Joint Legislative Public Hearing on 2018-2019 Executive Budget Proposal: Topic Mental Hygiene - Testimonies

Hearing event notice and video:
https://www.nysenate.gov/calendar/public-hearings/february-13-2018/joint-legislative-public-hearing-2018-2019-executive

Transcript:

                                                                   1

 1  BEFORE THE NEW YORK STATE SENATE FINANCE
    AND WAYS AND MEANS COMMITTEES
 2  -----------------------------------------------------

 3          JOINT LEGISLATIVE HEARING

 4             In the Matter of the
           2018-2019 EXECUTIVE BUDGET ON
 5                MENTAL HYGIENE
    
 6  -----------------------------------------------------

 7  
    
 8                           Hearing Room B
                             Legislative Office Building
 9                           Albany, New York
    
10                           February 13, 2018
                             9:38 a.m.
11  
    
12  PRESIDING:

13           Senator Catharine M. Young
             Chair, Senate Finance Committee
14  
             Assemblywoman Helene E. Weinstein
15           Chair, Assembly Ways & Means Committee
    
16  PRESENT:

17           Senator Liz Krueger 
             Senate Finance Committee (RM)
18  
             Assemblyman Robert Oaks
19           Assembly Ways & Means Committee (RM)
    
20           Senator Diane Savino
             Vice Chair, Senate Finance Committee
21  
             Assemblywoman Aileen Gunther
22           Chair, Assembly Committee on Mental Health
    
23           Senator George A. Amedore, Jr. 
             Chair, Senate Committee on Alcoholism 
24            and Drug Abuse
    

                                                                   2

 1  2018-2019 Executive Budget
    Mental Hygiene
 2  2-13-18
    
 3  PRESENT:  (Continued)
    
 4           Assemblyman Angelo Santabarbara
    
 5           Senator John E. Brooks
    
 6           Senator Fred Akshar 
    
 7           Assemblyman John T. McDonald III 
    
 8           Assemblywoman Melissa Miller
    
 9           Assemblywoman Carmen de la Rosa
    
10           Assemblyman Luis Sepulveda
    
11           Senator Gustavo Rivera
    
12           Assemblywoman Crystal D. Peoples-Stokes
    
13           Assemblywoman Patricia Fahy
    
14  

15

16

17

18

19

20

21

22

23

24

                                                                   3

 1  2018-2019 Executive Budget
    Mental Hygiene
 2  2-13-18
    
 3                   LIST OF SPEAKERS
    
 4                                    STATEMENT  QUESTIONS
    
 5  Ann Marie T. Sullivan, M.D.
    Commissioner
 6  NYS Office of Mental Health            9         14
    
 7  Kerry A. Delaney 
    Acting Commissioner 
 8  NYS Office for People With
     Developmental Disabilities          107        112
 9  
    Arlene González-Sánchez 
10  Commissioner
    NYS Office of Alcoholism
11   and Substance Abuse Services        152        157
    
12  Denise M. Miranda 
    Executive Director
13  NYS Justice Center for the
     Protection of People with 
14   Special Needs                       209        215
    
15  Mark van Voorst
    Executive Director
16  The Arc New York                     235        239
    
17  Harvey Rosenthal 
    Executive Director 
18  Elena Kravitz
    Director for Policy and
19   Public Engagement
    NY Association of Psychiatric
20   Rehabilitation Services
        -and-
21  Glenn Liebman
    CEO
22  Mental Health Association
     in New York State                   244        257
23  
    
24  

                                                                   4

 1  2018-2019 Executive Budget
    Mental Hygiene
 2  2-13-18
    
 3              LIST OF SPEAKERS, Continued 
    
 4                                     STATEMENT  QUESTIONS
    
 5  Wendy Burch
    Executive Director
 6  Ariel Kaufman 
    Board Member
 7  National Alliance on Mental 
     Illness of New York State            
 8   (NAMI-NYS)                           262
    
 9  Kelly A. Hansen
    Executive Director
10  NYS Conference of Local
     Mental Hygiene Directors             269       276      
11  
    
12  Randi DiAntonio
    LMSW at OPWDD
13  Darlene Williams
    Occupational Therapist at OMH
14  NYS Public Employees Federation
     (PEF)                                281
15  
    Samantha Howell
16  Executive Director
    National Association of Social 
17   Workers, NYS Chapter                 292
    
18  Paige Pierce
    CEO
19  Families Together in NYS              298       302
    
20  Dr. Ellie Carleton
    Residential Treatment Team Leader
21  Astor Services for Children
     and Families                         304       309
22  
    Christy Parque
23  CEO and President
    The Coalition for
24   Behavioral Health                    310
    

                                                                   5

 1  2018-2019 Executive Budget
    Mental Hygiene
 2  2-13-18
    
 3              LIST OF SPEAKERS, Continued 
    
 4                                     STATEMENT  QUESTIONS
    
 5  Ann M. Hardiman 
    President and CEO
 6  Michael Seereiter
    Executive Vice President/COO
 7  New York Alliance for 
     Inclusion & Innovation               317
 8  
    Arnold Ackerley
 9  Administrative Director
    Clint Perrin
10  Director of Policy
    Self-Advocacy Association
11   of New York State                    322
    
12  John J. Coppola
    Executive Director
13  NY Association of Alcoholism 
     & Substance Abuse Providers          327       337
14  
    Stephanie M. Campbell
15  Executive Director
    Friends of Recovery New York          340
16  
    Donna Tilghman
17  SAPIS Chapter Secretary
    Kevin Allen
18  SAPIS Chapter Chair 
    DC 37, New York City Board of
19   Education Employees Local 372, 
     Substance Abuse Prevention and 
20   Intervention Specialists (SAPIS)     347
    
21  
    
22  
    
23  
    
24  

                                                                   6

 1  2018-2019 Executive Budget
    Mental Hygiene
 2  2-13-18
    
 3              LIST OF SPEAKERS, Continued 
    
 4                                     STATEMENT  QUESTIONS
    
 5  Winifred Schiff
    Associate Executive Director
 6   for Legislative Affairs
    InterAgency Council of Developmental
 7   Disabilities Agencies
        -and-
 8  Barbara Crosier
    VP, Government Relations
 9  Cerebral Palsy Associations
     of New York State
10      -for-
    Coalition of Provider
11   Associations (COPA)                  353
    
12  Antonia Lasicki
    Executive Director
13  Association for Community Living
        -for-
14  Bring It Home Coalition               361       
    
15  Maclain Berhaupt
    State Advocacy Director
16  Supportive Housing Network 
     of New York                          373
17  
    
18  
    
19  
    
20  
    
21

22

23

24

                                                                   7

 1                 CHAIRWOMAN YOUNG:  Good morning.  

 2          We're running late, so I'd like to begin.  

 3                 I'm Senator Catharine Young, and I'm 

 4          chair of the Senate Standing Committee on 

 5          Finance.  And we are joined today by our vice 

 6          chair, Senator Diane Savino; our ranking 

 7          member, Senator Liz Krueger; and Senator John 

 8          Brooks.

 9                 CHAIRWOMAN WEINSTEIN:  I'm 

10          Assemblywoman Helene Weinstein, chair of the 

11          Assembly Ways and Means Committee.  

12                 We are joined by the chair of our 

13          Mental Health Committee, Aileen Gunther; 

14          Assemblymember John McDonald; and 

15          Assemblymember Angelo Santabarbara.  I'm 

16          sorry, and our ranker, Assemblyman Bob Oaks.

17                 ASSEMBLYMAN OAKS:  And Assemblywoman 

18          Missy Miller.

19                 CHAIRWOMAN YOUNG:  Thank you.  

20                 Pursuant to the State Constitution and 

21          Legislative Law, the fiscal committees of the 

22          State Legislature are authorized to hold 

23          hearings on the Executive Budget.  Today's 

24          hearing will be limited to a discussion of 

                                                                   8

 1          the Governor's proposed budget for the Office 

 2          of Mental Health, the Office for People With 

 3          Developmental Disabilities, the Office of 

 4          Alcoholism and Substance Abuse Services, and 

 5          the Justice Center for the Protection of 

 6          People with Special Needs.

 7                 Following each presentation, there 

 8          will be some time allowed for questions from 

 9          the chairs of the fiscal committees and other 

10          legislators.

11                 So we would like to begin.  And I 

12          would first welcome Dr. Ann Sullivan, 

13          commissioner of mental health.  

14                 Following the presentation by 

15          Dr. Sullivan, so you can get in the queue, 

16          there will be Kerry Delaney, acting 

17          commissioner of the Office for People With 

18          Developmental Disabilities; the Honorable 

19          Arlene González-Sánchez, commissioner of the 

20          Office of Alcoholism and Substance Abuse 

21          Services; and Denise Miranda, executive 

22          director of the Justice Center for the 

23          Protection of People with Special Needs.

24                 Good morning, Commissioner.  Welcome.

                                                                   9

 1                 COMMISSIONER SULLIVAN:  Good morning.  

 2          Senator Young, Assemblywoman Weinstein and 

 3          members of the Senate and Assembly fiscal and 

 4          mental health committees, I want to thank you 

 5          for the invitation to present this year's 

 6          Office of Mental Health budget.

 7                 The Office of Mental Health is 

 8          responsible for ensuring that the citizens of 

 9          the state receive mental health services.  

10          The most effective care and the care that 

11          provides our citizens the best opportunity 

12          for full and enriching lives, is care that is 

13          provided in people's homes, neighborhoods and 

14          communities.  To that end, OMH has and in 

15          this budget continues to expand community 

16          services to provide better care to more New 

17          Yorkers.  

18                 However, in recognition that for some 

19          individuals a hospital stay remains a 

20          necessary part of their care, New York State 

21          retains the largest number of psychiatrist 

22          inpatient beds available in the nation, and 

23          we will continue to preserve access to this 

24          vital safety net as we work to transform the 

                                                                   10

 1          system.

 2                 For your continuing support of 

 3          community mental health investment, our 

 4          efforts to provide individuals with mental 

 5          illness the right service at the right time 

 6          in the right setting have started to bear 

 7          fruit.

 8                 Since 2014, with a commitment of more 

 9          than $90 million thus far, we have been able 

10          to provide services to approximately 35,000 

11          new individuals through December of 2017, 

12          including new supported housing for more than 

13          1300 individuals, state-operated community 

14          services, including crisis residences and 

15          mobile integration teams that have served an 

16          additional 10,000 individuals, a wide range 

17          of locally operated community-based services, 

18          including peer crisis respite, first-episode 

19          psychosis programs, community support teams, 

20          and home and community-based waiver services 

21          for more than 20,000 individuals and 

22          families.  

23                 Because these community services are 

24          now in place, we can provide inpatient 

                                                                   11

 1          services when needed and ensure the necessary 

 2          outpatient care and supports are available 

 3          when an individual is discharged.  Our 

 4          ability to serve more citizens of the state 

 5          has increased through the combination of 

 6          these improvements and these new and existing 

 7          services.

 8                 For the next fiscal year, OMH will 

 9          continue the path towards greater access to 

10          community-based care, targeted towards an 

11          individual's needs.  Importantly, the 

12          2018-2019 Executive Budget proposes to, one, 

13          continue the investment in community 

14          services.  The budget adds another 

15          $11 million annually to expand capacity in 

16          the less restrictive and integrated 

17          community-based settings.  This will increase 

18          the amount of annualized investment to $103 

19          million since reinvestment began in fiscal 

20          year 2015.  This also includes 200 additional 

21          supported-housing opportunities in the 

22          community and other community-based services.  

23                 The budget supports additional 

24          residential capacity, including additional 

                                                                   12

 1          homeless housing, which will open in fiscal 

 2          year 2019 through the long-standing 

 3          New York/New York program.  The budget also 

 4          authorizes $50 million in new local capital 

 5          spending, to enable the expansion of crisis 

 6          respite capacity in the community to avoid 

 7          unnecessary emergency room visits and 

 8          inpatient hospitalizations.  

 9                 Twenty new ACT teams, Assertive 

10          Community Treatment teams, were recently 

11          established and will be fully operationalized 

12          in fiscal year 2019 to serve an estimated 

13          1280 new clients.  Ten teams in New York City 

14          will work specifically with homeless 

15          individuals, and the remainder throughout the 

16          state will work with high-need individuals.

17                 The budget provides an additional 

18          $10 million for existing supported housing 

19          and single-room occupancy programs, helping 

20          to preserve access and maintain housing 

21          capacity.

22                 To address the workforce shortage, OMH 

23          has approved a total of 62 providers to use 

24          telepsychiatry, with an additional 24 

                                                                   13

 1          providers under review.  OMH has plans to 

 2          expand regulations further, allowing licensed 

 3          psychologists, social workers and licensed 

 4          mental health counselors, in addition to 

 5          psychiatrists, to utilize video technology to 

 6          deliver treatment.  

 7                 To improve access to treatment for 

 8          maternal depression, OMH will expand its 

 9          Project TEACH to connect OB-GYN and primary 

10          care providers with mental health specialists 

11          who treat mothers with maternal depression.  

12          Also OMH and DOH will launch a strategic 

13          awareness campaign to provide critical 

14          information about symptoms and treatment 

15          options.  OMH will also support advancing 

16          cutting-edge specialty programs, including a 

17          mother/baby inpatient unit and outpatient 

18          programs that focus on maternal depression.  

19                 Finally, OMH is committed to a 

20          significant prevention agenda to promote 

21          mental wellness, prevent disorders, and 

22          intervene early in the trajectory of mental 

23          illness.  This includes such initiatives as 

24          New York State's Suicide Prevention Plan, 

                                                                   14

 1          expansion of school-based mental health 

 2          clinics, and the OnTrackNY early psychosis 

 3          intervention program.  

 4                 Again, thank you for this opportunity 

 5          to address you on the 2018-2019 OMH budget, 

 6          which supports and continues the work we have 

 7          begun to transform New York's mental health 

 8          system.  

 9                 Thank you.

10                 CHAIRWOMAN YOUNG:  Thank you, 

11          Commissioner.  

12                 (Scattered applause from audience).

13                 CHAIRWOMAN YOUNG:  I do have some 

14          questions based on your testimony, just what 

15          we see in the Governor's budget proposal.  So 

16          the Executive Budget proposes to reduce the 

17          number of state-operated residential beds by 

18          a hundred and replace them with 200 

19          community-based scattered-site supportive 

20          housing units that would be operated by 

21          not-for-profits.  

22                 The Executive also proposes a second 

23          year of clinic restructuring, reviewing and 

24          taking administrative action to reduce the 

                                                                   15

 1          overlap of services and ensure that clinics 

 2          are operating at optimal patient capacity 

 3          based on community need.

 4                 So the Governor anticipates 

 5          $2.1 million in savings from the reduction of 

 6          state-operated residential beds, with $1.2 

 7          million invested in not-for-profit supportive 

 8          housing beds, for a net savings of $1 million 

 9          in this coming fiscal year.  There would be a 

10          loss of 55 FTEs associated with this 

11          proposal.

12                 So one of the questions I had regards 

13          whether the actions proposed in the 

14          Governor's budget, such as the transfer of 

15          residential beds and clinical restructuring, 

16          represent the start of a future trend of 

17          shifting state-operated services -- 

18          specifically, residential services -- to 

19          not-for-profit providers.

20                 COMMISSIONER SULLIVAN:  Thank you.  

21                 The purpose of moving the residential 

22          beds is really to fully integrate those 

23          clients in the community.  When the 

24          residential beds which we are closing were 

                                                                   16

 1          established -- it was like 30 years ago we 

 2          began developing these.  They're large 

 3          buildings, large institutions where 

 4          individuals are really separated from living 

 5          in the community but would be capable of 

 6          living in the community.  

 7                 So transitioning individuals from that 

 8          particular kind of housing to the community I 

 9          think is really in line with what Olmstead 

10          requires, and also what's really best care 

11          for the clients.  

12                 We have additional housing in the 

13          system, what we call our transitional-level 

14          housing, on our campuses.  We are not in any 

15          way decreasing that.  And we in fact, on some 

16          campuses, are further developing that 

17          transitional level of housing.  

18                 But these became housing where 

19          individuals stayed way too long, and they 

20          would be able to actually be in the 

21          community.  So we're getting two-for-one 

22          here, where basically the cost of keeping 

23          those services on the campus enables us to 

24          open, for every one we close on the campus, 

                                                                   17

 1          two slots in the community.  Which is really 

 2          better for the client.  

 3                 What I think we really need on our 

 4          campuses are really these transitional-level 

 5          housing, not what had become kind of almost 

 6          really long-term, close to permanent housing 

 7          for individuals on our campuses, which is not 

 8          what we really wanted.  

 9                 In terms of the clinic restructuring, 

10          this is really an attempt to just make our 

11          clinics as productive as is required of kind 

12          of clinics everywhere.  We have been very 

13          careful at this.  We have looked at six 

14          clinics over the course of this year, and 

15          those reports have been sent to the 

16          Legislature.  And basically each one that we 

17          have either downsized or closed to merge with 

18          another one of our clinics, we have discussed 

19          with the local stakeholders, with the county, 

20          with the local legislators to make sure that 

21          this makes sense.

22                 Some of our clinics, for example, had 

23          a census of maybe only 60 individuals, which 

24          is really too small for a clinic.  But they 

                                                                   18

 1          were kind of close enough for many of those 

 2          clients to come to another state hospital 

 3          clinic or, if they preferred, we made sure if 

 4          they wanted to go to other services in the 

 5          community, they could do that.

 6                 One of the big moves was actually two 

 7          clinics which we had on the Staten Island 

 8          campus, and there was really no reason to 

 9          keep them separate.  And one clinic had room, 

10          and basically we were able to move those 

11          clients, all of them, to the other clinic, 

12          not use that other space for clinic space, 

13          and consolidate staff.  

14                 So it's really to make it more 

15          efficient.  It's not a trend in any way for 

16          the state to not be involved with clinic 

17          services of the seriously mentally ill.  We 

18          realize that's our responsibility, especially 

19          with those that have utilized our inpatient 

20          state hospitals.

21                 CHAIRWOMAN YOUNG:  Well, I wanted to 

22          ask about that.  Because I think I've been 

23          consistent about saying that I believe that 

24          this state should do more to help people with 

                                                                   19

 1          serious mental illness, and I don't believe 

 2          that we do enough.

 3                 And you see it out in the streets 

 4          every day with the exploding homeless 

 5          population that we have, not only in the 

 6          cities -- and New York City certainly has 

 7          been grappling with this -- but all across 

 8          the state.  We see it in rural areas, we see 

 9          it in smaller city areas.  And OMH has 

10          reduced approximately 650 adult and 

11          children's beds in recent years.  And this is 

12          in line with the negotiated agreement that 

13          the Governor had with the Legislature.  

14                 But in order to close a bed, it must 

15          be vacant for a continuous 90-day period 

16          before it can be reduced.  And all of these 

17          reductions must be fully reinvested into 

18          community services for the mentally ill, 

19          which I think is good, but I will point out 

20          that there have been situations where the 

21          Governor has reduced beds, and then shortly 

22          thereafter these facilities are over census.  

23                 This highlights issues of supply and 

24          demand that are fluid in nature, as you know, 

                                                                   20

 1          with this population.  And the Governor has 

 2          stated that beds will be reopened as needed 

 3          if the funded bed number per facility is 

 4          pierced.  

 5                 So for example, at Creedmoor 

 6          Psychiatric Center in Queens, the census has 

 7          exceeded the number of funded beds for a 

 8          three-month period, based on OMH reports.  So 

 9          the question is, what processes are in place 

10          at OMH to reevaluate the number of funded 

11          beds at a facility when the census exceeds 

12          capacity?

13                 COMMISSIONER SULLIVAN:  When the 

14          census exceeds capacity, we definitely open 

15          up the additional beds.  Now, usually -- for 

16          example, Creedmoor there is a unit where you 

17          can expand the services, so you can admit a 

18          certain number of additional clients.  We've 

19          been able to do that when we've had to.  

20                 So yes, we monitor it extremely 

21          closely.  We have not closed any bed in any 

22          facility where there hasn't been a 90-day 

23          vacancy.  And in fact at Creedmoor when that 

24          happens we absolutely do not close any of the 

                                                                   21

 1          beds.  

 2                 When you look across the system, we 

 3          have instituted a centralized admission 

 4          process in the city now so that we can 

 5          basically know exactly where we need to have 

 6          beds.  And sometimes -- not always, but 

 7          sometimes it's okay for a client to go to one 

 8          of our other hospitals that may have a 

 9          vacancy if the client wants to.  But we 

10          monitor it extremely closely.  And we have 

11          gotten the waiting list down to close to two 

12          weeks to wait to get into our hospitals.  So 

13          when that begins to go up, we look very 

14          carefully at the beds.  And if we need to 

15          temporarily expand beds to meet those needs, 

16          we do.  

17                 On the overall issue of lowering 

18          beds and providing mental health services, 

19          the answer really here is to get truly robust 

20          outpatient services.  And we're really trying 

21          to do this across the state, things that 

22          include things like crisis respite, mobile 

23          integration teams -- all the things that can 

24          keep clients in the community.  Eventually 

                                                                   22

 1          individuals leave hospitals.  And if we don't 

 2          want them to come back, we have to have that 

 3          kind of robust transformation into the clinic 

 4          system, into the outpatient support system 

 5          for the seriously mentally ill.  

 6                 So we really are working very hard 

 7          with that.  But when the beds are needed, we 

 8          will expand those beds if they are needed.  

 9                 CHAIRWOMAN YOUNG:  Okay.  And I'd like 

10          to follow up.  And I may be on a theme here, 

11          but I think it's a cause for concern.  Our 

12          jails across the state are filled with people 

13          with psychiatric issues.  They act out, and 

14          they end up in jail.  Local governments are 

15          not equipped, you know, to deal with people 

16          with mental illness.  And on top of it, we 

17          see that people are going to emergency rooms, 

18          they're being boarded in hospitals.  And so 

19          with this reduction of beds, it is a cause 

20          for concern.

21                 So you're saying that you will commit 

22          that OMH will add new beds where there's 

23          significant need?  Specifically in cases 

24          where there is a lack of open beds at 

                                                                   23

 1          state-operated facilities and then we are 

 2          faced with the situation that I just 

 3          described with people going to emergency 

 4          rooms, people languishing in hospital beds.

 5                 COMMISSIONER SULLIVAN:  When there's a 

 6          need to -- so far, truthfully, it has been 

 7          temporary.  When there's a need to 

 8          temporarily re-expand some beds, we do that.

 9                 But the problems that exist relative 

10          to individuals in emergency rooms and 

11          unfortunately jails and prisons are not just 

12          the state hospital beds.  This involves the 

13          work that we are doing with the Article 28 

14          facilities, with a lot of the community-based 

15          services.  And all those services, in 

16          addition to having them, have to really work 

17          well together.  

18                 So one of the initiatives which we're 

19          working very hard on is a survey of all the 

20          crisis services across New York State.  If 

21          you're going to help individuals not end up 

22          in jails and prisons and you're going to help 

23          them not to go to emergency rooms when they 

24          don't need to, you need a robust mobile 

                                                                   24

 1          crisis intervention system.  

 2                 Working with many of the PPSs in the 

 3          DSRIP program, working with many of the 

 4          counties who have pieces of this system, 

 5          we're trying to get a robust system across 

 6          the state that can interface with police, in 

 7          response to the CIT programs.  That robust 

 8          mobile crisis service is what will ultimately 

 9          help us and help those individuals not kind 

10          of trail into the criminal justice system.  

11                 I absolutely agree with you that too 

12          many of our clients over the years have gone 

13          into the criminal justice system.  I think 

14          the answer to that, though, is really to have 

15          the right kind of intervention at the 

16          community level -- and hospital beds when you 

17          need them, but the right kind of intervention 

18          at the community level is where the real 

19          diversion point should come.  And that's what 

20          we're trying to grow with the $100 million 

21          that we've reinvested in community services.  

22                 CHAIRWOMAN YOUNG:  Thank you.  Under 

23          the Regional Center of Excellence plan which 

24          was actually rejected by the legislature in 

                                                                   25

 1          2014, approximately 600 adult beds and 100 

 2          children's beds were estimated to be 

 3          eliminated from the state-operated inpatient 

 4          system.  And this is an estimate, since we've 

 5          never been able to get from the Governor's 

 6          office or from the agency exact details 

 7          beyond facility and ward closures.  

 8                 With the current system of bed 

 9          reduction in place, the Governor will 

10          approximately reach their previous long-term 

11          goal in the next year.  And I want to point 

12          out there have been no facility closures as a 

13          result of the Senate's intervention.  But 

14          under the Executive Budget this year, the 

15          amount of total bed reductions since 2014 are 

16          approximate in number to the reductions 

17          proposed under the now-abandoned RCE plan.  

18                 What is the long term plan for 

19          inpatient service reductions, such as what 

20          number is the end goal?  What do you have in 

21          mind?

22                 COMMISSIONER SULLIVAN:  You know, 

23          quite honestly, we don't have an end goal 

24          number because I think you can't do that.  

                                                                   26

 1          You have to only lower -- as we have been 

 2          doing -- beds that are vacant.  And if you 

 3          kind of come up with an end number, then 

 4          you're not really following that, you're kind 

 5          of saying, Well, this is my goal of beds I 

 6          want to get to.  

 7                 So I'm not sure what the end number 

 8          is.  When we propose 100 beds in this year's 

 9          budget, we're talking about looking very 

10          closely -- and never -- we've been very 

11          careful about this, in respect of the 

12          Legislature -- never closing a bed that is 

13          not 90 days vacant.  So we have to see.  And 

14          it really does depend upon utilization in 

15          Article 28 hospitals, community-based 

16          services, et cetera.  So there are some 

17          hospitals where we have closed beds, others 

18          where we haven't.  And I think it's a much 

19          more rational plan than just thinking of, 

20          well, we'll close a facility here, close a 

21          facility there.  We're closing it based on 

22          the need for those beds to be utilized.  

23                 So while we have proposed because we 

24          think, perhaps -- we can't do it unless 

                                                                   27

 1          there's that 90-day vacancy.  So I can't 

 2          honestly give you a target number.  And I 

 3          think we will have to see as we -- because we 

 4          have to keep up services if we need them.  We 

 5          just have to.

 6                 CHAIRWOMAN YOUNG:  So you're talking 

 7          about reinvesting in community services, 

 8          which I think is a good idea.  And we've had 

 9          those over the past several years.  But there 

10          continues to be major issues related to 

11          individuals discharged from state psychiatric 

12          centers, related to emergency room use as 

13          well as readmission to inpatient settings.  

14                 And since the reinvestment funding has 

15          not significantly improved these metrics, why 

16          does the Governor's budget actually propose 

17          additional funding for community services 

18          outside reinvestment dollars?  Why don't we 

19          have additional funding going into community 

20          services?  All that we really see are these 

21          reinvestment dollars that are included in the 

22          Governor's proposal.

23                 COMMISSIONER SULLIVAN:  I think 

24          that -- it's a tough -- let me just say it's 

                                                                   28

 1          also a very difficult budget.  But there are 

 2          some dollars that have gone into community 

 3          services.  For example, Medicaid savings on 

 4          the 20 ACT teams -- ACT teams are Assertive 

 5          Community Treatment teams, which are the most 

 6          effective way of dealing with some very 

 7          high-need seriously mentally ill in the 

 8          community.  And we are increasing that by 20 

 9          across the state, which is significant.  That 

10          came out of savings that was in the Medicaid 

11          premium in terms of mental health.  So that 

12          was an investment also in community-based 

13          services.  

14                 We have, through a variety of 

15          mechanisms, increased what we call 

16          first-episode psychosis teams, which are now 

17          up to I believe about 18 across the state.  

18          These teams work with individuals with an 

19          early diagnosis of schizophrenia in their 

20          teens and going into the middle twenties, 

21          helping them stay in school, helping them get 

22          jobs, helping stop this whole cycle of the 

23          chronic mentally ill eventually ending up in 

24          institutions.  And we've been very successful 

                                                                   29

 1          with that.  We are one of the largest states 

 2          to have expanded this program across the 

 3          state.  I think if we put up another five 

 4          teams, which we are continuing to try to 

 5          figure out kind of how to do, we could 

 6          probably saturate the state for every new 

 7          diagnosed schizophrenic.  

 8                 So basically I think the issue here is 

 9          that we are for many areas improving the 

10          mental health service system.  For example, 

11          intensive outpatient services is something 

12          which is -- we have just passed in the 

13          regulations which will enable clinics to 

14          provide very intensive services and get 

15          appropriately reimbursed through Medicaid for 

16          those services.  That's a new regulation 

17          that's just out.  We have now established it 

18          I believe in 10 clinics and we will be 

19          establishing it in more.  

20                 So there's many ways, in addition to 

21          reinvestment, that community services are 

22          also expanding.  

23                 CHAIRWOMAN YOUNG:  Thank you for that 

24          answer.

                                                                   30

 1                 Now, so you know that we have a real 

 2          lack of psychiatrists, especially across the 

 3          state.  And when you're in a rural area such 

 4          as the one I represent, it is impossible to 

 5          find a psychiatrist.  So what is the 

 6          department doing to try to attract more 

 7          psychiatrists to practice in New York?

 8                 COMMISSIONER SULLIVAN:  This is very, 

 9          very difficult.  I mean, it's a national 

10          shortage across the country.

11                 In our state system we now have a 

12          program to do tuition reimbursement for 

13          psychiatrists.  Now, that's within the state 

14          system.  But when people graduate from school 

15          we have what we call the DANY program, which 

16          will provide stipends of up to $30,000 a year 

17          for five years to pay off tuition if you stay 

18          in the state system.  

19                 We piloted that in the state system, 

20          and we've been getting good results.  It took 

21          about a year or two for it to catch on, but 

22          now we have I think about 15 psychiatrists 

23          that we've been able to find across the 

24          system.  So that's one way to think about 

                                                                   31

 1          having psychiatrists stay in New York State, 

 2          is something like loan reimbursement.  This 

 3          is only now for the state system.

 4                 However, there is a program for 

 5          underserved areas through the Department of 

 6          Health.  And the Department of Health, we're 

 7          working with them, and they have expanded 

 8          that to now include our psychiatrists as 

 9          well.  So that is for psychiatrists across 

10          the state.  And that you have to apply for, 

11          but that gives tuition reimbursement of up to 

12          $120,000 for a three-year commitment.  So 

13          that's one area.

14                 The other is the use of 

15          telepsychiatry.  I think that when we've 

16          looked at a lot of graduating psychiatrists, 

17          a lot of them are actually interested in 

18          telepsychiatry, and we have changed the 

19          regulations now to be able to really make 

20          that easy to do.  Initially you had to kind 

21          of be a psychiatrist sitting in a clinic 

22          somewhere.  Now a psychiatrist can do it from 

23          their office, their home, and basically can 

24          do it through clinic settings or we're 

                                                                   32

 1          getting very close to having it totally in 

 2          home-based settings as well.  So I think that 

 3          that will help with the shortage.  

 4                 The other is I think just working with 

 5          our --

 6                 CHAIRWOMAN YOUNG:  If I may, 

 7          Commissioner, actually I'm glad you went 

 8          there on telepsychiatry, because we've 

 9          expanded telehealth services in the state.  I 

10          have a bill on expanding telepsychiatry.  So 

11          you're saying you think that would be a good 

12          idea, then.

13                 COMMISSIONER SULLIVAN:  Yeah, I 

14          think -- well, I think telepsychiatry, 

15          telemedicine is really a big part of the 

16          future of healthcare.  And I think we need to 

17          get increasingly creative about how we use 

18          it, as long as we keep an eye on what's 

19          happening.  But I think we can get 

20          increasingly creative about how we use it, 

21          and it's incredibly helpful for both the 

22          client, I think, and for the practitioner.

23                 So yes, I think we're in the process 

24          of really working on the regulations so that 

                                                                   33

 1          telepsychiatry will become increasingly 

 2          utilized in New York.

 3                 CHAIRWOMAN YOUNG:  Thank you.  I'm 

 4          going to come back, but I just have a couple 

 5          more questions.  Thank you.

 6                 CHAIRWOMAN WEINSTEIN:  So we've been 

 7          joined by Assemblyman Sepulveda.  

 8                 For questions we go to our Mental 

 9          Health chair, Aileen Gunther.

10                 ASSEMBLYWOMAN GUNTHER:  So I have a 

11          few questions also.  Thank you very much.  

12                 So the number of people receiving 

13          mental health treatment in prisons continues 

14          to rise, while the overall prison population 

15          is actually decreasing.  Do you believe this 

16          is a result of any of the bed closures that 

17          have happened across New York State?

18                 COMMISSIONER SULLIVAN:  Truthfully, I 

19          don't think it's the result of bed closures.  

20          I think it is still the problem of not having 

21          adequate community-based services.  Beds are 

22          only a temporary place for individuals to be.  

23          They ultimately need to be well-integrated 

24          into the community and get the services they 

                                                                   34

 1          need.  That's what can prevent prison use.

 2                 You know, in the individuals who have 

 3          left prison, there is a cohort that we worked 

 4          with for the appropriate services for the 

 5          seriously mentally ill.  And this involved 

 6          connecting them with housing and intensive 

 7          wraparound services when they left prison.  

 8                 The usual returnee rate is 

 9          significant, within three years to prison for 

10          both individuals with mental illness and 

11          individuals without.  For those seriously 

12          mentally ill individuals that we got the 

13          right community-based services, we cut that 

14          returnee rate in half.  So we're working very 

15          hard to continue to have those intensive 

16          supported housing systems and the intensive 

17          wraparound services.  You can decrease 

18          individuals going into the prison system with 

19          that.  

20                 We just need to, as we have been 

21          doing, continually move dollars in the 

22          appropriate way from very costly inpatient 

23          care to community-based care and getting the 

24          right balance.  And I think that -- it's not 

                                                                   35

 1          easy to do, but I think it's something that 

 2          we're working very hard on.

 3                 ASSEMBLYWOMAN GUNTHER:  Well, 

 4          obviously when you look at the statistics I 

 5          guess we haven't reached the right balance, 

 6          because there are more people than ever 

 7          receiving mental health services who have a 

 8          diagnosis that are in jail beds today.  

 9                 And the Executive has proposed to 

10          establish a jail-based restoration program 

11          for people deemed incompetent to stand trial.  

12          Do you believe that a jail is the best 

13          setting for an individual with mental health 

14          issues?  

15                 COMMISSIONER SULLIVAN:  The 

16          individuals that we're proposing to have 

17          jail-based restoration clinically are 

18          individuals who if they weren't in the 

19          justice system would basically be outpatient 

20          restoration.  They wouldn't be going into a 

21          hospital.  

22                 The way the law is written currently, 

23          if you are either in a jail or a prison to be 

24          restored, you have to go into a hospital from 

                                                                   36

 1          a jail, you don't have a choice really of a 

 2          lesser-restrictive setting.

 3                 Now, jail-based restoration has been 

 4          done in 10 states and supported by the 

 5          Judicial Council.  If you do it, you've got 

 6          to do it right.  I think it -- I don't think 

 7          jails are the best places, but I think you 

 8          can do a very good job of jail-based 

 9          restoration if you have the right standards, 

10          which we will have.  We will make sure that 

11          there are appropriate clinical staff, 

12          including psychiatric staff, social workers, 

13          psychologists.  And it has to be done with 

14          the standards that other places that have 

15          done jail-based restoration have done.

16                 To that end, there's $850,000, if a 

17          county is interested, to help support really 

18          getting that started and to support 

19          continuing those excellent services in the 

20          jails.  So I think if it's done well, I think 

21          it can be appropriate for individuals.  

22                 The good thing about it is that it 

23          prevents this kind of movement back and forth 

24          from one place to the other for individuals, 

                                                                   37

 1          and it has also been shown to decrease their 

 2          actual time in confinement.  So if you have a 

 3          good jail-based restoration program, you're 

 4          working with the DAs, you're working with the 

 5          judicial system, the community-based system 

 6          to get the clients out quicker.  And I think 

 7          that's a very important thing.  We also know 

 8          that when the mentally ill go into jails and 

 9          prisons, they spend a longer time there than 

10          the general population.  

11                 So I think if done well and 

12          appropriately, it can be very good.

13                 ASSEMBLYWOMAN GUNTHER:  Well, do you 

14          think that -- as far as I'm concerned, you 

15          know, you have people that work in the jail 

16          system and the education process.  Is there 

17          an education process to identify people that 

18          are coming in that are paranoid, that have 

19          been off their meds because maybe they 

20          haven't been able to afford them?  And so 

21          that identification of the person that needs 

22          mental health care.  

23                 COMMISSIONER SULLIVAN:  Definitely in 

24          the prison system, everyone who comes in is 

                                                                   38

 1          screened at the time that they arrive in the 

 2          prison system.  And many jails across the 

 3          counties and in New York City are doing that 

 4          as well.

 5                 ASSEMBLYWOMAN GUNTHER:  Well, when we 

 6          talk about housing, in New York State there's 

 7          almost 12,000 individuals with mental illness 

 8          in adult care facilities.  So they are in 

 9          adult care facilities, which I consider not 

10          an appropriate placement.

11                 Do you believe the personal needs 

12          allowance needs to be increased so that 

13          people do not have to live in adult care 

14          facilities?

15                 COMMISSIONER SULLIVAN:  I think that 

16          it's very important that individuals can move 

17          out of those adult care facilities.  When 

18          they move out of the adult care facilities, 

19          there's a change in the way they can then 

20          monitor their dollars.  And actually for many 

21          of them, with appropriate supports and making 

22          sure they get all the other benefits they can 

23          get, when they move into a community-based 

24          setting, they do have more dollars to spend 

                                                                   39

 1          on what they want to spend it on.  

 2                 In the adult care facilities, because 

 3          the institution is providing many of those 

 4          services, the allowances are smaller.  

 5                 So I think the goal here is to help 

 6          individuals move into community-based 

 7          settings but also make sure, if they do, that 

 8          they get all the supports they would need -- 

 9          things like food stamps, et cetera, 

10          everything else that they need to support 

11          them so that their allowances in the 

12          community-based settings do become larger in 

13          terms of the actual dollars they can use for 

14          their own self care.

15                 ASSEMBLYWOMAN GUNTHER:  Part Y of the 

16          health and mental hygiene budget defines 

17          which duties and tasks can be performed by an 

18          individual without a clinical license.  There 

19          have been concerns that this proposal could 

20          have unintended consequences on students 

21          pursuing a bachelor's or master's degree in 

22          social work.  Is it the intent of this 

23          proposal to alter current authorized duties 

24          for these students?  How many of these 

                                                                   40

 1          student interns would the behavioral health 

 2          service provider --

 3                 COMMISSIONER SULLIVAN:  The intent of 

 4          this is really not to change what is the -- 

 5          it doesn't, it couldn't change what is the 

 6          scope of practice for individuals who are 

 7          licensed or unlicensed.  It maintains that 

 8          scope of practice.

 9                 What it does is tighten up the degree 

10          of supervision, which has in many ways been 

11          going on all these years, of these 

12          individuals within the system.  So that we 

13          really know, if you're licensed, this is what 

14          you can do, and if you're unlicensed, this is 

15          what you can do.  It's based on the current 

16          scope of practice.  We're not touching scope 

17          of practice.

18                 I think that it might affect some 

19          clinics in terms of the work flow that they 

20          have to do, because they might require in 

21          some cases -- not in all -- some increased 

22          supervision over individuals.  It should not 

23          deter students from being -- students have 

24          always been supervised in these settings, and 

                                                                   41

 1          students have always had clear, outlined 

 2          responsibilities based upon their schools and 

 3          what they require.  

 4                 So it shouldn't really change the 

 5          placement of students at all.  I think that 

 6          the issue here is just to kind of tighten up, 

 7          make sure that we have a very clear picture 

 8          going forward.

