvanians, many
8 of whom are estimated to have behavioral health
9 conditions.
10 We are glad that Governor Corbett has
11 proposed taking expansion dollars to invest in our
12 commonwealth, but we have serious concerns about
13 his timeline. Governor Corbett has not yet
14 developed or submitted an 1115 Waiver, which is
15 required to begin this process. His office reports
16 that they have submitted a concept paper, but that
17 does nothing to begin the process. Only an 1115
18 Waiver can do that, and we have received no
19 indication of when that might be submitted.
20 States who do not expand in 2014 will
21 be left with what is being termed the expansion
22 "donut hole" population, which is the gap for
23 individuals below 100 percent of the federal
24 poverty level who will not qualify for subsidies
25 based on the exchange and also will not qualify for 79
1 Medicaid.
2 In PA, we are estimated to have between
3 four hundred and four hundred forty thousand of
4 these individuals. This is significant for
5 behavioral health because SAMHSA reports that 6.5
6 percent of these people are living with serious
7 mental illness. That's twenty-six thousand
8 Pennsylvanians, and it doesn't even account for our
9 citizen who may have moderate or mild behavioral
10 health conditions.
11 So, while Governor Corbett is going
12 back and forth with the federal government,
13 hundreds of thousands of Pennsylvanians are left
14 without insurance, the unemployed are left waiting
15 on good jobs in the health sector, and our economy
16 is losing millions of dollars each day.
17 We encourage the governor to expand
18 Medicaid and hope that you will all consider
19 sending that message to Governor Corbett as well.
20 So, in summary, The Philadelphia
21 Alliance recommends the following four
22 recommendations.
23 Number one, rather than revising our
24 legal language, we should revisit the
25 implementation of our current involuntary 80
1 commitment laws and ensure that they are
2 implemented correctly through training, data
3 collection, and the release of a bulletin.
4 Number two, we should invest in
5 outpatient mental health services, a vital
6 component of our mental health safety net, which is
7 currently suffering tremendously.
8 Number three, we should invest in
9 prevention programming, an unbillable service,
10 which is difficult to fund.
11 And, four, we should expand Medicaid, a
12 program which is proven to increase access to good
13 behavioral health benefits.
14 So, I thank you again for your interest
15 in this issue. I thank you for having this
16 conversation. And I thank you for your commitment
17 to our citizens living with mental health
18 conditions.
19 I will be staying after my testimony,
20 and I’ll be happy to answer any questions.
21 REP. MURT: Thank you, Alyssa.
22 Our next two testifiers are
23 Mr. Christopher Wysocki, the administrator of the
24 Juniata Valley Behavioral Health and Development
25 Services, and Ed Michalik, the administrator for 81
1 the Berks County Mental Health Developmental
2 Disabilities Program.
3 Good morning and thank you for being
4 with us today.
5 MR. WYSOCKI: Good morning, Chairman
6 DiGirolamo and Rep. Murt and members of the
7 committee.
8 My name is Chris Wysocki, and I'm the
9 administrator for Juniata Valley Behavioral and
10 Developmental Services. My agency is a joinder
11 that serves rural counties of Huntingdon, Mifflin
12 and Juniata. Also testifying with me today is
13 Dr. Ed Michalik, who is the Administrator of Berks
14 County Mental Health and Developmental Disabilities
15 Program, a larger county which includes the city of
16 Reading.
17 Ed and I currently serve as co-chairs
18 of the Mental Health Committee of the PA
19 Association of County Administrators of Mental
20 Health and Developmental Services, which is an
21 of the County Commissioners Association
22 of PA. PACA MH/DS represents county administrators
23 who oversee mental health and intellectual
24 disabilities programs as well as supports
25 coordination organizations which perform the case 82
1 management function for individuals with
2 intellectual disability and behavioral
3 HealthChoices county oversight entities that are
4 responsible for Medicaid-funded managed care for
5 behavioral health services. We are testifying
6 today on behalf of CCAP and PACA MH/DS.
7 The Mental Health Procedures Act is one
8 of several tools we have to support individuals
9 with mental illness. The Mental Health
10 Intellectual Disabilities Act of 1966 requires
11 counties to maintain twenty-four/seven access to
12 emergency services. It also requires counties to
13 provide an array of recovery-focused community
14 mental health services.
15 State law also provides for mental
16 health directives, which an individual uses to
17 communicate their treatment wishes if they are
18 suffering from a mental disorder and judged unable
19 to make decisions for themselves or are otherwise
20 unable to communicate.
21 Other proven tools include Wellness
22 Recovery Action Plans, which are designed by an
23 individual with mental illness, to identify a plan
24 to respond to certain triggers or early warning
25 signs as well as crisis planning and general 83
1 wellness. Counties also administer resources for
2 intellectual disabilities and early intervention.
3 The Mental Health Procedures Act
4 establishes procedures for both inpatient and
5 outpatient voluntary and involuntary treatment.
6 However, involuntary commitment is viewed as a last
7 resort because it rarely results in a recovery-
8 oriented outcome and is expensive to taxpayers.
9 Research has shown that most effective
10 entry to treatment for an individual with mental
11 illness is a voluntary one. By fostering trusting
12 relationships and supporting the individual with
13 supports such as case management, supported housing
14 and peer services, the individual is given the
15 opportunity to engage in their own treatment plan.
16 Community inclusion has been proven to be effective
17 in the mental health recovery process.
18 Any amendments to the Mental Health
19 Procedures Act, particularly those related to
20 involuntary commitment, must be carefully
21 contemplated to maintain the appropriate balance
22 between the rights of individuals who need
23 treatment and public safety.
24 In spite of the recent acts of violence
25 with tragic outcomes, statistically, individuals 84
1 with mental illness are more likely to be victims
2 of crime than to perpetrate a violent crime. The
3 American Journal of Psychiatry recently published a
4 study which found no relationship between
5 psychiatric disorders and the use of firearms or
6 between psychiatric disorders and offenses
7 involving multiple victims.
8 We also must be careful to avoid stigma
9 which will discourage people from seeking mental
10 health treatment.
11 In 2013, CCAP members voted to amend
12 the county platform to support a comprehensive
13 legislative review and evaluation of the
14 Commonwealth’s Mental Health Procedures Act and
15 accompanying policy and procedure for voluntary and
16 involuntary mental health commitments, in close
17 collaboration with counties.
18 A PACA mental health/developmental
19 disabilities subcommittee involving counties of
20 various sizes began a review of the Mental Health
21 Procedures Act. Through our mental health
22 committee, we have also been sharing best
23 practices. As an example, some counties self
24 identified a need to foster better collaboration
25 between the mental health office and the courts and 85
1 have reviewed the policies and procedures
2 established by other counties to strengthen this
3 partnership.
4 We are not recommending any amendments
5 to the Mental Health Procedures Act at this time
6 but have developed the following recommendations:
7 Identify best practice models, as well as effective
8 policies and procedures that increase collaboration
9 between counties and the court system in
10 involuntary commitment proceedings; re-visit a
11 draft involuntary outpatient commitment bulletin
12 developed by DPW in 2010, with the goal of
13 finalizing to offer some clarification regarding
14 interpretation of the existing Mental Health
15 Procedures Act.
16 The draft bulletin should be amended to
17 address the following issues: Better define the
18 list of services that can be included in outpatient
19 treatment plans, and outpatient plans should be
20 driven by clinical needs as determined by the
21 treatment team; develop training for mental health
22 review officers, including education on services
23 and resources available in the local community for
24 individuals with mental illness and to provide a
25 legal basis for more consistent court 86
1 interpretations between counties; educate policy
2 makers and the public about funding deficiencies
3 for community-based, recovery-oriented mental
4 health services and the impacts of proposed
5 amendments to the act which could result in
6 increased demand, resulting from more involuntary
7 commitments and decrease the capacity of the
8 delivery of voluntary treatment.
9 PACA MH/DS is also supportive of the
10 Office of Mental Health and Substance Abuse
11 Services' work to convene regional meetings on
12 crisis and commitment procedures. In these
13 sessions, county delegations from the mental health
14 office and the courts are evaluating tabletop
15 scenarios to determine how they would apply the
16 Mental Health Procedures Act to those scenarios.
17 This should provide insight into the areas where
18 additional training or policy clarification is
19 required.
20 DR. MICHALIK: Rep. DiGirolamo, Rep.
21 Murt, members of the committee, thank you for
22 allowing us to testify.
23 I'd like to address the current various
24 legislative proposals that are out there to amend
25 the MH Procedures Act. 87
1 There are currently various legislative
2 proposals to amend the MHPA’s provisions regarding
3 criteria for involuntary commitment, sharing of
4 information, and adding assisted outpatient
5 treatment. We would like to offer the following
6 feedback based on counties’ review of these
7 proposals.
8 Broadening involuntary commitment
9 criteria will impact resources in the system, which
10 is already underfunded.
11 Counties believe it is essential that
12 the standard for involuntary commitment continue to
13 include a criterion that requires an act in
14 furtherance of a threat. Some proposals have
15 attempted to broaden the language in ways that will
16 be very difficult to apply and interpret, and the
17 end result will be a steep increase in the number
18 of involuntary commitments, which, as noted before,
19 are costly and not as effective as voluntary
20 treatment or other forms of crisis intervention.
21 of the ability to share
22 limited information about a threat without patient
23 consent would be helpful for situations where a
24 mental health professional deems a threat that
25 should be disclosed to a law enforcement agency or 88
1 an endangered individual. However, this must be
2 approached so as not to create additional
3 professional liability for the mental health
4 professional.
5 Any legislation to codify duty-to-warn
6 standards should be based solely on existing case
7 law.