 9                 There's also a grandfather clause 

10          which gives clinics a good period of time to 

11          be able to work on any issues that might be 

12          there.  And the grandfather clause goes back 

13          and will be there until 2020.  

14                 So I think this bill offers a way out 

15          of what has been a many, many year extension 

16          and exemption that enables us to make sure 

17          that we're doing the right things in the 

18          clinic without any significant impact on the 

19          workforce.  Although there will be some 

20          changes in work flow in some clinics.

21                 ASSEMBLYWOMAN GUNTHER:  Through my 

22          office, one of the constant subjects we talk 

23          about is the fact that so many people that do 

24          have insurance, that the psychiatrist does 

                                                                   42

 1          not accept the reimbursement.  So therefore 

 2          they do not have access to a psychiatrist to 

 3          actually control their medications or put 

 4          them on the appropriate medications.

 5                 Is there anything that we can do as 

 6          the State of New York that we're paying such 

 7          high premiums to have insurance, yet that 

 8          insurance doesn't give us access to mental 

 9          health?

10                 COMMISSIONER SULLIVAN:  We have been 

11          working with the Department of Financial 

12          Services to look very carefully at the parity 

13          issue, especially for commercial payers.

14                 There was a very interesting Milliman 

15          study that was done which showed that 

16          out-of-network use across the country was 

17          much higher for any kind of behavioral health 

18          service than for any medical service.

19                 So with the Department of Financial 

20          Services, with the Milliman report, we are 

21          looking at critical parity issues here in 

22          terms of access for mental health care.  In 

23          some ways there is better access -- there's 

24          significantly better access through the 

                                                                   43

 1          Medicaid system for mental health care than 

 2          there is for commercial payers.  And very 

 3          often what happens is that there's a 

 4          difficulty with networks actually being 

 5          adequate.  And sometimes there's difficulties 

 6          with people knowing how to access in 

 7          insurance.  

 8                 So we're working within the state to 

 9          see what we can do.  But the biggest issue 

10          here is to make sure that parity is being 

11          followed to the letter of the law.  And the 

12          state has been very supportive of working on 

13          mental health parity in many instances.  So 

14          we're continuing to work on that.  It's a 

15          very serious issue.

16                 ASSEMBLYWOMAN GUNTHER:  You know, 

17          within my district one of the things I do 

18          notice is that when we talk about bed 

19          closures for like emergent care, like in 

20          hospitals, that we are closing the beds.  And 

21          what you often see is that we are utilizing 

22          the emergency room.  And sometimes people in 

23          crisis stay in the emergency room for two to 

24          three days until there's a bed available, and 

                                                                   44

 1          especially with children in crisis.

 2                 There are -- you know, if you go to 

 3          Four Winds, I mean, their census is always 

 4          full.  And you go across the board, and the 

 5          census is full.  And so we are closing the 

 6          beds, but how much are we spending on 

 7          emergent care and having a one-to-one in a 

 8          hospital emergency room until a bed is 

 9          available?  And you know what, we cannot put 

10          children on medications without observing the 

11          effect of that.  

12                 And I personally know that I get calls 

13          from parents across New York State, not just 

14          in my district, of their kids not being able 

15          to access the care that we need.  And we know 

16          that children are being diagnosed earlier, 

17          and their needs are greater.  And yet between 

18          insurance and not letting -- the 

19          psychiatrists don't accept, you know, our 

20          private insurance -- that the access to care 

21          to me is just very, very difficult.  

22                 And I think that when children are in 

23          crisis, the quicker that we can get them in 

24          care -- but it doesn't seem to be working 

                                                                   45

 1          that way, even though we pay very high 

 2          premiums, we supposedly deliver the greatest 

 3          healthcare, but there's something missing.

 4                 And then if you look in terms of the 

 5          jails and the more people that are needing 

 6          treatment in the jail system, there's a 

 7          message there.  There's an underlying 

 8          message.  And you know what, I do think we 

 9          have to balance.  And I think that revisiting 

10          what's going on in real time in communities 

11          is very important.

12                 COMMISSIONER SULLIVAN:  No, 

13          absolutely.  And we work very closely with 

14          the communities and with the local county -- 

15          local mental hygiene directors.  

16                 There are two bed systems in New York 

17          State; there's the state hospital beds and 

18          there's the acute-care hospital beds.  And 

19          the acute-care hospital beds have anywhere of 

20          a length of stay of usually two to four 

21          weeks.  The acute-care hospital system is 

22          something that we have worked very hard also 

23          to preserve.  And we have worked -- whenever 

24          there are threatened bed closures on the 

                                                                   46

 1          acute-care side, we have worked very closely 

 2          with those facilities and with those 

 3          communities.  

 4                 The acute care is the initial access 

 5          valve from the emergency rooms, et cetera.  

 6          And what we've often found as we've worked 

 7          with the acute-care hospitals and the 

 8          emergency rooms is setting up, again, this 

 9          kind of continuum of care, especially with 

10          kids.  Because many children who come to 

11          emergency rooms, if you have a mobile crisis 

12          team or a mobile integration team, which we 

13          have put in certain communities across the 

14          state that work with that ED and with those 

15          kids, that you don't need to have them 

16          admitted, that partly the admission is a 

17          default position because they don't have 

18          respite beds for youth, because they don't 

19          have mobile crisis intervention for youth.  

20          If you do, those can have a significant 

21          improvement in what tends to clog up the 

22          emergency rooms.  

23                 Similarly, we've worked with the 

24          counties, which are great in working with us 

                                                                   47

 1          in this, and with some of them we have put 

 2          some services in schools.  Because a big 

 3          issue of kids going to emergency rooms is 

 4          often referrals from schools.  And if you put 

 5          mental health teams or clinics in schools, 

 6          you decrease that volume that then goes to 

 7          the emergency room.

 8                 So when you have an area that's in 

 9          distress -- and I'm not saying we solve this 

10          perfectly all the time -- what you really 

11          have to do is look at the multiple factors 

12          that are causing that distress.  One is 

13          making sure you have acute-care beds.  You 

14          have to also make sure you have state beds.  

15          But you also need to look at who's coming 

16          into those emergency rooms and making sure 

17          that you have the wraparound services.  

18                 And we've been trying increasingly to 

19          do this for kids.  Where we have put up 

20          crisis respite beds for kids, that has had a 

21          significant impact on those kids going to 

22          emergency rooms and going to hospitals, 

23          because we have another way for individuals 

24          to get the help they need.  

                                                                   48

 1                 So that's what we're going to be 

 2          expanding, especially with some of the crisis 

 3          respite capital dollars this year, is to 

 4          increase that.  And we want to increase that 

 5          significantly for kids.

 6                 CHAIRWOMAN WEINSTEIN:  Thank you.  

 7                 We've been joined by Assemblywoman 

 8          Crystal Peoples-Stokes.

 9                 CHAIRWOMAN YOUNG:  And we've been 

10          joined by Senator George Amedore.  

11                 And our next speaker is Senator John 

12          Brooks.  Senator Brooks.

13                 SENATOR BROOKS:  Good morning.

14                 COMMISSIONER SULLIVAN:  Good morning.

15                 SENATOR BROOKS:  A couple of areas I 

16          would like to address, first on the homeless 

17          situation.  

18                 You know, we're seeing and I'm getting 

19          ongoing complaints in different areas that we 

20          have people that are showing up at libraries, 

21          people who are showing up at railroad 

22          stations and sleeping during the night.  How 

23          much direct outreach do you have in the 

24          various areas of the state to try to identify 

                                                                   49

 1          and bring these people in?  Or are you 

 2          relying totally on the local communities, the 

 3          local counties to address that?

 4                 COMMISSIONER SULLIVAN:  A good portion 

 5          of the state aid that we give to local 

 6          counties goes to the outreach teams that 

 7          work -- to work with the homeless.  So while 

 8          they are -- and I think best served by the 

 9          local counties providing those kinds of 

10          services, a lot of it is supplemented or 

11          sometimes largely paid for by the state aid 

12          that we give to the counties, and the 

13          counties use that state aid to do the 

14          outreach.

15                 Another piece of the importance is 

16          housing, to tell you the truth.  And that's 

17          why across the state we are increasing, every 

18          chance we get, supported housing for 

19          individuals with serious mental illness, so 

20          that they really have a place to go.  

21                 And then the third is our expansion of 

22          Assertive Community Treatment teams and ACT 

23          teams, which we've also increased across the 

24          state as well as in New York City.  Those 

                                                                   50

 1          teams work very well with these clients and 

 2          can help support them in terms of moving into 

 3          housing.

 4                 Often with individuals who have become 

 5          chronically homeless, on the street, the 

 6          outreach teams have to do a lot of work to 

 7          get them to begin to really see their lives 

 8          differently and see the possibility of 

 9          housing.

10                 But we invest a fair amount -- I don't 

11          know the exact number of state aid -- in 

12          doing that pretty much across the state.  But 

13          we need to have the supported housing 

14          available.  And that's something that we're 

15          continuing to grow so that these individuals 

16          can be in safe environments.

17                 SENATOR BROOKS:  In terms of housing, 

18          one of the things that we're seeing in many 

19          communities is an increasing number of zombie 

20          houses where people have left those houses.  

21          Are you working in any way to try to recover 

22          those houses at a lower cost to expand the 

23          housing you can provide?

24                 COMMISSIONER SULLIVAN:  I'm not -- I'm 

                                                                   51

 1          not actually sure.  I think that's a 

 2          suggestion we'll look into.  I don't know.  I 

 3          mean, I know our providers are out there 

 4          looking for sites.  A lot of them have been 

 5          supported apartments.  But in terms of using 

 6          some of that housing, I'm not sure.  I know 

 7          we have converted some, but it's usually 

 8          fairly large areas.  We -- I'd look into 

 9          that, I'll look into that and let you know.

10                 SENATOR BROOKS:  Because I know within 

11          my district there are some communities with a 

12          large number of zombie houses available.

13                 COMMISSIONER SULLIVAN:  Yeah, mm-hmm.

14                 SENATOR BROOKS:  In terms of, again, 

15          opening up more local community beds, how 

16          tightly are you managing that expansion with 

17          the demand in those communities?  Are you 

18          having problems in certain areas of the state 

19          where the demand is much higher than your 

20          ability to provide the housing?

21                 COMMISSIONER SULLIVAN:  In terms of 

22          local inpatient beds, it can vary.  I mean, 

23          we have parts of the state where the local 

24          inpatient acute-care occupancy is probably 

                                                                   52

 1          about 85 percent, 80 percent.  We have other 

 2          areas of the state where that occupancy on 

 3          the acute-care Article 28 side can be as high 

 4          as 90 percent, 95 percent.  

 5                 So when we have that high occupancy, 

 6          we work with the counties to see other 

 7          options that we can use.  And that's why in 

 8          this budget there's a significant $50 million 

 9          in capital for what we call respite beds.  

10          Respite beds are beds which can both prevent 

11          admissions but also help individuals leave 

12          inpatient services more rapidly.  

13                 So we are particularly looking across 

14          the state at establishing those respite beds 

15          in areas where they are particularly needed 

16          because of the high occupancy in inpatient 

17          acute-care article 28 hospitals.

18                 SENATOR BROOKS:  And to just pick up 

19          on the comments that have been made by some 

20          of my colleagues here today, I think we 

21          really, really have to get a handle on what's 

22          happening in the prisons in terms of people 

23          with mental illness in those facilities.  

24          And, you know, I think we're way behind the 

                                                                   53

 1          eight ball on this.  And the fact that we 

 2          have a system where these people are being 

 3          probably picked up off the streets more times 

 4          than not where we've neglected to identify 

 5          them there and then put into this process, 

 6          and they're not really getting the help they 

 7          need, I just think that's an area we have to 

 8          put tremendous attention to.

 9                 COMMISSIONER SULLIVAN:  I think you're 

10          absolutely right.  And I know this -- I'm 

11          sure there's no -- you're absolutely right 

12          that we need to put the emphasis -- and I 

13          think where -- you know, it's interesting, I 

14          think in some ways we know how to do this.  

15          It's getting all the services arranged so it 

16          can happen.  

17                 We have a few counties where, in 

18          combination with the CIT training, which has 

19          been great in terms of being paid for by the 

20          Senate and Assembly to really provide the CIT 

21          training, connected with the mobile crisis 

22          centers, connected with stabilization 

23          centers, connected with the community -- when 

24          you talk to the sheriffs in those areas, they 

                                                                   54

 1          are bringing less individuals to the jails 

 2          and prisons.  

 3                 Now, that hasn't yet gotten to the 

 4          point of seeing gross numbers going down.  

 5          But it works.  And I think that's something 

 6          that we are going to continue to look at.  

 7          That's part of our looking at crisis services 

 8          across the state, making sure that every 

 9          county has that experience of planning both 

10          between the sheriff's office, between mental 

11          health services and between the legal system.  

12          And if you can pull all those pieces 

13          together, you can see a decrease in the 

14          number of individuals who manage to wend 

15          their way into the jails and then ultimately 

16          into the prison system.

17                 So that's really our goal.  It is  

18          taking much longer than anyone would like.  

19          And it really is something that I think we 

20          will be -- we are emphasizing and will 

21          continue to emphasize over the next few years 

22          to really get to see those numbers come down.

23                 SENATOR BROOKS:  I guess the last 

24          comment I would make, in speaking with some 

                                                                   55

 1          of the families and the rest, they've got 

 2          concerns as to where programs are going and 

 3          heading.  And I think we need to do a better 

 4          job explaining to people our long-range plans 

 5          as to how we're trying to address situations, 

 6          and give families more comfort that we 

 7          understand where we're going, there are 

 8          programs.  You know, we seem to be in a 

 9          situation where we're playing more catch-up 

10          than talking about where we're going to 

11          address certain situations.

12                 So I think, you know, better public 

13          relations in terms of the direction we're 

14          going in, what problems we have, and 

15          recognizing how we're going to handle those 

16          situations I think would be helpful.

17                 COMMISSIONER SULLIVAN:  Yeah.  No, 

18          you're absolutely correct.  And I think it's 

19          our responsibility to increasingly work with 

20          families and with clients to understand what 

21          we have, what's available, and also where -- 

22          get their input on where our gaps are and 

23          where we are not serving them as well as we 

24          need to.  

                                                                   56

 1                 And I think that dialogue has to be 

 2          ongoing and robust.  And, you know, sometimes 

 3          we're better at it than others, but we're 

 4          going to continue to work very hard to make 

 5          sure that we speak with families and clients 

 6          to know what their needs are and also so they 

 7          understand what we have, yes.

 8                 CHAIRWOMAN YOUNG:  Thank you.

 9                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

10          Sepulveda.

11                 ASSEMBLYMAN SEPULVEDA:  Good morning, 

12          Commissioner.

13                 COMMISSIONER SULLIVAN:  Good morning.

14                 ASSEMBLYMAN SEPULVEDA:  So what's OMH 

15          doing to remedy the problem of people with 

16          mental illness in solitary confinement?  The 

17          SHU exclusion law says that people with 

18          serious mental illness should not be in 

19          solitary confinement.  Still, there are about 

20          800 people with mental illness in solitary 

21          confinement.  Is the statute too restrictive?  

22          Should we amend it?  Because the difference 

23          between serious mental illness and mental 

24          illness sometimes is not easily defined.  

                                                                   57

 1                 What is OMH doing to remedy this 

 2          problem?  We have over 800 people still, 

 3          despite the law -- and then I'll have a 

 4          follow-up question after you respond.

 5                 COMMISSIONER SULLIVAN:  We follow very 

 6          closely the SHU law.  The law states that 

 7          individuals with -- the law as it is written 

 8          states that individuals with serious mental 

 9          illness can't be in the SHU for more than 

10          30 days.  During those 30 days, we work very 

11          closely with them.  And after those 30 days, 

12          if unfortunately they would still be in SHU, 

13          they move into one of our treatment programs 

14          in the prison.  So that's the law.  

15                 But what we are doing now is working 

16          very, very closely with DOCCS to divert 

17          people from ever getting into SHU, not even 

18          getting to that 30-day period.  And a lot of 

19          it is systems within the prison that would -- 

20          things that sometimes our mentally ill 

21          clients do that could get them to be 

22          considered for SHU, and we're trying to 

23          circumvent that and cut it off before they 

24          ever reach the SHU.  We're working very 

                                                                   58

 1          closely on that with DOCCS.  

 2                 But we follow the law.  And we make 

 3          sure that if mentally ill individuals are in 

 4          SHU, that they get the four hours of -- the 

 5          programming out of SHU that they need.  And 

 6          we work very closely with DOCCS to try to 

 7          avert any individuals from getting in.  And 

 8          it's getting better.  It's not where it needs 

 9          to be yet, but it's getting better.

10                 ASSEMBLYMAN SEPULVEDA:  The definition 

11          of serious mental illness versus mental 

12          illness, is that too restrictive?  Do you 

13          suggest that we amend the law so we can 

14          include more individuals?

15                 COMMISSIONER SULLIVAN:  I think, you 

16          know, it's -- I think absolutely it should 

17          stand for serious mental illness.  I think 

18          that there have to be a lot of discussions 

19          about broadening the law.  And I think that 

20          that's something that needs to be discussed 

21          between agencies and with DOCCS.  And I don't 

22          think that that's solely a decision of 

23          Mental Health, so that's something we would 

24          need to discuss.

                                                                   59

 1                 ASSEMBLYMAN SEPULVEDA:  You know, 

 2          Commissioner, we've spoken about the issue of 

 3          suicide for some time now.  It's a personal 

 4          issue for me.  Can you tell me if you have 

 5          any data on how many people that are in 

 6          solitary confinement either have successfully 

 7          or have attempted suicide while in solitary 

 8          confinement?

 9                 COMMISSIONER SULLIVAN:  I can't -- I'm 

10          sorry, I can't give you the exact number for 

11          solitary confinement.  Unfortunately, the 

12          number of suicides in the prison system over 

13          years fluctuates per year, very sadly, from 

14          somewhere usually between 12 to 16, 17 

15          individuals.  I can't tell you exactly how 

16          many of those individuals were in solitary 

17          confinement.

18                 ASSEMBLYMAN SEPULVEDA:  So OMH doesn't 

19          keep any of this -- that kind of data?

20                 COMMISSIONER SULLIVAN:  We do, I 

21          just can't -- I can get it to you.  I can get 

22          it to you.  I'm sorry, no, I just don't know, 

23          but I can get it to you.  We do know.  We do 

24          know.

                                                                   60

 1                 ASSEMBLYMAN SEPULVEDA:  Okay, I'd 

 2          appreciate it.  Please get that to me.  

 3                 Now, back in 2015, Samuel Harrell and 

 4          Karl Taylor were both on the OMH caseload and 

 5          were reportedly beaten to death by 

 6          Corrections staff in 2015.  What steps has 

 7          OMH taken to ensure that this doesn't occur 

 8          again and to protect patients that are 

 9          suffering from mental illness from staff 

10          abuse and are responded to in an effective, 

11          therapeutic manner?  

12                 COMMISSIONER SULLIVAN:  Well, we work 

13          very closely with -- first of all, we have 

14          throughout the prison system a series of 

15          services that go all the way from crisis beds 

16          to residential beds to outpatient clinic 

17          services.  So it's really almost like a 

18          community-based treatment service within the 

19          prison system.

20                 As part of that, we also work very 

21          closely with DOCCS and we work jointly 

22          together in assessing -- in training DOCCS in 

23          terms of working with individuals who have 

24          mental illness, and also in being aware of 

                                                                   61

 1          signs and symptoms of individuals who might 

 2          have mental illness.  

 3                 So we -- it's a combination of our 

 4          clinical services which we provide and also 

 5          our relationship with DOCCS in terms of 

 6          training.

 7                 We work very closely with the staff 

 8          throughout the prison system in terms of 

 9          trying to raise awareness of individuals who 

10          have mental health problems, and we then 

11          provide the services within the system.  We 

12          serve about 10,000 inmates with a mental 

13          health problem a year, and about 25 percent 

14          of those have serious mental illness.

15                 So we -- a lot of issues also can 

16          revolve around just making sure that the 

17          staff have the appropriate training.  And we 

18          are doing that with some motivational 

19          interview training, cognitive behavioral 

20          training, and a number of trainings which we 

21          have instituted across the prison system to 

22          continually upgrade the skill sets of our 

23          staff.  And some of that training also occurs 

24          with DOCCS.

                                                                   62

 1                 ASSEMBLYMAN SEPULVEDA:  I'll get a 

 2          second round.  I'll come back for additional 

 3          questions.

 4                 CHAIRWOMAN YOUNG:  Thank you.  

 5                 Our next speaker is Senator Krueger.

 6                 SENATOR KRUEGER:  Good morning, 

 7          Commissioner.

 8                 COMMISSIONER SULLIVAN:  Good morning.

 9                 SENATOR KRUEGER:   So you went over in 

10          your testimony a little bit about expanding 

11          housing opportunities within OMH and the fact 

12          that there's a $13 million increase in 

13          funding of adult home beds.  While explaining 

14          to me how that money is going to be used, can 

15          you also address the fact that many of us are 

16          hearing from organizations who already 

17          provide OMH beds in supportive housing 

18          settings and other community-based settings 

19          who point out that they get so much less per 

20          year to run their beds compared to new 

21          programs being approved by the state within 

22          Housing, OPWDD, OASAS, that they actually 

23          wonder why would they continue to run program 

24          beds under OMH for so much less money than 

                                                                   63

 1          they could conceivably get if they dropped 

 2          you and went and applied to run facilities 

 3          under other state funding streams?

 4                 COMMISSIONER SULLIVAN:  Yes, thank 

 5          you.  And that's -- it's a very difficult 

 6          issue.  But we have been -- over the past 

 7          four years we have added a total of 

 8          $42 million, including the $10 million in 

 9          this year's budget, to up the rates for 

10          supported housing for the older housing.  

11          That has brought up the number significantly, 

12          so that now in the city, while still not as 

13          high as it should be -- I believe it's 

14          17,700, something like that, of the stipend 

15          that we give, when in the past it was like 

16          14,900 four years ago.  So it's gone up.  

17          It's gone up considerably.  It's not as high 

18          as some of the other supported housing 

19          programs that are coming out, but it is a 

20          significant increase.

21                 All the new housing that OMH is doing, 

22          whether it's out of our reinvestment dollars 

23          or out of our two-for-one community-based 

24          conversions, are all going to be at the 

                                                                   64

 1          higher rates.  So the issue still remains 

 2          with getting some of that older housing rates 

 3          up to where it needs to be.  We're continuing 

 4          to work on that.  But I think we have put in 

 5          $42 million.  

 6                 Also with the increase in direct 

 7          service workers dollars, a lot of that for 

 8          our system lies with direct service workers 

 9          in housing.  So that has given another boost, 

10          in a way, to at least the staff who work in 

11          our housing services.  

12                 But we're continuing working to get 

13          those numbers where they need to be.  And 

14          there's another $10 million investment, in a 

15          very tight budget year this year, to bring up 

16          those rates.

17                 SENATOR KRUEGER:  And you also talked 

18          before about I guess the hypothetical, it 

19          seems to me, of when people leave adult homes 

20          and go into other community settings.  Does 

21          that actually happen anywhere?  Are there 

22          actual places that people can go that they're 

23          leaving these disturbing adult homes and 

24          going into better-quality programs?  Or is 

                                                                   65

 1          that a -- I don't know, I feel like that's a 

 2          fairy tale as opposed to an actual reality 

 3          for anyone.

 4                 COMMISSIONER SULLIVAN:  No, well, 

 5          actually -- actually, you know, under -- we 

 6          have moved, from the adult home system in 

 7          New York City, 650 individuals into 

 8          community-based apartments.  And those 

 9          apartments I believe the number that have 

10          returned to adult homes or have not been 

11          satisfied is extremely low.  We're talking 

12          maybe five or six individuals.  

13                 So 650 individuals have moved 

14          successfully into community-based 

15          apartments -- with a lot of help, with a lot 

16          of the wraparound services -- and the stories 

17          are really quite remarkable.  I mean, they 

18          really talk about how they never really 

19          thought they could live independently like 

20          this, that they could, you know, take care of 

21          themselves.  

22                 We do a lot of work when they move to 

23          help them join into the community, because it 

24          is a difference from going from a big 

                                                                   66

 1          structure where there's lots of people to 

 2          your own apartment.  So we have staff and 

 3          peers who can kind of work with them and help 

 4          them understand what are the recreational 

 5          things in their area, introduce them to them.  

 6          And their lives have really significantly 

 7          changed.  

 8                 So 650 people have moved out of the 

 9          adult home, and we're continuing that 

10          movement and will continue to move more and 

11          more individuals.

12                 SENATOR KRUEGER:  And there were 

13          already also several questions around what 

14          happens with people with mental illness in 

15          our prison population.  And the Governor has 

16          a proposal in his budget which I actually 

17          support for geriatric parole, the recognition 

18          that people above the age of 55 with other 

19          serious illnesses are of no danger to the 

20          community and they should be let out of 

21          prison.  

22                 But letting someone out of prison to 

23          the streets of New York City, into the 

24          shelter system or an ER, is a completely 

                                                                   67

 1          unacceptable and inhumane solution.  

 2                 I would project, based on what we know 

 3          about people with mental illness in our 

 4          prison system, that a significant percentage 

 5          of these people will have mental illness.  

 6          Are you being brought in to discuss a plan 

 7          for how we're moving people, if we do 

 8          geriatric parole, into programs and services 

 9          as opposed to putting them on a bus and 

10          waving goodbye?

11                 COMMISSIONER SULLIVAN:  Absolutely.  

12          It's important, it's very important.  One of 

13          the key first steps is housing.  So we're 

14          looking at, as this would happen, what kind 

15          of housing of our supported housing system we 

16          can dedicate to helping those individuals 

17          move.  

18                 And then the other is we have in the 

19          prison -- and we will be working with the 

20          prison to work especially with this 

21          population -- we have what we call reentry 

22          programs for individuals who are seriously 

23          mentally ill for about 12 to 16 months before 

24          they leave prison, to be in a specialized 

                                                                   68

 1          program to help them get ready to leave.  So 

 2          those individuals can partake in that.  

 3                 Then when they leave, they will need 

 4          appropriate housing, so we need to look at 

 5          our housing resources.  And they will also 

 6          need wraparound services in that housing.  

 7          And when we have done the housing with the 

 8          wraparound services, we have great results.  

 9          Generally, you know, we decrease the 

10          returning to prison, decrease 

11          hospitalizations, everything.

12                 So we are going to be looking at that 

13          particularly for that population, so that 

14          they can have a real successful reentry into 

15          the community.

16                 SENATOR KRUEGER:  Thank you.

17                 CHAIRWOMAN YOUNG:  Thank you.

18                 CHAIRWOMAN WEINSTEIN:  Assemblywoman 

19          Melissa Miller.

20                 Oh, and before she begins, we've been 

21          joined by Assemblywoman Carmen de la Rosa.

22                 ASSEMBLYWOMAN MILLER:  Hi.  How are 

23          you?  I just have one question.  

24                 You spoke before about the push to 

                                                                   69

 1          create a more robust community crisis 

 2          intervention and crisis services.  Are we not 

 3          there yet, and yet we're discharging patients 

 4          fairly quickly from these beds?  Could that 

 5          be one of the reasons that maybe we're seeing 

 6          the unmet need of patients, that's why 

 7          they're showing up in jails or back in ERs so 

 8          quickly, and maybe we're -- that's the hope, 

 9          where you're hoping to reinvest some of that 

10          money back into those services.  But is that 

11          service not yet fully in place?

12                 COMMISSIONER SULLIVAN:  It's not fully 

13          in place.  And I think it depends on -- it's 

14          more in place in certain parts of the state 

15          than in other parts of the state, but I 

16          couldn't honestly say that it's in place 

17          everywhere that it needs to be.

18                 But when someone -- we're still 

19          developing ways to ensure that individuals, 

20          when they leave hospitals, especially when 

21          they're leaving acute-care hospitals, that 

22          they have the kinds of wraparound services 

23          that enable them to successfully get into the 

24          community.  And that includes 

                                                                   70

 1          sometimes programs where individuals, whether 

 2          it's the Health Home coordinator or other 

 3          individuals, work with those individuals to 

 4          help them adjust in the community.

 5                 Now, somewhere along the line mental 

 6          illness can be a very relapsing illness, so 

 7          you can have a crisis.  You need them when 

 8          you have that crisis to hopefully be able to 

 9          stabilize so that you don't have to go to a 

10          hospital.  There's some wonderful respite 

11          programs -- one of them is in New York City, 

12          called Parachute -- where individuals who 

13          begin to decompensate have the opportunity to 

14          go into a respite program with lots of 

15          supports so that they don't ever have to hit 

16          that emergency room or go to the hospital.  

17                 And I think as we have more of those 

18          services, we will begin to have less 

19          individuals going to the hospital.  

20          Individuals, once they are better, will leave 

21          hospitals.  I mean, you can't keep people in 

22          hospitals after they are better.

23                 ASSEMBLYWOMAN MILLER:  But sometimes 

24          they're not even getting --

                                                                   71

 1                 COMMISSIONER SULLIVAN:  The question 

 2          is what are you sending them to in the 

 3          community.

 4                 ASSEMBLYWOMAN MILLER:  They're not 

 5          even getting into the hospital.  They'll be 

 6          held in the ER for three, four, five days, 

 7          there's not a bed, and then they're being 

 8          discharged from the ER and back -- you know, 

 9          got through the short-term crisis, then back 

10          right out onto the street or wherever it is 

11          they are.  Then they're getting into trouble, 

12          they're winding up in jail, they're winding 

13          up in a different place in crisis.  Or worse, 

14          hurting somebody or themselves.  

15                 COMMISSIONER SULLIVAN:  One of the 

16          major initiatives we're working on with DOH 

17          and managed Medicaid -- the majority of -- 

18          almost all of these individuals are on 

19          Medicaid -- is to have incentives within 

20          managed care to do really robust discharge 

21          planning and connecting to community services 

22          when someone leaves the hospital, and 

23          building incentives --

24                 ASSEMBLYWOMAN MILLER:  Or ER.

                                                                   72

 1                 COMMISSIONER SULLIVAN:  Or ER, I'm 

 2          sorry, yes, the hospital or ER -- and 

 3          building those incentives into the payment 

 4          structures of managed care companies.

 5                 Now, this is new.  This is something 

 6          which is in the DOH budget.  And we really 

 7          believe that working through managed care, 

 8          working with them, working with hospitals, 

 9          working with community-based providers to 

10          make sure that we pay for the kinds of 

11          services that individuals need when they 

12          leave emergency rooms and when they need 

13          acute-care inpatient services.

14                 We have to get the payment service and 

15          the service system aligned so that especially 

16          those high-risk individuals get the services 

17          they need.  And that's something we're going 

18          to be working on this year, and it's in the 

19          DOH budget.

20                 ASSEMBLYWOMAN MILLER:  I think -- 

21          because I applaud, I think it's a wonderful 

22          goal.  But if it's not fully there, we can't 

23          ignore it and just, you know, oh, we're 

24          there, and put these people out prematurely 

                                                                   73

 1          if the service isn't there yet to meet their 

 2          needs and give them the supports that they 

 3          need.

 4                 COMMISSIONER SULLIVAN:  I think the 

 5          issue is that individuals can only be in 

 6          mental hospitals against their will if 

 7          they're acutely dangerous.

 8                 ASSEMBLYWOMAN MILLER:  But what about 

 9          a transition?

10                 COMMISSIONER SULLIVAN:  But the 

11          transition is what we need to fund, that's 

12          the issue.  We need to fund those 

13          transitions.

14                 ASSEMBLYWOMAN MILLER:  Or a transition 

15          residence.

16                 COMMISSIONER SULLIVAN:  And we do have 

17          some transition residences and respite beds, 

18          which we have the $50 million in capital 

19          which we're going to be putting up.  Those 

20          will be transition beds.  Which will be very 

21          helpful, I think, to the system.

22                 Thank you.  

23                 ASSEMBLYWOMAN MILLER:  Thank you.

24                 CHAIRWOMAN YOUNG:  Thank you.

                                                                   74

 1                 Our next speaker is Senator Savino.

 2                 SENATOR SAVINO:  Thank you, Senator 

 3          Young.

 4                 Good morning, Commissioner.  I want to 

 5          go back to the discussion about the reduction 

 6          in beds.  I'm curious as to whether or not -- 

 7          I see sitting behind you Commissioner Arlene 

 8          González-Sánchez of OASAS.  And I'm somewhat 

 9          curious as to whether or not we -- are your 

10          agencies coordinating together?  You know, we 

11          are all struggling with this opioid abuse 

12          crisis, but quite honestly it's bigger than 

13          just opioids, it's addiction in general.

14                 And many of the patients in New York 

15          State that are struggling with addiction went 

16          down that road starting in their doctor's 

17          office, whether it was pain management or 

18          psychiatry or a combination of the two.  We 

19          know that depression and pain intersect.  We 

20          know that many people who have been in an 

21          accident or the victim of an assault, who 

22          have chronic pain, also suffer from 

23          posttraumatic stress disorder.  And we see 

24          patients who are being prescribed almost a 

                                                                   75

 1          toxic combination of drugs to handle their 

 2          pain, their depression, their anxiety.  Many 

 3          of them are chronically addicted now under 

 4          the care of a psychiatrist and a doctor. 

 5                 So when those patients go into crisis 

 6          because of abusing their medication, which 

 7          they get legally from their physician, where 

 8          do they go?  Right now they go into the 

 9          emergency room, they go from the emergency 

10          room maybe into a detox bed if you can find a 

11          detox bed when they're being released.  So 

12          what I'm wondering is, is there the kind of 

13          proper coordination between OMH and OASAS to 

14          really begin to address this new category?  

15          We've always had MICA patients -- mentally 

16          ill, chemically addicted -- but this is 

17          almost of an epic proportion, the number of 

18          patients who are cycling in and out and not 

19          really getting the services that they need, 

20          because it seems to be disjointed. 

21                 So can you speak to the types of 

22          coordination that exist between OMH and 

23          OASAS, and do you think we could do better?  

24          Are we directing the money properly to help 

                                                                   76

 1          really get a handle on this crisis?

 2                 COMMISSIONER SULLIVAN:  I think we 

 3          work very well with OASAS, and we're 

 4          really -- the important thing here is for 

 5          both -- for those who treat mental illness to 

 6          understand and be able to appropriately use 

 7          medications for individuals who are addicted 

 8          to, to understand addiction.  And for 

 9          individuals who are primarily addiction 

10          treatment, to understand and work with mental 

11          health.  

12                 And we have done together a lot of 

13          training.  We also have a dual licensure 

14          program now where our clinics can be licensed 

15          in both addiction services and mental health 

16          services.  And when you do that, when you say 

17          that you're licensed, then you make sure that 

18          everyone is really well-trained and that the 

19          services are well-designed to be able to have 

20          that kind of single point of entry so when 

21          someone comes in, a clinician, skilled, can 

22          decide which kinds of services someone needs 

23          the most of.

24                 I absolutely agree with you that we 

                                                                   77

 1          need to be making sure that psychiatrists are 

 2          well-trained in understanding the risks of 

 3          using some of these drugs.  I think some of 

 4          them are, and some are not.  But we've been 

 5          doing a lot of training of psychiatrists 

 6          across the state, we've been doing a lot of 

 7          training of psychiatrists who are primarily 

 8          mental health clinicians, in using 

 9          appropriate medications for addiction 

10          services, because some of them were not as 

11          up-to-speed.  So we've been doing training in 

12          that area.

13                 So yes, we're working very closely.  I 

14          think our -- both our goals I think is to 

15          have any family member or any individual who 

16          comes in for help, that they can get the help 

17          they need whichever door they come in, 

18          whether they come in something that's a 

19          little more mental health than addiction or a 

20          little more addiction than mental health.

21                 So yes, we're working very closely to 

22          try and work together to fight this crisis.

23                 SENATOR SAVINO:  I'm glad to hear 

24          that.  I just wonder if perhaps maybe instead 

                                                                   78

 1          of reducing the number of beds at OMH, 

 2          perhaps maybe we should reclassify them for 

 3          this particular purpose.  Just a suggestion.

 4                 Finally, on the adult home transition 

 5          I heard you respond, I think it was to 

 6          Senator Krueger, that since -- was it last 

 7          year or the year before, we've moved 

 8          650 people from adult homes to 

 9          community-based residential settings on their 

10          own, which is a great thing, and that only 

11          five people have returned to the adult home.

12                 But does that mean that 645 are still 

13          living on their own independently?

14                 COMMISSIONER SULLIVAN:  Yeah.  Yeah.

15                 SENATOR SAVINO:  Because what I was 

16          concerned about is that maybe some of them 

17          are decompensating on their own and moving 

18          into nursing homes.  Because we've heard from 

19          some of our nursing home providers that they 

20          are now providing almost residential 

21          treatment to people who used to live in an 

22          adult home or an adult facility.

23                 COMMISSIONER SULLIVAN:  I don't think 

24          of that cohort.  I'm not saying that there 

                                                                   79

 1          aren't others that maybe have transitioned to 

 2          nursing homes or discharged perhaps from 

 3          acute care and then go to nursing homes.  But 

 4          not that cohort.  The vast majority, they 

 5          have really been successful in the community.

 6                 SENATOR SAVINO:  Okay.  Thank you.

 7                 SENATOR KRUEGER:  Thank you.

 8                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

 9          Santabarbara.

10                 ASSEMBLYMAN SANTABARBARA:  Thank you.

11                 Thank you, Commissioner, for being 

12          here.  And thank you for your testimony.  

13                 You talk about supportive housing 

14          opportunities and the investments that we 

15          have made.  And I know in my district there's 

16          still a significant shortage of supportive 

17          housing, and in the Capital Region.  I know 

18          at the last round of funding we did see -- we 

19          were able to add some additional 

20          opportunities.  But what I'm hearing from 

21          places like Schenectady ARC in Schenectady 

22          County and Montgomery ARC in Montgomery 

23          County in my district -- which are both here 

24          today -- is that the direct care crisis is 

                                                                   80

 1          presenting a challenge to support these new 

 2          opportunities.

 3                 So the turnover rates continue, the 

 4          vacancy rates continue.  And last year we did 

 5          include some funding to support direct care, 

 6          direct care staff.  But has any thought been 

 7          given to the new housing opportunities in 

 8          relation to the direct care crisis?

 9                 COMMISSIONER SULLIVAN:  For mental 

10          health, what we try to do in terms of 

11          supportive housing for individuals who are 

12          mentally ill when we have either reinvestment 

13          dollars or whatever other source, we look at 

14          needs in various communities.  

15                 So I think we try to look at the needs 

16          where they're greatest, to try to get 

17          providers to put up the beds in those areas.  

18          So I think we continue to look and to work on 

19          that.  I think we're not where we need to be 

20          yet in terms of having enough supported 

21          housing.  But as dollars continue to come 

22          into the system for the seriously mentally 

23          ill, we continue to look at other places in 

24          the state that need those the most.

                                                                   81

 1                 And when RFPs come into those, that's 

 2          part of the judgment as to where housing 

 3          should go.

 4                 ASSEMBLYMAN SANTABARBARA:  If the 

 5          shortage continues, is there additional 

 6          investments that are planned for the future 

 7          to reduce that shortage?

 8                 COMMISSIONER SULLIVAN:  Yeah, we're 

 9          trying to reduce the shortage as much as we 

10          can.

11                 ASSEMBLYMAN SANTABARBARA:  Just one 

12          more question.  You mentioned the $50 million 

13          for transition beds earlier.  Where are those 

14          located?

15                 COMMISSIONER SULLIVAN:  That RFP will 

16          come out, and then we will get responses.  

17          And we're hopeful that we get responses from 

18          all over the state.  And that's $50 million 

19          in capital to develop the respite beds.  And 

20          those could be anywhere in the state.  As 

21          soon as the budget's over, we'll get the 

22          paperwork out and we'll start to get requests 

23          for those beds.

24                 ASSEMBLYMAN SANTABARBARA:  Thank you.

                                                                   82

 1                 COMMISSIONER SULLIVAN:  Thank you.

 2                 CHAIRWOMAN WEINSTEIN:  Thank you.

 3                 CHAIRWOMAN YOUNG:  Thank you.

 4                 Commissioner, I do have some follow-up 

 5          questions.  We were talking about children's 

 6          services, and I believe there are a lack of 

 7          children's services in the state.  What 

 8          concerns me too is that the Governor's 

 9          proposed budget has a delay of the 

10          implementation of expanded Medicaid mental 

11          health services for children.  These 

12          services, as you know, were originally 

13          scheduled to be implemented on July 1st of 

14          this year and now will be delayed for two 

15          years.  The Governor has indicated that this 

16          delay is to preserve the financial plan.  

17                 And some providers -- this is part of 

18          the problem -- had already hired staff and 

19          made preparations.  These providers now face 

20          substantial challenges in the face of this 

21          delay.

22                 So the question is, will the 30-day 

23          amendments that are out this Thursday include 

24          any assistance to help these providers that 

                                                                   83

 1          are impacted by the delay in children's 

 2          services?

 3                 COMMISSIONER SULLIVAN:  That's being 

 4          discussed.  I can't answer whether or not the 

 5          30-day amendments at this point will. 

 6                 I do know that we, as the Office of 

 7          Mental Health, will be working very closely 

 8          with the impacted child agencies.  We have 

 9          something that we call the technical 

10          assistance program, and we'll be working very 

11          closely with them to assist them in whatever 

12          the delay is, whether it -- hopefully to help 

13          them be able to redesign so that they will 

14          not be at financial risk. 

15                 Basically there were some changes that 

16          were federal changes to HCBS services, the 

17          waiver services for kids, that were 

18          independent of this delay.  But some -- they 

19          happened about the same time, so they 

20          unbundled some services, making it more 

21          difficult for certain providers to bill, 

22          et cetera.  We're going to be working with 

23          them very closely to be able to do that.

24                 So we're going to be doing a lot of 

                                                                   84

 1          technical assistance.  Some providers are not 

 2          in difficulty; even though they had changed 

 3          some things, they've been able to adapt.  

 4          Others are.  So we're going to be working 

 5          very closely with them from the OMH 

 6          perspective on a technical assistance side.

 7                 CHAIRWOMAN YOUNG:  So it sounds like, 

 8          Commissioner, the answer is no, that these 

 9          will not be in the 30-day amendments.

10                 COMMISSIONER SULLIVAN:  I don't know, 

11          actually, Senator.  I can't answer it, 

12          Senator.

13                 CHAIRWOMAN YOUNG:  Well, I would urge 

14          you to discuss this with the Division of 

15          Budget and the Governor, because obviously 

16          there's a critical need out in the 

17          communities regarding children's services.  

18          And I think that even though there's a 

19          financial impact, I think delaying them is 

20          the wrong direction to take.  So thank you.

21                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

22          Oaks.

23                 ASSEMBLYMAN OAKS:  Yes, thank you, 

24          Commissioner. 

                                                                   85

 1                 Earlier there was some discussion on 

 2          the jail-based restoration program.  And just 

 3          checking with you, at this point has there 

 4          been specific -- I know this is the 

 5          Governor's proposal.  Has there been talks 

 6          back and forth with the county sheriffs and 

 7          the local jails, and have counties expressed 

 8          an interest in this program at this point?  

 9          Just where are we?

10                 COMMISSIONER SULLIVAN:  We have had 

11          some discussions.  We don't have any firm 

12          commitments from any counties yet.

13                 ASSEMBLYMAN OAKS:  Okay.  And do we 

14          know, is there funding behind it?  And, you 

15          know, how will counties, should they choose 

16          to do it, how much -- do we know how much 

17          they would receive back, a portion of what 

18          they spend on it or whatever is the actual 

19          cost, been discussed?

20                 COMMISSIONER SULLIVAN:  Yeah, there's 

21          $850,000 in the budget to support the 

22          establishment of a pilot for this.  And also 

23          some of those dollars could be ongoing, 

24          depending upon the need, after it's 

                                                                   86

 1          established.

 2                 Basically what counties pay now -- the 

 3          cost for a restoration bed is about $120,000.  

 4          Counties pay half of that, which is about 

 5          $60,000.  With jail-based restoration, 

 6          because you don't have the overhead costs of 

 7          inpatient hospitalization, counties would 

 8          probably be expected to pay something like 

 9          $20,000, $25,000.  So there's significant 

10          savings to the county if they do this.  And 

11          also there's the $850,000 which is in the 

12          budget to support the establishment of 

13          jail-based restoration.

14                 ASSEMBLYMAN OAKS:  Thank you on that.

15                 I didn't see funding in the Governor's 

16          proposal for the Joseph P. Dwyer program, 

17          which serves veterans in 16 counties around 

18          the state for things like posttraumatic 

19          stress and addiction and employment or even 

20          just welcoming veterans as they're returning 

21          back home.

22                 Hopefully -- I know in last year's 

23          budget there was a $3.1 million line for 

24          that.  Hopefully it will get restored -- and 

                                                                   87

 1          we're talking about restorative things -- 

 2          restored through negotiations with the 

 3          Legislature.  Do you see the importance of 

 4          this program or these types of programs as a 

 5          part of the important kind of community-based 

 6          services to supplement other state and local 

 7          programs that we have?

 8                 COMMISSIONER SULLIVAN:  I think 

 9          that's -- the Peer-to-Peer program is a very 

10          valuable program.  I think it's very 

11          important for our veterans.  It is not in our 

12          budget, so I can't speak to the restoration, 

13          but it's not in our budget.  But those kinds 

14          of services for vets are very valuable and 

15          have been shown to have a significant impact 

16          on the lives of veterans.

17                 ASSEMBLYMAN OAKS:  Thank you very 

18          much.

19                 CHAIRWOMAN YOUNG:  Thank you.

20                 Senator Savino.

21                 SENATOR SAVINO:  Thank you.  

22                 One follow-up; I'll probably ask this 

23          of the other two commissioners as well.  As 

24          you know, there has been some concern on the 

                                                                   88

 1          part of the service providers over the years 

 2          about rising costs and their ability to meet 

 3          the demands of the minimum wage increase.  So 

 4          I was wondering if you could talk about 

 5          how -- whether or not we're addressing 

 6          that for the agencies that are going to be 

 7          providing services to the mentally ill.

 8                 COMMISSIONER SULLIVAN:  Yeah, 

 9          basically the increase in salaries we have 

10          for the agencies providing mentally ill -- 

11          3.2 -- a 6.5 percent increase for direct 

12          service, and for clinicians, a 3.25 percent 

13          increase in the direct -- in salaries.  And I 

14          think that that is very welcome and very 

15          important for our staff, and I think it can 

16          make a significant difference.  So we're very 

17          pleased that that's in the budget, and I 

18          think it's very supportive of our agencies.

19                 SENATOR SAVINO:  And finally, in the 

20          Governor's budget there's a proposal to 

21          clarify -- that's what it says, clarifying 

22          which tasks and assignments performed by 

23          certain individuals require psychology, 

24          social work or mental health practitioner 

                                                                   89

 1          licensure.  This applies to social and mental 

 2          hygiene workers employed by programs or 

 3          service organizations; OMH is one of them.

 4                 Can you -- the Governor wants to 

 5          extend the current exemption of licensure 

 6          through July 1, 2020.  Can you give me a 

 7          sense of the history of this exemption?  

 8          because as you know, a lot of effort went 

 9          into developing a license for social workers, 

10          so that the degree and the work would allow 

11          them to advance.

12                 So this continuation of the exemption 

13          of licensed professionals in this field is an 

14          issue that NASW and others have a concern 

15          about.  Can you explain the history and why 

16          we're continuing this exemption?

17                 COMMISSIONER SULLIVAN:  Yeah.  When 

18          the initial legislation was passed, it was 

19          largely affecting individuals who are what we 

20          say in kind of private practice.  In other 

21          words, that are licensed.  An unlicensed 

22          social worker should not be able to provide 

23          independent services in a private practice or 

24          an unregulated setting.

                                                                   90

 1                 We have always had, in our Article 31 

 2          clinics -- which is where the exemption 

 3          exists, the only place it exists -- and in 

 4          the clinics in the state system, we've always 

 5          had a system of supervision, where treatment 

 6          plans are signed off on by physicians and 

 7          supervisors, where there are treatment team 

 8          meetings, where there's joint treatment 

 9          planning.  It's really quite intense.

10                 And that level of supervision over the 

11          years has been felt to really be sufficient 

12          in terms of protecting the individuals who 

13          receive the services and in ensuring that the 

14          individuals who provide them are of the 

15          caliber that they need to be.  But 

16          technically, no, they are still unlicensed.

17                 Now, within the system as it exists 

18          even now, individuals can never do anything 

19          beyond their scope of practice.  That's 

20          determined by their schools and where they 

21          come from.  So that scope of practice is what 

22          is there.  What the exemption did was not 

23          require some levels of supervision, which are 

24          now in the new proposal, that as tightly or 

                                                                   91

 1          as -- what am I trying to say here -- as 

 2          well-documented, because they'd had this 

 3          other system.

 4                 So, for example, now we're trying to 

 5          align the two so that instead of having an 

 6          exemption out there, we are really providing 

 7          the appropriate services.  However, almost 

 8          all of the services that unlicensed people 

 9          provide can still be provided within our 

10          system.  The one area is the ability to 

11          diagnose, and the ability to diagnose should 

12          be under supervision by State Ed requirements 

13          for certain work that is done.

14                 So what it really does is kind of 

15          tighten it up.  And I think letting the 

16          exemption be there for another two years 

17          enables the clinics that -- to be ready, and 

18          then people coming in in the future.  

19          Students who are coming to -- there should be 

20          no significant change in there, because they 

21          were always supervised.

22                 So I think where it came from 

23          historically was this concept of unlicensed 

24          individuals without a lot of supervision 

                                                                   92

 1          being out there maybe doing things.  But 

 2          this -- in our system, we have this whole 

 3          layer of supervisory structure, which is why 

 4          the exemption went on so long.

 5                 SENATOR SAVINO:  All right.  Thank 

 6          you.

 7                 CHAIRWOMAN YOUNG:  Thank you.

 8                 CHAIRWOMAN WEINSTEIN:  Thank you.  

 9          We've been joined by Assemblywoman Pat Fahy.

10                 And to Carmen de la Rosa for a 

11          question.

12                 ASSEMBLYWOMAN DE LA ROSA:  Thank you.

13                 Thank you, Commissioner, for being 

14          here and for providing testimony.

15                 You know, last session my colleagues 

16          and I made it a priority to talk about 

17          suicide prevention in our communities, 

18          specifically for the African-American 

19          children and the Latino children, because 

20          we're seeing trends, upward trends in 

21          children, at early ages, attempting suicide. 

22          And so the task force as well as the caucus, 

23          we got together and we made it a priority to 

24          not only push for funding for local providers 

                                                                   93

 1          that were working in our communities, but to 

 2          also push to make sure that the services were 

 3          culturally fluent in our communities.  And we 

 4          actually passed legislation to do that.

 5                 And I see that the last point in your 

 6          testimony talks about, you know, the 

 7          significant investment and commitment to 

 8          making sure that these services are provided 

 9          in our state.  

10                 So I have two questions.  The first 

11          one is, what does that look like in your 

12          budget?  What are the programs that OMH is 

13          trying to put together to make sure that 

14          these services come down to minority 

15          communities?  And the second is, how is OMH 

16          working with local providers to make sure 

17          that each sort of corner of the state is 

18          touched?

19                 COMMISSIONER SULLIVAN:  Thank you.

20                 You know, I think that the budget 

21          right now for -- is about $3 million for 

22          overall suicide prevention.  We also have a 

23          grant of $3.5 million for suicide prevention.  

24          So that makes about $6.5 million directly for 

                                                                   94

 1          suicide prevention.

 2                 I think that -- there's a couple of 

 3          things that we're doing.  One is a very 

 4          wide-based clinical training for providers, 

 5          training for communities, training for first 

 6          responders, training for teachers, community 

 7          organizations, et cetera, on suicide 

 8          prevention, safe talk, a whole host of 

 9          various trainings that we do.  And last year 

10          we touched about 7,000 individuals in 

11          training across the state.

12                 Those touch our minority communities, 

13          but they -- I can't say that they were 

14          specific -- I mean, every place we do it, we 

15          do it specific to that cultural area, but I'm 

16          not saying that they were specifically geared 

17          towards those communities, except where we 

18          provided them.  So that I can't break out for 

19          you exactly -- I could get it to you if you 

20          need -- how many of those touched minority 

21          communities, et cetera.  But depending upon 

22          where we do the trainings, we take into 

23          account all the cultural issues about the 

24          training.

                                                                   95

 1                 So that's a training system that we 

 2          have set up and we have been doing now for 

 3          over five or six years on an ongoing basis.  

 4          That touches the communities.  The other 

 5          areas that we have where we've been spending 

 6          a good amount of dollars, including a grant, 

 7          is something called working with all the 

 8          mental health providers.  You know, as we 

 9          know, 20 percent of individuals who 

10          unfortunately successfully commit suicide 

11          have had contact with a mental health 

12          provider a month before.  So that's a kind of 

13          red flag that maybe our providers aren't 

14          being as attuned to what they should be, 

15          wherever they are located across the state.

16                 So that's called Zero Suicide, and we 

17          have invested a lot of training and work on 

18          that and had a grant from the federal 

19          government, from SAMHSA -- that's the 

20          3.5 million -- within health systems to 

21          expand and to get the appropriate screening 

22          in emergency rooms, the appropriate screening 

23          in inpatient units and in clinics, and 

24          enabling staff to do really evidence-based 

                                                                   96

 1          best practices in suicide.

 2                 The third arm is a collaborative we've 

 3          had with 170 clinics across the state in 

 4          terms of suicide prevention.  Some of those 

 5          are in minority communities, some of those 

 6          are in other communities.  And they are 

 7          working with us on doing suicide best 

 8          practices.

 9                 And then lastly on the introduction 

10          into collaborative -- in collaborative 

11          care -- and a lot of this has happened 

12          through DSRIP, and also through other funding 

13          within budgets for collaborative care -- of 

14          screening for depression in primary care 

15          clinics, both for adults and for adolescents.  

16          And this is really probably one of the most 

17          important places to be doing this kind of 

18          screening.  And we have done this, again, 

19          across communities across the state, 

20          including minority communities.  

21                 The PHQ-9, which is the screening 

22          tool, has been translated into multiple 

23          languages and is available across the state.  

24          And that kind of screening really identifies 

                                                                   97

 1          individuals who otherwise would not be coming 

 2          forward.  And that kind of screening occurs 

 3          in primary care clinics.

 4                 Now, in addition to all that, we know 

 5          that we have targeted populations that have 

 6          been growing in suicide attempts and risks.  

 7          One is the Latino community; another is the 

 8          LGBTQ community.  And the Governor has 

 9          established a task force which is looking at 

10          particularly the gaps in what we are doing, 

11          that we are not doing as much as we should.  

12                 And that task force is looking 

13          particularly at those populations and will be 

14          coming out with recommendations I believe 

15          towards the end of this year.  And they're 

16          doing focus groups, they are doing real 

17          connections into the grassroots, into the 

18          communities, to say what will work.

19                 We are doing all this, and we're 

20          hopeful it will have an impact.  But 

21          nationally, the suicide rate has not gone 

22          down despite so many efforts.  So one of the 

23          things we would like the task force to be 

24          doing is getting us some ideas about the 

                                                                   98

 1          very, very best practices so that when we do 

 2          do more, we know that we're doing it with the 

 3          best possible outcome.  So while we're doing 

 4          a lot, we really need to do more.  

 5                 And it's just unfortunate that -- we 

 6          know that Zero Suicide, in terms of working 

 7          with mental health professionals, has an 

 8          impact.  Community interventions do have an 

 9          impact.  But it has not had the kind of 

10          impact across the country that we would still 

11          like to see in terms of really bringing down 

12          the number of individuals who unfortunately 

13          die by suicide.

14                 ASSEMBLYWOMAN DE LA ROSA:  Well, the 

15          only thing that I would say is that as far as 

16          the task force is concerned, one of the 

17          things that's very important to us is that 

18          that diversity exists.  You know, not only 

19          across cultures, across language, but also 

20          across genders.  Right?  We want to make sure 

21          that we have women that are represented 

22          there, that we have service providers that 

23          are actually doing the work in our 

24          communities represented there -- 

                                                                   99

 1                 COMMISSIONER SULLIVAN:  Yes.

 2                 ASSEMBLYWOMAN DE LA ROSA:  -- and that 

 3          we have LGBTQ individuals as well.  So I 

 4          would just say that that's really important 

 5          for us.

 6                 COMMISSIONER SULLIVAN:  Yes.  Yes.  

 7          Thank you.

 8                 SENATOR SAVINO:  Before Senator 

 9          Amedore asks a question, I would like to note 

10          that Senator Gustavo Rivera has joined us. 

11                 Senator Amedore.

12                 SENATOR AMEDORE:  Thank you, 

13          Commissioner, for being here and for your 

14          insight.

15                 I've got a quick question, and I'm 

16          going to ask the same question to 

17          Commissioner Sánchez of OASAS.  

18                 According to published reports, over 

19          half the population in local jails suffer 

20          from substance abuse disorder.  Over 

21          two-thirds of these individuals have been in 

22          jail before.  This is a huge problem that 

23          needs to be addressed.

24                 So what consideration has OMH or this 

                                                                   100

 1          administration given to reaching out to serve 

 2          this population?

 3                 COMMISSIONER SULLIVAN:  In terms of -- 

 4          I think really -- in some ways I think that 

 5          is best answered by Commissioner González.

 6                 However, obviously those individuals 

 7          do come for access to care through our 

 8          clinics, et cetera, and through our -- to 

 9          psychiatrists and social workers in our 

10          system of care.  And what we have done is 

11          really upped the ante here in terms of 

12          getting our people trained to be able to kind 

13          of provide the kinds of services that can be 

14          provided to individuals to help divert any of 

15          the problems that can come down the road.

16                 So we're working very closely with 

17          training and with having dual licensure, 

18          having every door be a door that you can open 

19          to come in for service.  And that's what 

20          ultimately can prevent individuals from 

21          winding their ways into jails and prisons.  

22          And certainly to the extent that when we 

23          screen someone in our prison system for 

24          mental health issues, we also note any 

                                                                   101

 1          substance use issues and work with DOCCS, who 

 2          provide those services in the prison system.

 3                 SENATOR AMEDORE:  So is there any 

 4          available funding to the counties through 

 5          local mental health agencies or the sheriff 

 6          to deal with this problem?

 7                 COMMISSIONER SULLIVAN:  Local aid, 

 8          sometimes state aid has been used for these 

 9          purposes in the counties.  We give state aid 

10          to the counties, and the counties then report 

11          back to us on how they want to use those 

12          dollars.  And I know that some of those have 

13          been used for jail-based services in the 

14          counties.

15                 SENATOR AMEDORE:  Okay, thank you.

16                 CHAIRWOMAN WEINSTEIN:  Assemblywoman 

17          Gunther.

18                 ASSEMBLYWOMAN GUNTHER:  It's my last 

19          question.

20                 And I think there's now a new 

21          requirement to teach mental health in the 

22          schools, which I think is fabulous, I really 

23          do.  But is there going to be any funding in 

24          the budget, with all the schools having 

                                                                   102

 1          mandates, et cetera?  They're struggling.  

 2          And I was wondering if there's any money in 

 3          the budget to help schools provide this 

 4          service to our children.

 5                 COMMISSIONER SULLIVAN:  There's no 

 6          direct dollars in the budget, but we have met 

 7          with the schools, and we are providing a lot 

 8          of technical assistance in terms of 

 9          curriculum, which is what they really need, 

10          in some ways, to provide this.  So we're 

11          working very closely with them.

12                 And the school district 

13          superintendents are very excited about doing 

14          this.  I think that they have really shown a 

15          great willingness to incorporate this into 

16          the curriculum.  

17                 And I absolutely agree with you, I 

18          think in terms of reducing stigma and 

19          ultimately being able to have really an 

20          impact on future generations, this kind of 

21          mental health education in schools is 

22          critical.  So we're really providing 

23          technical assistance in whatever way possible 

24          for a standardized curriculum.

                                                                   103

 1                 ASSEMBLYWOMAN GUNTHER:  I agree with 

 2          you, and I think it's so important that kids 

 3          recognize other kids' depression, or 

 4          perhaps -- and I think this is a great 

 5          learning tool for all of our children.

 6                 COMMISSIONER SULLIVAN:  Absolutely.

 7                 ASSEMBLYWOMAN GUNTHER:  Thank you.

 8                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

 9          Sepulveda.

10                 ASSEMBLYMAN SEPULVEDA:  In that light, 

11          was there recently cuts to mental health 

12          services at community colleges?  I believe 

13          there were programs that were set up, but was 

14          there a cut recently?

15                 COMMISSIONER SULLIVAN:  I don't know 

16          that.  I'm not aware of that.  But I can 

17          check it for you.  I don't know.  I'm sorry.

18                 ASSEMBLYMAN SEPULVEDA:  Now, this is 

19          by way of statement and a comment.  But we 

20          hear about wonderful programs that are trying 

21          to be implemented or implemented, but do you 

22          have any sort of data to indicate the success 

23          of these particular programs?  In terms of 

24          prisons, I'm sorry.

                                                                   104

 1                 COMMISSIONER SULLIVAN:  Oh, within the 

 2          prisons.

 3                 ASSEMBLYMAN SEPULVEDA:  Yes.

 4                 COMMISSIONER SULLIVAN:  We track any 

 5          of the programs that we put in, and we track 

 6          it in terms of whether or not assaults go 

 7          down, whether or not -- individuals' 

 8          satisfaction with the programs, et cetera.  

 9          So we do get numbers.  

10                 And basically they do show 

11          improvement.  And I think that we're not 

12          where we need to be entirely yet.  But yes, 

13          when we put in the programs into the prisons 

14          in terms of training, et cetera, we get 

15          positive responses both from the prisoners 

16          and from the outcomes in terms of, you know, 

17          a decrease in incidents, which we like to 

18          see, and also an improvement in outcomes in 

19          terms of mental health, ability to go back 

20          into the general population, et cetera.  So 

21          we track that, and we do see improvement.

22                 These are evidence-based practices 

23          which kind of research-wise have been shown 

24          to work.  So if you do them right, they 

                                                                   105

 1          should improve care.

 2                 ASSEMBLYMAN SEPULVEDA:  And does that 

 3          include any sort of racial assessment, the 

 4          decisions by OMH, across the board from 

 5          diagnosis to treatment?

 6                 COMMISSIONER SULLIVAN:  I'm sorry?  I 

 7          don't --

 8                 ASSEMBLYMAN SEPULVEDA:  As part of 

 9          this analysis that you -- the data that you 

10          collect, do you also collect data on the 

11          racial impact, the racial assessment of the 

12          treatment from -- from diagnosis to treatment 

13          on some of the programs and policies that OMH 

14          is pushing?

15                 COMMISSIONER SULLIVAN:  Yes.  Yes.

16                 ASSEMBLYMAN SEPULVEDA:  Is that 

17          readily available?

18                 COMMISSIONER SULLIVAN:  I can get it 

19          to you by -- we can get to you what we have 

20          by program.  We look at outcome measures, we 

21          look at metrics -- for example, like hospital 

22          readmissions, we look at metrics -- length of 

23          stay, that kind of thing.  We can get you 

24          impact on the programs, yeah.

                                                                   106

 1                 ASSEMBLYMAN SEPULVEDA:  And just a 

 2          general statement.

 3                 Since I've been here, the Executive 

 4          Budget has proposed cutting funding of 

 5          budgets for these types of mental health 

 6          programs.  I think the Mental Health budget 

 7          should be sacred, certainly on the issue of 

 8          suicide.  I believe that the funding that's 

 9          available now is woefully inadequate, and any 

10          proposal to cut it more -- I know there's a 

11          20 percent across the board cut for most of 

12          the agencies for the state.  But when you 

13          consider the potentially major issues we have 

14          with suicide, especially amongst the Latino 

15          community 11 to 19 -- we've spoken about this 

16          before.  Any cut to these types of budgets I 

17          think would be shameful.  And I think that we 

18          have to do a much better job, the Executive 

19          Budget has to do a much better job, to not 

20          just prevent any cuts, but should increase 

21          the budget so that we can stop what I believe 

22          is potentially an epidemic that's happening 

23          now in our communities with Latino suicide 

24          and suicide amongst communities of color.

                                                                   107

 1                 So hopefully with the little funding 

 2          that you have, you can do the best you can.  

 3          But we shouldn't be discussing cutting any 

 4          budgets on mental health, we shouldn't be 

 5          discussing cutting budgets for suicide 

 6          prevention.  If anything, we should be 

 7          discussing how do we increase it so that we 

 8          can implement some of these that I know have 

 9          been successful but are woefully, woefully 

10          and shamefully inadequately funded.

11                 Thank you.

12                 CHAIRWOMAN WEINSTEIN:  Thank you for 

13          being here.  I think you've answered many of 

14          the -- all of the questions.  Thank you so 

15          much.

16                 COMMISSIONER SULLIVAN:  Thank you.

17                 SENATOR SAVINO:  Thank you, 

18          Commissioner.

19                 (Discussion off the record.)

20                 SENATOR SAVINO:  Next we're going to 

21          hear from Kerry Delaney, acting commissioner 

22          of the New York State Office for People With 

23          Developmental Disabilities.

24                 ACTING COMMISSIONER DELANEY:  Good 

                                                                   108

 1          morning, Senator Savino, Assemblymember 

 2          Weinstein, Assemblymember Gunther, and other 

 3          members of the Legislature.  I'm Kerry 

 4          Delaney, acting commissioner of the Office 

 5          for People With Developmental Disabilities.  

 6          Thank you for the opportunity to provide 

 7          testimony today about Governor Cuomo's 2019 

 8          Executive Budget proposal and how it will 

 9          benefit the nearly 139,000 New Yorkers with 

10          intellectual and developmental disabilities 

11          who are eligible for OPWDD services.  

12                 Under the Governor's leadership, OPWDD 

13          continues to make significant strides in the 

14          transformation to a more integrated, 

15          person-centered system of services and 

16          supports for the people we serve.  The 2019 

17          Executive Budget proposal includes more than 

18          $7 billion in state and federal funding for 

19          OPWDD programs and services.  

20                 The budget proposal supports the 

21          investment of $120 million in annual 

22          all-shares funding to provide new and 

23          expanded services for new and currently 

24          eligible individuals; $15 million in capital 

                                                                   109

 1          funding to expand affordable housing 

 2          opportunities; and over $275 million in 

 3          all-shares funding to help service providers 

 4          enhance staff salaries, $85 million of which 

 5          is provided to fund minimum-wage increases, 

 6          and over $190 million of which is provided to 

 7          support a 6.5 percent wage increase for 

 8          direct support and direct care staff, and a 

 9          3.25 percent increase for clinical staff.  

10                 The Executive Budget proposal also 

11          supports two new critical initiatives that 

12          I'd like to highlight for you this morning.  

13          The first initiative is a residential pilot 

14          program, to be jointly operated by OPWDD and 

15          the Office of Mental Health, to serve 

16          individuals with both developmental 

17          disabilities and significant mental health 

18          challenges.  This program will ensure that 

19          there are available and appropriate 

20          residential opportunities for individuals 

21          with significant challenges, to assist them 

22          to stabilize and return to the community.  

23                 The second initiative would be 

24          supported with a state investment of 

                                                                   110

 1          $39 million to support the transition from 

 2          OPWDD's Medicaid Service Coordination program 

 3          to a Comprehensive Care Coordination model. 

 4                 As you may know, we have developed a 

 5          new model of enhanced, cross-system care 

 6          coordination to be implemented by current 

 7          service providers who are forming Care 

 8          Coordination Organizations authorized under 

 9          the federal Health Homes program. 

10          Implementing enhanced care coordination will 

11          be the first step in our system's multiyear 

12          move to managed care.  

13                 I'd like to provide you with an update 

14          now on how OPWDD has been investing the 

15          resources you have been providing to improve 

16          the lives of the people we serve.  In 2017, 

17          nearly 2,100 people accessed either certified 

18          or more-independent, noncertified residential 

19          services for the first time.  Nearly 1,300 

20          people moved to a certified residence, 

21          75 percent of whom came from home.  

22                 To meet future demand, OPWDD recently 

23          approved the creation of an additional 459 

24          certified opportunities by over 50 service 

                                                                   111

 1          providers across New York State.  This 

 2          expands OPWDD's residential footprint, which 

 3          supports more than 41,000 individuals at a 

 4          cost exceeding $5.2 billion annually and 

 5          remains the largest in the nation.  

 6                 OPWDD's more-independent residential 

 7          assistance opportunities are expanding even 

 8          faster than certified opportunities.  The 

 9          more than 5,300 rental vouchers issued in 

10          2017 were more than double the number issued 

11          five years ago.  For the third consecutive 

12          year, the budget proposes to invest an 

13          additional $15 million in capital to expand 

14          affordable housing capacity for individuals 

15          eligible for OPWDD services.  These funds are 

16          in addition to the resources available from 

17          New York's five-year, $20 billion affordable 

18          and supportive housing plan, which also helps 

19          support the development of residential 

20          opportunities.  

21                 Unwavering support from the Governor 

22          and the Legislature in recent years has 

23          enabled OPWDD and our service providers to 

24          provide an array of services and supports 

                                                                   112

 1          that are among the richest and most 

 2          integrated in the nation.  Together we have 

 3          built a system that now supports 78,000 

 4          people in day habilitation or employment 

 5          services; 43,000 people in respite services; 

 6          and 16,800 people are now participating in 

 7          self-direction after an increase of nearly 

 8          40 percent in 2017.  

 9                 Thank you for your continued support 

10          and advocacy.  We look forward to working 

11          with you and all of our stakeholders to 

12          achieve real and lasting system-wide 

13          transformation on behalf of our friends, 

14          neighbors and loved ones with intellectual 

15          and developmental disabilities.  

16                 Thank you.

17                 SENATOR SAVINO:  Thank you, 

18          Commissioner.  

19                 Starting with questions is Senator 

20          Krueger.

21                 SENATOR KRUEGER:  Hi, Commissioner.

22                 So partly you -- I think you partly 

23          answered when you described the joint beds 

24          with OMH, because of the concern, again, in 

                                                                   113

 1          the community -- I don't know if you heard me 

 2          when I asked the commissioner of OMH about 

 3          what seemed to be inequity in the payment 

 4          structure for whether you're running a 

 5          program serving someone with mental illness 

 6          as opposed to the other O contracts for 

 7          supportive housing.

 8                 So when you are doing joint projects, 

 9          are these then buildings with units that are 

10          defined as an OMH unit versus an OPWDD unit?  

11          And is it the same payment structure for both 

12          sets of units?

13                 ACTING COMMISSIONER DELANEY:  We 

14          actually are working jointly with OMH to 

15          develop those units, and we are now working 

16          on how they will be certified and operated.  

17          But we will ensure that there is sufficient 

18          funding for those units to operate.

19                 SENATOR KRUEGER:  But would you agree 

20          that it would not be right to have two 

21          different formulas of payments?

22                 ACTING COMMISSIONER DELANEY:  I think 

23          equity is very important.  I think we need to 

24          have adequate payments to make sure that 

                                                                   114

 1          people can get the services that they need, 

 2          so that they can receive those 

 3          community-based supports.

 4                 SENATOR KRUEGER:  And then in your 

 5          testimony you talk about 16,800 people now 

 6          participating in self-directed services, 

 7          which is an increase of nearly 40 percent in 

 8          2017.  Can you explain a little bit to me 

 9          what we mean by self-directed services?

10                 ACTING COMMISSIONER DELANEY:  Sure.  

11          Self-directed services are an option that we 

12          have available for individuals who want to 

13          have more control over arranging and the 

14          delivery of their services.

15                 So in more traditional service models, 

16          an individual works with an agency; that 

17          agency will arrange staffing, will arrange 

18          the programs the individual needs.  In 

19          self-direction, individuals will work 

20          directly to hire their own staff, to arrange, 

21          for example, classes they're interested in 

22          attending.  So it gives people a lot more 

23          control over the services that they're 

24          receiving and their staffing.

                                                                   115

 1                 SENATOR KRUEGER:  And how do you 

 2          evaluate that model compared to models that 

 3          are actual programs that you contract with?

 4                 ACTING COMMISSIONER DELANEY:  Well, 

 5          these are programs that individuals with 

 6          self-direction participate in.  So for 

 7          example community habilitation, where an 

 8          individual hires a community habilitation 

 9          worker to go with them in the community and 

10          help them learn skills.  So oftentimes 

11          they're the same types of work that's 

12          happening in traditional provider settings, 

13          but the individual is just arranging for 

14          their own services.  

15                 We look at things like individual 

16          satisfaction.  We have a number of groups 

17          around the state that we are meeting with 

18          that contain our stakeholders who are talking 

19          with us about either their concerns about 

20          self-direction or areas where they feel 

21          self-direction is really assisting them to 

22          get the services that they need.  And 

23          overall, it does have very high satisfaction 

24          reported from participants.

                                                                   116

 1                 SENATOR KRUEGER:  So your population 

 2          at OPWDD is sort of one of the later ones to 

 3          explore moving into Medicaid managed care 

 4          through Health Homes.  And I guess the public 

 5          comment period just closed a month ago.  So 

 6          yesterday many of us sat through an entire 

 7          day of hearings on health and Medicaid where 

 8          there were endless people who testified, 

 9          Here's what's not working with Health Homes, 

10          here we've done Health Homes, or here it's 

11          time to stop Health Homes. 

12                 So you're late into the entire story 

13          line.  You still believe that this is a model 

14          that makes sense for the population you're 

15          serving, even though there's a lot of lessons 

16          to be learned about what the state rolled out 

17          with different populations.

18                 ACTING COMMISSIONER DELANEY:  I do.  I 

19          do.

20                 SENATOR KRUEGER:  And how are you 

21          going to be different and not make the 

22          mistakes?

23                 ACTING COMMISSIONER DELANEY:  I do 

24          think it's still a model that needs to be 

                                                                   117

 1          pursued.  We have looked at and spoken with 

 2          our sister state agencies about challenges 

 3          that they've had, about things that are 

 4          working, and we really believe that this is 

 5          the right model because of the cross-system 

 6          care coordination.  

 7                 Oftentimes people with developmental 

 8          disabilities have needs that cross the mental 

 9          health system, they have physical health 

10          needs, and bringing those services all 

11          together behind one care manager we think 

12          really will be helpful.  But many of the 

13          challenges that have been experienced we are 

14          working on ways to ensure our system has 

15          resolved before we roll out Health Homes 

16          later this year.

17                 SENATOR KRUEGER:  And how many Health 

18          Home providers do you estimate working with?

19                 ACTING COMMISSIONER DELANEY:  We have 

20          not finalized the review process yet.  We had 

21          10 applicants to become CCO Health Homes.  

22          We've now approved six.  We have four more 

23          that are still under review.

24                 SENATOR KRUEGER:  And the six that 

                                                                   118

 1          you've approved are already working with 

 2          other populations so they have a track 

 3          record, or they're new entities?

 4                 ACTING COMMISSIONER DELANEY:  No, we 

 5          felt that it was very important, after 

 6          listening to our stakeholders, that OPWDD's 

 7          Health Homes be comprised of OPWDD providers, 

 8          who really understand the unique and 

 9          habilitative nature of our services.  So our 

10          providers are actually starting OPWDD 

11          eligible-individual-specific Health Homes.

12                 SENATOR KRUEGER:  My time's up.  Thank 

13          you.

14                 ACTING COMMISSIONER DELANEY:  Thank 

15          you.

16                 CHAIRWOMAN WEINSTEIN:  Thank you.

17                 Assemblywoman Gunther.

18                 ASSEMBLYWOMAN GUNTHER:  Thank you for 

19          coming today.

20                 As you know, last year's budget 

21          included funding to increase salaries for 

22          direct care workers.  The first phase, a 

23          3.25 percent increase, was due to take effect 

24          January 1st of this year.  Have DSPs been 

                                                                   119

 1          receiving those increases?

 2                 ACTING COMMISSIONER DELANEY:  We have 

 3          been working with the Department of Health on 

 4          incorporating the funding for that first 

 5          3.25 percent increase.  That increase in 

 6          rates will be posted by the end of this week.  

 7          It will be retroactive to January 1st.  So 

 8          DSPs should start seeing those increases very 

 9          soon.

10                 ASSEMBLYWOMAN GUNTHER:  Since 2010, we 

11          have had two COLAs for our DSPs, one being 

12          just .2 percent.  Do you believe this has had 

13          an effect on the ability to recruit and 

14          retain DSPs?  DSPs is direct support 

15          professionals, by the way.

16                 ACTING COMMISSIONER DELANEY:  I think 

17          there are a number of factors that impact our 

18          ability to recruit and retain DSPs as a 

19          system, salary obviously being one of the 

20          most significant.  That is why the Governor 

21          and the Legislature last year worked together 

22          to provide about $191 million in funding to 

23          support what will amount to a 6.5 percent 

24          increase over the course of this year, so the 

                                                                   120

 1          January and April amounts.

 2                 So we are going to be monitoring the 

 3          impact of that increase.  There are also a 

 4          number of other actions that we're taking to 

 5          try to help develop and continue to 

 6          professionalize our direct support workforce, 

 7          including working with community colleges and 

 8          other entities to try to develop a workforce 

 9          for our DSPs.

10                 ASSEMBLYWOMAN GUNTHER:  Do you believe 

11          that it would be beneficial to create a 

12          career ladder and credentialing?  You know, 

13          the care that direct support professionals 

14          give on a daily basis to a lot of times our 

15          most vulnerable folks, and it's not 

16          considered a career.  And it's been -- you 

17          know, having just opened a casino, which 

18          we're grateful for, but the -- as far as the 

19          reimbursement.

20                 The other issue I think is important 

21          to talk about is most of the people that work 

22          in DSPs across New York State are women, many 

23          of them women with children.  

24                 So I think that, you know, in order to 

                                                                   121

 1          provide this care, we have to look at the 

 2          whole picture.  And I think a career ladder 

 3          is important, and I also think that there are 

 4          women -- and these are low wages.  You know, 

 5          now that we increased minimum wage, look at 

 6          the care they're giving to this vulnerable 

 7          population.

 8                 ACTING COMMISSIONER DELANEY:  Yes.  I 

 9          think the two issues you raised are 

10          incredibly important in how we can recruit 

11          and retain additional DSPs.  

12                 First, with respect to the credential, 

13          as you know, several years ago we did a 

14          comprehensive study designed to look at how a 

15          credential would operate in our system.  We 

16          have now been working over the last several 

17          years to develop a pilot program for a 

18          credential, which we anticipate to be 

19          operational within the next year or so.  

20                 And you're absolutely right, about 

21          75 percent of the direct support workforce 

22          are women.  And one of the things we've been 

23          looking at -- and in addition to the work of 

24          the Governor's Task Force on Women and Girls, 

                                                                   122

 1          we're looking at issues related to improving 

 2          the economic standing of women -- is we've 

 3          been looking at how we can make our 

 4          workplaces more flexible, more 

 5          individual-friendly, looking at flexible 

 6          scheduling, working with our providers, on 

 7          how we can really take the workforce that we 

 8          have, which is predominantly women, and adapt 

 9          in some ways to the needs that women have.