8 Counties oppose assisted outpatient
9 proposals contained in Senate Bill 77 and House
10 Bill 550. This legislation will overburden
11 currently available financial resources to support
12 treatment.
13 Psychiatric services, for which PA has
14 documented shortages in twenty-seven of our
15 counties, will be strained due to involvement in
16 assisted outpatient proceedings required by this
17 legislation. Significant costs will accrue to
18 local courts and mental health programs.
19 I would like to return to the theme
20 that we started with, which is that involuntary
21 commitment procedures should be limited in use.
22 Lack of funding in the mental health system
23 continues to cause insufficient access to
24 treatment.
25 We urge legislators to commit adequate 89
1 funding for the mental health system. In PA, there
2 have been several cuts to base-funded mental health
3 services over the past decade. Base-funded
4 services are funded through state and county
5 dollars to provide crisis treatment. A county
6 survey compiled by PACA MH/DS in December 2012
7 highlights services which were severely impacted by
8 the 10 percent budget cut in fiscal year 2012-2013.
9 Crisis services have been cut and waiting lists for
10 services have increased.
11 It is also important to acknowledge our
12 successes. PA has benefited from behavioral
13 HealthChoices, the Medicaid managed care program
14 for behavioral health services. The current
15 structure of behavioral HealthChoices assures a
16 designated funding stream for mental health and
17 drug and alcohol services. Behavioral health
18 services are more readily available than they were
19 ten years ago, and providers and managed care
20 organizations are accountable to program standards.
21 The program met or exceeded all of its objectives
22 while saving the commonwealth at least four billion
23 dollars compared to projected spending prior to
24 HealthChoices.
25 Because the Medicaid HealthChoices 90
1 funds and the state mental health base dollars are
2 coordinated at the local level along with some
3 state substance abuse funds, we have been able to
4 coordinate and leverage limited public funds in
5 ways that benefit your constituents who have more
6 needs for mental health services during this recent
7 economic downturn.
8 Any change in the Mental Health
9 Procedures Act must be carefully evaluated for its
10 impact on individuals with mental disorders and
11 counties' capacity to serve people who need our
12 programs to aid in their recovery. The act's
13 policy is intertwined with state and county
14 budgets. If the general assembly proceeds with any
15 changes to the act, funding must be addressed,
16 since counties are unable to afford any additional
17 unfunded mandates.
18 The association applauds the members of
19 the general assembly for taking a measured response
20 to issues related to mental illness and violence by
21 authorizing studies which are conducted pursuant to
22 Senate Resolution 6 and House Resolution 226.
23 I wish to add that I'm a member of the
24 advisory committee of the Joint State Government
25 oversight commission's advisory committee pursuant 91
1 to Senate Resolution 6.
2 We thank you for the opportunity to
3 testify today and are available to answer any
4 questions.
5 MAJORITY CHAIRMAN DIGIROLAMO: Thank
6 you, Dr. Michalik. Thank you, Chris. Appreciate
7 your testimony.
8 Our final testifier this morning is
9 Rebecca May-Cole, from the Behavioral Health and
10 Aging Coalition.
11 MS. MAY-COLE: Good morning.
12 REP. MURT: Good morning. Thank you
13 for being with us.
14 MS. MAY-COLE: Thank you.
15 As the final testifier today, I guess I
16 have the benefit of saying what they said.
17 But I’m also here to talk specifically
18 about how involuntary commitment addresses or
19 impacts older adults, because we do have some
20 pretty specific needs as it relates to older
21 adults.
22 Let me just first say that the
23 Behavioral Health and Aging Coalition is a
24 statewide organization. We've been around since
25 1999. We have about thirty-five hundred members. 92
1 And our focus is on the behavioral health needs of
2 older adults in PA. And by behavioral health, I
3 mean mental health, drug and alcohol, as well as
4 issues of dementia.
5 As has been stated before, this issue
6 is a very controversial one. We need to balance
7 the many perspectives that are at play, the civil
8 rights of individuals with a mental illness and the
9 need to ensure that people who need treatment are
10 receiving that treatment. And if you add in the
11 problem of older adults experiencing psychiatric
12 symptoms, this becomes even more complex.
13 I wanted to start by, you know,
14 recognizing that we're talking about the commitment
15 law, but as others have said, I belive that the -
16 it's essential that we first recognize the need to
17 prevent individuals from reaching the point of
18 being considered for involuntary treatment. If we
19 addressed many of the issues that exist at the
20 community level, we can prevent people from
21 reaching the point of needing involuntary
22 commitment. It should be a last resort, used only
23 when there are no other less-restrictive options
24 available.
25 And let me identify some of the 93
1 problems that we could address to help prevent some
2 of these situations.