10                 ASSEMBLYWOMAN GUNTHER:  I've heard 

11          complaints from providers that they don't 

12          even receive their rates, you know, their 

13          rates for the next year in order to make an 

14          appropriate budget, until six months after 

15          the beginning of the fiscal year.

16                 Is OPWDD doing anything about that?  

17          And I hear this from many of the providers:  

18          How can you have a budget for a year when you 

19          don't know what your rates are going to be?  

20          And I just think that they're living on the 

21          edge at this moment.  You know that salaries 

22          are difficult to go up.  And basically I feel 

23          that the least we can do is give them their 

24          rates so they can make an appropriate budget.  

                                                                   123

 1          And I hear this from all the agencies across 

 2          New York State.

 3                 ACTING COMMISSIONER DELANEY:  It is 

 4          accurate that rates that were effective 

 5          July 1st of 2017 were only published months 

 6          later.  That is not a situation that we 

 7          wanted to be in or that the Department of 

 8          Health wanted to be in.  They are the lead 

 9          rate-setting entity for Medicaid, as you 

10          know.  

11                 However, we and the Department of 

12          Health began hearing a number of concerns 

13          from providers about the expected impact of 

14          those rates.  And we really felt that it was 

15          important to take the time, before we just 

16          went out with the rates, to understand what 

17          those concerns were.  And we actually made a 

18          number of changes to the methodology based on 

19          what we heard from providers during that time 

20          period.  So we really did take that time to 

21          try to improve the rate methodology so that 

22          the end product was better and was something 

23          that many of our provider associations who 

24          helped us in this process could support.

                                                                   124

 1                 ASSEMBLYWOMAN GUNTHER:  Well, they 

 2          live very close to the edge.  And when you 

 3          get a letter a year later that you owe 

 4          New York State a million dollars and you have 

 5          to come up with the money, it makes it very, 

 6          very difficult to budget at all.  And I mean, 

 7          these are large agencies that are really 

 8          providing such vital services.

 9                 The Executive Budget also provided 

10          $30 million for OPWDD service expansion.  Do 

11          you feel there's a sufficient amount of 

12          resources to meet housing and other 

13          community-based needs?

14                 ACTING COMMISSIONER DELANEY:  So the 

15          $30 million becomes $60 million when you add 

16          in the federal share.  And when you look at 

17          the commitments for last year that are 

18          annualizing and what we expect to bring 

19          online this year, it's really the value of 

20          $120 million that we receive for services 

21          this year.

22                 We do believe that that commitment 

23          will meet individuals' needs.  In fact we 

24          were able to, as you know, put out a request 

                                                                   125

 1          for services for 459 new housing 

 2          opportunities.  So we believe that that 

 3          funding will really help us this year to grow 

 4          our service system.

 5                 ASSEMBLYWOMAN GUNTHER:  Do we have an 

 6          accurate number -- I know that I have a lot 

 7          of parents that come and meet with our 

 8          office, and I just think this is an important 

 9          point.  What they feel is like they have 

10          young people that have been together since 

11          early childhood, and a lot of the housing, it 

12          seems that goes to emergent situations.  That 

13          there's 459 spots, and there's a waiting 

14          list, but what happens is when there's an 

15          aging parent, that person goes to the top of 

16          the list.

17                 So movement in that 459 doesn't seem 

18          to be -- there doesn't seem to be much 

19          movement.  And I think that having talked to 

20          parents, that the trepidation, the anxiety -- 

21          and also, when we talk about self-directed 

22          care, there are young people that I've met, 

23          they've been in the same school, they're in 

24          the DD community for seven, 10 years.  And 

                                                                   126

 1          the parents are friendly.  So their wish in 

 2          life is that they stay together.  And because 

 3          of the housing situation, that might never 

 4          happen.

 5                 And, you know, in the past like 

 6          parents have, you know, offered to pay for 

 7          the house itself, to put their finances 

 8          together and buy the house.  But we need the 

 9          service.  And, you know, I think in the 

10          future that what I'm hearing is there are not 

11          enough available spots, even though we made 

12          some investment, that we don't even have any 

13          realization of how many people are waiting in 

14          line.

15                 ACTING COMMISSIONER DELANEY:  One of 

16          the things that we've done over the course of 

17          the last several years is to really try to 

18          take a proactive look at who will need 

19          housing in our system in the coming years.  

20          We looked at what the natural turnover is, 

21          and with 41,000 opportunities, you can 

22          imagine we have significant turnover each 

23          year.  And then we looked at what we think 

24          will be needed investments, so that we can 

                                                                   127

 1          make sure that parents and loved ones 

 2          understand that we are developing new 

 3          opportunities as we need them.

 4                 We've actually worked with a number of 

 5          families who have come to us with those kind 

 6          of creative options and said they wanted to 

 7          work towards buying a residence, could a 

 8          provider provide staffing for that, and we've 

 9          successfully done that on a number of 

10          occasions.  And flexibility and creativity --

11                 ASSEMBLYWOMAN GUNTHER:  I had one in 

12          my community that I know of that worked with 

13          an ARC.

14                 ACTING COMMISSIONER DELANEY:  Yes.

15                 ASSEMBLYWOMAN GUNTHER:  But only one.

16                 ACTING COMMISSIONER DELANEY:  Yes.  

17          They can sometimes be difficult within our 

18          current structure of the Home and 

19          Community-Based Services Waiver, but we've 

20          done it successfully.  We want to do more of 

21          that.  And in the 1115 waiver that we're 

22          moving to, that's the place where we want to 

23          try to provide a lot more of that flexibility 

24          and ability to more creatively meet people's 

                                                                   128

 1          needs.

 2                 ASSEMBLYWOMAN GUNTHER:  The next thing 

 3          I wanted to talk about is telemedicine, which 

 4          I'm very fond of.  

 5                 Do you believe that the use of 

 6          telemedicine can be an effective way to 

 7          improve health outcomes and improve 

 8          efficiencies in the OPWDD system?

 9                 ACTING COMMISSIONER DELANEY:  I 

10          absolutely do.  I think, as Commissioner 

11          Sullivan indicated, telemedicine is certainly 

12          something we'll be talking about a lot in the 

13          future of healthcare in the coming years.

14                 But for many of our individuals, the 

15          individuals we serve, particularly those who 

16          have concerns, difficulty leaving their 

17          homes, what we want to do is enable them to 

18          receive access to specialty services that 

19          they need right from their homes.  Certainly 

20          it has to be carefully done.  We have to make 

21          sure that where someone needs emergency 

22          response, they can have that.  

23                 But we think telemedicine will overall 

24          improve the quality of care and individual 

                                                                   129

 1          outcomes for the people we serve, and also 

 2          help us provide services in areas where we 

 3          don't have enough providers and people would 

 4          have to travel very long distances to see a 

 5          specialist that they might need.

 6                 ASSEMBLYWOMAN GUNTHER:  The Executive 

 7          Budget also includes $38.9 million to support 

 8          the establishment of Care Coordination 

 9          Organizations, or CCOs.  Can you provide more 

10          detail about what this funding will be used 

11          for and how it will be distributed in 

12          New York?

13                 ACTING COMMISSIONER DELANEY:  Sure.  

14          We are, as I noted, establishing Care 

15          Coordination Organizations under the federal 

16          Health Home program.  Those entities will 

17          have a number of startup costs, including IT, 

18          which is a very significant cost --

19                 ASSEMBLYWOMAN GUNTHER:  And difficult 

20          in places in upstate New York.

21                 ACTING COMMISSIONER DELANEY:  And 

22          difficult, absolutely.  

23                 -- and a number of other costs as they 

24          start up these new organizations, which will 

                                                                   130

 1          be made up of OPWDD providers.  So that 

 2          funding is really going to support these 

 3          startup costs in IT and in other things.

 4                 CHAIRWOMAN WEINSTEIN:  Thank you.

 5                 Senate?

 6                 SENATOR SAVINO:  Senator Brooks.

 7                 SENATOR BROOKS:  Thank you.

 8                 And good morning.  Or good afternoon, 

 9          whatever it is.  Just a couple of points.

10                 First I think on the caregivers.  I 

11          think it is absolutely critical that we work 

12          on a career-path-type program for them.  I 

13          think these folks are doing an outstanding 

14          job, and we really haven't given them the 

15          recognition and the compensation that they 

16          deserve.

17                 On your transition plan to the managed 

18          care program, we're hearing a lot of concern 

19          from the parents, as they're not really sure 

20          what's totally happened.  Can you talk about 

21          how you're providing them the information on 

22          what's going on, what benefits they're going 

23          to see from these programs, and what input 

24          they'll have in the care given to these 

                                                                   131

 1          individuals going forward?

 2                 ACTING COMMISSIONER DELANEY:  Sure.  

 3          We have been talking about the move to 

 4          managed care in our system for a number of 

 5          years, and we've held a number of public 

 6          forums.  We have released a number of 

 7          stakeholder messages, webinars, we have 

 8          videos on our website.  We are really trying 

 9          to work with the individuals we serve and 

10          their parents, to understand what the next 

11          several years in our system will bring.  We 

12          are always looking for how we can improve 

13          communication to the people we serve and 

14          their families.  

15                 But we have been talking about these 

16          changes for a number of years.  We've been 

17          meeting with parent groups, with advocacy 

18          groups, and trying to get the understanding 

19          out there of the changes coming to our 

20          system, and we'll continue to do so.

21                 SENATOR BROOKS:  From a housing 

22          standpoint, as has been pointed out, there 

23          are a number of parents rightly concerned 

24          with what the future is going to hold.  

                                                                   132

 1                 Can you address or put together a 

 2          situation where you're providing some of 

 3          these parents with an indication of your 

 4          longer-range planning so they can see that 

 5          these facilities are going to be available 

 6          for their children when that time comes?  It 

 7          is a major concern.  As has been mentioned, 

 8          many of the parents are looking to put funds 

 9          together or use their own home for that 

10          purpose.  So it's a major concern.

11                 And I think there's that uncertainty 

12          for the parents on what the long-range 

13          planning is in terms of facilities going 

14          forward.  I think it's important that we 

15          communicate it to the people.

16                 ACTING COMMISSIONER DELANEY:  Yes, 

17          absolutely.  And our hope is that parents and 

18          people in our system will see that for the 

19          first time in several years, our proactive 

20          development of residential supports that we 

21          began this year with the 459 opportunities, 

22          is exactly OPWDD doing that -- looking at 

23          what our needs will be and projecting that 

24          into the future, and beginning development so 

                                                                   133

 1          that we have opportunities available when 

 2          people need them.

 3                 SENATOR BROOKS:  Are you comfortable 

 4          with where you are in terms of facility and 

 5          what we have in terms of short-term needs 

 6          right now?

 7                 ACTING COMMISSIONER DELANEY:  Yes.  I 

 8          believe that with the plans that we have for 

 9          new development, I believe we'll be able to 

10          meet the needs of those who will need housing 

11          in our system in the coming years.

12                 SENATOR BROOKS:  Okay, thank you.

13                 CHAIRWOMAN WEINSTEIN:  Assemblywoman 

14          Melissa Miller.

15                 ASSEMBLYWOMAN MILLER:  Hi.  Good 

16          morning.

17                 ACTING COMMISSIONER DELANEY:  Hi.  

18          good morning.

19                 ASSEMBLYWOMAN MILLER:  I know that 

20          we've spoken about this, and I want to thank 

21          you for your commitment to working with me on 

22          making some of these changes.  But for the 

23          sake of everybody else, I just want to 

24          reiterate a little bit of what we spoke about 

                                                                   134

 1          and what my concerns are.

 2                 As far as self-direction and the 

 3          self-direction budget that I had some 

 4          concerns over, my first question was 

 5          basically about transparency and who decides 

 6          what funds can and can't be used for.  Is 

 7          there a panel that is put together, and by 

 8          whom?  Because it doesn't seem to me that the 

 9          family has much input as to what the 

10          individuals who are receiving the budget 

11          funds -- you know, we should have some input 

12          over what those funds are used for.

13                 So I was just curious who decides.

14                 ACTING COMMISSIONER DELANEY:  You 

15          absolutely should have input into how those 

16          funds are used.  Every person who comes into 

17          the OPWDD system receives an assessment as 

18          far as what their needs are, what their 

19          strengths are, where they need support.  At 

20          that point people should be presented with a 

21          range of options that will be available to 

22          meet their needs.  So at that point in our 

23          process, families and individuals should have 

24          significant input into what services their 

                                                                   135

 1          loved one will be receiving.

 2                 ASSEMBLYWOMAN MILLER:  But that isn't 

 3          what -- at what point are the decisions made?  

 4          What items or what services are approved in a 

 5          self-direction budget, and what are not?  

 6                 For instance -- and this was the next 

 7          point -- it seems that skilled care services 

 8          or, in our case, an enhancement of a skilled 

 9          care service seems to be a nonapproved 

10          service.  So we were looking to -- since my 

11          son has skilled care needs, we were looking 

12          to enhance a private-duty-nursing hourly 

13          rate.  And that was a firm no, as something 

14          you cannot do with a self-direction budget.

15                 However, he is excluded from most of 

16          the approved items that you can use a 

17          self-direction budget for, because of his 

18          skilled care needs.  So it seems somewhat 

19          discriminatory.

20                 So I was just curious, who does decide 

21          what is approved and what is not approved?

22                 ACTING COMMISSIONER DELANEY:  And I 

23          will tell you that self-direction for people 

24          that have medical challenges or significant 

                                                                   136

 1          mental health challenges has been one of the 

 2          most difficult issues that we have confronted 

 3          as we've been trying to grow self-direction, 

 4          because there are some very strict Medicaid 

 5          rules about how funding can be used in 

 6          various settings, and the federal government 

 7          is very concerned that funding streams are 

 8          separated.

 9                 That's one of the very reasons why 

10          we're moving into Health Homes and managed 

11          care, because we do believe that when you 

12          bring these sources of funding together and 

13          you look together at all of the different 

14          funds that are available to help meet 

15          someone's needs, we can do a much better job 

16          actually of analyzing and saying are there 

17          additional nursing hours needed, how do we 

18          make that happen, versus looking at it purely 

19          from the, well, in self-direction, we can't 

20          pay for this.  

21                 We change from looking at what the 

22          funding stream can pay for and what the 

23          requirements are to what are the individual's 

24          needs and how do we bring those resources to 

                                                                   137

 1          bear to meet those needs.

 2                 ASSEMBLYWOMAN MILLER:  But it's -- a 

 3          large part of the population have these 

 4          medical needs, so it's --

 5                 ACTING COMMISSIONER DELANEY:  It is.  

 6          It is.  And again, it's been one of our -- 

 7          one of the greatest challenges that we have 

 8          had with self-direction, and I know something 

 9          that has been very frustrating to many 

10          parents and loved ones in our system who feel 

11          that self-direction really is not something 

12          that can meet their needs.  And it's 

13          something we're really looking to fix.

14                 ASSEMBLYWOMAN MILLER:  Especially 

15          because the push is so towards 

16          self-direction.

17                 ACTING COMMISSIONER DELANEY:  Right.  

18          Well, we do want to get to a place where 

19          everyone who's interested in self-directing 

20          can do so.  But that should not come at the 

21          expense of people who want or need a 

22          different type of service model or option.  

23          And that should be available to those 

24          individuals.

                                                                   138

 1                 ASSEMBLYWOMAN MILLER:  Okay.  My next 

 2          question is about residential facility.  And 

 3          there is a need, obviously, across the state, 

 4          but I have been contacted by numerous 

 5          families, and there seems to be a need for 

 6          one upstate, specifically in the Capital 

 7          District.

 8                 And it seems to be -- the families 

 9          have been asking for more of a campus-style.  

10          I was happy that you were acknowledging that 

11          there is a need and that you are in agreement 

12          that a campus-style might be an approach that 

13          would work to meet the needs for individuals 

14          that have both behavioral challenges as well 

15          as complex medical needs or skilled care 

16          needs.  It would provide, you know, similar 

17          to like a college-style campus where you 

18          could meet all of the needs without having to 

19          really leave a facility.

20                 Is there a way that maybe OPWDD could 

21          work collaboratively with the Department of 

22          Health, similar to how you work with OMH, for 

23          funding for setting rates in order to provide 

24          the necessary level of skilled care to meet 

                                                                   139

 1          those needs?

 2                 ACTING COMMISSIONER DELANEY:  Yes.  So 

 3          first I would say we have looked very closely 

 4          and worked very hard with our stakeholders to 

 5          make sure that everyone lives in the most 

 6          community-integrated setting possible.  As 

 7          you and I have talked about, there are some 

 8          individuals who because of their medical 

 9          needs might benefit from living with other 

10          individuals.  And maybe for them an 

11          apartment-style setting is not the right 

12          opportunity.

13                 We're certainly willing to talk with 

14          you, with our families, with our advocates 

15          about how we can design and make sure that we 

16          have the right opportunities for individuals 

17          who may have skilled nursing needs or other 

18          types of needs that sometimes can be 

19          difficult in the community.

20                 CHAIRWOMAN WEINSTEIN:  Thank you.

21                 Senate?

22                 CHAIRWOMAN YOUNG:  Senator Savino.

23                 SENATOR SAVINO:  Thank you, Senator 

24          Young.

                                                                   140

 1                 Thank you, Commissioner.  Good to see 

 2          you.  

 3                 I want to talk about an issue -- as 

 4          you know, you'll be coming to Staten Island 

 5          and to Brooklyn soon for the annual 

 6          breakfast, and one of the issues that always 

 7          comes up is the length of time it takes for 

 8          housing opportunities for families.  As you 

 9          know, there's several families who have been 

10          waiting a very long time.  

11                 And so I know -- I've read your 

12          testimony and, you know, the numbers of units 

13          that you think will be available soon.  But 

14          of the ones that are already existing -- and 

15          this is an increasing concern.  I had the 

16          opportunity to visit a home in Staten Island 

17          that's run by AHRC.  It's a beautiful home, 

18          you could see that the people who -- the 

19          consumers that live there are very happy 

20          there.  But as we're seeing, many people are 

21          aging in place.  

22                 Well, we would like them to age in 

23          place in a home that they may have lived in 

24          for several years now.  And some of these 

                                                                   141

 1          homes, unfortunately, were not designed to 

 2          help people who are developing complex 

 3          physical problems as they age.  So they're 

 4          oftentimes waiting a very long time to get 

 5          approval for changes to the home that will 

 6          accommodate people who are aging in place.  

 7                 Is there anything you can do to 

 8          expedite that process?

 9                 ACTING COMMISSIONER DELANEY:  You 

10          know, the issue of how people with 

11          developmental disabilities age in the 

12          community is very similar to that that's 

13          confronted by everyone else, which is how do 

14          we make sure that we have the right supports 

15          in place as someone ages and as their needs 

16          change.

17                 Our service system probably has not 

18          been as easy to navigate in those situations.  

19          We are looking at how we can speed up and how 

20          we can make better the process by which 

21          providers come to us and say that they need 

22          some funding to help make modifications to 

23          allow individuals to stay in their homes.

24                 SENATOR SAVINO:  Well, I would 

                                                                   142

 1          encourage you guys to develop that expedited 

 2          process, because it would be disruptive. 

 3                 Now, it would not be a budget hearing 

 4          if I didn't turn to one of my favorite issues 

 5          that I think every commissioner has to 

 6          address because it's -- when I embarked on 

 7          this journey to bring medical marijuana to 

 8          New York State, I never thought I would be 

 9          like peeling back the layers of an onion.  

10          And so now what we're seeing is patients or 

11          consumers who are residing in homes that are 

12          licensed and operated by your partner 

13          agencies.  They are suffering from the same 

14          physical ailments and the same chronic 

15          conditions that the general public does, and 

16          many of them are eligible to become medical 

17          marijuana patients in New York State.  

18                 But there seems to be some 

19          concern about the delivery or the dispensing 

20          of medication in these residential 

21          facilities.  We addressed this with school 

22          nurses, who in State Ed issued an advisory to 

23          school districts about nurses being able to 

24          dispense medical marijuana without it being 

                                                                   143

 1          in violation of their license, which says 

 2          that they can't handle Schedule 1 substances.  

 3          But in this instance they can, because we've 

 4          made that Schedule 1 substance legal in 

 5          New York State.

 6                 I have heard from some parents of some 

 7          of the consumers who are residing in homes 

 8          that they're encountering the same thing, 

 9          because there seems to be some concern on the 

10          part of the partner agencies about whether 

11          their staff can administer the medication to 

12          people who are entitled to it.  

13                 So have you addressed that with the 

14          agencies?  Or are you able to do that, or do 

15          you need some direction on how to make that 

16          happen?

17                 ACTING COMMISSIONER DELANEY:  Yes, we 

18          are working with the Department of Health, 

19          which as you know is the lead state agency 

20          tasked with implementing medical marijuana in 

21          New York State.  

22                 There have been a number of 

23          complexities that have given us some pause as 

24          far as being able to implement as 

                                                                   144

 1          expeditiously as we would like to.  First we 

 2          had issues with the State Board of Nursing, 

 3          as you referenced.  We're also somewhat 

 4          concerned about recent federal guidance in 

 5          this area and the impact of that on direct 

 6          support professionals.  So we are working 

 7          with the Department of Health on what our 

 8          next best step should be in light of those 

 9          complexities.

10                 SENATOR SAVINO:  I'm glad to hear that 

11          you guys are working on it.  I would probably 

12          like to speak offline with you about that if 

13          there's a legislative issue that needs to 

14          address the problem or if it's purely 

15          regulatory.  But I do think that we need to 

16          find a solution.

17                 I wrote to both the president -- as 

18          you can imagine, he didn't reply -- but I 

19          have also written to the four U.S. Attorneys 

20          in New York State to ask them to respect not 

21          only the Legislature and the Governor, who 

22          have created this program, but the rights of 

23          the patients in New York State who have 

24          registered for it.  Hopefully one of them 

                                                                   145

 1          will respond to me.

 2                 But in the meantime I look forward to 

 3          working with you on this because it doesn't 

 4          help us to have patients who become certified 

 5          and then are incapable of having access to 

 6          the medication that they -- that we've 

 7          determined is best for them.  Thank you.

 8                 ACTING COMMISSIONER DELANEY:  Thank 

 9          you.

10                 CHAIRWOMAN YOUNG:  Thank you.

11                 I'd like to announce that we've been 

12          joined by Senator Fred Akshar.

13                 CHAIRWOMAN WEINSTEIN:  Thank you.

14                 Assemblyman Angelo Santabarbara.

15                 ASSEMBLYMAN SANTABARBARA:  Thank you, 

16          Commissioner.  Thank you for being here 

17          today.  Thank you for your testimony.  

18                 I just wanted to get an update on the 

19          development of certified and noncertified 

20          housing opportunities that you talked about.  

21          What I hear in my district, and a lot of 

22          people hear the same issue, parents talk 

23          about their child not being able to get a 

24          placement unless they're in an emergency 

                                                                   146

 1          situation.  So with the new priority system, 

 2          how is it working for deciding who's eligible 

 3          for these opportunities?  And does it offer 

 4          more opportunities to those that are still on 

 5          the waiting list -- that is still very 

 6          long -- and that are not necessarily in those 

 7          emergency situations, but still in need of 

 8          residential housing?

 9                 ACTING COMMISSIONER DELANEY:  Sure.  

10          So we have heard concern from families, from 

11          parents of the individuals we serve, about 

12          access to a housing opportunity in our 

13          system.  

14                 It is accurate that we always 

15          prioritize those who have an emergency need 

16          first, because they truly have an emergency 

17          need, as you can imagine.  However, each year 

18          we help many other people access residential 

19          placements in our system who are not of that 

20          emergency need category.  

21                 The 459 opportunities that we're now 

22          working with providers to develop are not for 

23          people that are in that highest category of 

24          need, it's for people who are living at home 

                                                                   147

 1          with their caregivers.  In some cases we are 

 2          seeing some new development for people with 

 3          mental health needs.  

 4                 But parents absolutely should 

 5          understand that we are working and doing all 

 6          we can to ensure sufficient opportunities for 

 7          residential placements in our system for 

 8          those who will need them.

 9                 ASSEMBLYMAN SANTABARBARA:  And I 

10          talked about this earlier, there's still, you 

11          know, a significant shortage of DSPs, direct 

12          care staff, and the turnover rates are still 

13          there, the vacancy rates.  And, you know, we 

14          talked about the funding in the budget last 

15          year, but without continued investment in our 

16          direct care staff, the new opportunities that 

17          we've seen still, it still presents a 

18          challenge, you know, to staff those 

19          opportunities.

20                 So what more can be done to support 

21          the direct care workers and recruit and 

22          retain this critical piece of the puzzle?

23                 ACTING COMMISSIONER DELANEY:  I think 

24          there are a number of things.  Obviously the 

                                                                   148

 1          $191 million that's going into our system 

 2          from the increases for the #bFair2DirectCare 

 3          campaign is one.  The career ladders that we 

 4          are looking at is another.  Looking at how we 

 5          develop and professionalize and continue to 

 6          professionalize the direct support workforce 

 7          is another.

 8                 So there are a number of things that 

 9          we need to do to ensure that we have an 

10          adequate direct support workforce, from 

11          compensation to specific targeted 

12          recruitment.

13                 ASSEMBLYMAN SANTABARBARA:  And my last 

14          question is about children who are remaining 

15          in hospitals for too long because they don't 

16          have adequate access to services.  Is there 

17          something being done in the budget to address 

18          this issue?  It's a very significant issue.

19                 ACTING COMMISSIONER DELANEY:  Yes, we 

20          are aware of circumstances where children end 

21          up in the hospital, end up in situations 

22          where we don't want them to have to be.

23                 One of the key things that we look at 

24          is how can we prevent this from happening, as 

                                                                   149

 1          much as how can we help people leave those 

 2          settings.  That's why we and the Office of 

 3          Mental Health, because it's very often kids 

 4          that have significant psychiatric issues, are 

 5          working on a program -- there's actually two 

 6          programs.  There's one for adults, which will 

 7          be downstate, and one for children that will 

 8          be in the western part of the state, that 

 9          will help us to better address the 

10          cross-system needs of those children.  

11                 Because oftentimes the problem comes 

12          in when you have two different government 

13          systems trying to work together to meet those 

14          needs, developing a cross-system coordinated 

15          program we think will really help and assist 

16          in this issue.

17                 ASSEMBLYMAN SANTABARBARA:  Thank you.

18                 ACTING COMMISSIONER DELANEY:  Thank 

19          you.

20                 CHAIRWOMAN WEINSTEIN:  Thank you.

21                 Assemblywoman Miller.

22                 ASSEMBLYWOMAN MILLER:  Thank you.

23                 I just wanted to finish up what I was 

24          asking before and then just make one comment.

                                                                   150

 1                 When I met with your team last week, I 

 2          did ask for an actual number -- I haven't 

 3          received it yet -- of the actual number of 

 4          patients or individuals that are over 21 that 

 5          are living in residential facilities that are 

 6          children's facilities, up to age 21, and have 

 7          been for some time.

 8                 ACTING COMMISSIONER DELANEY:  Sure.

 9                 ASSEMBLYWOMAN MILLER:  Just curious 

10          what that actual number is.  But what that 

11          does -- because I know of a few families who 

12          have children who are over 21 who have been 

13          living in those residential facilities for 

14          several years and feel that not enough has 

15          been done or that there really just is no 

16          appropriate placement.  They feel somewhat 

17          forced into choosing a less than appropriate 

18          placement, and rather than choose that, 

19          they're just staying where they are.

20                 But that is what's creating this 

21          waiting list and these backlogs for everybody 

22          else, and it puts everybody in a very unsafe 

23          situation -- the children who are in the home 

24          with 22-, 23-, 24-, 25-year-olds when they 

                                                                   151

 1          shouldn't be there, the staff -- it's a 

 2          strain on everybody.  So it's just not a 

 3          healthy situation for anybody involved.

 4                 So if you could just get me that 

 5          number at some point, I would appreciate it.

 6                 ACTING COMMISSIONER DELANEY:  Sure, I 

 7          will do so.

 8                 ASSEMBLYWOMAN MILLER:  Thank you.

 9                 And I just wanted to make a comment.  

10          Like Senator Brooks, I too was getting a lot 

11          of feedback and comments to my office when 

12          there was the open comment period about the 

13          conversion process, the transition process, 

14          to the care coordination, the 1115.  But I 

15          have to applaud you for the efforts you've 

16          been making because as a parent myself with a 

17          child in the process, the webinars, the 

18          workshops, the outreach has been 

19          extraordinary and very, very helpful, and I'm 

20          hearing that as well. 

21                 So I am hearing very positive feedback 

22          on the families are responding to that, and 

23          that is helping them.  So that response to 

24          parents asking for help is very -- you know, 

                                                                   152

 1          something to applaud you for.  So thank you.

 2                 ACTING COMMISSIONER DELANEY:  I'm glad 

 3          to hear that.  Thank you.

 4                 CHAIRWOMAN WEINSTEIN:  Thank you.

 5                 CHAIRWOMAN YOUNG:  Thank you.

 6                 Everybody set?  Okay.  So that 

 7          concludes your appearance today.  We truly 

 8          appreciate it, Commissioner, and look forward 

 9          to having more positive dialogue.  

10                 Our next speaker is Commissioner 

11          Arlene González-Sánchez, New York State 

12          Office of Alcoholism and Substance Abuse 

13          Services.

14                 So we welcome the commissioner.  Thank 

15          you for being here.

16                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

17          you.

18                 CHAIRWOMAN YOUNG:  Anytime you want to 

19          go ahead.

20                 If we could have some order in the 

21          house, please.  Go ahead, Commissioner.  

22                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

23          you.  Good afternoon, Senator Young, 

24          Assemblymember Weinstein, Senator Amedore, 

                                                                   153

 1          and distinguished members of the Senate and 

 2          Assembly.  My name is Arlene 

 3          González-Sánchez.  I am the commissioner of 

 4          the New York State Office of Alcoholism and 

 5          Substance Abuse Services.  

 6                 First, thank you all for supporting 

 7          our mission and providing me the opportunity 

 8          to present Governor Cuomo's 2018-2019 

 9          Executive Budget as it pertains to OASAS.

10                 Before I discuss the specific details 

11          of the upcoming Executive Budget, I want to 

12          take a moment to share with you our 

13          accomplishments to date.  We have opened new 

14          programs and expanded existing services to 

15          respond to the needs created by the opioid 

16          epidemic.  We have added treatment capacity 

17          and have launched Peer Engagement and Family 

18          Support Navigator Programs, and opened Youth 

19          Clubhouses, Recovery Centers and Addiction 

20          Resource Centers in every region of the 

21          state.  

22                 We have more than 160 prevention 

23          agencies, at least one in every county, 

24          providing education-based programming, public 

                                                                   154

 1          awareness activities, positive alternatives 

 2          and counseling services.  Overall, more than 

 3          60 percent of our prevention programs target 

 4          elementary school children.  And we recently 

 5          launched a $2.5 million prevention initiative 

 6          at 20 SUNY and CUNY colleges designed to help 

 7          prevent and reduce underage drinking and drug 

 8          use on college campuses.  

 9                 To ensure the availability of 

10          treatment services throughout the state, we 

11          have implemented telepractice and now have 

12          more than 20 mobile treatment vehicles, 

13          providing services and transporting people to 

14          treatment programs.  More are expected to 

15          come online this year.  Additionally, we have 

16          expanded our educational campaigns and 

17          created a Youth and Young Adult Statewide 

18          Recovery Network.  

19                 We've opened our first 24/7 Open 

20          Access Center, to help people access 

21          treatment on demand by providing assessments 

22          and referrals to the appropriate level of 

23          care 24 hours a day, seven days a week.  

24                 It gives me great pleasure to inform 

                                                                   155

 1          you that today we will be announcing the 

 2          award of more than $4 million to open l0 more 

 3          Open Access Centers, resulting in there being 

 4          at least one in every region of the state.  

 5          So as you can see, we have been implementing 

 6          the Governor's strategies for combating the 

 7          opioid epidemic and developing new programs 

 8          for New Yorkers in need of our services.  But 

 9          we realize that much more work still needs to 

10          be done.  

11                 The Governor's Executive Budget 

12          proposes nearly $787 million that supports 

13          OASAS's ability to respond to needs 

14          identified by our constituents throughout the 

15          state, and allows us to move forward on our 

16          key priorities, including the full annual 

17          salary increases of 6.5 percent for direct 

18          care and support positions and 3.25 percent 

19          for clinical titles, as well as the increase 

20          in the minimum wage for funded OASAS 

21          providers.  

22                 We will open 203 new residential 

23          treatment beds and 350 Opioid Treatment 

24          Program slots.  In addition, we are 

                                                                   156

 1          continuing a scholarship program to support 

 2          250 new candidates to become Certified 

 3          Recovery Peer Advocates.  And in the coming 

 4          weeks, we will announce the award of 

 5          $10 million in capital funding to develop new 

 6          detox beds throughout the state.  

 7                 The Executive Budget allows us to 

 8          develop seven regional Problem Gambling 

 9          Resource Centers and gives us the flexibility 

10          to expand evidence-based prevention models in 

11          schools that teach children self-regulation 

12          and positive decision-making, focusing on 

13          school engagement and achievement as 

14          protective factors.  

15                 The budget also includes funding to 

16          support on-site, peer-delivered substance use 

17          disorder treatment services in eight homeless 

18          shelters in New York City and 14 shelters in 

19          the rest of the state, reaching a total of 

20          22 shelters statewide.  

21                 There is a proposed surcharge on 

22          opioid prescriptions, to be assessed at 

23          2 cents per morphine milligram equivalent. 

24          These funds will be used to support opioid 

                                                                   157

 1          prevention, treatment and recovery efforts. 

 2          Opioids purchased by OASAS programs to treat 

 3          addiction, like methadone and buprenorphine, 

 4          will be exempt from the surcharge.  

 5                 So to conclude, the 2018-2019 

 6          Executive Budget proposal includes funding to 

 7          support OASAS's continued work to develop 

 8          innovative new services and advance key 

 9          initiatives, to confront the opioid epidemic.  

10          We look forward to your continued partnership 

11          and support as we advance these priorities.  

12                 Thank you for your time today.

13                 CHAIRWOMAN YOUNG:  Thank you.

14                 Our first speaker will be Senator 

15          George Amedore, who is the chair of our 

16          Committee on Alcoholism and Drug Abuse.  

17          Senator Amedore.

18                 SENATOR AMEDORE:  Thank you, 

19          Senator Young.  

20                 And thank you, Commissioner, for being 

21          here today.  It's always a pleasure to work 

22          with you, and there's no question this 

23          substance abuse disorder is wreaking havoc in 

24          every part of the State of New York in every 

                                                                   158

 1          which way, whether it's gambling, alcohol, 

 2          whether it's tobacco, whether it is now the 

 3          scourge of heroin and the increase of opiate 

 4          deaths, we're trying to tackle this in a 

 5          multipronged approach.  And I know that 

 6          you've given us testimony that you've 

 7          increased prevention and educational 

 8          opportunities, so thank you for that.

 9                 The 24-hour Open Access Centers have 

10          been -- are new, and they have been helpful.  

11          The clubhouses have been helpful, 

12          particularly with our young adolescents and 

13          after-school programs.  And the need for more 

14          recovery peer advocates and the investment in 

15          such plays a big part of how we're going to 

16          eradicate this epidemic that we see.

17                 As you mentioned, the Governor has 

18          proposed a surcharge on the first sale of 

19          opiates.  And, you know, I want to discuss 

20          that a little bit with you, because according 

21          to Commissioner Zucker, the surcharge is 

22          meant to be paid for by the pharmaceutical 

23          companies.  However, under the language of 

24          the bill, the surcharge is levied at the 

                                                                   159

 1          first sale in the state.  

 2                 So my question is, what is the first 

 3          sale?  And when in the supply chain is it 

 4          going to occur?

 5                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  The 

 6          last part of your question, when --

 7                 SENATOR AMEDORE:  When in the supply 

 8          chain is it going to occur, that first sale?

 9                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay, 

10          so the way it was written was so that the 

11          surcharge would be, of course as you 

12          indicated, at the first point of sale to the 

13          state, essentially targeting the 

14          manufacturers and the distributors who I 

15          don't think I have to beleaguer the issue 

16          that they have really financially gotten a 

17          lot of monies out of the sale of these 

18          opioids, and I think that maybe they need to 

19          take a little responsibility for the increase 

20          in the sale of these opioids.

21                 In terms of --

22                 SENATOR AMEDORE:  But -- excuse me, 

23          Commissioner, I'm not -- I'm not actually 

24          asking who's meant to pay for the surcharge, 

                                                                   160

 1          I'm asking who actually will pay for the 

 2          surcharge.

 3                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Those 

 4          specifics, I think it's better to ask the Tax 

 5          Department, who will be actually implementing 

 6          that.  That is out of my jurisdiction, so I 

 7          really don't want to say something that's 

 8          incorrect.  So I'm not in a position to 

 9          answer that.

10                 SENATOR AMEDORE:  Okay.  So can the 

11          first sale be a consumer?

12                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  This 

13          first sale is not the consumer.  The first 

14          sale is who sells the actual product to the 

15          state, in which case it would be the 

16          manufacturer and the distributors.

17                 SENATOR AMEDORE:  Okay, but I'm 

18          thinking of those who get their prescription 

19          drugs on mail order.  Is there any language 

20          regarding a mail order pharmaceutical -- or 

21          pharmacies?

22                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I am 

23          not familiar to that extent on the language 

24          of the bill.  Again, I think that that's a 

                                                                   161

 1          better question to the Tax Department, who 

 2          will be monitoring how this surcharge will be 

 3          delivered.

 4                 SENATOR AMEDORE:  Okay.  You also 

 5          mention in your testimony that the exclusions 

 6          of Suboxone and buprenorphine, which are -- 

 7          OASAS providers are excluded from this.  But 

 8          what about those who are not and those 

 9          medically assisted treatment centers?

10                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  We've 

11          heard similar concerns.  And what I say is 

12          that I think that there's still room for some 

13          discussions around those items.

14                 SENATOR AMEDORE:  Has there been any 

15          discussion regarding exclusion of hospice or 

16          palliative care or cancer patients that -- be 

17          considered on --

18                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  It's 

19          the same -- my same answer.  We heard of 

20          concerns that have been raised, and I believe 

21          that there's still room for discussion.

22                 SENATOR AMEDORE:  Well, I would hope 

23          that there would be discussion and exclusions 

24          for this, particularly at the end of life and 

                                                                   162

 1          at hospice, when there's a large amount of 

 2          morphine or other opiate type of medication, 

 3          you know, that it would really put a huge 

 4          financial burden on those services.

 5                 You know, what are -- are there any 

 6          new opiate prevention, treatment, education 

 7          initiatives that will be brought online with 

 8          the funding received from the surcharge?

 9                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Well, 

10          it's -- the language says that the money 

11          could only be used to develop, you know, 

12          opioid prevention, treatment and recovery 

13          services.  Based on that, my assumption is 

14          that monies will be -- we will be allowed to 

15          use some of those monies to be able to, 

16          moving forward, deliver some of the services 

17          that we have planned.

18                 SENATOR AMEDORE:  Would that be 

19          medically assisted treatment centers?

20                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I'm 

21          sorry?

22                 SENATOR AMEDORE:  Would that include 

23          medically assisted treatment centers?

24                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  It 

                                                                   163

 1          would include all of our services within our 

 2          budget.