3 To start, individuals and families are
4 not aware of the early signs and symptoms of mental
5 health conditions especially in older adults,
6 because older adults can exhibit some of these
7 signs differently than folks who are younger. And,
8 so, this can be addressed by doing more community
9 outreach, efforts such as providing Mental Health
10 First Aid to community members can assist in
11 improving awareness of the signs and symptoms of
12 mental health conditions.
13 There is supposed to be a new Mental
14 Health First Aid program coming out that addresses
15 older adults specifically. There's one for
16 children, and there's one for adults, and they're
17 working on one for older adults. And this will
18 also help with issues of stigma. Older adults are
19 not ones who voluntarily say, you know, "I have a
20 mental illness.” They wouldn't even recognize that
21 terminology. They would say many other things,
22 like, "I'm feeling blue,” or "I'm feeling down,” or
23 "I'm sleeping," "I don't have energy."
24 Sometimes they talk about physical
25 complaints that aren't actually associated with 94
1 anything that can be found medically. A lot of
2 complaints of pain and things like that, too.
3 Individuals and families who know
4 something is wrong don’t know where to turn. If
5 you’re not connected to the mental health system,
6 it can be very confusing to know how to navigate
7 through it. Again, community outreach, letting
8 them know services are available.
9 Providing such information to local
10 primary care physicians can be helpful also. Older
11 adults don’t tend to go to traditional mental
12 health services. They go to their primary care
13 physician.
14 Many primary care physicians don’t have
15 a good understanding of the mental health system
16 and don’t know where to refer older adults for
17 age-specific care, if such care even exists, the
18 number of services that are available to older
19 adults specifically for older adults. You’ll hear
20 a lot of providers who say that they provide
21 services at all age ranges, which is, you know,
22 true. They’re not going to turn somebody away
23 necessarily because they’re an older adult. But
24 older adults have specific needs.
25 If you have somebody with, you know, a 95
1 mental illness who is twenty-two and is just now
2 starting to exhibit the symptoms and understand
3 what's going on, and you have somebody who’s
4 eighty-seven who's having some symptoms, you know,
5 there're very different issues at play here, and we
6 need to have specific services for those
7 individuals.
8 And some of the cuts that happened, as
9 others have talked about, the 10 percent cuts that
10 happened recently, have resulted in some of those
11 programs that were specifically devoted to older
12 adults, they have been closed because they were
13 unable to continue funding them.
14 Long-term care don't have
15 staff that's adequately trained to work with an
16 older adult experiencing psychiatric symptoms and
17 don't have adequate relationships with mental
18 health providers who could come in and provide such
19 assistance. The reason for this is mostly due to
20 inadequate funding and reimbursement.
21 Mental health providers don't have
22 programs specifically designed for older adults,
23 which I had mentioned. Some of that is because
24 they don't understand that there are unique needs
25 for older adults. 96
1 There’s also an assumption that older
2 adults have Medicare, which means that all of their
3 health care needs will be covered by Medicare.
4 This is not the case. Medicare funds only a
5 specific set of traditional mental health
6 services. It doesn’t cover things like peer
7 support, which has been proven to be very, very
8 beneficial. And the reimbursement for Medicare is
9 very low.
10 On top of that, the Medicare
11 requirements relating to the types of professionals
12 who are approved to provide the services are
13 difficult to -- or at a very high level, which
14 makes that service being provided by those
15 individuals more expensive.
16 And I’ve already addressed the funding
17 cuts. But restoring those cuts of -- I believe it
18 was 2012-2013, the 10 percent cut, would go part of
19 the way toward ensuring the need -- that needed
20 services are available. However, I do believe that
21 services were underfunded even before the 10
22 percent cut had happened.
23 Linkages between the aging and mental
24 health systems are still inadequate. Even though a
25 lot of effort has been made by the Department of 97
1 Aging, the OMHSAS, and our organization to improve
2 these relationships, problems still remain, and we
3 need to continue to work on improving these
4 relationships.
5 Now, I would like to talk about,
6 specifically, the Mental Health Procedures Act.
7 The implementation, as many others have said, is
8 inconsistent across the commonwealth. And when you
9 add the complicating layer of older adult issues,
10 the process becomes even more convoluted.
11 And here is why. When an older adult
12 is in a mental health crisis situation, they're
13 referred to the mental health delegate, who
14 determines their eligibility for involuntary
15 emergency examination and treatment. Prejudice
16 against older adults in the form of ageism is alive
17 and well in some parts of PA. If an older adult is
18 experiencing psychiatric symptoms in these areas,
19 the assumption is made that the person has
20 dementia.
21 And, in extreme cases, crisis
22 intervention has refused to come out to even
23 evaluate an older adult because of this. Somebody
24 may call and say, "I have an older adult who is,”
25 you know, "threatening suicide.” They're sitting 98
1 there. They have, you know, the pills in front of
2 them, whatever it is. And crisis intervention will
3 say, "Well, they're an older adult, we can't see
4 them.” There's no reason why that should be
5 happening, whether or not they have a dementia
6 diagnosis.
7 And the reason why this dementia
8 diagnosis is crucial is because, according to
9 Section 102 of the act: Persons who are senile -
10 now we call that dementia -- shall receive mental
11 health treatment only if they are also diagnosed as
12 mentally ill, but these conditions of themselves
13 shall not be deemed to constitute mental illness.
14 That phrase or that section is used to
15 say that if you have dementia, you automatically
16 are not allowed to have -- to have that treatment,
17 even though if you do have a co-occuring mental
18 illness that can be treated.
19 Let me be explicitly clear that if
20 someone has a dementia diagnosis, this alone does
21 not preclude them from accessing services under
22 this section. In fact, in 2006, the Office of
23 Mental Health and Substance Abuse Services
24 published a bulletin which clearly states: A
25 diagnosis of dementia should never be a reason to 99
1 deny mental health crisis intervention or
2 community-based treatment to a person when it is
3 accompanied by a mental health disorder.
4 We don't believe legislation is
5 necessary to address the problem of inconsistency.
6 We do, however, believe that adequate training
7 would be what is needed to address this problem.
8 Specific training toward delegates and judges
9 regarding the correct implementation of the
10 involuntary commitment standards, including how to
11 respond to older adults, would go a long way toward
12 improving consistency in implementation.
13 And others have mentioned that there
14 was training maybe around 2010, 2011, around the
15 Mental Health Procedures Act that happened. The
16 difficulty is that a lot of the folks who really
17 needed to be there were not there. And it wasn’t
18 specifically targeted to the involuntary commitment
19 process.
20 In order to appropriately structure
21 such training, we believe an environmental scan
22 should be conducted, as others have mentioned, to
23 understand the number of involuntary commitments of
24 older adults, specifically, that are currently
25 occurring, how many are being denied and for what 100
1 reason, where the process is initiated. Is it
2 family members bringing people in? Is it Area
3 Agencies on Aging making referrals? You know,
4 where are these referrals coming from, are these
5 calls from?
6 A comprehensive report of the current
7 implementation would help determine exactly how and
8 where to target training efforts.
9 Clearfield and Jefferson Counties have
10 an innovative program called JOACT, it's the Joint
11 Older Adult Crisis Team, in which the county mental
12 health and aging systems have come together to
13 determine a process whereby an identified older
14 adult undergoes an assessment, and specific
15 procedures are followed to ensure that the needs of
16 that older adult are met should the assessment
17 identify that the person is at risk of harm.
18 Encouraging or even mandating a similar process in
19 all counties of PA would help to address the issues
20 I've already identified.
21 I've spoken at length about the
22 problems in the mental health and aging systems as
23 it relates to involuntary mental health
24 commitments. I've also addressed the problems of
25 inconsistent application of the Mental Health 101
1 Procedures Act. So, now I want to just summarize
2 the recommendations that we’re making.
3 Conduct community outreach with family
4 members, primary care physicians, nursing
5 facilities, housing complexes, and any other place
6 where older adults are served or touched. This
7 outreach could include listings of resources that
8 are available locally, information about
9 recognizing the signs and symptoms of mental health
10 disorders in older adults, and how to
11 respond.
12 Implement training. Training is needed
13 for the community at large, again, primary care
14 physicians, all of those that I just identified, as
15 well as the Area Agencies on Aging, mental health
16 providers, undergraduate and graduate students,
17 mental health delegates, judges, and others
18 involved in the official commitment process. This
19 training should include, again, recognizing the
20 signs and symptoms of mental health disorders
21 specifically in older adults, and, for delegates
22 and judges, the appropriate way to implement the
23 commitment process for older adults.
24 We need to implement screening, better
25 screening. Primary care physicians, Area Agencies 102
1 on Aging, and others should be provided with
2 screening tools they can use to identify when an
3 older adult may be dealing with a mental health
4 disorder. And this ties in directly with the
5 outreach that identifies the services that are
6 available locally.
7 And, finally, increasing -- oh, not
8 finally -- increasing funding, which we've already
9 mentioned. Restoring the cuts will go part of the
10 way, but, better yet, dedicating funding to support
11 programming specifically for older adults would
12 ensure that their needs are being met. And you may
13 already know, we are seeing a large number of older
14 adults coming into our system as people are aging,
15 and, in particular, Baby Boomers.
16 Improved communication and linkages
17 between mental health and aging.
18 This increased outreach and training,
19 increased funding, as well as implementing programs
20 similar to the JOACT program that I mentioned —
21 and I have information about that if anybody would
22 like more information -- would definitely be
23 helpful.
24 Thank you again for the opportunity to
25 be here today. And, as the last speaker, I'm happy 103
1 to stay for questions or can go sit down and you
2 can call me up again.