 3                 SENATOR AMEDORE:  Okay.  How does the 

 4          department intend to monitor or establish 

 5          enforcement that requires this legislation to 

 6          ensure that the surcharge is not going to be 

 7          passed on to the consumer?

 8                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Again, 

 9          that's something that, you know, I would say 

10          that we need to work on and discuss further.

11                 SENATOR AMEDORE:  Let's move to 

12          for-profit providers.  As you know, I have 

13          carried a bill for several years, sponsored a 

14          bill for several years which would allow 

15          providers, all providers in the state, not 

16          just not-for-profits, to participate in 

17          OASAS's RFP process, the request for 

18          proposal.  This legislation has passed the 

19          Senate several times.  What can we do to make 

20          progress in this area?

21                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Well, 

22          you know, we welcome for-profit providers to 

23          be part of our delivery of care, we just 

24          can't fund for-profits.  In fact, we do have 

                                                                   164

 1          several for-profits that we do license.  So 

 2          there's no intention to not continue that 

 3          practice.  If there are for-profit providers 

 4          that want to be licensed by us and are 

 5          willing to, you know, give the care that's 

 6          needed, we will entertain doing so.

 7                 SENATOR AMEDORE:  Well, I hear from a 

 8          lot of for-profit providers that a lot of 

 9          times the RFP process is closed to them and 

10          they're not able to apply.  And that, you 

11          know, when we have such high demand for the 

12          services, the capacity that we're trying to 

13          build in the State of New York to service 

14          this problem that we have in society, I would 

15          just think that we would need all hands on 

16          deck, everyone who's involved in this to have 

17          the opportunity.

18                 So I would look forward to some 

19          assistance and your help on this.

20                 COMMISSIONER GONZÁLEZ-SÁNCHEZ: 

21          Absolutely.  I agree.  And if there's 

22          anything, just -- you know where to find me, 

23          we can talk.

24                 SENATOR AMEDORE:  As I asked the 

                                                                   165

 1          commissioner of OMH, I will ask you the same 

 2          question.  According to the published 

 3          reports, over half of the population in local 

 4          jails suffer from substance abuse disorder.  

 5          Over two-thirds of these individuals have 

 6          been in jail before.  This is a huge problem 

 7          that needs to be addressed.

 8                 So what consideration has OASAS or 

 9          this administration given to reach out to 

10          serve this population?

11                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  So 

12          thank you for that question because, you 

13          know, we've been working really very closely 

14          with the commissioner of Corrections.  

15                 Currently we have -- out of the 

16          54 state correctional facilities, 52 of them 

17          provide SUD services behind the wall.  And 

18          what we do is we have developed guidelines 

19          that they are to use performing the 

20          counseling that they do behind the wall.  We 

21          monitor those guidelines,  we monitor them, 

22          we go, we visit, we do site visits to ensure 

23          that they are doing what the guidelines are 

24          requiring.  

                                                                   166

 1                 We also meet with some of the inmates 

 2          that are receiving the services to get their 

 3          input as to how it's going, and so on and so 

 4          forth.

 5                 Separate and aside from that, there's 

 6          like five programs that are specifically for 

 7          parole violators that are under the umbrella 

 8          of DOCCS.  Edgecombe is the one in New York 

 9          City that a lot of people are very familiar 

10          with.  And there will be three more opening 

11          throughout the state, I believe in Orleans, 

12          Hale Creek, and Willard.  And these programs 

13          will be running a Vivitrol program with these 

14          inmates -- or not really inmates but parole 

15          violators.  And I'm sure you know that 

16          Bedford Hills does have a medication assisted 

17          treatment program for women who are pregnant 

18          who are incarcerated.

19                 Aside from that, you know, there are 

20          like 58 county jails throughout the state -- 

21          I believe 58, if my brain is working.  We 

22          have already established 35 Vivitrol programs 

23          in those county jails, and this coming year 

24          12 more will come on board.  So that means we 

                                                                   167

 1          have -- 35, 12 -- 47.  We will be in 47 out 

 2          of the 58 county facilities.  They will be 

 3          offering Vivitrol assistance to individuals 

 4          that come in front of them.

 5                 Also let me just remind you that DOCCS 

 6          also provides a -- you know, Narcan for 

 7          inmates that are being released back into the 

 8          community.  

 9                 So you know, we're very aggressively 

10          working with DOCCS to see how we could 

11          continue to improve on services and how can 

12          we work better with them behind the wall.

13                 SENATOR KRUEGER:  Thank you.

14                 SENATOR AMEDORE:  Thank you. I'm out 

15          of time.

16                 SENATOR KRUEGER:  We'll come back for 

17          a second round, I'm sorry.

18                 Assembly?  

19                 CHAIRWOMAN WEINSTEIN:  Assemblywoman 

20          Gunther.

21                 ASSEMBLYWOMAN GUNTHER:  On behalf of 

22          my good friend Linda Rosenthal, who couldn't 

23          be here today -- but she's probably 

24          watching -- can you explain why the increases 

                                                                   168

 1          in the Executive Budget are primarily for 

 2          continued funding of existing programs and 

 3          wage support and not new or expanded 

 4          programming?  And why are we not increasing 

 5          funding to match the scope of the ongoing 

 6          opioid crisis?

 7                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  So in 

 8          general this budget really accommodates over 

 9          $200,000 -- over $200,000 for programming 

10          directed at the opioid treatment, prevention 

11          and recovery.  It allows us to move forward 

12          with programs that will be opening, like I 

13          just indicated.

14                 ASSEMBLYWOMAN GUNTHER:  Two hundred 

15          million, right?

16                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Two 

17          hundred, yes.  Which I just finished saying, 

18          we will be opening more clubhouses, a couple 

19          more recovery centers, the 24/7 Open Access 

20          Centers.  There will be additional 

21          residential treatment beds that will be 

22          opening up.  This is all in this budget.  So 

23          these are all new services.  These are not 

24          services that have been implemented.  They 

                                                                   169

 1          will be implemented in this coming year.

 2                 ASSEMBLYWOMAN GUNTHER:  Thank you.

 3                 Is OASAS working with community-based 

 4          providers and DOH to increase harm-reduction 

 5          initiatives?  Have safe consumption or safe 

 6          injection sites been part of that discussion?

 7                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  We 

 8          always work with our community-based 

 9          providers to get input on whatever we do.

10                 With respect to safe injection 

11          facilities, what I can assure you is that 

12          given the epidemic that we have, we are 

13          looking at everything very seriously.  I'm 

14          working with the Department of Health, and 

15          everything's on the table.  We're giving 

16          everything serious consideration.

17                 ASSEMBLYWOMAN GUNTHER:  We hear from 

18          your presentation each year that there are 

19          enough beds for persons in need of care.  

20          However, we still hear about people traveling 

21          great distances to access appropriate 

22          treatment.  Are there currently an adequate 

23          number of beds with sufficient geographic 

24          representation to ensure those who need 

                                                                   170

 1          treatment are able to receive it?

 2                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  So 

 3          you're absolutely right, and thank you for 

 4          that question.  I hear that everywhere I go.

 5                 Just yesterday I went online myself, 

 6          and there were over a thousand beds available 

 7          throughout the state.

 8                 I continuously say, can I promise you 

 9          that there will be a bed, you know, down the 

10          block from where people live and they need?  

11          I can't promise that.  But is there a bed in 

12          this state that will serve the purpose?  Yes.  

13          I mean, just yesterday I actually looked.  So 

14          there is quite a bit of beds.

15                 I think that there are other issues 

16          that are in play here that get murky into the 

17          fact that there are no beds.  There are beds.  

18          There are beds available at any one time.

19                 ASSEMBLYWOMAN GUNTHER:  The last one 

20          is -- you know what, I was going to -- I'll 

21          ask you something that Linda didn't ask you.  

22          What about there are beds available, but 

23          insurance-wise and accepting insurances -- I 

24          mean, if you're not on Medicaid -- but a lot 

                                                                   171

 1          of insurances won't pay unless you fail like 

 2          three or four times, and they will not pay.

 3                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  If 

 4          that happens, it shouldn't be happening 

 5          because we passed, you know, regulations last 

 6          year that indicated that that could not 

 7          happen.  And there's no fail-first. 

 8                 And every time I hear that, I get a 

 9          little annoyed because that should not be 

10          happening.  I always tell people, if you know 

11          that that is happening, you need to reach out 

12          to us.  There is no fail-first.  You are to 

13          get the service that you need, as long as 

14          it's deemed necessary by a physician.  If a 

15          physician says this is the level of care you 

16          need, that's where you need to go.  Insurance 

17          companies cannot deny that access.

18                 If it does happen, please, reach out 

19          to us.  That's the only way we're going to be 

20          able to ensure that this doesn't continue.

21                 ASSEMBLYWOMAN GUNTHER:  What progress 

22          has the state made in implementing CARA?  Has 

23          there been an increase in providers in 

24          underserved areas as a result of this act?  

                                                                   172

 1          What is the state doing or can the state do 

 2          to encourage more providers to prescribe 

 3          buprenorphine?

 4                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay, 

 5          there's a couple of questions there.

 6                 With the CARA, we're hopefully going 

 7          into the second year.  With the first year, 

 8          we identified 16 regions, underserved regions 

 9          throughout the state.  And we have been able 

10          to develop the mobile vans that I've been 

11          talking about.  We're developing Centers of 

12          Treatment Innovations throughout the state in 

13          these 16 regions.  We've expanded capacity in 

14          terms of treatment beds.  So we've done a lot 

15          with the monies that we got through the STR 

16          grant last year.

17                 And moving forward, we're planning now 

18          on maybe adding another 16 or 17 more regions 

19          to have now a total of over 30-something 

20          regions that we will be addressing with the 

21          same similar programming.  So we've been 

22          really hard at work making sure that we, you 

23          know, get the money out in the street and do 

24          the things that we need to do.

                                                                   173

 1                 I need to remind you, the first phase 

 2          we really targeted in the very, you know, 

 3          rural areas where people -- I've not only 

 4          heard but I've experienced, as I've traveled 

 5          the state, where people would have to travel 

 6          two and three hours to just get medication.  

 7          I mean, the chances that people would do that 

 8          will be slim. 

 9                 So that's where we're focusing on 

10          doing the mobile treatment.  But we're also 

11          focusing on bringing telehealth.  You know, 

12          until we're able to maybe develop more stable 

13          clinics in those areas.  But we've been 

14          really, really implementing a lot of very 

15          innovative work and programming to address 

16          this.

17                 ASSEMBLYWOMAN GUNTHER:  Through my own 

18          office -- we're somewhat in the middle of an 

19          area where there is a lot of addiction and 

20          treatment, and one of the things that I have 

21          spent hours and hours on the phone is -- are 

22          people that do have private insurance, 

23          et cetera, but a lot of these addiction 

24          centers are asking for cash up-front.  

                                                                   174

 1          Namely, I've had as far as $45,000 to 

 2          $60,000.  

 3                 And, you know, I work very closely 

 4          with Catholic Charities and, you know, we 

 5          spent an afternoon looking.  And it's very, 

 6          very difficult sometimes when someone is in 

 7          that moment of readiness and you can't get 

 8          the bed.

 9                 Secondly, I do -- my other thought is, 

10          you know, as a nurse, I remember a long time 

11          ago when the joint commission said that no 

12          one should be free of pain {sic}.  And it 

13          seems to me at that point in history was when 

14          the use of Demerol, morphine and all those 

15          wonderful drugs and sending people home, you 

16          know, with a prescription not with two pills 

17          but 40 pills, happened.

18                 And what are we doing to control these 

19          drug manufacturers about, number one, 

20          advertising on our television and kind of 

21          encouraging everybody to be pain-free, that 

22          that's what life is all about.  And, you 

23          know, doing something to correct, I think, 

24          something that went very, very wrong.

                                                                   175

 1                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  So a 

 2          couple of things.  You know, we've been very 

 3          proactively out there with our own campaign, 

 4          really reaching out to as many people as we 

 5          can, trying to educate folks around what 

 6          their rights are and, you know, what to do in 

 7          certain situations.

 8                 It's very complicated.  I don't know 

 9          that, you know, we could address all of 

10          those.  But what we are doing is very 

11          aggressively out there with campaigns, 

12          talking to as many people as we can, 

13          informing them of their rights.  And when we 

14          are told that things are not going the way 

15          they should be going based on revised 

16          regulations, we will enforce them.

17                 ASSEMBLYWOMAN GUNTHER:  But again, I 

18          know right now we're going to charge them a 

19          surtax because I guess somebody must think 

20          there's some responsibility there.  But I 

21          also think that at this point in time using 

22          the television to like pound it in people's 

23          heads, you know, I think that's important to 

24          address.  And also prescribing habits.

                                                                   176

 1                 And I think that with prescribing and 

 2          also addressing some of those issues, we 

 3          educate the public with an advertisement.  

 4          So --

 5                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  And we 

 6          are doing advertisement -- TV advertisement 

 7          is a little over the top, but we are doing 

 8          advertisement --

 9                 ASSEMBLYWOMAN GUNTHER:  Not you, I 

10          meant the drug manufacturers.

11                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay.

12                 ASSEMBLYWOMAN GUNTHER:  Not you at 

13          all.  You're good.

14                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

15          you.

16                 CHAIRWOMAN WEINSTEIN:  Thank you.

17                 CHAIRWOMAN YOUNG:  Thank you. 

18                 Our next speaker is Senator Akshar.

19                 SENATOR AKSHAR:  Thank you very much, 

20          Madam Chairwoman.  

21                 Commissioner, always good to be in 

22          your company.  Allow me to begin, of course, 

23          by thanking you for being a good partner to 

24          me and the people that I represent in the 

                                                                   177

 1          Southern Tier, you and your team.  

 2                 I want to publicly thank you and the 

 3          Governor for all of your hard work on the 

 4          work we did at the former Broome 

 5          Developmental Center to bring additional 

 6          treatment services online there.  It was a 

 7          very heavy lift, of course, in our community.  

 8          However, it's done and I applaud you and your 

 9          staff for that.  

10                 I just want to hit a couple of things 

11          if I can.  I want to go back to the 

12          surcharge, as Senator Amedore spoke about.  I 

13          just want to be clear about something, that 

14          this surcharge could in fact, as the Governor 

15          has proposed, generate something like 

16          $127 million in revenues.  Is that your 

17          understanding?

18                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes.  

19          If it passes, if it starts July 1st, yes, 

20          that's what's anticipated.

21                 SENATOR AKSHAR:  Okay, you know that 

22          there is probably no bigger fan of OASAS than 

23          I, so I have concerns about this surcharge, 

24          of course, because my understanding is that 

                                                                   178

 1          that $127 million is simply going to supplant 

 2          current funding, and it's not for new 

 3          services.  Is that your understanding as 

 4          well?

 5                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  That 

 6          is not my understanding, being that the way 

 7          it is written, it says it goes into a fund 

 8          and it's to be used only for treatment, 

 9          prevention and recovery services to deal with 

10          the opioid epidemic.

11                 And as I indicated, moving forward, 

12          you know, I would expect that some of that 

13          funding we would be able to tap into for 

14          future programming.

15                 SENATOR AKSHAR:  So with all due 

16          respect, Commissioner, am I to believe 

17          sitting here that we will have access -- I 

18          say "we," you and your agency will have 

19          access to an additional $127 million if 

20          passed as proposed by the Governor to deal 

21          with this particular issue?

22                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  What 

23          it says is that the monies could only be used 

24          to provide prevention, treatment and recovery 

                                                                   179

 1          services to deal with the epidemic.

 2                 Having said that, there may be other 

 3          departments like the Department of Health 

 4          that may provide and do provide very critical 

 5          services around addiction that they may be 

 6          able to access dollars.  That's the way it's 

 7          written.

 8                 But it's our anticipation that we will 

 9          be able to access some of those dollars as 

10          well.

11                 SENATOR AKSHAR:  One would always feel 

12          so much more comfortable if we could put that 

13          $127 million in the proverbial lockbox and 

14          make sure that nobody else took that money 

15          from you, of course.

16                 Let me change topics, if I may, and go 

17          back to substance use disorder within the 

18          confines of correctional facilities.  Are you 

19          familiar with the recent report published by 

20          the Conference of Local Mental Hygiene 

21          Directors in which they're asking for 

22          $12.8 million to address SUD in the 57 county 

23          correctional facilities throughout the state?

24                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes, I 

                                                                   180

 1          am familiar.

 2                 SENATOR AKSHAR:  So is that something 

 3          that you would support?

 4                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I 

 5          think we need to talk about it and look at 

 6          it.  It's something that has been presented 

 7          to me.  It's something, as I indicated, we 

 8          ourselves have been talking with the 

 9          commissioner of DOCCS to see how we could 

10          better implement services and complement 

11          services that exist there.

12                 So it's under review, and that's all I 

13          can really say at this point.

14                 SENATOR AKSHAR:  Sure, I appreciate 

15          that.

16                 With that said on that particular 

17          issue, giving local control to the local 

18          mental health providers and so on and so 

19          forth, with oversight from OASAS -- of course 

20          it's under review, as you just said -- is 

21          that something that you're comfortable with, 

22          or that too needs additional discussion?

23                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I 

24          think that needs additional discussion.

                                                                   181

 1                 SENATOR AKSHAR:  Okay, let me move to 

 2          the topic of fentanyl and -- I'm running out 

 3          of time.  Is OASAS seeing an influx of 

 4          overdoses related to increased use of 

 5          fentanyl?

 6                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes.

 7                 SENATOR AKSHAR:  Okay.  Is the agency 

 8          taking any particular steps to deal with this 

 9          particular issue?

10                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Well 

11          like I said, we are very aggressively out 

12          there, campaigns -- we have a lot of 

13          campaigns to inform people of fentanyl, 

14          because a lot of the overdoses that we are 

15          seeing is really the fentanyl that is lysed 

16          in the chemical.  

17                 So it's really important that we get 

18          the word out there, that we educate people as 

19          much as we can about the dangers of fentanyl, 

20          and the fact that people think they know what 

21          they're buying but they really don't.  Never 

22          before have we heard of people OD'g on 

23          cocaine.  Well, it's not the cocaine, it's 

24          the fentanyl that's in there.

                                                                   182

 1                 So we are aggressively doing whatever 

 2          we can to inform the public about the 

 3          fentanyl piece and to access, you know, 

 4          treatment.  We're out there also aggressively 

 5          trying to get people to seek treatment.

 6                 SENATOR AKSHAR:  As you well know, my 

 7          background's in law enforcement.  And one 

 8          thing that I have been consistent about since 

 9          the day I was elected in dealing with this 

10          particular issue is that we should focus less 

11          attention on enforcement and more on 

12          prevention and treatment, recovery and so on 

13          and so forth.

14                 However, this is one particular area 

15          in which I think we need to make 

16          improvements.  Clearly the federal government 

17          has moved fentanyl, its derivatives, so on 

18          and so forth, into a schedule.  We are 

19          lagging behind in that particular area, and 

20          I'm wondering if you have a position on 

21          whether or not it's time for the State of 

22          New York to make some changes as -- where 

23          fentanyl is concerned.

24                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I 

                                                                   183

 1          believe just recently there was a press 

 2          release that there is consideration to have 

 3          fentanyl and fentanyl analogs as well as 

 4          synthetic marijuana to be part of this 

 5          scheduling.

 6                 SENATOR AKSHAR:  I would hope that 

 7          regardless of our politics or regardless of 

 8          what side of the aisle we sit on, that this 

 9          is an area where we could come together and 

10          find some common ground.  Because clearly 

11          this influx of fentanyl is killing people by 

12          the masses, and we have to address it.

13                 I'll end on this, by simply saying 

14          thank you once again for your commitment to 

15          the people of this great state.  And you have 

16          a difficult job, and I want to personally 

17          thank you again for the friendship that we've 

18          developed.  Thank you.

19                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

20          you, Senator.

21                 SENATOR AKSHAR:  Thank you, Madam 

22          Chairwoman.

23                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

24          Oaks.

                                                                   184

 1                 ASSEMBLYMAN OAKS:  Yes, thank you.  

 2                 One of the Governor's proposals in the 

 3          budget is allowing BOCES to enter into an MOU 

 4          with non-component school districts to 

 5          develop what have been called Recovery High 

 6          School programs.  So I was just checking -- 

 7          at this point, have any BOCES expressed an 

 8          interest in operating one of these types of 

 9          schools?  

10                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes.  

11          Actually, we did an RFI, we got 11 responses 

12          from throughout the state, so there are 11 

13          areas that have expressed interest.  And in 

14          the coming weeks, we will be meeting with all 

15          11 to discuss next steps.

16                 ASSEMBLYMAN OAKS:  And that would 

17          include, obviously -- so is the proposal just 

18          to do a single one, model one, or is it --

19                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  

20          Originally we had anticipated three, but 

21          we're going to meet with the schools and see 

22          how far they are.  Every one will be 

23          different, and we will be able to implement 

24          as many as we can throughout the state.  

                                                                   185

 1                 This has been something that has been 

 2          very well received, and not only well 

 3          received but very much needed, especially 

 4          with a lot of our young people who are 

 5          addicted and are in the high-school age and 

 6          really should be able to finish their 

 7          education in a setting where they get the 

 8          support that they need.

 9                 ASSEMBLYMAN OAKS:  And do we have a 

10          sense of how the funding would work for those 

11          recovery schools?

12                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yeah, 

13          I don't have that.  I could try to get 

14          something to you, but I don't have it off the 

15          top of my head.

16                 ASSEMBLYMAN OAKS:  I'd appreciate it.  

17          Thank you.

18                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay.  

19                 CHAIRWOMAN YOUNG:  Thank you.

20                 Actually, I have a couple of 

21          questions, Commissioner.  And again, we 

22          appreciate you being here today.  

23                 But I know that this is an issue of 

24          importance that we would like to have 

                                                                   186

 1          answered, and I know that Senators Amedore 

 2          and Akshar both asked about it.  We want to 

 3          have the specifics of the opioid surcharge 

 4          proposal that the Governor has put forward, 

 5          the $127 million.  And you've been asked 

 6          twice about it, and you haven't given any 

 7          specifics.  So we're hoping that you can 

 8          provide those to us.

 9                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay.  

10          I will try.  I mean, I've been as specific as 

11          I can.

12                 CHAIRWOMAN YOUNG:  So how would the 

13          $127 million actually be spent?

14                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  The 

15          way it indicates in the bill is that it could 

16          only be used for the prevention, treatment, 

17          and recovery of opioids.

18                 CHAIRWOMAN YOUNG:  But -- so that's 

19          kind of a broad, broad, broad, broad 

20          overview.  But what exactly would the money 

21          be spent on to meet those ends?

22                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Well, 

23          from a department perspective, it would be to 

24          develop more clubhouses, recovery supports, 

                                                                   187

 1          if we need to expand residential treatment 

 2          programs, if we need to continue to expand 

 3          mobile capacity.  It would mean all of that 

 4          if that was to go forward.

 5                 I mean, all of that is what we have in 

 6          our current budget system moving forward to 

 7          address the opioid epidemic.  I can't tell 

 8          you I'm going to open six clubhouses, 

 9          seven -- because the details have yet to be 

10          determined.  And I need to also make some 

11          analysis as to where there's still some 

12          needs, you know, in terms of areas that there 

13          are gaps that we don't have certain basic 

14          things that we would maybe need to look at.

15                 So I'm not being evasive purposely, 

16          I'm just trying to be honest and up-front.

17                 CHAIRWOMAN YOUNG:  So you don't have 

18          that analysis already as to where there are 

19          gaps in the system?

20                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  We do 

21          have -- I do have -- I have -- I know where 

22          the gaps are, and we know what we would need 

23          to do if we needed to move forward, and we 

24          have the money to address those gaps, yes.

                                                                   188

 1                 CHAIRWOMAN YOUNG:  Okay.  So you just 

 2          said you need to do the analysis, but now you 

 3          say that you haven't.  So what I would say to 

 4          you is if you have a specific plan, I would 

 5          recommend that you get that to the 

 6          Legislature as soon as possible.  

 7                 This is a serious issue, to raise 

 8          these taxes.  And without any kind of 

 9          specifics, it's hard for us to make any kind 

10          of informed decision on whether or not we 

11          would go ahead with this.  As you know, we 

12          have a concern about the tax burden already 

13          in New York State, and to have kind of this 

14          open-ended -- not even plan that you've 

15          talked about, really doesn't do much to 

16          advance the issues that you're talking about.

17                 So we would like to see if you could 

18          get it to our offices, a detailed explanation 

19          of the plan, how the money would be used, 

20          where it would be used, when it would be 

21          used.  That would be very, very helpful to 

22          us.

23                 And just following up on that, you had 

24          said that you're trying to fund new services 

                                                                   189

 1          and those are coming online.  The question 

 2          that I have, are these actual services that 

 3          were supposed to be put forward this year, 

 4          and they're not new services but they're 

 5          services that were already funded in this 

 6          year's budget and they just haven't come 

 7          online yet?

 8                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  No, 

 9          these are -- the new services that I spoke 

10          about are services that are coming online 

11          this fiscal year.

12                 CHAIRWOMAN YOUNG:  So they are not --

13                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  They 

14          are new services.

15                 CHAIRWOMAN YOUNG:  But are they new, 

16          or should they have already been services 

17          that were already established?  

18                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Some 

19          of them may have been procured last year but 

20          weren't operational.  They will become 

21          operational this year, and the funding is in 

22          this year's budget.

23                 CHAIRWOMAN YOUNG:  And what are those 

24          new services again?

                                                                   190

 1                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  The 

 2          203 treatment beds, the 75 -- up to maybe 

 3          75 detox beds throughout the state, the 

 4          $10 million.  I believe we have a couple of 

 5          clubhouses that we will be bringing online.  

 6          The 24/7 access centers that we're 

 7          announcing, that we just announced, these are 

 8          all new services, and all the dollars are in 

 9          this current budget.

10                 CHAIRWOMAN YOUNG:  Okay, thank you.

11                 (Discussion off the record.)

12                 CHAIRWOMAN WEINSTEIN:  Thank you --

13                 CHAIRWOMAN YOUNG:  No, we have other 

14          speakers.  

15                 So on the list we have Senator Savino, 

16          then Senator Rivera, Senator Krueger, and 

17          finally Senator Brooks.  We have a lot.

18                 SENATOR SAVINO:  Thank you.  Thank 

19          you, Senator Young.

20                 Good afternoon, Commissioner.

21                 So I'm going to ask you the same 

22          question that I asked Commissioner Sullivan 

23          from OMH.  Knowing that there are so many 

24          patients suffering with addiction treatment 

                                                                   191

 1          disorder that also have mental health issues, 

 2          do you believe there's sufficient 

 3          coordination between your agencies to help 

 4          address that, whether it's through detox 

 5          beds, into inpatient settings, or a 

 6          coordination of programs?  

 7                 And is there -- what more can we do to 

 8          bring in, I think, the medical providers, 

 9          particularly psychiatrists who are treating 

10          these patients, many of whom are taking 

11          psychotropic drugs, they're also taking 

12          Ativan or Xanax or Valium for their anxiety 

13          disorder or posttraumatic stress, as well as 

14          pain medication?

15                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  So as 

16          Dr. Sullivan indicated, you know, we've been 

17          very proactively working among ourselves, 

18          including with the Department of Health, to 

19          better get a better integration of care, not 

20          only between mental health and addiction but 

21          also primary health.  

22                 There's language actually in the 

23          budget now that allows for one single 

24          licensure, which I think is going to really 

                                                                   192

 1          help and move this integration process 

 2          further.

 3                 And, you know, we continue the best 

 4          that we can to work together to ensure -- 

 5          because I believe that that's the key.  You 

 6          can't treat people for different parts.  You 

 7          know, you have to treat them altogether, 

 8          everything in the same.  So we continue to 

 9          work towards, you know, a better integrated 

10          plan, and I think we're getting there.  

11                 Now, with the single licensure, I 

12          think you're going to see that that may open 

13          other opportunities.

14                 SENATOR SAVINO:  I certainly hope so.

15                 Assemblywoman Gunther asked about the 

16          denial of coverage by some insurance 

17          carriers.  And while there may not be as many 

18          instances of the fail-first requirement -- 

19          because as you pointed out, we outlawed 

20          that -- I do think the bigger problem is a 

21          lot of insurance carriers don't provide the 

22          right type of coverage.  

23                 So if you're on Medicaid, you're fine, 

24          because there's no restrictions.  If you are 

                                                                   193

 1          a 55-year-old woman who's disabled and is on 

 2          Medicare, you're pretty much on your own.  

 3          There's no programs that accept Medicare, and 

 4          that is I think the bigger problem that we're 

 5          seeing, is an inconsistency in insurance 

 6          coverage for addiction treatment.  

 7                 And so that leaves a lot of people 

 8          out.  So if they get out -- if they go to 

 9          detox and they get out, they have to go to 

10          outpatient, and many of them are not able to 

11          go to -- I mean, this is, as you know, this 

12          is a new kind of addiction problem we're 

13          seeing where, you know, people are saying 

14          that they can't get off of these drugs 

15          because they're that much more potent and 

16          that much more dangerous.

17                 So I think -- I really think that's 

18          the challenge for us, is how do we get 

19          consistency across all insurance carriers so 

20          that everyone, when they finally realize that 

21          they need help, are able to access the help 

22          best suited for them.

23                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yeah.  

24          And we have been working with DFS along those 

                                                                   194

 1          lines to see how we could maybe implement 

 2          some changes along those policies.

 3                 But it is difficult.  I mean, it's 

 4          something that -- you know, it's outside of 

 5          my realm.  But, you know, DFS has been very 

 6          helpful in terms of listening to us and 

 7          working with us to see what we can do to 

 8          resolve that issue.

 9                 SENATOR SAVINO:  And I think someone 

10          asked you about the issue of locations where 

11          people could -- what is the term that's used?  

12          Where they can come in and be -- supervised 

13          injection sites?  I have my own concerns 

14          about that because of what they're injecting.  

15                 But I have a piece of legislation that 

16          I've introduced, along with 

17          Assemblyman O'Donnell, to add addiction 

18          treatment disorder as a qualifying condition 

19          under the medical marijuana program.  

20                 As you know, the majority of opioid 

21          abusers who are in treatment are under 

22          medical therapy as well.  So they're either 

23          replacing their opioids with Suboxone or 

24          methadone or Vivitrol or whatever the other 

                                                                   195

 1          medications are.  

 2                 And so there's sufficient evidence in 

 3          other states that have medical marijuana 

 4          programs that placing your opioids with 

 5          medical marijuana, instead of one of the 

 6          other medical treatments, has been 

 7          successful.  

 8                 I don't know if you have an opinion on 

 9          that.  If you don't, that's fine.  What I 

10          would appreciate is, though, if you could 

11          look into it and see if you think that would 

12          be something that would work here in 

13          New York.

14                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yeah.  

15          I don't have an opinion right now, but what I 

16          can tell you is that we are looking at 

17          everything, together with DOH.

18                 SENATOR SAVINO:  Okay.  Thank you.

19                 CHAIRWOMAN YOUNG:  Thank you.

20                 Our next speaker is Senator Rivera.

21                 SENATOR RIVERA:  Hello, Commissioner.  

22          How are you?  Just -- I just -- just a couple 

23          of quick questions.  

24                 A few of my colleagues already asked 

                                                                   196

 1          about this, and I just want to reiterate 

 2          that -- so that it's clear on both sides of 

 3          the aisle, whether it's Senator Young, 

 4          Senator Akshar, or Senator Amedore and 

 5          myself, who is obviously in quite a different 

 6          wing of the thing, we both are concerned 

 7          about the details of this surcharge, the 

 8          opioid surcharge.  

 9                 I want to reiterate, like Senator 

10          Akshar said, that language should be added -- 

11          and I did not see it -- that is -- that -- so 

12          it's a lockbox.  And I know this is not you, 

13          but I just want it for the record, there 

14          needs to be a lockbox on it.  We know too 

15          much about dedicated taxes that don't 

16          actually go to the things that they're 

17          dedicated to.  Ask MTA about that.

18                 So there's that.  The fact that having 

19          a more detailed plan about $127 million -- 

20          which is a good chunk of change, certainly 

21          necessary for the crisis that we're dealing 

22          with -- having a more detailed plan would be 

23          a welcome -- would be something very welcome 

24          to us.  

                                                                   197

 1                 And also clarification on the issue of 

 2          first points of sale.  We had -- just 

 3          yesterday we had pharmacists come in and tell 

 4          us that they were extremely concerned.  

 5          Because even though they were, like the rest 

 6          of us, concerned about the crisis, they -- 

 7          because of the way that many pharmacies do 

 8          their purchasing, they would be the first 

 9          point of sale.  So it would not get the 

10          manufacturers or the distributors.  It would 

11          get the pharmacists.  

12                 And if you have local pharmacies, 

13          that's going to be a problem.  They would 

14          have to restructure the whole way that they 

15          do their business, and they might not stock 

16          some things that are necessary in some 

17          medical cases.  

18                 And so on that first point of sale, do 

19          you have any further clarification on that 

20          issue?

21                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I 

22          don't.  I don't.

23                 SENATOR RIVERA:  Okay.  So that is 

24          something -- again, and I know it is not you, 

                                                                   198

 1          Commissioner, but it is obviously -- it is 

 2          going to potentially, hopefully accrue to the 

 3          agency that you run so that you have more 

 4          resources to do the good work that you do, so 

 5          that would be important.

 6                 And lastly, I just want to -- just 

 7          like Assemblymember Gunther asked earlier 

 8          about supervised injection facilities, I'm 

 9          glad that the state is looking into them.  We 

10          had a brief discussion about it yesterday 

11          with the commissioner of Health, and he said 

12          basically the same thing, that the state is 

13          looking at it.  I would certainly suggest 

14          that we need to seriously look at it, as it 

15          is a policy area that is -- it is an area 

16          that we need to go into if we're really going 

17          to deal with this crisis.  

18                 So I just wanted to put those things 

19          out there.  Sorry that you do not have 

20          further clarification, but I am hoping that 

21          we can get you more resources to do the work 

22          that you do.

23                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay.

24                 SENATOR RIVERA:  Thank you.

                                                                   199

 1                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

 2          you.  

 3                 CHAIRWOMAN YOUNG:  Thank you.  

 4                 Our next speaker is Senator Krueger.

 5                 SENATOR KRUEGER:  Hi, Commissioner.

 6                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Hi.

 7                 SENATOR KRUEGER:  Okay.  So Senator 

 8          Rivera just started off where I was going to, 

 9          which is it's critical we understand what's 

10          new money for new things versus just 

11          replacement.  Because your budget shows an 

12          $80 million increase, and yet you're 

13          expecting $127 million from this tax.  So 

14          that's why there are red flags being raised.  

15          Okay?

16                 Second, even though it was also asked, 

17          but I was not satisfied with the answer -- 

18          and you said ask Tax and Finance, but I think 

19          it's very important for you to go back and 

20          help us get the answer.  So the Governor has 

21          proposed this opioid manufacturer surcharge.  

22          If you sat through yesterday's hearing, you 

23          heard from the pharmacies, panicked that they 

24          would be the ones expected to collect the 

                                                                   200

 1          money, which would be a charge to the 

 2          consumer which they wouldn't be able to bill 

 3          the opioid manufacturers for or the 

 4          wholesalers for, because they have no 

 5          negotiating room with the wholesalers or 

 6          manufacturers, many of which are out of 

 7          state.

 8                 What I think we need to know, is the 

 9          Governor proposing this as a kind of excise 

10          tax, the way we do excise taxes on alcohol or 

11          tobacco?  Where, even if you're a 

12          manufacturer out-of-state, we make you pay 

13          it?  Or are we talking about a situation 

14          where this would land on pharmacies and 

15          consumers to deal with?  Which I think most 

16          of us here think that's the wrong punch line.  

17                 Okay?  So yes, maybe it's someone 

18          else's division, but as the commissioner who 

19          sits here for OASAS, we need to get that 

20          information back from you --

21                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay.  

22                 SENATOR KRUEGER:  -- about who 

23          actually would pay it and how it would be 

24          collected.  Okay.  

                                                                   201

 1                 So I want to go on to ask you about 

 2          something that people didn't ask about yet.  

 3          In your testimony you talked about having 

 4          funds to open up up to seven gambling 

 5          addiction sites.  So are we going to open up 

 6          seven gambling addiction sites?  And tell me 

 7          what the basis for that is.

 8                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes, 

 9          actually we should be making the announcement 

10          shortly.  

11                 The monies come from -- remember, last 

12          year we said that there would be some fees on 

13          table games and so on and so forth.  That's 

14          what's funding this initiative.  

15                 And there are seven centers that have 

16          been identified throughout this state, and 

17          currently I believe the RFP is being reviewed 

18          by OSC, so it should be out shortly and we 

19          should be able to identify these seven 

20          centers in the very near future.

21                 SENATOR KRUEGER:  And so you're going 

22          to put out an RFP to providers to run these?

23                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes.  

24          Yes.

                                                                   202

 1                 SENATOR KRUEGER:  So --

 2                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  We 

 3          have to bid it out, yes.

 4                 SENATOR KRUEGER:  Right.  

 5                 Is there going to be any coordination 

 6          between the gambling addiction sites and 

 7          other substance abuse providers for alcohol 

 8          or drugs?  

 9                 Because I've been doing quite a bit of 

10          reading of the scientific research, and 

11          basically the researchers have concluded that 

12          it's a comorbidity of being someone who could 

13          be trapped in gambling addiction and also 

14          addiction to other items such as alcohol 

15          and/or drugs, because it has the same 

16          triggers in the brain.  And that we have more 

17          and more models that trigger addiction in our 

18          brains on a daily basis.  

19                 So we've been expanding gambling -- 

20          and as I told you, I was concerned about the 

21          fact that there's more and more research 

22          showing that smartphones and computers and 

23          games are also being programmed to train us 

24          for an addiction.  I actually think Cathy 

                                                                   203

 1          Young and I need a 12-step program for our 

 2          phones.  

 3                 (Laughter.)

 4                 SENATOR KRUEGER:  I'm naming myself 

 5          first.  But --

 6                 CHAIRWOMAN YOUNG:  I'm not giving up 

 7          my phone.

 8                 (Laughter.)  

 9                 SENATOR KRUEGER:  I'm not either.  But 

10          I'm just highlighting the addiction issue.

11                 So is there going to be co-programming 

12          between other addiction issues and gambling 

13          at these centers?  

14                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  

15          Absolutely.  There has to be, yes, 

16          coordination of care.

17                 SENATOR KRUEGER:  And so the money for 

18          gambling addiction treatment is a formula off 

19          of the casinos?

20                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Yes.  

21          The funding came -- remember, there was a 

22          $500 charge for each table game.  And the 

23          results thus far has been the $3.5 million.

24                 SENATOR KRUEGER:  So $3.5 million for 

                                                                   204

 1          this coming year with -- as there's a growth 

 2          in the table games.  But not the slot 

 3          machines, just the table games?

 4                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  I 

 5          think it's table games and it could be slot 

 6          machines too.  I can't remember right now, 

 7          but -- yeah, I think so.  Yes.  Yes.

 8                 SENATOR KRUEGER:  Yes, okay.

 9                 So as these sites come online and 

10          get -- the assumption is they'll get bigger, 

11          although maybe not -- that we will have an 

12          increased, ongoing funding stream that can't 

13          be used for anything else?  

14                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  That's 

15          the way I understand it, yes.

16                 SENATOR KRUEGER:  Thank you.

17                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Okay.  

18                 CHAIRWOMAN YOUNG:  Senator Brooks.

19                 SENATOR BROOKS:  Thank you, 

20          Madam Chair.  

21                 Commissioner, it's good to see you.

22                 Obviously we're in a situation with 

23          the opioid addiction that's an epidemic 

24          throughout the country, and one that we're 

                                                                   205

 1          not doing so well with.  Back at home, I'm a 

 2          first responder, and I see many of these 

 3          cases firsthand.  

 4                 One of the things we did in our 

 5          offices, we established workgroups in all of 

 6          the communities that we're trying to address 

 7          and put programs forward, including drug 

 8          take-back programs and educational programs 

 9          for the community.  

10                 But the reports show last year, on 

11          Long Island alone, more than 600 lives were 

12          lost from addiction.  Do you have any 

13          specific programs targeted for Long Island 

14          that you're working on?

15                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  

16          Actually, yes.  We actually opened the first 

17          recovery center, THRIVE, in Long Island.

18                 SENATOR BROOKS:  Right.  I was there.

19                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  We've 

20          also opened family support programs there.  

21          We've also expanded young adult beds in 

22          Long Island.  And as we move forward, we're 

23          going to continue to see -- my understanding 

24          is that, you know, there's a request for 

                                                                   206

 1          additional recovery centers in Long Island.  

 2          And so as we move forward, these are some of 

 3          the things that we're going to continue to 

 4          address and look at.  

 5                 Having been in Long Island for a 

 6          while, I understand the complexities of the 

 7          travels and so on and so forth.  

 8                 So yes, we are looking at Long Island 

 9          the same way we're looking at other parts of 

10          the state that need, you know, specific 

11          attention.

12                 SENATOR BROOKS:  Okay.  I think -- 

13          I've been at THRIVE, I think it's a great 

14          program.  Obviously, I think we should be 

15          expanding that.  

16                 The fentanyl is an absolute problem 

17          we've got to be addressing.  

18                 I think one of the driving points 

19          that's being made here by everyone, you know, 

20          we're putting in place a fee to raise an 

21          additional $127 million to go into this 

22          effort.  Everybody, I think, in the 

23          Legislature, regardless of party, is 

24          absolutely committed to addressing this 

                                                                   207

 1          epidemic.  But I think we are asking, and we 

 2          have a right to know, exactly how those funds 

 3          are going to be used specifically, enhancing 

 4          programs that you know are working or changes 

 5          in new programs.  

 6                 But, you know, there was a commercial 

 7          years back:  Where's the beef?  I think 

 8          that's what we're saying, because this 

 9          problem isn't going away.  We're making 

10          limited progress.  We're asking people in a 

11          state right now that pay some of the highest 

12          taxes going, we're going to put in a new 

13          program, a new tax that hopefully is not 

14          going to be passed on to the residents, but 

15          funded by the manufacturers of these drugs.  

16                 But I think it's critical that we know 

17          exactly how these funds are being used, and I 

18          think it's critical that we start measuring 

19          the various programs that we have in terms of 

20          what is successful and not.  And certainly 

21          the programs that you have that are 

22          successful can be passed down to workgroups 

23          like we have, or we can work with you to 

24          enhance and utilize those programs.  

                                                                   208

 1                 So I think this whole problem has been 

 2          a cooperative effort.  But I think the 

 3          Legislature is saying we're going to put 

 4          forward a significant money source, but we 

 5          want to see exactly how that's going to be 

 6          used.  This problem is an everyday problem in 

 7          every single community, in almost every 

 8          family.  And we've got to get it resolved.

 9                 So I thank you for everything that 

10          you're doing.  I think it's clear both sides 

11          have the same request:  What are we doing 

12          with the money, number one?  And perhaps most 

13          importantly, how is that being charged, how 

14          is that being collected?  

15                 And I apologize, that was -- Madam 

16          Chairman -- Chairwoman, excuse me, I 

17          apologize.  Thank you.

18                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

19          you.   

20                 CHAIRWOMAN YOUNG:  Thank you,  

21          Senator.  

22                 I think we're done?  Okay.  Well, 

23          thank you, Commissioner, for being here 

24          today.  We really appreciate your testimony.

                                                                   209

 1                 COMMISSIONER GONZÁLEZ-SÁNCHEZ:  Thank 

 2          you.

 3                 CHAIRWOMAN YOUNG:  Our next speaker is 

 4          Executive Director Denise Miranda, New York 

 5          State Justice Center for the Protection of 

 6          People with Special Needs.

 7                 Thank you for appearing today.  We 

 8          appreciate it.  Anytime you're ready.

 9                 EXECUTIVE DIRECTOR MIRANDA:  Good 

10          afternoon, Senator Young, Assemblywoman 

11          Weinstein, Assemblywoman Gunther, and other 

12          distinguished members of the Senate and 

13          Assembly.

14                 CHAIRWOMAN YOUNG:  Could you get 

15          closer to your mic?

16                 EXECUTIVE DIRECTOR MIRANDA:  Sure.  Is 

17          this better?

18                 CHAIRWOMAN YOUNG:  A little bit, yeah.

19                 EXECUTIVE DIRECTOR MIRANDA:  My name 

20          is Denise Miranda, and I am the executive 

21          director of the New York State Justice Center 

22          for the Protection of People with Special 

23          Needs.  I would like to thank you for the 

24          opportunity to testify today regarding 

                                                                   210

 1          Governor Cuomo's 2018-2019 Executive Budget 

 2          proposal for the Justice Center.

 3                 New York has a history of implementing 

 4          changes that shape the course of the nation, 

 5          and the Justice Center is no exception.  I 

 6          can unequivocally say those receiving 

 7          services in the State of New York are safer 

 8          today than they were five years ago.  Our 

 9          agency's Staff Exclusion List has prevented 

10          400 people who committed heinous acts against 

11          individuals with special needs from working 

12          in direct care positions.  The Justice 

13          Center's Criminal Background Check Unit 

14          prevents several hundreds of applicants with 

15          convictions including assault, rape, and 

16          murder from working with vulnerable 

17          populations.

18                 But we believe our mission consists of 

19          more than investigating after an incident has 

20          happened.  It also centers on preventing it 

21          in the first place.  To do that, the 

22          Justice Center works extensively with 

23          providers, advocacy organizations, and other 

24          relevant stakeholders.  In 2017, more than 

                                                                   211

 1          125 external on-site training and outreach 

 2          seminars involving various stakeholders were 

 3          conducted across the state.  

 4                 Another key agency effort focuses on 

 5          reviewing cases and identifying abuse and 

 6          neglect-related trends.  The agency produces 

 7          the Spotlight on Prevention, a tool developed 

 8          for providers, individuals and family 

 9          members.  The Spotlight includes educational 

10          materials on the dangers of being left 

11          unattended in vehicles, of recognizing 

12          caregiver fatigue, and on the danger of the 

13          inappropriate use of restraints.  These 

14          efforts will continue in 2018. 

15                 While we are very proud of the work 

16          that has been accomplished, the 

17          Justice Center is no stranger to criticism, 

18          and l want you to know that we have heard 

19          you.  I recognize there needs to be a balance 

20          between our oversight responsibilities and 

21          the anxiety and fears of the dedicated 

22          workforce.  I have spent the past year 

23          meeting with service recipients, caregivers, 

24          direct care workers, and providers to hear 

                                                                   212

 1          their feedback.

 2                 I have also spent considerable time 

 3          reviewing the operations, policies, and 

 4          procedures of the Justice Center.  To support 

 5          quality and efficient investigations, we 

 6          continue to regionalize our staff to high 

 7          volume areas.  This move, combined with 

 8          technology improvements and training for 

 9          staff, has cut case cycle time by 40 percent.  

10                 Another key initiative was the 

11          creation of the 72-hour case assessment 

12          model.  This process holds initial 

13          classification of an incident while 

14          additional information is gathered from the 

15          provider, to ensure appropriate 

16          classification.  This allows investigators to 

17          process serious cases of abuse and neglect 

18          more efficiently.  

19                 In our continued effort to expedite 

20          cases, we have secured a memorandum of 

21          understanding with the Department of Health, 

22          giving our investigators immediate access to 

23          death certificates.

24                 Additionally, in response to concerns, 

                                                                   213

 1          we've eased the burden on mandated reporters.  

 2          In cases where there are multiples witnesses, 

 3          only one is now required to report.  This 

 4          model allows workers to focus on providing 

 5          care while still giving the Justice Center 

 6          critical information about an incident.  

 7                 In the interest of transparency, we 

 8          post monthly aggregate data reports 

 9          summarizing the Justice Center’s abuse and 

10          neglect work.  Additionally, we are now 

11          publicly posting our findings regarding 

12          visits to New York State correctional 

13          facilities to monitor their compliance with 

14          the Special Housing Unit Exclusion Law. 

15                 While our goal is to maintain an 

16          environment free from abuse and neglect, 

17          unfortunately incidents do happen.  It is our 

18          duty to hold workers involved in abuse and 

19          neglect responsible for their conduct. We 

20          believe the work of the Justice Center is 

21          crucial to the health, safety, and support of 

22          our most vulnerable populations. 

23                 The Governor's Executive Budget 

24          supports the Justice Center in a number of 

                                                                   214

 1          ways, by operating 16 regional offices and a 

 2          24/7 hotline to receive reports of abuse and 

 3          neglect; expanding our Individual and Family 

 4          Support Unit to help family members and 

 5          individuals throughout the investigative 

 6          process; offering extensive training for both 

 7          internal and external investigators; 

 8          supporting training for all staff on the 

 9          various ways diversity fosters professional 

10          and culturally appropriate interactions with 

11          our varied stakeholders; and collaborating 

12          with provider agencies and our Advisory 

13          Council on the best ways to educate the 

14          workforce about their responsibilities.

15                 This year will mark the five-year 

16          anniversary of the Justice Center.  It will 

17          be a year of continued improvement.  We will 

18          be evaluating the processes by which the 

19          agency operates and examining areas for 

20          efficiency improvements.  This includes an 

21          audit of all investigatory training, a 

22          thorough examination of our intake model, 

23          exploring an expedited track for cases with 

24          certain fact patterns, and a shortened time 

                                                                   215

 1          frame for appeals.  We will also be enhancing 

 2          our collaborative efforts with stakeholders 

 3          at all levels.

 4                 The Justice Center looks forward to 

 5          working with our partners in the Legislature, 

 6          state oversight agencies, and our other 

 7          stakeholders to enhance the protections for 

 8          some of New York’s most vulnerable people.

 9                 I now welcome your questions.

10                 CHAIRWOMAN YOUNG:  Thank you very 

11          much.  And I appreciate your testimony.  I'm 

12          glad to hear of some of the advances, because 

13          the Legislature has brought those to the 

14          agency's attention in the past.

15                 So for example, on the mandated 

16          reporters, if, you know, 10 people are 

17          witnessing an incident, only one has to 

18          report now.  That's what you're saying?

19                 EXECUTIVE DIRECTOR MIRANDA:  The 

20          requirements for mandated reporting have been 

21          relaxed.  So if a person is a mandated 

22          reporter and they're aware that a report has 

23          already been made and that they were named in 

24          that report as a witness, they no longer have 

                                                                   216

 1          the obligation to make that report.  

 2                 We're hoping that that will ease the 

 3          burden for providers in ensuring the safety 

 4          and quality of the people that they're caring 

 5          for.

 6                 CHAIRWOMAN YOUNG:  That seems like a 

 7          great change, because it was very duplicative 

 8          before.  So it sounds like progress.  

 9                 But one of the issues that we still 

10          see is that staff who are being investigated 

11          as a result of a complaint may either be 

12          placed on administrative leave or terminated.  

13          The length of time for investigation forces 

14          providers to hire new staff, and employees 

15          then can be left in employment without pay 

16          until the situation is resolved.  So 

17          obviously those situations create a lot of 

18          issues.  And this -- these situations may 

19          last a significant amount of time.  

20                 So you talk a little bit about some 

21          upcoming reforms.  What specific actions has 

22          the center taken in response to the numerous 

23          complaints regarding the length of time for 

24          investigations?  Because from what we're 

                                                                   217

 1          hearing, it continues to be an issue.

 2                 EXECUTIVE DIRECTOR MIRANDA:  So I've 

 3          traveled the state, and I heard that concern 

 4          throughout the various meetings that we've 

 5          had.  

 6                 We recognize the burden that's placed 

 7          on providers, and so in an effort to be 

 8          responsive, we're constantly trying to 

 9          improve our cycle times.  But we have to be 

10          mindful that we do have to balance the need 

11          for a thorough investigation with 

12          efficiencies.  

13                 I'm very happy to report that case 

14          cycle time is down by 40 percent.  In 2016, 

15          the average was 117 days.  In 2017, we're 

16          down to 71 days.  Cycle time is still a 

17          priority for us, and we'll continue to 

18          improve those numbers.  

19                 We also have a 72-hour protocol that 

20          was introduced this year, and the 72-hour 

21          protocol seeks to pull certain cases of abuse 

22          and neglect so that they can be assessed for 

23          the accuracy of the classification.  

24                 And so what happens in that process is 

                                                                   218

 1          that we're able to communicate directly with 

 2          a provider and get information that will help 

 3          us make a more informed decision regarding 

 4          the category.  These are desk-review sort of 

 5          audits.  

 6                 And so what we found in looking at 

 7          2500 cases is that we were able to reclassify 

 8          approximately 47 percent of those cases.  So 

 9          looking at that model and seeing what we've 

10          learned, we hope to implement that overall at 

11          the Justice Center to make sure that we can 

12          be responsive.

13                 CHAIRWOMAN YOUNG:  Anytime you can get 

14          the time period -- any time period to be 

15          shorter -- even over two months still -- I 

16          don't know, it still seems like a long time 

17          for some of these investigations to hang out 

18          there.

19                 But we really want to make sure that 

20          people are protected.  And -- however, there 

21          continues to be complaints that the Justice 

22          Center has a law enforcement approach for 

23          every investigation, regardless of the nature 

24          of the complaint.  And this has led to fear 

                                                                   219

 1          and anger among provider staff.  

 2                 I know that I've personally spoken to 

 3          people in my district office who have come to 

 4          me, and they're very concerned about the very 

 5          heavy-handed way things sometimes are handled 

 6          by the Justice Center.

 7                 So how do you respond to these 

 8          allegations, and what actions have been taken 

 9          to make it more a helpful approach and less 

10          of a coming-down-on-your-head approach?  

11          Because not everything that you investigate 

12          has the same level of seriousness.  

13                 EXECUTIVE DIRECTOR MIRANDA:  

14          Absolutely.  And so we recognize that that is 

15          an important concern that is articulated by 

16          many of the providers, and so we've engaged 

17          extensively in outreach.  We've conducted 

18          over 48 workshops for DSPs, to make sure that 

19          we're able to answer questions and correct 

20          misconceptions that exist regarding the 

21          Justice Center.

22                 We employ 175 investigators.  I think 

23          it's noteworthy that only 15 percent, a 

24          little less than 15 percent of these 

                                                                   220

 1          investigators are sworn police officers.  We 

 2          recognize that very few cases are criminal in 

 3          nature, which is a good thing.  And so we 

 4          recognize that we need to certainly make 

 5          adjustments in our tone.  

 6                 And so to that end, we're very proud 

 7          to share with you that our investigative 

 8          workforce comes from a background of 

 9          employment within the settings that we have 

10          jurisdiction.  So over 50 percent of the 

11          investigators have actually worked in these 

12          service settings.  Additionally, many of our 

13          investigators also have family members who 

14          are in these service settings.

15                 So with respect to the approach, there 

16          have also been some policy changes.  We 

17          eliminated the use of the word "suspect" this 

18          year, which I think was very important.  I 

19          think the word "suspect" should only be used 

20          in a criminal context.  I think language 

21          matters, and I think that reflects a shift in 

22          how we're approaching business at the 

23          Justice Center.

24                 CHAIRWOMAN YOUNG:  I think language 

                                                                   221

 1          matters too, and I -- I mean, that's a great 

 2          example to point out the power that you have.  

 3          And by calling somebody a suspect, obviously 

 4          that has very negative connotations.  And 

 5          oftentimes I talk to people who are being 

 6          investigated by the Justice Center, and they 

 7          just feel like their lives and their careers 

 8          are over.  

 9                 So if it's not a serious complaint, 

10          you still have to follow up on it, we 

11          understand that.  But at the same time, 

12          anything that you can do to kind of parse out 

13          the levels of seriousness, I think it would 

14          be helpful.

15                 Now, the most recent information from 

16          the Justice Center indicates approximately 

17          11,254 closed cases.  Does that sound correct 

18          to you?

19                 EXECUTIVE DIRECTOR MIRANDA:  That 

20          sounds correct.

21                 CHAIRWOMAN YOUNG:  Okay.  So of this 

22          amount, only 4,169 -- or 35 percent -- were 

23          found to be substantiated.  So that's quite a 

24          difference.  And I was wondering -- I wanted 

                                                                   222

 1          to get your thoughts about it, because of the 

 2          Justice Center's closed cases, with 

 3          approximately 35 percent found to be 

 4          substantiated, there is a discrepancy there.  

 5                 So why is there such a discrepancy 

 6          between the reports of abuse and neglect that 

 7          are investigated and the actual number of 

 8          cases that are substantiated?  Is this a 

 9          staff training problem?  What is it?

10                 EXECUTIVE DIRECTOR MIRANDA:  No, I 

11          would maintain that the staff is extremely 

12          well trained at the Justice Center.  But the 

13          reality --

14                 CHAIRWOMAN YOUNG:  No, but I mean also 

15          out in the field.  

16                 So say, for example, you're at an 

17          OPWDD facility.  I had one person come to me 

18          and say they were put on report because there 

19          was a participant in the house, a program 

20          participant who had a nickname that he 

21          preferred to go by.  And apparently the 

22          supervisors wanted him to be called by his 

23          full name, his real name, whether it's 

24          William or Robert or whatever.  And they were 

                                                                   223

 1          reported because they continued to call him 

 2          by his nickname.

 3                 So like -- if there are complaints 

 4          like that, isn't that a staff training issue 

 5          more than anything else?  So -- that's a 

 6          two-part question.

 7                 EXECUTIVE DIRECTOR MIRANDA:  So with 

 8          respect to the example you gave, I'm not 

 9          familiar with the specifics.  But I can 

10          certainly assure you that in 2018 the 

11          Justice Center would not find that, as you 

12          described it, to be an incident of abuse and 

13          neglect.

14                 We do realize that these cases are 

15          substantiated approximately one-third, as you 

16          mentioned.  And I think it's important to 

17          remember that these are extremely complicated 

18          cases.  We're dealing with sometimes multiple 

19          victims with very different capacities.  

20          We're dealing with trauma.  We're also 

21          dealing with circumstances that are difficult 

22          with respect to the care that these people 

23          are receiving.  

24                 So I think that the substantiation 

                                                                   224

 1          rate is consistent with the Child Abuse 

 2          Hotline, which is the 33 percent number.  And 

 3          so we're confident that we'll continue to 

 4          assess cases in a reasonable way to make sure 

 5          the cases like you're mentioning, Senator, 

 6          are not part of that pool of cases that are 

 7          classified as abuse and neglect.

 8                 CHAIRWOMAN YOUNG:  Okay, thank you.  

 9                 And you just brought up trauma, which 

10          is great, because that's where I wanted to go 

11          to next.  

12                 And the Justice Center provides 

13          background information and contact to assist 

14          providers, and also they give it to family 

15          members for individuals who have been 

16          suffering from some sort of trauma.  Can you 

17          share more details of your efforts in that 

18          direction?  Because I think that's a great 

19          idea.

20                 EXECUTIVE DIRECTOR MIRANDA:  So we've 

21          trained all of our investigators to make sure 

22          that they are using an appropriate approach 

23          when investigating these cases.  And this is 

24          a trauma-informed, evidence-based, 

                                                                   225

 1          victim-centered approach that we are using.

 2                 We've also been doing a lot of 

 3          education with our investigators to help them 

 4          understand that when we're talking about 

 5          trauma, we're talking about trauma across the 

 6          field.  Right?  So if you're a witness, or 

 7          perhaps you are a subject in an 

 8          investigation, inherently this is a traumatic 

 9          experience.  And so we want to make sure that 

10          our investigators are leading with that in 

11          mind, and using that approach, whether you're 

12          a witness, whether you're a subject, or 

13          whether you're a victim of abuse and neglect.

14                 So we've done extensive training and 

15          invested a significant amount of resources in 

16          that effort.

17                 CHAIRWOMAN YOUNG:  Okay, thank you.

18                 Assembly?

19                 CHAIRWOMAN WEINSTEIN:  Assemblywoman 

20          Gunther.

21                 ASSEMBLYMAN GUNTHER:  Well, we just 

22          met the other day, and I was certainly 

23          impressed by the changes that you've 

24          initiated in the Justice Center -- not making 

                                                                   226

 1          it punitive, but more educational.  And we do 

 2          appreciate that.

 3                 Do you think that the definition of 

 4          abuse and neglect should be changed, like 

 5          statutorily?

 6                 EXECUTIVE DIRECTOR MIRANDA:  I believe 

 7          the statute as it exists is fine.  I believe 

 8          that we are able, as an agency, to make sure 

 9          that we're using a reasonable standard when 

10          we're making these assessments.  

11                 There's been a lot of discussion about 

12          the use of "neglect" and making sure that the 

13          appropriate cases are being classified.  

14          That's not a function of changing the 

15          statute.  That's a matter of making sure that 

16          the lens with which we're looking at these 

17          cases is appropriate given the circumstances 

18          that people are working in every single day.

19                 ASSEMBLYMAN GUNTHER:  Thank you.

20                 CHAIRWOMAN YOUNG:  Thank you.

21                 Senator Krueger.

22                 SENATOR KRUEGER:  Hi.  Thank you for 

23          your testimony today.

24                 So I think I want to just do a little 

                                                                   227

 1          bit of follow-up on the questions.  So if -- 

 2          I just want to double-check on the record 

 3          you're right, that if a third of your cases 

 4          are being concluded as something needed to be 

 5          done, there was in fact abuse or neglect, 

 6          that is a standard that is not uncommon in 

 7          other kinds of mandatory reporting hotline 

 8          type of situations?

 9                 EXECUTIVE DIRECTOR MIRANDA:  So every 

10          case that comes into the Justice Center 

11          that's classified as abuse and neglect will 

12          conclude with either a substantiation or an 

13          unsubstantiation.  

14                 Cases are unsubstantiated perhaps 

15          because we're unable to meet our burden, our 

16          standard of proof, which is preponderance of 

17          the evidence.  Sometimes they are 

18          unsubstantiated because there may be false 

19          allegations, we see that as well.  So there 

20          are a host of different reasons why a case is 

21          unsubstantiated.  

22                 But I think, you know, the 

23          Justice Center is here to ensure that that 

24          one-third of the people where cases are 

                                                                   228

 1          substantiated, that those individuals are 

 2          held accountable.  Right?  And that we're 

 3          able to issue corrective action plans.  And 

 4          whether that's retraining, changing policies 

 5          or looking at supervision levels, that abuse 

 6          and neglect is being accounted for but also 

 7          being prevented.

 8                 SENATOR KRUEGER:  And just to remind 

 9          us all, the reason that we created the 

10          Justice Center was because there were so many 

11          complaints being brought to the state, to 

12          individual legislators, to police and DAs of 

13          problems happening, so to speak, on the 

14          state's watch for the most vulnerable people.  

15          I mean, all the agencies that you oversee 

16          serve people who are in institutional-type 

17          settings and are quasi -- the responsibility 

18          of the State of New York.  That's correct, 

19          right?

20                 EXECUTIVE DIRECTOR MIRANDA:  Correct.

21                 SENATOR KRUEGER:  So while there is 

22          going to be a stress between those who think 

23          you're pushing too hard and those who may 

24          think you're not pushing hard enough, again, 

                                                                   229

 1          I think I wanted to remind myself that there 

 2          was a very specific reason we created the 

 3          Justice Center.

 4                 My understanding is that there was a 

 5          decision concerning whether the Justice 

 6          Center had prosecutorial authority and 

 7          whether you needed DAs to be the leads in 

 8          court.  And I'm curious whether, based on 

 9          that decision, you're finding that you need 

10          to change your protocols or that you need the 

11          Legislature to change the statute.

12                 EXECUTIVE DIRECTOR MIRANDA:  So the 

13          constitutional issue is an important 

14          question.  Thank you for asking it.

15                 There's nothing in the State 

16          Constitution that prohibits the Legislature 

17          from appointing a special prosecutor.  We 

18          receive our authority in the same fashion as 

19          county DAs, through the Legislature.  We have 

20          concurrent authority with county DAs, and we 

21          enjoy a very collaborative and supportive 

22          relationship with them.  

23                 There are, as you mentioned, a small 

24          handful of cases in Albany County, but there 

                                                                   230

 1          are also cases downstate in the Bronx as well 

 2          as in Kings County where motions to dismiss 

 3          based on the constitutional challenge of 

 4          prosecutorial authority have been denied.  

 5                 We're very confident that upon appeal, 

 6          the cases here in Albany -- that we will be 

 7          successful and the Justice Center will remain 

 8          in good stead.

 9                 SENATOR KRUEGER:  Thank you.  Thank 

10          you for your work.

11                 CHAIRWOMAN YOUNG:  Thank you.  

12                 Assembly?  

13                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

14          Santangelo -- I'm sorry, Santabarbara.  

15          Angelo Santabarbara.

16                 ASSEMBLYMAN SANTABARBARA:  That's 

17          okay.  It's sort of a combination of names.

18                 CHAIRWOMAN WEINSTEIN:  It's been a 

19          long couple of weeks.

20                 ASSEMBLYMAN SANTABARBARA:  That's 

21          okay.

22                 Thanks for being here today, and 

23          thanks for your testimony.  Just a few 

24          questions.

                                                                   231

 1                 In the testimony you talk about you've 

 2          eased the burden for mandated reporters, and 

 3          you list a couple of changes.  How are these 

 4          changes going to help compared to what was in 

 5          place before that?

 6                 EXECUTIVE DIRECTOR MIRANDA:  Sure.  So 

 7          previously -- and under the Justice Center, 

 8          there's an obligation, mandated reporting of 

 9          any abuse and neglect.  That's any person who 

10          witnesses or has knowledge of an event.  

11                 So we take for an example an incident, 

12          perhaps, of abuse or neglect that may occur 

13          in a dining room where there are four or five 

14          DSP workers.  Under our previous guidance, 

15          all four or five would have to make their own 

16          individual report to the Justice Center.  

17          Now, with the relaxed requirements, we only 

18          require for one person to make that report.  

19                 And I think it's important to realize 

20          that that one person who makes the report 

21          doesn't necessarily have to be a DSP who's 

22          providing care, it can be a supervisor.  So 

23          our hope is that we are leaving workers where 

24          they need to be, right -- working, taking 

                                                                   232

 1          care of individuals with special needs, and 

 2          not creating situations where we're pulling 

 3          staff away to make phone calls that are 

 4          duplicative.

 5                 ASSEMBLYMAN SANTABARBARA:  And my next 

 6          question is around the -- sort of the 

 7          auditing process.  You're talking about 

 8          looking for improvements on operations and 

 9          efficiency.  How often does that happen?  Is 

10          it every time an incident is reported, or is 

11          it periodic?

12                 EXECUTIVE DIRECTOR MIRANDA:  I'm 

13          sorry, can you repeat the question?  The 

14          beginning again?

15                 ASSEMBLYMAN SANTABARBARA:  You talk 

16          about evaluating the process and the 

17          efficiencies of your operations, and you talk 

18          about an audit of investigatory training 

19          that's going to happen.  Does that happen 

20          every time, or is it just a periodic --

21                 EXECUTIVE DIRECTOR MIRANDA:  So audits 

22          are built into the agency.  I will say, 

23          though, upon arriving here a year ago, we've 

24          done a deep dive as to our various processes 

                                                                   233

 1          to see where we can make improvements.  

 2                 You know, the Justice Center is also a 

 3          new agency, we'll be turning five years old 

 4          this year.  I think it's important for us to 

 5          use this opportunity to assess what has 

 6          worked and what hasn't worked so well, and to 

 7          make those changes.

 8                 So while some of the audits that I 

 9          mentioned are operationalized and occur on a 

10          regular basis, we're taking a more holistic 

11          look and view of the entire agency to see 

12          where we can improve efficiencies, whether 

13          it's investigative cycle times or the appeal 

14          process.  All of these areas are areas that 

15          are points of focus for 2018.

16                 ASSEMBLYMAN SANTABARBARA:  And my last 

17          question is on the training for internal and 

18          external investigators.  What does that 

19          training consist of?

20                 EXECUTIVE DIRECTOR MIRANDA:  Sure.  So 

21          our internal investigators receive an 

22          extensive training process when they come 

23          on board.  As I mentioned, about 50 percent 

24          of them actually have experience working in 

                                                                   234

 1          the service settings, so we find that to be, 

 2          I think, of great value to the agency.  They 

 3          will receive training on forensic 

 4          interviewing, evidence collection, working 

 5          with people with special needs, as well as, 

 6          as I mentioned before, the victim-centered, 

 7          evidence-based, trauma-informed approach of 

 8          investigating these cases.

 9                 Additionally, every year we convene an 

10          in-service, and all 157 of our 

11          investigators are brought up to Albany and we 

12          have a three-day training program where we 

13          will discuss new trends, perhaps there will 

14          be some training on legal issues that have 

15          presented within the past year.  We'll 

16          discuss different approaches, and there will 

17          be guest speakers.  And so we'll offer a more 

18          robust training.  But we ensure that that 

19          occurs every single year and that every 

20          investigator participates.

21                 With respect to external 

22          investigators, our law enforcement academy 

23          conducts trainings, and they trained over 

24          500 individuals outside of the agency.  And 

                                                                   235

 1          the goal there is to make sure that we're 

 2          able to educate people as to working with 

 3          this population that has very distinct and 

 4          special needs.

 5                 ASSEMBLYMAN SANTABARBARA:  Thank you.

 6                 CHAIRWOMAN YOUNG:  Are you all set?

 7                 CHAIRWOMAN WEINSTEIN:  Yeah.  We're 

 8          done.

 9                 CHAIRWOMAN YOUNG:  Okay.  So I want to 

10          thank you for your testimony today.  And we 

11          need to protect our most vulnerable 

12          New Yorkers, and I know that you're working 

13          hard at it, and I know that you've made 

14          several changes at the center which sound 

15          like they're very positive, and I would just 

16          say to you, keep going.

17                 EXECUTIVE DIRECTOR MIRANDA:  Thank 

18          you.

19                 CHAIRWOMAN YOUNG:  Thank you.

20                 CHAIRWOMAN WEINSTEIN:  Thank you.

21                 CHAIRWOMAN YOUNG:  Our next speaker is 

22          the Arc New York and its executive director, 

23          Mark van Voorst.  The Arc.

24                 Welcome.

                                                                   236

 1                 MR. VAN VOORST:  Excuse me?

 2                 CHAIRWOMAN YOUNG:  Welcome.

 3                 MR. VAN VOORST:  Thank you.

 4                 CHAIRWOMAN YOUNG:  Good to see you.  

 5          Look forward to your testimony.

 6                 MR. VAN VOORST:  Thank you.  

 7                 Senator Young, Assemblywoman 

 8          Weinstein, Senators and Assemblypeople, thank 

 9          you for giving me the opportunity to speak to 

10          you today.  

11                 I come to you today with two and a 

12          half months of experience as the executive 

13          director of the Arc New York, but 40 years of 

14          experience in the field.  I started off as a 

15          direct support worker, and before coming to 

16          the Arc New York I had completed a 16-year 

17          stint in the city, so I'm familiar with the 

18          upstate/downstate issues.

19                 One of the things that I wanted to 

20          point out before we get into some of the more 

21          specific requests that we have is that a lot 

22          of our requests probably wouldn't be even 

23          relevant had the Legislature, OMRDD -- or 

24          OPWDD, as it's now called in the voluntary 

                                                                   237

 1          sector -- not actually established what is 

 2          truly the gold standard of service provision 

 3          in the entire country.  

 4                 We have historically done a tremendous 

 5          job.  The Arc of New York itself serves 

 6          roughly 60,000 individuals.  It employs 

 7          30,000 staff and it operates in 52 counties.

 8                 With that as a backdrop, though, there 

 9          are serious issues that we are currently 

10          facing.  I'm not going to go through the 

11          testimony which I have provided to you in 

12          writing, but there are a couple of things 

13          that I do want to highlight.  

14                 The most significant problem we are 

15          facing is our ability to hire and retain 

16          competent staff.  We are extremely grateful 

17          for the money that has been given to us, the 

18          3.25 -- 3.25 for direct support and then 

19          3.25 for clinical staff -- is obviously a 

20          tremendous help to our burden.  However, 

21          having said that, we also want to highlight 

22          that it is only the beginning of a process 

23          that we hope continues.  And we actually need 

24          it to occur at a faster pace than it was 

                                                                   238

 1          originally planned, because the statistics 

 2          seem to suggest that not only are our vacancy 

 3          rates increasing, but our turnover rates are 

 4          increasing.

 5                 Now, ironically, this should not have 

 6          come as a surprise to anyone.  In 2006, HHH 

 7          provided a report to the United States 

 8          Congress on direct support professionals.  

 9          And at that time, so 12 years ago, the 

10          vacancy rate was already noted to be roughly 

11          37 percent and was estimated to hit 

12          50 percent by 2020.  We are well on our way 

13          to hitting 50 percent.

14                 The voluntary sector has prided itself 

15          on providing the best quality of care for 

16          individuals with developmental disabilities.  

17          Our ability to continue to do that is being 

18          weakened at this point because we cannot find 

19          and retain sufficient staff.  The numbers 

20          suggest at this point that our vacancy rate 

21          is somewhere around 24 percent.  Our turnover 

22          rate within the first six months is somewhere 

23          around 30 percent.  And the way you have to 

24          understand this, I think, is to put it in the 

                                                                   239

 1          context -- if you had a family who was in a 

 2          nursing home or receiving medical care and 

 3          you had that kind of turnover rate, what 

 4          would your level of comfort be?  

 5                 We can hardly get staff trained before 

 6          they're leaving.  It's costing us a fortune 

 7          to hire new people.  And so accelerating the 

 8          dollar amount that we can pay staff and doing 

 9          a couple of other things that I've outlined, 

10          I think, in my testimony would be extremely 

11          helpful to trying to stabilize the field.  

12          But this is a long-term problem, and we need 

13          to begin to work on it extremely quickly if 

14          we hope to maintain the gold standard.

15                 Thank you.

16                 CHAIRWOMAN YOUNG:  Thank you.  

17                 Where are staff leaving to?  Where are 

18          they going for jobs?

19                 MR. VAN VOORST:  Probably any job 

20          that's somewhat easier.  It's an extremely 

21          difficult position.  This is not a specialty 

22          where you can say, okay, this person does one 

23          thing.  Direct support professionals do just 

24          about everything that you can imagine with a 

                                                                   240

 1          person of need.  But they're leaving for jobs 

 2          that pay more.  They're leaving for jobs with 

 3          less responsibility.  We're competing with 

 4          the Burger Kings, with the Walmarts.  There 

 5          are tremendous stresses that are placed on 

 6          the staff that work for us.

 7                 I know that, you know, the executive 

 8          director of the Justice Center has made 

 9          tremendous strides in trying to improve the 

10          relationship between the Justice Center and 

11          the field, and I give her tremendous credit 

12          for that because the past year has seen many 

13          changes.  However, direct support staff still 

14          are extremely fearful of the Justice Center, 

15          because once your name is on that list as 

16          a -- she doesn't call them suspects anymore, 

17          but they themselves would call themselves 

18          suspects -- they're sitting out there for 

19          weeks, if not months at a time, not knowing 

20          what their future is -- and for things that, 

21          you know, probably in the criminal world 

22          would not be regarded as criminal, but in our 

23          world can come very close to having sort of 

24          criminal consequences.  Peoples' lives are 

                                                                   241

 1          getting ruined.

 2                 The other thing I just wanted to 

 3          quickly highlight, though -- and again, this 

 4          is not to take away anything from the 

 5          #bFair2DirectCare campaign, because it has 

 6          been a tremendous success -- is that's what 

 7          we actually looked at, one level of staff 

 8          that we're hurting for.  We actually have a 

 9          huge need for mid-line supervisory staff, who 

10          are leaving in droves and we cannot seem to 

11          find clinical staff who want to work in this 

12          field at the salaries that we can pay as 

13          well.

14                 So you have actually three types of 

15          employees who are critical to our ability to 

16          perform top-quality care who we actually are 

17          now having a difficult time attracting.

18                 CHAIRWOMAN YOUNG:  Thank you for that 

19          answer.  

20                 And just to switch gears for a second, 

21          I've had several agencies that serve people 

22          with disabilities, and they've come to me and 

23          said that they have a very substantial case 

24          for a rate appeal, and rate appeals are 

                                                                   242

 1          almost impossible to get through right now.

 2                 MR. VAN VOORST:  Correct.

 3                 CHAIRWOMAN YOUNG:  Could you address 

 4          that problem?

 5                 MR. VAN VOORST:  The only thing I can 

 6          tell you, Senator, is rate appeals don't 

 7          exist anymore.  They stopped several years 

 8          ago, and that's a huge problem.  

 9                 In fact, one of the chapters of the 

10          Arc of New York went out of business -- 

11          actually merged with another county -- 

12          because it was costing them so much to 

13          operate one four-person facility that they 

14          financially couldn't sustain themselves, and 

15          they collapsed.  So there are no more rate 

16          appeals.

17                 CHAIRWOMAN YOUNG:  And what happened 

18          to the people served by that agency?

19                 MR. VAN VOORST:  Well, fortunately the 

20          Arc of New York is comprised of 52 chapters, 

21          and we had a chapter that was adjacent -- 

22          actually, it wasn't adjacent, it was somewhat 

23          south of where this chapter was -- where they 

24          were able to take over the operations and 

                                                                   243

 1          continue to supply the services to the 

 2          individuals.

 3                 CHAIRWOMAN YOUNG:  So this would be 

 4          Niagara County and Cattaraugus County.

 5                 MR. VAN VOORST:  Correct.

 6                 CHAIRWOMAN YOUNG:  Okay.  All right.  

 7          Thank you for that answer.

 8                 I think we're all set, but we 

 9          appreciate you taking the time today.

10                 MR. VAN VOORST:  If I'm not going to 

11          be asked -- I would like to put one thing on 

12          the table, and I spoke to Assemblymember 

13          Gunther about this.  

14                 Telemedicine has been mentioned a 

15          couple of times today.  It is absolutely 

16          essential that OPWDD begin to move this 

17          forward.  You know, for years and years our 

18          industry has been criticized for overusing 

19          emergency rooms and hospitals.  Well, there's 

20          a reason for that.  There's a reason when 

21          state survey teams -- or prior to Denise 

22          taking over the Justice Center, there was 

23          this constant questioning of nursing 

24          decisions.  To protect themselves, nurses 

                                                                   244

 1          would say:  Well, I'm not going to make that 

 2          call, I'm going to send somebody to the ER.  

 3                 There are organizations out there now 

 4          where you can use telemedicine where you're 

 5          actually -- the person picking up the phone 

 6          is an ER physician.  There's tremendous costs 

 7          savings associated with it.  And at this 

 8          stage I can't conceive of a reason why we 

 9          wouldn't want to push telemedicine as quickly 

10          as we possibly can.

11                 CHAIRWOMAN YOUNG:  I totally agree on 

12          telemedicine, telehealth.