3 Thank you.
4 REP. MURT: Thank you, Rebecca.
5 We do have some questions.
6 Mr. Chairman.
7 MAJORITY CHAIRMAN DIGIROLAMO: Okay.
8 Thank you.
9 What great testimony today. Heard a
10 lot of really compelling testimony. And I heard a
11 lot of different ideas and recommendations, but I
12 think what I heard from almost everybody is the
13 need for funding, county-based funding for mental
14 health.
15 So, I’d just like to start out the
16 question, and maybe a question for Chris and Ed, if
17 you don’t mind coming up.
18 A couple of years ago, we cut the
19 funding for Human Services in the state by 10
20 percent, which I believe was about eighty-four
21 million dollars. So, for the last two years, we’ve
22 experienced a cut to Human Services in county
23 funding of a hundred sixty-eight million dollars.
24 And three-quarters of that money, I believe, goes
25 to mental health services, so, you know, preventing 104
1 people from getting in a crisis, and I mean, I know
2 that's what that money would go for.
3 Would you mind just talking just a
4 little bit about — about how that would have
5 affected your job in the county, the 10 percent
6 cuts.
7 MR. WYSOCKI: The rural counties that I
8 provide support for, services for, we've had to cut
9 services. Now, the county-based dollars, just to
10 talk about that just real briefly, are really to
11 help provide services for those individuals who
12 aren't qualified for the Medicaid services. Okay.
13 The HealthChoices does an excellent job providing
14 the treatment services for that. So, the county
15 dollars pays for treatment for the working poor.
16 Okay.
17 The other thing that it does is it
18 provides the support services that are not
19 considered medically necessary. Supported housing,
20 peer support in some circumstances, it pays for
21 part of psychiatric rehabilitation, and in some
22 counties, that is not even part of their
23 HealthChoices. So, all those services had to be
24 cut back and ratcheted back in some way.
25 It increased our waiting list for 105
1 services. It is — in a rural county, it is not
2 surprising to have to wait sometimes six and eight
3 weeks to see a psychiatrist, to get into outpatient
4 services. And that was the case before the cuts.
5 Now it's even worse.
6 DR. MICHALIK: I have to echo
7 particularly all of Chris's remarks, but in Berks
8 County alone, and if -- you really have to look at
9 the picture over ten years. It just wasn't the 10
10 percent cuts before, but that was the hardest and
11 most difficult to absorb and came in a series of
12 years of reduced funding. Particularly where the
13 cuts have been applied are in our base funded
14 system, as Chris pointed out, that serves people
15 not on Medicaid.
16 Our Medicaid system, under the
17 HealthChoices program, one of the best things that
18 ever happened in years and years to the mental
19 health and behavioral health system.
20 However, those discretionary funds,
21 those base funds that we have are specifically
22 where the cuts were applied, and that affects
23 crisis intervention, outpatient, peer support, all
24 these other programs that those before us have
25 testified, that intervene early on in people's 106
1 lives and the crises to prevent the need for
2 involuntary commitment. So, exactly where the
3 money is needed, that’s where it ended up being
4 cut. And we can’t just say it was the last year,
5 because we have to look at -- I’ve been around a
6 long time, thirty years. So, when you look at
7 particularly the last ten years, it’s been a steady
8 eroding of those funds.
9 MAJORITY CHAIRMAN DIGIROLAMO: Well, I,
10 for one -- I mean, I think if we approach our next
11 year’s budget, I mean, if we can get money back
12 into this human service funding, I mean, I think
13 that’s the one place all throughout the budget that
14 we need to put more money into.
15 Have you or the association taken a
16 look at how Medicaid expansion or what the governor
17 has proposed in his plan for Healthy PA, how that
18 would affect your counties or the counties across
19 PA as far as mental health -- the mental health
20 issue goes? Have you taken a look at that?
21 DR. MICHALIK: I think, right now,
22 we’re in the middle of the analysis stage of it, as
23 details become available. I think any type of
24 Medicaid expansion would be good, because,
25 obviously, the bringing of the local Medicaid 107
1 dollars through HealthChoices to the counties has
2 enhanced the mental health system, particularly for
3 those who are eligible for Medicaid.
4 We wish we had the same thing on the
5 other side, for those that are not Medicaid
6 eligible. As Chris related, the working poor,
7 these are the people that have been affected the
8 most by the economic downturn, where they're having
9 a lot of difficulties and not yet eligible for
10 Medicaid.
11 But as for our county, I think the
12 association is just in the initial analysis
13 stages. It's very new. Paint's not dry yet.
14 MR. WYSOCKI: Yeah. I would support
15 that same thing. We're just trying to wrap our
16 heads around it. And any expansion would help the
17 county-based dollars as well, because we end up
18 covering the services for those people, the working
19 poor.
20 MAJORITY CHAIRMAN DIGIROLAMO: Those
21 are the people that the expansion would cover.
22 Has the -- has the state association
23 taken a position on Medicaid expansion, or your
24 committee that you represent?
25 MR. WYSOCKI: Not at this point. We 108
1 have not made a — that. And I’m not sure about
2 CCAP.
3 MAJORITY CHAIRMAN DIGIROLAMO: Okay.
4 Okay. Thank you, Mr. Chairman.
5 REP. MURT: Before you gentlemen leave,
6 I just want to say, you said something in your
7 testimony that was very useful. And you mentioned
8 how much more successful voluntary commitments are
9 over involuntary commitments. And that’s a fact, I
10 think, which we were not aware, but I appreciate
11 you mentioning that.
12 Does anyone else have any questions for
13 Chris or Dr. Michalik?
14 DR. MICHALIK: One other addition to
15 your comment, Rep. Murt. Through the use of
16 earlier intervention and crisis intervention
17 services and diversion that many of the testifiers
18 had talked to, it’s always better if we look at our
19 own personalized and our families and community
20 members, that if you get involved earlier, people
21 realize that they need to change and realize that
22 they need help and they reach out for help and then
23 are empowered to seek their own help, that greatly
24 short circuits the need for government and
25 legislation to tighten up and do anything more 109
1 serious. And it costs a lot more money, also, once
2 you get to that point.
3 REP. MURT: Thank you.
4 DR. MICHALIK: Thank you.
5 REP. MURT: I have a couple questions
6 for Mr. Secretary, Secretary Marion, if you don't
7 mind.
8 Mr. Secretary, you mentioned the term
9 "delegate." Is a delegate a family member? Is it
10 a county employee? Is it an advocate? Who is a
11 delegate?
12 DEPUTY SECRETARY MARION: A delegate is
13 a designated representative of the local
14 administrator for the mental health program run by
15 the counties. Under the act, the administrator has
16 authority on the initial decision to sign a
17 warrant, which would then empower authorities to
18 take an individual to an emergency room for an
19 evaluation. So, the delegate is simply anybody
20 designated to fulfill that role within the county
21 program.
22 REP. MURT: Another question I have is,
23 do we know what the average length of stay is in a
24 hospital facility after an involuntary commitment?
25 DEPUTY SECRETARY MARION: No. We don't 110
1 have that data isolated. We’re not sure if we can
2 work our way backwards through our encounter data
3 for HealthChoices. That’s been referenced a number
4 of times. We probably have the most sophisticated
5 information base around services delivered through
6 the HealthChoices program. So, as we look at the
7 multiple dimensions of emergency response and then
8 commitment, we could possibly try to isolate out
9 whether we know anything more about individuals who
10 are committed versus those not committed.
11 But, again, in terms of the sequencing,
12 you’re talking about from a petition to a
13 delegate’s decision to sign a warrant, which then
14 brings the individual to an emergency room where he
15 or she would be evaluated by a physician at the
16 emergency room. And that is the first decision
17 regarding commitment. And that is a medical
18 decision at that point in time. And that is in
19 advance of the subsequent hundred-and-twenty hour
20 hearing, which is the first time the hearing
21 officer becomes involved.
22 So, the first commitment decision is
23 made by medical professional.
24 REP. MURT: Just to follow up on that.
25 Mr. Secretary, when an individual would go to the 111
1 emergency room, how long after that would their 303
2 hearing be? Did you say a hundred twenty hours?
3 Or -
4 DEPUTY SECRETARY MARION: It's a
5 hundred-twenty-hour rule, and, so, for practical
6 considerations, it will occur within those three
7 days.
8 REP. MURT: Is the individual usually
9 in a hospital facility during that time or -
10 DEPUTY SECRETARY MARION: Well, there's
11 a number of decisions. If an individual, at the
12 point in time the petition's filed and in the
13 emergency room, oftentime there's an opportunity to
14 engage again with the individual and to encourage a
15 voluntary admission versus the involuntary
16 commitment route. So, there are a number of sort
17 of conversions or changes where the individual, at
18 the ER, makes a choice to go voluntarily versus
19 through the commitment process.
20 And, then, it's going to become a
21 medical condition whether or not the individual
22 stabilizes before the hearing or not. Some
23 individuals may discharge, may stabilize before the
24 hearing actually occurs. But, oftentimes -- and I
25 will defer to others who are closer to that 112
1 process, and it's one of those thing we'll chart
2 out as part of our information-gathering process.
3 REP. MURT: One final question,
4 Mr. Secretary.
5 As part of the commonwealth's municipal
6 police officer training program, do we mandate any
7 training content in dealing with mental health
8 issues?
9 DEPUTY SECRETARY MARION: I think for
10 very practical considerations, departments across
11 the commonwealth are -- if they're not doing it in
12 their basic -- I don't believe there's much -- I
13 don't -- a designated amount in -- during the
14 academy phase.
15 (Whereupon, there was a brief
16 discussion with someone in the audience.)