13                 Thank you so much.

14                 MR. VAN VOORST:  Thank you.

15                 ASSEMBLYWOMAN GUNTHER:  Thank you.  

16                 CHAIRWOMAN YOUNG:  Our next speakers 

17          are Executive Director Harvey Rosenthal and 

18          Director for Policy and Public Engagement 

19          Elena Kravitz, from the New York State 

20          Association of Psychiatric Rehabilitation 

21          Services, Incorporated, and also Glenn 

22          Liebman, CEO of Mental Health Association of 

23          New York State.  I think.  Is that correct?

24                 MR. LIEBMAN:  Yes, it is.

                                                                   245

 1                 CHAIRWOMAN YOUNG:  Okay.  Very good.  

 2                 MR. ROSENTHAL:  Good afternoon.  

 3                 CHAIRWOMAN YOUNG:  Good afternoon.

 4                 MR. ROSENTHAL:  Thank you, Senator 

 5          Young, Assemblywoman Weinstein, and members 

 6          of the committee, Ms. Gunther --

 7                 CHAIRWOMAN YOUNG:  As you know, we're 

 8          asking the speakers to summarize their 

 9          testimony, so --

10                 MR. ROSENTHAL:  What's that?

11                 CHAIRWOMAN YOUNG:  We're asking the 

12          speakers to summarize their testimony instead 

13          of reading it word for word.  So if you could 

14          do that, that would be great.

15                 MS. KRAVITZ:  A summary.  Summarize.

16                 MR. ROSENTHAL:  Summary?  Oh, a 

17          summary.  I'm sorry.  I didn't bring my 

18          hearing aids.

19                 (Laughter.)

20                 MR. ROSENTHAL:  So speaking of my 

21          hearing aids, this is my 25th year of 

22          providing testimony, and I hope that 25 is 

23          the charm.  

24                 So I want to first introduce Elena 

                                                                   246

 1          Kravitz to you.  She is our new policy 

 2          director.  I'm particularly proud to have 

 3          stolen her back from New Jersey.  She was a 

 4          Brooklyn native, but -- she has a great 

 5          story, we won't have time for you to hear it 

 6          today.  And she'll be doing some incredible 

 7          work.  But we're also proud that she sits on 

 8          the highest body in the nation, which is the 

 9          Interdepartmental Serious Mental Illness 

10          Coordinating Council.  

11                 So Elena -- and welcoming Glenn, of 

12          course.  You'll be hearing from him.  He's my 

13          partner and colleague, and we'll be going 

14          over a number of issues.  So I'm going to go 

15          fast.

16                 NYAPRS is a statewide -- a unique 

17          statewide coalition of people with mental 

18          illnesses, like Elena and me, and community 

19          providers who have been working for 37 years 

20          to try to transform the system, to move one 

21          from illness to wellness and from 

22          institutions to the community and from 

23          coercion to rights and things like that.

24                 Over the years we've worked on a 

                                                                   247

 1          number of issues together with the 

 2          Legislature, and last year we were very 

 3          grateful that you funded the $1.9 billion for 

 4          supportive housing over 35 years, crisis 

 5          intervention teams, raised the age of 

 6          criminal liability, and the increase in the 

 7          workforce that you just heard about.  

 8                 We're very grateful for that, and 

 9          we're also grateful to the Governor for some 

10          of the things he put in his budget -- the ACT 

11          teams reinvestment, the crisis in community 

12          beds.

13                 I'm not going to talk about -- I am 

14          going to talk about the housing issue.  

15          Housing, stable housing, is essential to hope 

16          and health and recovery.  We work on the 

17          streets of New York City with people that are 

18          frequently readmitted in emergency rooms or 

19          hospitals, jails and prisons, and the one 

20          thing they share, so many of them in common, 

21          is they didn't have stable housing.

22                 So it's really important not only to 

23          build new housing, but to keep and maintain 

24          the housing we have now.  And even though the 

                                                                   248

 1          Governor -- he puts up $10 million, it's not 

 2          enough by any means.  And so we're a member 

 3          of the Bring It Home, Better Funding for 

 4          Better Care Campaign, and we urge the 

 5          Legislature and the Governor to make a 

 6          commitment to put in $120 million to 

 7          stabilize 40,000 units of mental health and 

 8          permanent housing in five program types over 

 9          the coming years.  

10                 I'm going to focus a little bit on 

11          criminal justice.  I was so glad to hear the 

12          questions earlier.  This is a top priority 

13          for us.  We have way too many people in jails 

14          and prisons.  Right now we have people 

15          suffering in the box who are 23 hours a day 

16          in the dark -- and you heard earlier today 

17          that's 850, I think.  And even though we have 

18          that law we all worked on to pass, there 

19          still are these procedures where people can 

20          be put in the box.

21                 Actually, I'm out of order here, but 

22          the way to really prevent folks even getting 

23          into prison is at the arrest level.  And so 

24          the training of police to be more responsive, 

                                                                   249

 1          and to not escalate but to be able to handle 

 2          a situation and avoid a tragedy or an arrest, 

 3          is critical.  The Legislature has been great 

 4          on that, the Senate in particular has 

 5          funneled money -- if you look at my 

 6          testimony, you'll see a broad number of 

 7          communities that have received that funding.  

 8          And Mrs. Gunther, last year you funded for 

 9          half a million dollars an alternative to 

10          outpatient commitment that's very -- it goes 

11          to people before tragedy and before crisis 

12          whenever possible.  We're looking forward to 

13          seeing how that goes.

14                 I mentioned earlier about solitary 

15          confinement.  There are 844 people in the OMH 

16          caseload in the SHU.  Thirty percent of the 

17          suicides in 2014 to 2016 happened in the SHU.  

18          Rates of suicide attempts and self-harm, 

19          11 times higher in solitary confinement.  

20          Even though Colorado has implemented a 

21          program to cut solitary confinement from 

22          1,500 to 18, for our population, New York is 

23          still -- is lagging behind.

24                 As part of the Mental Health 

                                                                   250

 1          Alternatives to Solitary Confinement 

 2          Coalition, we urge the Legislature to pass 

 3          the HALT legislation.  We want to 

 4          particularly appeal to the Senate because our 

 5          understanding is last night Speaker Heastie, 

 6          he made a commitment to pass this bill, which 

 7          would not only get into this issue about 

 8          serious mental illness, or mental illness, it 

 9          would ban solitary confinement with 

10          vulnerable groups -- the young and elderly, 

11          people with physical or mental disabilities, 

12          pregnant women and new mothers, and LGBTQI 

13          individuals.  Long overdue.  

14                 If you're not mentally ill before you 

15          get in the SHU, you will be afterwards.  We 

16          really have to stop this practice.  So we 

17          urge you, we urge you for help in this area.

18                 I won't talk about the living wage, 

19          because Glenn will.  You heard earlier about 

20          adult homes.  I think it is tragic that only 

21          14 percent of the 4500 that were supposed to, 

22          by a court settlement, be able to move into 

23          supportive housing have moved.  I know 

24          there's been some progress, but it's 

                                                                   251

 1          miniature.  

 2                 And I'm glad that the Governor's 

 3          budget is funding $5 million for specialized 

 4          peer supporters to go to the adult homes and 

 5          instill hope and trust and help the people 

 6          move all the way through the very complex 

 7          process into the community.  I think you 

 8          heard earlier, too, that -- I know last year, 

 9          at the end of last year, the operators, adult 

10          home operators, were able to get a bill 

11          passed through both houses that would 

12          increase their rates.  The Governor, he 

13          vetoed it, partly because he didn't want to 

14          do budget outside of budget.  

15                 But we really urge and insist that if 

16          there's a hike to the operators, there needs 

17          to be an equal hike to the personal needs 

18          allowance of the residents.  They live on so 

19          little money.

20                 We are very -- again, one more year, 

21          really happy to see the funds from the 

22          downsizing of facilities into the community.  

23          This reinvestment money, $11 million this 

24          year, goes to mobile intensive outreach 

                                                                   252

 1          teams, peer bridger and respite programs, 

 2          crisis intervention, warm line and housing 

 3          services, family empowerment services, 

 4          managed care transitional supports, forensic 

 5          ACT team and social club services.  It's 

 6          critical, and we're grateful to the Governor 

 7          and the Legislature for supporting this year 

 8          after year.

 9                 Are you doing prescriber prevails?

10                 MR. LIEBMAN:  No --

11                 CHAIRWOMAN YOUNG:  Yeah, Harvey, I was 

12          wondering if you could kind of summarize --

13                 MR. ROSENTHAL:  Actually, you know 

14          what --

15                 CHAIRWOMAN YOUNG:  And then we'll let 

16          Glenn go.  

17                 MR. ROSENTHAL:  -- the rest of my 

18          issues he's going to take.

19                 CHAIRWOMAN YOUNG:  Perfect.

20                 MR. ROSENTHAL:  So I'll yield to my 

21          partner.

22                 CHAIRWOMAN YOUNG:  Thank you.

23                 MR. LIEBMAN:  Thank you very much.  

24          And I appreciate you squeezing me in here at 

                                                                   253

 1          the last minute.  I thank Harvey as well for 

 2          working with me on this.

 3                 So my name is Glenn Liebman.  I'm the 

 4          director of the Mental Health Association of 

 5          New York State, and this is my 16th year of 

 6          testifying.  I really appreciate it very 

 7          much. 

 8                 Our organization is comprised of 

 9          26 affiliates in 52 counties throughout 

10          New York State.  Largely we provide 

11          community-based mental health services; we're 

12          also involved in a lot of education and 

13          advocacy as well.  And we want to thank 

14          Assemblymember Gunther for being part of our 

15          press conference yesterday when we introduced 

16          a new mental health license plate -- as well 

17          as Senator Ortt, who I know is not here 

18          today.  But we thank them for all their 

19          support, not just for that.

20                 But there has been a major sort of 

21          change, and New York is leading the way on a 

22          lot of anti-stigma efforts.  The license 

23          plate, we have a mental health tax check-off.  

24          And more significantly, we even have a mental 

                                                                   254

 1          health education bill in New York State now, 

 2          which is great.  And I appreciate questions 

 3          being asked about that, because it's going to 

 4          be operationalized on July 1st of this year.  

 5                 And we're very excited to make sure 

 6          that all schools across New York State and 

 7          all students across New York State now have a 

 8          greater knowledge about mental health in 

 9          schools, and I'll get into just that briefly.  

10          And I'll be very brief, because frankly there 

11          are 13 issues we're covering, and I obviously 

12          won't cover -- carry -- Harvey did carry most 

13          of them.  

14                 But I did want to talk about workforce 

15          specifically.  I think workforce -- you've 

16          heard it from everybody, it's a continuing 

17          theme.  What you all did last year was 

18          phenomenal.  The #bFair2DirectCare campaign 

19          and everybody who was involved -- and this 

20          was the greatest change in over a decade for 

21          living wage, for the direct care workforce.  

22          It was a great victory, and we as the mental 

23          health organizations and behavioral health 

24          organizations also were able to receive 

                                                                   255

 1          funding for that.  And again, that was 

 2          terrific.  

 3                 But it's a step.  It's a step in a 

 4          staircase of need, frankly.  We have a lot of 

 5          issues that are going on.  This is a great 

 6          add to the workforce, but we need so much 

 7          more.  We need continuous support.  We're 

 8          looking for -- and it's in our budget 

 9          proposal -- we're looking for a 3.25 percent 

10          increase, much like you had last year, to be 

11          implemented January 1st of this year for the 

12          so-called 100, 200, 300 series in the direct 

13          care workforce, which also includes clinical 

14          staff as well, which we think is essential to 

15          support because many of us in the mental 

16          health system recognize that our clinical 

17          folks are really in many ways our direct care 

18          folks.  So we're really appreciative of 

19          hopefully your support in this.

20                 And the other thing I'll just touch on 

21          is the mental health education bill.  Again, 

22          we look at this as a groundswell of support.  

23          We look at this as a major transformation of 

24          the system of care, but there is absolutely 

                                                                   256

 1          no money behind it.  And this is -- we don't 

 2          want this to go down as an unfunded mandate.  

 3          We don't want to look at this as the great 

 4          experiment -- we finally broke through the 

 5          schools and all that, and yet there's no 

 6          money behind that.  

 7                 So we have a proposal that we put out 

 8          that's in your testimony as well in creating 

 9          a mental health education resource center, 

10          which we think is very important.  

11                 And again, I keep -- so many of these 

12          issues are so important, and Harvey did a 

13          great job in covering them, but I just want 

14          to also thank Senator Krueger.  

15                 Senator Krueger, thank you for 

16          bringing up gambling prevention.  And really, 

17          nobody talks about it, and it's so important.  

18          We have a $4 billion gaming industry in 

19          New York State, and we work very closely with 

20          the gambling prevention folks -- they get 

21          $1 million.  A $4 billion industry, 

22          $1 million in prevention.  So there's got to 

23          be a complete sea change in that area.  

24                 And again, I can go on and on, but you 

                                                                   257

 1          have my testimony.  And we're very strongly 

 2          supportive of NYAPRS and many of our other 

 3          colleagues who you will hear from.

 4                 CHAIRWOMAN YOUNG:  Thank you.  

 5                 I do have a couple of questions.  

 6          So -- and I appreciate everything that you 

 7          said.  I had a conversation with Commissioner 

 8          Sullivan regarding the Governor's plans to 

 9          actually close more inpatient beds, which I'm 

10          very concerned about because, as you know, 

11          we're over census in several of the 

12          facilities, so beds stay closed and there are 

13          too many people that need to be served.  

14                 Could you give your perspective on 

15          that?

16                 MR. ROSENTHAL:  Well, we have been a 

17          supporter of the downsizing of the state 

18          hospital system.  I started when there were 

19          5,000 beds, and at one point there was 

20          92,000 -- 90,000 to 100,000 -- 92,000.  

21                 But I think the OMH has taken the 

22          right direction with preinvesting the 

23          services before the closures and putting in 

24          play the kinds of services and the continuum 

                                                                   258

 1          that should really support people and prevent 

 2          readmissions.  

 3                 I will say, too, that the Governor's 

 4          managed-care redesign is very street-based 

 5          and very outreach, engagement, and diversion.  

 6          So I think there's a number of instances 

 7          where the right resources are on the street 

 8          and that in -- we don't want to keep 

 9          expensive hospital beds open.  We have I 

10          don't know how many campuses all over the 

11          state, and we really -- the focus ought to be 

12          on the community.  

13                 And when people do need inpatient 

14          services, they are available, including the 

15          Article 28s.

16                 CHAIRWOMAN YOUNG:  But we do have 

17          people that go to the hospital and just -- or 

18          the emergency room, and they're languishing 

19          there in some cases.  So I think there's a 

20          balance.  

21                 And I agree with you that the pendulum 

22          has swung, I think.  So back in the day, we 

23          used to have all kinds of developmental 

24          centers and psychiatric centers that were 

                                                                   259

 1          just warehousing people inappropriately, I 

 2          fully agree with that.  And then the pendulum 

 3          swung in the other direction.  

 4                 And I guess what we have to find is 

 5          the balance.  Because people with mental 

 6          illness, let's face it, are still severely 

 7          underserved in this state in so many ways, 

 8          whether it's been urban areas -- and we see 

 9          the exploding homelessness that we discussed 

10          earlier.  But that's all over the state where 

11          we see homelessness on the rise.  We see 

12          people in jail cells, as you pointed out, 

13          local jails.  The sheriff's departments 

14          aren't equipped to deal with people with 

15          mental illness.  And so we see a lot of the 

16          problems that are out there.  

17                 And one of the questions I have, 

18          though, has to do with whether or not -- so 

19          let me preface it by saying this.  I'm 

20          excited about the transitional housing and 

21          supportive housing that's included in the 

22          budget, because I think that's sorely needed.  

23          But is that sometimes quite a step down, to 

24          go from inpatient to transitional housing?  

                                                                   260

 1          And you talked about the managed care, but 

 2          could we just talk about that for a second?  

 3          Because I'm concerned that maybe there's too 

 4          much of a step down.  Is there something that 

 5          should be in the middle?

 6                 MR. ROSENTHAL:  Well, you mean -- for 

 7          example, the crisis respite beds to some 

 8          degree are --

 9                 CHAIRWOMAN YOUNG:  Right.

10                 MR. ROSENTHAL:  -- a diversion.

11                 CHAIRWOMAN YOUNG:  Yeah.  Right.  So 

12          things like that.

13                 MR. ROSENTHAL:  And maybe will 

14          function if people do relapse sort of 

15          quickly, they'll be able to go there?

16                 CHAIRWOMAN YOUNG:  Right.  Could you 

17          address that?  Because it's -- I think that 

18          there may be a gap --

19                 MR. ROSENTHAL:  I understand your 

20          point.  I have seen people backed up in the 

21          Capital District Psychiatric Center waiting 

22          for a bed.  

23                 I'm not saying this is black and white 

24          either, Senator.  I just -- I don't know the 

                                                                   261

 1          answer is to keep the state hospital beds 

 2          open, though.

 3                 CHAIRWOMAN YOUNG:  But again, we have 

 4          a census that is going over in some cases.  

 5                 Glenn, did you want to say something?

 6                 MR. LIEBMAN:  Just from my 

 7          perspective -- and I agree with Harvey that 

 8          we have been long, strong advocates of 

 9          reinvestment for many years.  And we're glad 

10          to see that there's over $100 million now 

11          annualized for reinvestment.  

12                 There -- you know, as a family member, 

13          and many of us are, you know, I've seen 

14          firsthand some of the issues around housing 

15          and bed use and inpatient facilities.  But I 

16          really, you know, agree and the Mental Health 

17          Association agrees that, you know, we are 

18          very supportive of, you know, that money 

19          going to the community.  

20                 And I think that the failure of the 

21          system -- and the closures of the beds aside, 

22          the failure of the system is we've been so 

23          underfunded for so long -- you know, the 

24          outcomes in terms of community-based services 

                                                                   262

 1          are so much stronger than what you're seeing 

 2          in outcomes from other arenas.  And yet we 

 3          have been severely underfunded for as long as 

 4          we've been doing this.  

 5                 So had we been properly funded from 

 6          the get-go, I think a lot of the issues that 

 7          we see right now would not be appearing to as 

 8          us, unfortunately, as they are.

 9                 CHAIRWOMAN YOUNG:  Thank you, Glenn.

10                 Assembly?

11                 CHAIRWOMAN WEINSTEIN:  No.  We're 

12          done.

13                 CHAIRWOMAN YOUNG:  I think we're done.  

14                 Thank you.  Thanks for testifying 

15          today.

16                 MR. ROSENTHAL:  Thank you.

17                 SENATOR KRUEGER:  Thank you very much.  

18                 MR. LIEBMAN:  Thank you.

19                 CHAIRWOMAN YOUNG:  Our next speaker is 

20          Executive Director Wendy Burch, from the 

21          National Alliance on Mental Illness of 

22          New York State.  

23                 Welcome.

24                 MS. BURCH:  Thank you.  Good 

                                                                   263

 1          afternoon.  Can you hear me okay?

 2                 My name is Wendy Burch, and I am the 

 3          executive director of the National Alliance 

 4          on Mental Illness of New York State.  With  

 5          me today is Ariel Kaufman, a NAMI-NYS board 

 6          member and a family member of someone with a 

 7          serious mental illness.  We represent 

 8          thousands of New Yorkers living with a mental 

 9          illness as well as the family members who 

10          love and support them.  We appreciate the 

11          opportunity to testify today.

12                 You have our written testimony, so 

13          briefly, our focus is to ensure that those 

14          living with a mental health condition have 

15          the tools necessary to pursue their recovery.  

16          One of the most important is access to safe 

17          and affordable housing, which is why NAMI-NYS 

18          is an active participant in the Bring It Home 

19          campaign.  

20                 When providers don't have the adequate 

21          funding to retain qualified staff, our loved 

22          ones suffer.  Instead of focusing on 

23          improving their health, they find themselves 

24          hospitalized, incarcerated, or living on the 

                                                                   264

 1          streets.  They must have a home before they 

 2          can begin to think about the things that many 

 3          of us take for granted, like having a job and 

 4          being an active part of the community.

 5                 NAMI-NYS also wants to ensure that the 

 6          budget addresses community reinvestment.  For 

 7          someone living in recovery, access to 

 8          services is vital to sustained progress.  For 

 9          every hospital that closed, we've been 

10          assured that $110,000 will be invested in 

11          community resources.  These community 

12          investments are not only essential for those 

13          living with mental illness to have meaningful 

14          lives, they also save the state the 

15          astronomical costs associated with 

16          hospitalization and incarceration.

17                 MS. KAUFMAN:  I'm proud to be here 

18          today representing NAMI-NYS and the tens of 

19          thousands of New York State families and 

20          individuals who live daily with the 

21          devastating effects of serious and persistent 

22          mental illness.  Not only have I worked in 

23          the behavioral health system for nearly 

24          20 years, I am also the caregiver and 

                                                                   265

 1          daughter of a father who lives with a serious 

 2          mental illness.  So these issues mean more to 

 3          me than just data, statistics, and politics.  

 4                 I ask all of you to envision a family 

 5          member that you care deeply about struggling 

 6          to recover from a life-changing illness that 

 7          affects their ability to reason, their 

 8          physical health, and their ability to 

 9          maintain the social ties that mean so much to 

10          them.  This is what families and caregivers 

11          of people with serious mental illness face 

12          every day.  

13                 We work tirelessly to troubleshoot a 

14          fragmented health system that lacks 

15          appropriate resources just to ensure that our 

16          loved ones get the medication, healthcare, 

17          and housing that they so desperately need in 

18          order to remain stable and connected to daily 

19          activities that many of us just take for 

20          granted -- like planning a meal, calling a 

21          friend, or following up on our physical 

22          health needs.  

23                 As deinstitutionalization has 

24          progressed, families have been faced with the 

                                                                   266

 1          troubling reality of whether or not their 

 2          loved one will be able to integrate into a 

 3          community that they have limited ties to in a 

 4          world that frequently stigmatizes their 

 5          battle to recover from mental illnesses that 

 6          they did nothing to cause.

 7                 My father lives in mental health 

 8          housing and receives treatment at a certified 

 9          community behavioral health center on 

10          Long Island.  Most recently, he experienced a 

11          life-changing event.  In his mid-60s, he 

12          began to experience tremendous pain in his 

13          back to the point where his 6-foot-5 frame 

14          was literally bent over a walker for months.  

15          He couldn't get out of the house to shop, and 

16          we needed an aide to come to his house just 

17          to complete simple daily tasks.  During this 

18          time his psychiatric symptoms began to spiral 

19          due to his fears about surgery and his 

20          inability to fulfill his daily routine.  

21                 Fortunately, this story does not end 

22          in sadness like so many others, because my 

23          dad lived in a permanent subsidized apartment 

24          in Long Island.  He was able to have surgery, 

                                                                   267

 1          go to rehab, get consistent psychiatric 

 2          treatment, and return home to an apartment 

 3          that was safe and supportive.  Without the 

 4          mental health housing system, these triumphs 

 5          would not have been possible.

 6                 That is why funding existing mental 

 7          health housing at sustainable rates is 

 8          imperative.  When properly funded and 

 9          staffed, this type of housing allows people 

10          to focus on recovery in a supportive and safe 

11          environment.  I believe that it is the duty 

12          of our Legislature to set aside political 

13          discourse and achieve a moral imperative by 

14          ensuring people like my father do not lose 

15          their housing or face limitations on their 

16          opportunities to leave institutional settings 

17          because there are no appropriately funded 

18          community housing options with wraparound 

19          services that fulfill the obligation that the 

20          state has to ensuring that disabled citizens 

21          receive the best quality care and treatment 

22          possible.

23                 NAMI-NYS calls upon the Legislature to 

24          make our families a priority by funding 

                                                                   268

 1          mental health housing and services in the 

 2          community at sustainable rates, to ensure 

 3          access to mental health services, properly 

 4          prescribed medication, and adequate resources 

 5          such as psychiatrists, psychologists, and 

 6          mental health professionals.  

 7                 Adequately funded mental health 

 8          housing and services keep people from falling 

 9          through the cracks, help avoid unnecessary 

10          incarcerations, hospitalizations, and 

11          repeated trips through the homeless system.  

12                 I do thank you for your motivation and 

13          desire to fix these long-standing issues, and 

14          thank you for allowing me to talk to you 

15          today.

16                 CHAIRWOMAN YOUNG:  Thank you.

17                 MS. KAUFMAN:  I've taken a lot out of 

18          this hearing today, and I do believe that all 

19          of you are on the same page as me, so I 

20          know --

21                 CHAIRWOMAN YOUNG:  Good.  Thank you.

22                 MS. BURCH:  And I had a couple more 

23          points to make, which I won't, because -- in 

24          the interests of time.  But I just wanted to 

                                                                   269

 1          mention that as you'll see in our testimony, 

 2          we do address enforcing insurance parity, 

 3          funding for CIT, and also reinstituting 

 4          prescriber prevails.

 5                 CHAIRWOMAN YOUNG:  Thank you very 

 6          much.  We really appreciate it.

 7                 MS. KAUFMAN:  Thank you.

 8                 MS. BURCH:  Thank you very much.

 9                 CHAIRWOMAN YOUNG:  Next we have 

10          Executive Director Kelly Hansen, New York 

11          State Conference of Local Mental Hygiene 

12          Directors.

13                 (Discussion off the record.)

14                 MS. HANSEN:  Good afternoon, ladies 

15          and gentlemen.

16                 CHAIRWOMAN YOUNG:  Good afternoon.

17                 MS. HANSEN:  My name is Kelly Hansen, 

18          and I am executive director of the Conference 

19          of Local Mental Hygiene Directors.  We 

20          represent the county mental health 

21          commissioners in each of the counties and the 

22          Department of Mental Health in the City of 

23          New York.  

24                 We have several topics on the budget 

                                                                   270

 1          to talk about, but I'm going to limit my 

 2          testimony to one specific issue, and it has 

 3          to do with the opioid and heroin epidemic.

 4                 Attached to my testimony is a copy of 

 5          a report that was conducted by the Conference 

 6          of Local Mental Hygiene Directors, our 

 7          organization, in collaboration with the 

 8          New York State Sheriffs' Association and the 

 9          New York State Association of Counties.  And 

10          what it does is it provides the evidence base 

11          and the research that shows that providing 

12          substance abuse disorder treatment and 

13          transition services to individuals in jails 

14          will increase public safety, save costs, and 

15          most importantly, save lives.  

16                 In listening to all of this testimony, 

17          I think almost everyone has raised an issue 

18          about the opioid and heroin crisis.  So the 

19          reason we did this study is that our 

20          directors of community services and the 

21          sheriffs have continually been seeing an 

22          increase in the number of individuals coming 

23          into the jails with a substance use disorder.  

24          And because we have kind of this drone view, 

                                                                   271

 1          the DCSs see all of the system together, 

 2          they're able to see the linkages between 

 3          criminal justice, foster care, all of this 

 4          other extra-collateral damage that's 

 5          happening because of the opioid epidemic.  

 6                 And what they were finding is that 

 7          there is no funding to offer services inside 

 8          the jail.  And that while there's been a lot 

 9          of support, with the Legislature and the 

10          Governor providing funding to provide 

11          services in the community, there's no money 

12          going into the jail.  

13                 And while they're putting together 

14          these new services -- on-call peer programs 

15          that can meet people in the emergency room, a 

16          24/7 crisis center, recovery centers, family 

17          support navigators -- there's all of these 

18          community services being put together, but 

19          there's a donut hole right in the middle, and 

20          that's the jail.  

21                 Because we know that addiction is 

22          directly linked with criminal justice 

23          activity.  National data will tell you that 

24          drugs and alcohol are implicated in 

                                                                   272

 1          80 percent of the crimes related to DWI, drug 

 2          abuse, domestic violence, property damage, 

 3          and personal injury.  

 4                 And we also know -- when we surveyed 

 5          our jails, we asked the sheriffs on this 

 6          particular day how many individuals -- what 

 7          was the percentage of individuals who have 

 8          come in on substance-use-related crime who 

 9          have been in the jail already.  And that 

10          number was 68 percent.  

11                 So people are coming in and out of the 

12          jail, and we know that that's an area where 

13          we're missing an opportunity.  So what the 

14          conference, the Sheriffs' Association, and 

15          NYSAC are doing is we're coming to you to ask 

16          for funding to be able to provide these 

17          services.  Because like it or not, the jail 

18          is part of the continuum of care.  We know 

19          that the jails are housing thousands of 

20          individuals with substance use disorder, and 

21          they have no money to provide any treatment.  

22                 We also know from the clinical 

23          standpoint, even more importantly, is that we 

24          are missing a huge opportunity to be able to 

                                                                   273

 1          offer treatment when an individual is clean 

 2          and sober and may have some insight into 

 3          their addiction, insight as to why they're 

 4          using, and be able to put in place, you know, 

 5          treatment services so that they know when 

 6          they leave there is another option other than 

 7          just going out and starting to use again, and 

 8          being able to transition.  

 9                 In New York State there's several 

10          counties who have put together model 

11          programs, so I'll just talk briefly about the 

12          Albany County SHARP program.  This is Sheriff 

13          Apple's program, the Sheriff's Heroin 

14          Addiction Recovery Program.  I actually had 

15          the opportunity to visit the program a couple 

16          weeks ago in preparation for our advocacy 

17          here, and it's a separate unit of the jail.  

18          It's outside of the general population.  They 

19          have a CASAC, who everyone loves, they have 

20          peer programs, they do groups, they do 

21          individual counseling.  And in talking with 

22          the women and the gentlemen who are in that 

23          program, they were grateful that they had 

24          this opportunity, they appreciated the 

                                                                   274

 1          support and the safety they had with other 

 2          folks in the unit as well.  

 3                 But I want to just give you this 

 4          number, because the reduction in recidivism 

 5          is astounding.  So Sheriff Apple's county 

 6          numbers are generally, out of everyone who is 

 7          coming into jail with a substance use 

 8          disorder -- they're screened for suicide and 

 9          substance use at booking -- 40 percent of 

10          those individuals are going to recidivate.  

11          That's what their number is.  

12                 For individuals who have been in the 

13          SHARP program, that number drops to 

14          12 percent.  That's a 28 percent reduction in 

15          recidivism.  And think of what that means for 

16          public safety for the community.  It means 

17          less crime, less court costs, less 

18          prosecution costs.  And it's a diversion 

19          program, because those folks will not be 

20          coming back into the jail after.  

21                 And in fact, a DCJS study that looked 

22          at over 1,000 New York State specific data 

23          elements, looking at the cost benefit of 

24          specific criminal justice interventions -- 

                                                                   275

 1          and by the state's own data, they indicated 

 2          that if you provided substance use disorder 

 3          services during incarceration, it would save 

 4          the system $2,100 per person in cost 

 5          avoidance.  Again, court, prosecution, law 

 6          enforcement, incarceration costs.  

 7                 And they also went a step further and 

 8          said it would save victims $670 per person 

 9          served in the program.  And those costs are 

10          tangible costs -- medical costs, mental 

11          health costs, property damage, and loss of 

12          earnings due to loss of wages due to injury.

13                 So we have evidence that shows that 

14          this works in county programs in New York 

15          State.  We have New York State data that 

16          indicates that there's a savings to the 

17          system.  And we haven't -- these are just the 

18          numbers.  We haven't even talked about the 

19          human component as well, which I know you all 

20          hear about repeatedly from the constituents 

21          in your county.  

22                 CHAIRWOMAN YOUNG:  Could you summarize 

23          the rest, please?  

24                 MS. HANSEN:  Yup, absolutely.

                                                                   276

 1                 So what we are asking for is an annual 

 2          appropriation to the counties of 

 3          $12.8 million, which we find and think is a 

 4          very reasonable amount, and -- 

 5                 (Interruption.)

 6                 CHAIRWOMAN YOUNG:  Okay.

 7                 MS. HANSEN:  So that is what we're 

 8          looking for in terms of some funding to go to 

 9          the counties to be able to provide substance 

10          use disorder treatment and transition 

11          services for people to be able to re-enter 

12          into the community with housing, hopefully, 

13          and treatment, and we would hope that we 

14          would have your support.  

15                 Those are my formal comments.  I don't 

16          know if you're interested, Senator; I could 

17          catch you at another time in terms of what 

18          the county directors are experiencing in 

19          terms of bed closures.

20                 CHAIRWOMAN YOUNG:  Okay.  Thank you.

21                 CHAIRWOMAN WEINSTEIN:  Assemblyman 

22          Oaks has a question.

23                 ASSEMBLYMAN OAKS:  Just -- I know one 

24          of the questions that came up before was on 

                                                                   277

 1          the jail-based restoration.  And I know in 

 2          speaking -- I know in this instance you're 

 3          talking about sheriffs and county mental 

 4          health kind of working together to say we can 

 5          do this within our setting.  

 6                 When I asked the question have any 

 7          counties come forward to do the restoration 

 8          one --

 9                 MS. HANSEN:  Competency restoration.

10                 ASSEMBLYMAN OAKS:  The sheriffs have 

11          not been as supportive on that end, I don't 

12          think, because of some of the challenges, or 

13          maybe feeling not capable of actually having 

14          success.  Are there any comments --

15                 MS. HANSEN:  Yes, absolutely.  And a 

16          very good question.

17                 So what we're asking for for the 

18          substance use disorder treatment -- and these 

19          are individuals who we know have a substance 

20          use disorder.  They're competent, they've 

21          been charged with a crime, and that we can -- 

22          the counties can bring in services from the 

23          community to be able to provide treatment in 

24          the jail, and hopefully they will not come 

                                                                   278

 1          back again.

 2                 On the jail-based restoration, which 

 3          the conference does not support -- it relates 

 4          to individuals who've been charged with a 

 5          crime and have been deemed incompetent to 

 6          stand trial and understand the charges 

 7          against them.  Those individuals will go from 

 8          the arrest and the county jail, they have a 

 9          psych eval, a determination of competency is 

10          made, and then they are sent to a state 

11          psychiatric center to be restored to 

12          competency, for which the county pays 

13          50 percent.  

14                 The state is saying that this jail -- 

15          that restoration could be done in the jails.  

16          As you said, the sheriffs are not supportive.  

17          We are not supportive because it is not the 

18          right therapeutic place, for someone who has 

19          been deemed incompetent, to be restored to 

20          competency in a jail.  They don't have the 

21          resources, they don't want to build these 

22          programs, and they're just not appropriate.  

23                 So in fact last year, when you guys 

24          were nice to take that provision out of the 

                                                                   279

 1          budget, at Commissioner Sullivan's direction, 

 2          OMH staff had been meeting all over the 

 3          summer with our attorneys, mental hygiene 

 4          legal services, the DAs association -- they 

 5          put together the workgroup that we wanted 

 6          them to and started working on what can we do 

 7          to help move the process, what can we do to 

 8          share information, what can we do -- because 

 9          what my members would tell you, what the 

10          county directors would say is it's extremely 

11          difficult to get a 730 bed -- which is what 

12          we refer, 730 of the Criminal Procedure Law.  

13                 And if you have an inmate who has a 

14          serious mental -- has a mental illness, 

15          serious mental illness in the jail and just 

16          needs that level of care -- 508 is what they 

17          refer to it as -- they don't even ask 

18          anymore, because there's no bed.  They can't 

19          get a bed.

20                 So we're not a fan of the jail-based 

21          restoration.  I was disappointed to see that 

22          the state booked savings again with this, 

23          after we had thought we had made some pretty 

24          significant progress.  And I'm sure we'll 

                                                                   280

 1          continue that workgroup.  

 2                 But yes, you're correct, Assemblyman, 

 3          there is no real appetite out there.

 4                 ASSEMBLYMAN OAKS:  Thank you.

 5                 CHAIRWOMAN YOUNG:  Thank you.  

 6                 ASSEMBLYWOMAN GUNTHER:  Just before 

 7          you go --

 8                 MS. HANSEN:  Yes.

 9                 ASSEMBLYWOMAN GUNTHER:  You know what?  

10          I do believe that there should be some sort 

11          of education, because you know, we just -- 

12          sometimes if -- the way that we approach a 

13          person, that some other approach would be 

14          different, but that if you do it calmly -- 

15          and a lot of times -- you know, we just saw 

16          something, and it's your approach.  And, you 

17          know, somebody else -- if you approach 

18          certain people quickly or fast or without any 

19          knowledge of what's going on, the reaction 

20          and the outcome is so much different.

21                 So that's why these kinds of programs 

22          in jail situations, incarceration situations, 

23          that you have to have that education to be 

24          able to approach and get better outcomes.

                                                                   281

 1                 MS. HANSEN:  Absolutely.  Absolutely.  

 2                 Thank you for your time.

 3                 CHAIRWOMAN YOUNG:  Thank you.

 4                 CHAIRWOMAN WEINSTEIN:  Thank you.  

 5                 CHAIRWOMAN YOUNG:  Our next speakers 

 6          are -- actually, a very good crew.  We have 

 7          the New York State Public Employees 

 8          Federation.  We have Darlene Williams, 

 9          occupational therapist at OMH; Greg Amorosi, 

10          legislative director; Randi DiAntonio, 

11          licensed master social worker.  

12                 So welcome.  Thank you for being here 

13          today.

14                 MR. AMOROSI:  Thank you for having us.

15                 MS. DiANTONIO:  Good afternoon.  I 

16          want to start by thanking Senator Young, 

17          Assemblywoman Weinstein, and Chairwoman 

18          Gunther and members of the Senate and 

19          Assembly for the opportunity to speak to you 

20          today about the 2018-2019 Executive Budget 

21          proposal as it relates to OPWDD.  

22                 My name is Randi DiAntonio.  I'm a 

23          licensed social worker, and I've been 

24          employed by OPWDD since 1999.  I'm here today 

                                                                   282

 1          representing the New York State Public 

 2          Employees Federation and the more than 3,000 

 3          members who provide services across New York 

 4          State to the developmentally disabled.  

 5                 Our members take very great pride in 

 6          the work that they do.  They care deeply 

 7          about the individuals that we serve.  And as 

 8          we've heard today, for the past several years 

 9          OPWDD has undergone a massive system 

10          transformation.  Some of these initiatives 

11          have resulted in positive impacts, while 

12          others have sounded really good on paper but 

13          unfortunately resulted in closures as well as 

14          services and choices being diminished, mostly 

15          due to lack of staffing and resources being 

16          provided.

17                 You have our written testimony, so I 

18          am going to touch on a few things briefly.  

19          This year's Executive Budget has some 

20          positives and some negatives.  We were very 

21          pleased that there were no additional 

22          closures in this budget.  

23                 We were also very pleased to see the 

24          continuation of the blue ribbon panels for 

                                                                   283

 1          the IVR facility in Staten Island, so that 

 2          there are ongoing discussions as to whether 

 3          it is logical or reasonable to move that 

 4          facility under the auspices of CUNY.  We are 

 5          supportive of it remaining under OPWDD, and 

 6          we believe the 100 or so PEF members there 

 7          have a lot to contribute.

 8                 We're also very positive about the 

 9          salary increases for the direct support 

10          professionals, even though they're not in our 

11          sector.  We believe that this really improves 

12          the likelihood of our system continuing to do 

13          the great work that it does.

14                 We are also supportive of the plan to 

15          convert the Bernard Fineson program into a 

16          transitional program for individuals who are 

17          being discharged from the OMH system into the 

18          OPWDD system.  We believe this model gives us 

19          a chance to evaluate and assess before 

20          plunking somebody into a setting that might 

21          not be in their best interest or anybody 

22          else's best interest.  

23                 We actually believe this model should 

24          be evaluated and potentially expanded across 

                                                                   284

 1          the state.  We've had several situations 

 2          where placements have occurred because of 

 3          emergencies, and they've been very unsafe for 

 4          both the consumer and the other individuals 

 5          in the home, as well as the staff.