17 DEPUTY SECRETARY MARION: So, two
18 things. There is an element provided during the
19 academy training for officers, and, then, there is
20 a recurring training. But what I want to
21 acknowledge are the number of departments who have
22 added on very specialized training above the
23 minimums to have better empowered their officers on
24 the street to respond to crises and attempt the
25 deescalate rather than, you know, contribute into 113
1 escalating the issue for individuals. So,
2 departments have been very attentive.
3 The Commission on Crime and
4 Delinquency, OMHSAS works in partnership with the
5 Commission on Crimes and Delinquency, who provides
6 funding to the police community to provide
7 specialized training above the minimum
8 requirements. So, as a commonwealth, we’re working
9 across agencies lines to try to raise the level of
10 opportunity officers have to get training.
11 REP. MURT: Any questions for the
12 secretary?
13 Thank you, Mr. Secretary.
14 I have a question for Jacob, if you
15 don’t mind.
16 Jacob, during your testimony you made
17 use of the expression "Assertive Community
18 Treatment programs." What do you mean by that?
19 What are you referring to as assertive
20 intervention?
21 MR. BOWLING: Sure. Well, I think,
22 generally speaking, assertive treatment would
23 involve professionals going out into the community
24 and engaging folks that have been identified who
25 have a higher level of disability. But there -- 114
1 there is actually an Assertive Community Treatment,
2 that's call ACT, A-C-T, model where people are
3 provided wraparound services, and these services
4 can include a social worker, a nurse, a peer
5 specialist, a psychiatrist. And it's provided in
6 the community. It's an interdisciplinary team.
7 And they've been shown to be very successful.
8 One of the models that's really worked,
9 especially among people who are street homeless
10 with severe mental health conditions, is the
11 Housing First model, which says, if we give people
12 stable housing, that can be a stable base from
13 which they can recover. So, they're given stable
14 housing, then provided this wraparound, very
15 assertive community treatment. And it's been shown
16 to have great success.
17 We would also -- you know, a few
18 testifiers mentioned peer support. Peer support is
19 a critical ingredient to engaging folks who maybe
20 aren't quite ready to pursue treatment yet,
21 engaging people who are in crisis. Because, coming
22 from a lived-experience perspective, coming from a
23 shared-experience perspective can be a really
24 powerful engagement tool.
25 REP. MURT: Thank you. 115
1 Any other questions for Jacob?
2 Thank you.
3 MR. BOWLING: I can send you some more
4 information about that model.
5 REP. MURT: If you don’t mind, we’d
6 appreciate that. Thank you.
7 MR. BOWLING: Sure.
8 REP. MURT: Just have two questions.
9 Lloyd, you might be the best point of
10 contact, if you don’t mind.
11 Thank you for your testimony. And you
12 made reference to different interpretations of the
13 Mental Health Procedures Act. How do we fix that?
14 MR. WERTZ: Well, going to the source
15 in the counties, it would seem to me, might be the
16 best way to make that happen and educate those
17 folks.
18 Furthermore, if you look carefully, I
19 don’t think there are regulations for the way the
20 Mental Health Procedures Act is implemented, as
21 there are for other licensed services throughout
22 the commonwealth. When I operated an inpatient
23 program, I had a manual. And I had darn well
24 better follow that manual or my license would be
25 provisional or pulled. 116
1 I don't think that exists in the
2 application of the MHPA, and the development of and
3 implementation of regulations across the
4 commonwealth would certainly go a long way in
5 helping that process.
6 REP. MURT: I have a question. You
7 might be the best person to ask, but I guess I
8 would throw this out to all of our testifiers. Are
9 there any states -- any other states in the country
10 that do this better than PA, that have a model that
11 we could emulate or look at?
12 MR. WERTZ: From a funding perspective?
13 REP. MURT: To you knowledge.
14 Well, I know we're not perfect with the
15 funding, but we're working on it.
16 But even in terms of programming and
17 services and approach they take or the model of
18 delivery, anything along those lines, anything that
19 we could copy and use here in the commonwealth.
20 MR. WERTZ: I don't have a lot of
21 experience outside of the commonwealth, but I will
22 tell you that I think what we have had over the
23 past thirty-five years or so has actually been
24 pretty effective, if it is allowed to be
25 implemented consistently and if the community 117
1 services for prevention and access to those
2 services are more readily available than we
3 currently find them.
4 REP. MURT: Thank you.
5 Any other questions?
6 Okay. Well, I want you to know how
7 grateful we are for all of your testimony, had some
8 really great information put forth today. This is
9 an ongoing process. We’ll be having additional
10 hearings in the future. And we’ll be asking Pam
11 and Melanie to compile the recommendations and see
12 if we can translate that into some kind of
13 legislative proposal.
14 So, thank you very much for
15 participating today, and I’d like to close our
16 hearing. Thank you.
17 (Whereupon, the hearing concluded at
18 11:09 a.m.)
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3 I HEREBY CERTIFY that the foregoing is
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9 BRENDA J. PARDUN, RPR 10 Court Reporter Notary Public 11
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