 6                 Now on to the things we're not so 

 7          pleased about.  When it comes to residential 

 8          opportunities, we do see that there's 

 9          $120 million in the Executive Budget, but not 

10          one single dime of it is going towards the 

11          state-operated end.  It's our position that 

12          this is really short-changing the needs of 

13          consumers with very highly specialized needs.  

14                 We have undergone closures throughout 

15          the state for the last several years, 

16          reducing the number of specialized inpatient 

17          and intensive treatment beds by 1300, give or 

18          take.  We have realized down to about 

19          150 beds, but that is not sufficient to take 

20          care of the needs of those who have 

21          behavioral, medical, or severely challenging 

22          psychiatric issues and are dually diagnosed.

23                 We believe that some of this money 

24          should be given towards the state-operated 

                                                                   285

 1          end to develop specialized services so that 

 2          people with these needs can be served in the 

 3          community-based settings and can be treated 

 4          in ways that will allow them to be 

 5          successful.

 6                 Additionally, we are pleased to hear 

 7          from the Justice Center that things are 

 8          changing.  However, I'm not sure that this is 

 9          rippling out into the field.  PEF continues 

10          to be concerned about the Justice Center and 

11          some of their practices.  We certainly 

12          understand and support the importance of 

13          thorough investigations, but in many cases 

14          their frivolous accusations end up putting 

15          people out of work and scaring people from 

16          coming to work with us, and for us, that are 

17          really skilled in their field.  

18                 I can tell you in my own district we 

19          have over 50 employees, primarily direct 

20          care, that are placed on administrative 

21          leave.  That ripples into how our members do 

22          their work, because if we don't have people 

23          in the homes that are familiar with our 

24          individuals that are supplying staff from one 

                                                                   286

 1          place to another, the quality of care and 

 2          ability to provide clinical services is 

 3          diminished.  

 4                 The last thing I'd like to touch on,  

 5          just for the sake of time, is the money being 

 6          put in towards the move to managed care and 

 7          CCOs.  While conceptually PEF supports the 

 8          idea of care coordination -- we ourselves 

 9          provided Medicaid service coordination from 

10          the state side for many, many years -- we are 

11          very skeptical that this is again another 

12          initiative that is not well resourced, not 

13          well thought out, and that there's almost 

14          unlimited numbers of details in how it's 

15          actually going to be implemented and what the 

16          impact will be on those living in 

17          state-operated homes.  

18                 What we have found is that the further 

19          disconnected the care coordinator or Medicaid 

20          coordinator is from the person and the 

21          treatment team, the less accountability and 

22          communication there is.  And we would like 

23          this to be slowed down, possibly done as a 

24          pilot, or to have more dialog about the 

                                                                   287

 1          direct impact this would have on the 

 2          consumers in the state system.

 3                 I thank you for your time.  I will 

 4          give the rest of my time to my colleague.  

 5          And I appreciate being here with you today.

 6                 CHAIRWOMAN YOUNG:  If you could 

 7          summarize, because you've gone over a lot of 

 8          time.  But that's fine.  If you could please 

 9          summarize, though, that would be good.

10                 MS. WILLIAMS:  Yes, I will.  I will 

11          not read the testimony, and I'll try my best 

12          to speak more from the heart than reading off 

13          information.

14                 CHAIRWOMAN YOUNG:  That's always the 

15          most effective.

16                 MS. WILLIAMS:  Every Tuesday afternoon 

17          before I start my 4 p.m. patient rights 

18          group, I tell our clients:  Your illness 

19          doesn't define you.  For the past 37 years, I 

20          have entered an OMH facility.  And my name is 

21          Darlene Williams, and I work as a certified 

22          occupational therapist.  And I'm a PEF 

23          member.  So I know the good, the bad, and the 

24          ugly.  

                                                                   288

 1                 For 2018-2019, OMH has proudly 

 2          emphasized their downsizing plans of 

 3          inpatient beds in order to reinvest more 

 4          resources into outpatient.  A 150-bed 

 5          reduction -- I think we heard someone else 

 6          talk about this earlier.  

 7                 With money being allocated into 

 8          outpatient, it hasn't done anything for our 

 9          outpatient staff members.  PEF members are 

10          still overburdened with excessive caseloads.  

11                 I was just talking to a social worker 

12          during a health and safety conference where 

13          she explained to me that she had a list of 

14          20 patients she was going to see for the day.  

15          She was starting her day at 9:00, and she was 

16          going to leave at 6:00, but her day actually 

17          was supposed to end at 5:00.  Well, her day 

18          didn't end -- she didn't go home until 

19          9 o'clock because she had to see -- three 

20          additional patients came in, with the 20 

21          patients that she was already scheduled to 

22          see.  Those three patients were released from 

23          their treatment facility.  Those three 

24          patients had no food to eat.  And she had to 

                                                                   289

 1          make sure that they had a place to live and 

 2          food to eat.

 3                 But our problems are not just limited 

 4          to outpatients, they also extend to 

 5          recruitment and retention.  I was just 

 6          watching television this morning, I heard 

 7          that President Trump has a problem also with 

 8          recruitment and retention.

 9                 (Laughter.)

10                 MS. WILLIAMS:  PEF continues to be 

11          concerned about recruitment and retention of 

12          professionals in OMH.  Recruitment and 

13          retention is still ongoing with our nursing 

14          professionals as well as psychiatrists.  But 

15          OMH has challenges recruiting other titles.  

16          I was just looking online for our civil 

17          service, and I think there are only maybe 

18          five occupational therapists within the State 

19          of New York.

20                 Occupational therapists as well as 

21          other titles go to the private sector, where 

22          the pay scale is more.  But these challenges 

23          are -- just don't boil down just to money.  

24          It's also the Justice Center, nurses working 

                                                                   290

 1          multiple voluntary or involuntary overtime, 

 2          not getting time off, and dealing with health 

 3          and safety issues of violent attacks.  Those 

 4          issues have not decreased.

 5                 One of the things that I have a guilty 

 6          pleasure of is that I look at Facebook, and I 

 7          saw that a nurse sent a meme with a skeleton 

 8          looking out of the window.  The skeleton 

 9          represented a nurse, she was waiting for her 

10          break to come.  I know nurses who keep food 

11          in their pockets so that they can treat 

12          patients and eat at the same time.

13                 First I would like to thank you for 

14          passing the bill last year to stop the 

15          closing and consolidation of the Western 

16          New York Psychiatric Center.  Unfortunately, 

17          the Governor vetoed the legislation.  But 

18          moving forward, we hope that you will 

19          continue to work with us to keep this 

20          children's facility open at its current 

21          location.  That just as well as there are 

22          plans for Hutchings Children Psychiatric 

23          Center, that all stakeholders be provided 

24          with the opportunity to weigh in on potential 

                                                                   291

 1          changes and deliver mental health services.

 2                 Lastly, the previous speaker spoke 

 3          about the jail-based restoration to 

 4          competency.  As an OMH employee, I know 

 5          firsthand that most of our patients would 

 6          want to receive treatment in a hospital 

 7          facility and not in a jail.  I have a son 

 8          who's a New York City detective, and each day 

 9          he's out there on those streets looking and 

10          taking care of the citizens of New York City.  

11          And he sees full well that we have people 

12          with mental illness who he has to arrest and 

13          place them in jail.  And he always says, 

14          "Mom, I think the best thing would be is to 

15          make sure that those individuals got help 

16          within a treatment-like setting instead of in 

17          a prison or in a jail."

18                 So I'm going to end by saying that at 

19          the end of the day we have limited resources, 

20          but like I said, our limited resources -- the 

21          mental illness doesn't define our patients, 

22          and our limited resources don't define us as 

23          mental health professionals.  We will 

24          continue to do our best with what we have.  

                                                                   292

 1                 And thank you for this opportunity.

 2                 CHAIRWOMAN YOUNG:  Thank you for being 

 3          here today.

 4                 Any questions?  

 5                 SENATOR KRUEGER:  We appreciate your 

 6          testimony.

 7                 MS. WILLIAMS:  Thank you.

 8                 MS. DiANTONIO:  Thank you.  

 9                 CHAIRWOMAN WEINSTEIN:  Thank you for 

10          your work in the community.  

11                 CHAIRWOMAN YOUNG:  Out next speaker is 

12          Executive Director Samantha Howell, National 

13          Association of Social Workers, New York State 

14          Chapter.

15                 Welcome.

16                 MS. HOWELL:  Thank you.  Good 

17          afternoon.

18                 CHAIRWOMAN YOUNG:  Go ahead.  If you 

19          could summarize your testimony, please.

20                 MS. HOWELL:  Of course.

21                 CHAIRWOMAN YOUNG:  Within five 

22          minutes.

23                 MS. HOWELL:  Thank you very much for 

24          allowing me to testify today and to be here 

                                                                   293

 1          with you.  My name is Samantha Howell, and 

 2          I'm the executive director for the National 

 3          Association of Social Workers.  I'm here 

 4          today also on behalf of our partners, the 

 5          National Association of Social Workers for 

 6          New York City, the New York State Society for 

 7          Clinical Social Workers, and the New York 

 8          State Association of Deans for the Schools of 

 9          Social Work.

10                 NASW is the largest social work 

11          membership association in the world, and the 

12          primary mission of social work is to enhance 

13          human well-being and help meet the basic 

14          human needs of all, with particular attention 

15          to vulnerable communities.

16                  Social workers possess a varied and 

17          broad set of skills necessary to practice 

18          appropriately and, therefore, the current 

19          licensure law that guides and directs social 

20          work in this state reflects the importance of 

21          education and experience that we think is 

22          necessary to engage in this profession.

23                 The current licensure law was passed 

24          as a consumer protection measure to ensure 

                                                                   294

 1          that licensed clinical social workers were 

 2          providing care to those in need.  But at the 

 3          time that the law was passed, there also was 

 4          included an exemption.  That exemption allows 

 5          seven state agencies, and the programs that 

 6          are funded and directed by them, to not hire 

 7          licensed social workers to provide the skills 

 8          that have been expressly reserved for social 

 9          workers.

10                 New York State, despite being the 

11          49th state to pass a licensure law for social 

12          workers, has some of the most stringent 

13          requirements including an MSW with over 

14          900 hours of curriculum-based content 

15          involving social work, at least 12 semester 

16          hours of clinical social work with a focus on 

17          skill development and diagnosis and 

18          assessment, and clinical social work 

19          practice, clinical social work treatment, and 

20          clinical social work practice with general 

21          and specific groups, as well as at least 

22          2,000 client contact hours under appropriate 

23          supervision.  

24                 This ensured that the people who were 

                                                                   295

 1          providing mental health treatment and 

 2          diagnosis have been properly trained and 

 3          supervised in those very skills.  But with 

 4          the exemption, these seven state agencies -- 

 5          OMH, OPWDD, OASAS, OCFS, OTDA, the Department 

 6          of Corrections and Community Supervision, as 

 7          well as the Office for Aging, and any local 

 8          mental hygiene or social services 

 9          department -- are exempt from hiring social 

10          workers for those very responsibilities.

11                 This is an unfathomable exemption for 

12          us to have in New York State.  One of the 

13          criticisms that has come up over the request 

14          to end the exemption this year is that it 

15          would be costly to hire licensed clinical 

16          social workers to provide diagnoses and 

17          treatment in these facilities.  But I ask 

18          you, where else would this happen within a 

19          profession? 

20                 Imagine going into an emergency room 

21          with a broken leg, and rather than seeing a 

22          surgeon to fix it, you're told:  Well there's 

23          somebody here who passed biology and they've 

24          been working on the job for a couple years, 

                                                                   296

 1          so we're going to let them patch you up.  

 2          That wouldn't happen.  

 3                 Nor would it happen in the legal 

 4          profession.  You couldn't go into a courtroom 

 5          and say, You know what, I passed civics, I 

 6          failed the bar a couple of times, but I think 

 7          I can handle this capital murder case.  That 

 8          doesn't happen.

 9                 And yet we are allowing individuals 

10          who don't have those 2,000-plus hours of 

11          supervised training to provide mental health 

12          diagnosis and treatment for people in need.  

13                 As a result, we are calling on the 

14          Legislature to finally end this exemption.  

15                 There's a couple of steps to this, 

16          because we are cognizant of the concerns that 

17          have been raised by other organizations.  We 

18          don't want people to lose their jobs 

19          unnecessarily, so we have requested a 

20          financial contribution in investing in the 

21          profession of just over $22 million total, 

22          which would include an $18 million incentive 

23          program for currently exempt agencies to 

24          increase the number of licensed social 

                                                                   297

 1          workers available; $4 million for a loan 

 2          forgiveness program, to encourage people to 

 3          enter the profession; and then an additional 

 4          financial contribution to help develop 

 5          appropriate test materials and do data 

 6          analysis.

 7                 We also have included several 

 8          recommendations we went over in testimony 

 9          today that I think will also go to help the 

10          profession, including a grandparenting window 

11          for people who have MSWs with at least two 

12          years of documented supervised experience to 

13          become licensed at the LMSW level, so that we 

14          can help move people who are currently 

15          unlicensed into licensed positions within 

16          these seven agencies.  

17                 Appropriately licensed clinical 

18          supervisors being directly involved -- there 

19          was testimony earlier today that while 

20          unlicensed individuals might be the first 

21          person of contact, that there's an 

22          institutional hierarchy of supervision.  We 

23          contend that is not enough.  We want direct 

24          supervision to be part of these provision of 

                                                                   298

 1          services, and we think that the state can do 

 2          this.  

 3                 And so, in conclusion -- I see I'm out 

 4          of time -- I want to just thank you so much 

 5          for your work.  Thank you for allowing me to 

 6          be here today.  And I urge you to let this 

 7          exemption end and implement a financial 

 8          investment in the social work profession.

 9                 Thank you.  

10                 CHAIRWOMAN YOUNG:  Thank you for being 

11          here today.  We appreciate it.

12                 Our next speaker is CEO Paige Pierce, 

13          Families Together in New York State.

14                 MS. PIERCE:  Good afternoon.  How are 

15          you?

16                 CHAIRWOMAN YOUNG:  Good afternoon.  

17          Well.

18                 MS. PIERCE:  I'm Paige Pierce.  I'm 

19          the CEO of Families Together in New York 

20          State.  We're a family-run, family-governed 

21          organization that represents families of kids 

22          with social, emotional, and behavioral needs.  

23          We represent thousands of families across the 

24          state who have had children in multiple 

                                                                   299

 1          systems including mental health, substance 

 2          use, special education, juvenile justice, and 

 3          foster care.  

 4                 I'm here today just to talk about the 

 5          mental hygiene budget.  You know, you guys 

 6          have seen me here before for Raise the Age, 

 7          you've seen me here for the child welfare 

 8          funding, but this is the year -- this should 

 9          have been the year that the state budget put 

10          children first.  It should have been the year 

11          that children were up at the top of the list.  

12                 And unfortunately, we weren't.  

13          Children and families really got a raw deal 

14          as it relates specifically to this budget.  

15          The Office of Mental Health's budget should 

16          have included $15 million for -- it wouldn't 

17          have been in Office of Mental Health budget, 

18          but it was for children and families with 

19          behavioral health needs, $15 million that was 

20          to shore up the -- to match the federal match 

21          for Medicaid managed care for children's 

22          behavioral health.  And they decided to kick 

23          the can down the road for two years.  

24                 And what they did by doing that was 

                                                                   300

 1          not only put providers in a difficult 

 2          position -- because they spent the last 

 3          several years gearing up for this, and have 

 4          reduced the services that did exist -- but 

 5          more importantly, it affects families and 

 6          children.  The children that would have 

 7          gotten those services are not going to 

 8          anymore.  

 9                 We spent six years, as part of the 

10          Medicaid Redesign Team for Children's 

11          Behavioral Health, designing a system that 

12          would be comprehensive and wrap around the 

13          child and family.  We used a lot of research, 

14          we knew -- we had experts on the team who 

15          knew what would work and what wouldn't, and 

16          we all agreed.  And we applied to CMS to get 

17          it approved, and it was approved.  

18                 And now, at the 11th hour, when it's 

19          time to flip the switch in July, they kicked 

20          it down the road for two more years.  The 

21          kids who are currently needing those services 

22          can't wait two years.  There's no reason for 

23          them to be at the bottom of the list, except 

24          that we hadn't already been -- because of 

                                                                   301

 1          other delays, we hadn't already implemented 

 2          the Medicaid managed care in our system.  But 

 3          that made us low-hanging fruit.  And just 

 4          because our kids weren't getting the services 

 5          they needed now, doesn't mean we can continue 

 6          for two more years.

 7                 So we're asking that $15 million that 

 8          was supposed to be earmarked for the state 

 9          match for the children's behavioral health 

10          Medicaid managed care be allocated for 

11          children's behavioral health services -- 

12          specifically, SPA services, which are what we 

13          call -- the State Plan Amendment, we call 

14          them SPA services.  It's SPA services like 

15          family care support, youth peer support, 

16          respite.  We know that those are the kinds of 

17          services that are inexpensive and will save 

18          millions of dollars down the road, millions.  

19                 Because the average childhood 

20          experiences that happened that are going to 

21          cause health problems later and all kinds of 

22          other problems later can be avoided if we can 

23          get children and families served first.

24                 Any questions?

                                                                   302

 1                 CHAIRWOMAN YOUNG:  Are you done?

 2                 MS. PIERCE:  I'm done.

 3                 CHAIRWOMAN YOUNG:  Well, I do want to 

 4          make a comment, I guess.

 5                 And so what you're talking about was 

 6          actually brought up in the questioning of the 

 7          commissioner of OMH.

 8                 MS. PIERCE:  Right.

 9                 CHAIRWOMAN YOUNG:  And could you give 

10          a little bit more of a sense -- and I think 

11          you've done a great job covering it, because 

12          now everyone's geared up to provide these 

13          services.  The families and the children are 

14          expecting these services, the providers are 

15          ready, and the plug is being pulled for two 

16          years.

17                 So could you give us a better sense of 

18          the impact on the providers and where they're 

19          at in the process?

20                 MS. PIERCE:  Yes.  So they spent a lot 

21          of money, a lot of money getting technical 

22          assistance so that they could make sure that 

23          they had like electronic health records and 

24          value-based payment structures.  Because 

                                                                   303

 1          that's all part of the scheme, right?  It's 

 2          all part of what they needed to have come 

 3          July 1.  None of that is going to be 

 4          necessary for the next two years, so they've 

 5          spent that money when they didn't have it.  

 6                 And worse is that the kids that would 

 7          have been being served under our Home and 

 8          Community-Based Waiver, which is a waiver 

 9          that we've had for, you know, 20 years that 

10          provides those kinds of soft services, they 

11          were -- people weren't being -- families 

12          weren't being referred to the Home and 

13          Community-Based Waiver.  We have 1800 slots 

14          statewide, 500 vacant waiver slots, 500 slots 

15          for kids who would have -- should be getting 

16          those services and they're not because they 

17          thought waiver was going away in July.  They 

18          thought that they were going to have the SPA 

19          services, and it was going to be available to 

20          so many more thousands, literally thousands 

21          more children. 

22                 And now not only are the kids that 

23          need the waiver not getting the slots filled, 

24          but the other kids who would have gotten the 

                                                                   304

 1          SPA services aren't going to get them.  

 2                 CHAIRWOMAN YOUNG:  So it's really 

 3          created a crisis, right?

 4                 MS. PIERCE:  It really has, for both 

 5          the providers and for the children and 

 6          families.

 7                 CHAIRWOMAN YOUNG:  Okay.  Thank you 

 8          for that.  That's very valuable testimony.  

 9                 Any questions?

10                 SENATOR KRUEGER:  Thank you again for 

11          coming back.

12                 CHAIRWOMAN YOUNG:  Thank you.

13                 MS. PIERCE:  Thank you.

14                 CHAIRWOMAN YOUNG:  Our next speaker is 

15          Dr. Ellie Carleton, residential treatment 

16          team leader, from Astor Services for Children 

17          and Families.

18                 DR. CARLETON:  Good afternoon.  My 

19          name is Ellie Carleton.  I'm a residential 

20          treatment team leader for the RTF, the 

21          Residential Treatment Facility, at Astor 

22          Services for Children and Families.  I am a 

23          licensed psychologist, and I have been 

24          working at Astor in the RTF for 20 years.  

                                                                   305

 1          And I appreciate the opportunity to be here 

 2          today.

 3                 Astor is a large provider of 

 4          children's early childhood and behavioral 

 5          health services in both the Hudson Valley and 

 6          the Bronx.  Last year, we served 10,000 

 7          children throughout our various programs.  

 8          Our RTF serves 20 children between the ages 

 9          of five and l4.  

10                  RTFs were created as a subclass of  

11          hospitals and were able to have -- the 

12          program has been funded 100 percent by 

13          Medicaid, as children were deemed a family of 

14          one for Medicaid purposes by virtue of their 

15          mental health disability.  RTFs have been 

16          viewed as a less restrictive, community-based 

17          alternative to state psychiatric inpatient 

18          treatment.  

19                 There are currently 18 RTFs in the 

20          state that serve nearly 500 children.  For 

21          many children and families, the RTF is their 

22          last hope.  The children that we serve in 

23          these programs have very serious emotional 

24          and behavioral disorders.  They are 

                                                                   306

 1          physically aggressive, lack social skills, 

 2          and demonstrate problems with impulse 

 3          control.  Many have psychotic disorders, 

 4          learning problems, and are prone to 

 5          self-injury.  Many have a history of 

 6          tremendous trauma.

 7                 The children's mental health community 

 8          has been participating and planning for the 

 9          transformation of the healthcare system; 

10          however, we've only been able to access a 

11          relatively small amount of money.  We have 

12          not been able to access capital dollars to 

13          any significant degree.  

14                 Older RTFs do not have the physical 

15          facilities to provide the kinds of services 

16          that children need and deserve.  Our programs 

17          are committed to reducing restraints, 

18          shortening lengths of stay, and the 

19          facilities that we have are not adequate to 

20          do so.  Programs that want to redesign their 

21          units to meet the needs of the children do 

22          not have a access to capital dollars.  

23                 RTFs are a critical safety net and 

24          need to be able to have the environments 

                                                                   307

 1          necessary to provide the highest quality of 

 2          care.

 3                 Astor is one of the few programs 

 4          that's been able to construct a brand-new 

 5          facility.  Our space is state-of-the-art and 

 6          allows for single bedrooms for each child.  

 7          The space was designed and constructed in 

 8          accordance to all OMH standards, and it's a 

 9          safe space, physically and emotionally, that 

10          helps meet the children's needs.

11                 We obtained a mortgage for 

12          construction, and those costs are being paid 

13          down due to an add-on on our Medicaid rate. 

14          If the RTF is to continue to operate as it 

15          has been since opening, there would be no 

16          concerns with this debt.  However, given all 

17          the work that is going on to transform the 

18          systems, we believe the future of our agency 

19          could be in jeopardy.  It is not a given that 

20          managed-care companies would include the rate 

21          in any payments that would occur when the 

22          program transfers to managed care.  

23                 We're budgeted at 98 percent 

24          occupancy, something we have achieved without 

                                                                   308

 1          difficulty.  However, we expect that 

 2          commercial payers will want to significantly 

 3          reduce length of stay, and this will result 

 4          in reduced occupancy as a percentage of care 

 5          days, which would put our ability to pay the 

 6          debt in jeopardy. 

 7                 We believe debt relief would provide 

 8          us with long-term security as well as the 

 9          flexibility needed to adjust in an 

10          environment that demands that we are very 

11          nimble to respond to the needs.

12                 In summary, RTFs are a vital provider 

13          in the continuum of care for the most needy 

14          and the most high-risk children.  We need 

15          capital to be able to provide the therapeutic 

16          facilities for this population that we are 

17          being asked to serve.  Hospital systems have 

18          been able to access hundreds of millions of 

19          dollars.  We ask that in the name of mental 

20          health parity, RTFs have the same 

21          opportunity.  

22                 Thank you.

23                 CHAIRWOMAN YOUNG:  Thank you for your 

24          testimony.  

                                                                   309

 1                 Any questions?

 2                 ASSEMBLYWOMAN GUNTHER:  Yeah.  I 

 3          actually visited the one in Rhinebeck.

 4                 So your length of stay in your 

 5          facility, average length of stay?  And just 

 6          because I visited there -- these children 

 7          really had very few options as far as where 

 8          to go, and I just think that it would be 

 9          important for people to know your success 

10          rate.

11                 DR. CARLETON:  Mm-hmm.  Our length of 

12          stays are over a year, the average length of 

13          stay.  

14                 And in terms of about 30 to 40 percent 

15          of our population is able to go to a lower 

16          level of care, typically back to their home.  

17          About another 40 percent move on, either to 

18          an adolescent facility or a slightly lower 

19          level of care, such as a community residence.  

20          And a small percentage go on to a long-term 

21          hospitalization before they can be stabilized 

22          and returned to a lower level of care.

23                 ASSEMBLYMAN GUNTHER:  Thank you.  

24          Thank you.  

                                                                   310

 1                 CHAIRWOMAN YOUNG:  Thank you.  

 2          Appreciate it.

 3                 Our next speaker is CEO and President 

 4          Christy Parque, Coalition for Behavioral 

 5          Health.

 6                 MS. PARQUE:  Hi.  Good afternoon.

 7                 CHAIRWOMAN YOUNG:  Good afternoon.  

 8          Thank you for being here.

 9                 MS. PARQUE:  Thank you for this 

10          opportunity.  My name is Christy Parque.  I 

11          am the president and CEO of The Coalition for 

12          Behavioral Health.

13                 And The Coalition is the umbrella 

14          advocacy and training organization of 

15          New York's behavioral health community, 

16          largely New York City and the outer counties 

17          surrounding New York City.  We represent 

18          about 140 community-based providers of 

19          substance use and mental health services.  We 

20          serve about 500,000 New Yorkers with these 

21          services.  And proudly, I represent about 

22          35,000 workers, and that's a lot of what I'm 

23          going to talk about today.

24                 You have my testimony, but I just want 

                                                                   311

 1          to give you some context.  I know that you've 

 2          had a lot of hearings and testimony in the 

 3          last two days, but as you know, the 

 4          behavioral health field in New York is in the 

 5          midst of transformation.  There's greater 

 6          emphasis on meeting the needs of people in 

 7          their communities, and that's rightly so, 

 8          while at the same time we seek to improve 

 9          efficiencies and outcomes in the delivery of 

10          Medicaid services.  The Coalition thoroughly 

11          embraces these goals and is trying to be an 

12          active partner in these areas.  

13                 Our members comprise an intricate 

14          network of safety-net providers throughout 

15          all the neighborhoods they serve.  They care 

16          for our most vulnerable among us.  They 

17          provide all kinds of services -- PROS, day 

18          treatment, clinic programs.  They provide it 

19          in every language, they provide it in sign 

20          language.  It is a comprehensive network of 

21          services that they provide.

22                 The Coalition's budget priorities 

23          reflect this comprehensive approach that we 

24          provide to our communities.  We strongly 

                                                                   312

 1          support measures that preserve and strengthen 

 2          community-based mental health and substance 

 3          use programs through reinvestment of 

 4          resources in community-based programs.

 5                 I will be focusing my testimony, and 

 6          you have it there, in three areas, which is 

 7          workforce, infrastructure, and access.  And 

 8          what I ask for you to do is as we move 

 9          forward through this transformation, invest 

10          in our success.  

11                 So you've heard the discussion of the 

12          3.25 percent.  Hooray, we really appreciated 

13          that last year.  We really are having a 

14          workforce crisis currently.  Our retention 

15          rates are challenging because people are 

16          leaving to go into other sectors like 

17          hospitals or government or managed-care 

18          organizations.  

19                 There is truly a workforce crisis 

20          trying to find culturally competent and 

21          language-proficient folks to run our 

22          programs.  And we are moving forward towards 

23          a sector where people can come in any 

24          right -- there's no wrong door -- any right 

                                                                   313

 1          door, any time, to get the services, and we 

 2          need the staff to do that.  

 3                 And things like regular COLAs, which 

 4          we've not had, and things like the 

 5          3.25 percent, go a long way to helping us to 

 6          retain our staff.  And there are some other 

 7          great ideas about helping to retain our 

 8          workforce.

 9                 I also want to talk about the clinical 

10          practice exemption.  We are absolutely a 

11          partner in trying to resolve this 

12          long-standing issue.  However, we cannot have 

13          a solution that exacerbates our workforce 

14          crisis.  Again, the biggest place where we 

15          would be impacted is around culturally 

16          competent and language-proficient folks.  

17                 I have one provider I was meeting with 

18          today, they have 35 LMHs, and they're all 

19          bilingual in Spanish or Haitian or French.  

20          None of their LCSWs are.  They receive 

21          supervision.  We have a highly qualified 

22          workforce, it's been highly qualified.  We 

23          have intense supervision, we have oversight 

24          by multiple agencies.  We're very confident 

                                                                   314

 1          in the high quality of the services we 

 2          provide.  

 3                 We of course want to be at the table 

 4          when we look at opportunities to deal with 

 5          this issue that I know that you're as tired 

 6          of as we are.  However, I have grave concern 

 7          for not just my workforce, but the bigger 

 8          piece of access.  If that one provider has to 

 9          let 35 staff go, who will serve those people 

10          in the languages that they need to be served 

11          in?  

12                 Related to enforcement of supporting 

13          our sector, we have a request related to the 

14          Statewide Health Care Facilities 

15          Transformation.  You were tremendous last 

16          year -- last year's budget put in 

17          $30 million, the Legislature came in at 

18          $75 million.  That was heroic.  We are so 

19          grateful.  That's going to get us to where we 

20          need to go.

21                 This year, however, have a 

22          $425 million budget for that pot.  Last year, 

23          the percentage we got was 15 percent.  This 

24          year we're at about 9 percent.  What we're 

                                                                   315

 1          requesting is that we get proportionally a 

 2          larger share of that.  We support that 

 3          assisted living, they should get what they 

 4          need.  However, we need to pull them out of 

 5          our pot and strengthen the community health 

 6          centers and the behavioral health clinics in 

 7          the districts.  

 8                 So we look for your support to try and 

 9          bring that parity up.  It's not a dollar ask, 

10          it's just rejiggering what that bucket looks 

11          like.  

12                 The other piece related to 

13          strengthening our sector is the Nonprofit 

14          Infrastructure Capital Program, which affects 

15          folks that are not in healthcare 

16          transformation, but it could be a senior 

17          center that needs a new boiler or a shelter 

18          that needs a program or a new heating system.  

19          This is available to all the nonprofits in 

20          the state.  

21                 Two-thirds of the folks that 

22          applied -- over 634 organizations applied -- 

23          two-thirds were denied.  So clearly there's a 

24          need for that.  There's no money in this 

                                                                   316

 1          year's budget.  We'd love to get some money 

 2          back in the budget.

 3                 And the final piece, as we address our 

 4          services related to access, we must keep in 

 5          mind that whatever actions the agencies take, 

 6          whatever actions the state takes, that we 

 7          have to preserve access because we are in a 

 8          crisis.  We're facing an opioid crisis.  We 

 9          have to ensure, as you heard around kids, 

10          that kids have the access to services.  We 

11          support the request that Paige mentioned.  

12                 We also support the Bring It Home 

13          campaign, because housing is healthcare, and 

14          the best way for recovery is in a safe, 

15          stable place.  

16                 And you have the rest of my 

17          recommendations.  I'm happy to take any 

18          questions. 

19                 CHAIRWOMAN YOUNG:  I don't think we 

20          have any questions, but we appreciate your 

21          testimony.  Thanks for being here.

22                 MS. PARQUE:  Thank you.

23                 CHAIRWOMAN YOUNG:  Our next speaker is 

24          President and CEO Ann Hardiman, New York 

                                                                   317

 1          Alliance for Inclusion and Innovation.

 2                 MR. SEEREITER:  Good afternoon.  I'm 

 3          Michael Seereiter, the executive vice 

 4          president and COO of the New York Alliance 

 5          for Inclusion and Innovation.  

 6                 Since the last time we presented 

 7          before you all, this is a new organization, 

 8          resulting from the merger of the New York 

 9          State Rehabilitation Association and the 

10          New York Association of Community and 

11          Residential Agencies.  My colleague and I, 

12          Ann Hardiman, are the two respective 

13          organization heads of those, and we're coming 

14          together as a new organization.

15                 Our number-one priority is the 

16          workforce issue, which Ann is going to speak 

17          about right now.

18                 MS. HARDIMAN:  Yes, I wanted to take 

19          the opportunity to thank you all, on behalf 

20          of the Be Fair coalition. You were awesome 

21          last year in supporting our move toward a 

22          living wage for DSPs.  The Executive Budget 

23          includes full funding to support 6.5 percent 

24          salary increases, and we thank you for that 

                                                                   318

 1          important increase.

 2                 Since then, we've done another 

 3          snapshot survey, and our data is worsening.  

 4          Providers in 2017 have vacancy rates of one 

 5          in seven, 14.4 percent.  They have a turnover 

 6          rate of 26.7 percent, up 8 percent from 2016 

 7          and up 42 percent from 2014.  One in three 

 8          DSPs leave in less than six months.  If you 

 9          calculate using $4,000 as their on-board 

10          training and recruitment cost, that's just a 

11          waste of money when people leave in under 

12          six months.

13                 Our overtime is 10 million overtime 

14          hours in 2017.  Due to this worsening crisis, 

15          we respectfully request a third installment 

16          of direct support for direct support 

17          professionals in the Be Fair campaign, with 

18          an investment of an additional $18.25 million 

19          in the budget this year.

20                 I also want to briefly mention around 

21          housing.  We all know how important housing 

22          is for people with developmental disabilities 

23          and with psychiatric disabilities.  They're 

24          foundational to health and well-being.  And 

                                                                   319

 1          the New York Alliance has created a housing 

 2          navigator training initiative that includes 

 3          some innovations in using assistive 

 4          technology to live more independently, and 

 5          also around other innovations like shared 

 6          living.

 7                 We know those are important.  We 

 8          respectfully ask, in light of the success of 

 9          this housing navigator program, where we've 

10          trained 150 housing navigators, that there be 

11          an additional add of $500,000 to expand that 

12          program.  

13                 We appreciate all your work and thank 

14          you for the Be Fair dollars.  And over to 

15          Michael for comments on managed care.

16                 MR. SEEREITER:  Our last component 

17          that we wanted to bring to your attention 

18          revolves around that systemic transformation 

19          for the OPWDD systems -- specifically, the 

20          Care Coordination Organizations and the shift 

21          towards managed care.  

22                 We submitted comments to OPWDD in 

23          three areas -- the Health Home application, 

24          the 1115 waiver, and the care coordination 

                                                                   320

 1          transition plan -- that were all made 

 2          available for public comment.  The common 

 3          theme, I think, from our comments in those 

 4          comments was our concern about the 

 5          unrealistic time frames, or what we think are 

 6          unrealistic time frames, and the insufficient 

 7          resources made available thus far to really, 

 8          I think, get those transitions right.  

 9                 The Care Coordination Organizations 

10          are proposed for essentially creating the 

11          Health Home model for the I/DD population.  

12          There are many unclear aspects of the 

13          transition that's scheduled to take place on 

14          7/1.  Technology is going to need to 

15          immediately replace the communication that 

16          has taken place between the care manager and 

17          now -- or, excuse me, the MSC and now the 

18          care manager and the provider of the services 

19          themselves.  

20                 What is the preparedness, what are the 

21          preparedness activities that organizations 

22          that are providing those services need to be 

23          undertaking now to be prepared for that 7/1 

24          implementation?  

                                                                   321

 1                 Likewise, on the managed-care 

 2          transition, the larger managed-care 

 3          transition that's scheduled for a few years 

 4          out, we believe that there are major 

 5          investments that are necessary in terms of 

 6          readiness, the tools and the capacity that 

 7          providers need to be ready to participate in 

 8          that new structure.  

 9                 I think IT is a wonderful example of 

10          that.  You were talking about EHR, 

11          participation with the Statewide Health 

12          Information System, and the ability to 

13          collect and analyze data in a way that really 

14          prepares organizations to participate in that 

15          new structure.  The ability to answer a 

16          question about whether the funding that is 

17          proposed to support one individual is 

18          actually sufficient, based on previous 

19          experience of the overall supports that are 

20          necessary for an individual.

21                 That transition, I think, actually has 

22          been exacerbated or will be exacerbated by 

23          the experience that we've been through with 

24          the rate rationalization exercises over the 

                                                                   322

 1          past four years, where we've moved actually 

 2          further away from some of the goals of moving 

 3          toward managed care and value-based payments.  

 4                 I think that this really speaks to the 

 5          need for larger investments in the system, 

 6          particularly in provider readiness activities 

 7          and investments in the technology and 

 8          capacities of providers to participate in the 

 9          new environment of managed care that's coming 

10          very, very quickly.

11                 Thank you.

12                 SENATOR KRUEGER:  Thank you.

13                 CHAIRWOMAN YOUNG:  Thank you very 

14          much.

15                 MS. HARDIMAN:  Thanks so much.

16                 CHAIRWOMAN YOUNG:  Our next speaker -- 

17          actually, we have two.  We have 

18          Administrative Director Arnold Ackerley and 

19          director of Policy Clint Perrin, from the 

20          Self-Advocacy Association of New York State.  

21                 If people want to get closer, too.  

22          After them, we have the Association of 

23          Substance Abuse Providers, and after that, 

24          Friends of Recovery.  If you could get closer 

                                                                   323

 1          to the front, that would be helpful.

 2                 Thanks for being here.  Please 

 3          summarize your testimony.

 4                 MR. PERRIN:  Hello.  

 5                 MR. ACKERLEY:  So first we just want 

 6          to thank you for allowing us to be here and 

 7          give testimony today.

 8                 MR. PERRIN:  New York State's system 

 9          of services for people with disabilities is 

10          undergoing a big change.  Part of this intent 

11          is to change -- to create more community 

12          integration and choice for people with 

13          disabilities. 

14                 Funding is needed so that this change 

15          meets the goals in a real way of our lives.  

16          For people with disabilities, solutions need 

17          to consider a full range of supports and 

18          services to ensure that the person has 

19          meaningful choices and sustainable 

20          opportunities for independence and inclusion. 

21                 It is important to consider housing, 

22          staffing, transportation and employment 

23          opportunities together when planning 

24          development for people with developmental 

                                                                   324

 1          disabilities. 

 2                 In addition to people with DD, there 

 3          are many people in need of housing and better 

 4          services -- veterans, the elderly, people 

 5          with mental health concerns.  We urge you, we 

 6          urge the Legislature to think of how to 

 7          mobilize communities to think of all its 

 8          members together to offer solutions and 

 9          create real communities.

10                 MR. ACKERLEY:  Okay.  So there's just 

11          a few points that we want to make.  Of course 

12          you have our testimony, so I won't read the 

13          whole thing.  But one area of concern that's 

14          come up is housing and the investment in 

15          housing opportunities.  

16                 The state -- which we're very grateful 

17          for that investment, and we're very grateful 

18          that OPWDD's budget was able to be increased 

19          again by 4 percent.  However, there's a 

20          preponderance of investment in legacy 

21          services still to this day -- traditional 

22          group homes, traditional day programs.  When 

23          you contrast that, there's about $120 million 

24          proposed, $15 million into independent 

                                                                   325

 1          settings.  

 2                 There's many people with developmental 

 3          disabilities that are currently living and 

 4          residing and receiving legacy services that 

 5          really could be in more independent settings.  

 6          There could be significant cost savings if we 

 7          were to invest more into getting people into 

 8          places they need to be, in more independent 

 9          settings.  And for those that really require 

10          these legacy services, moving them into them 

11          rather than continuing to invest in new 

12          development, which we know is still ongoing.

13                 In terms of #bFair2DirectCare, you 

14          know, workforce and the DSP turnovers, I 

15          think that you really understand that, and 

16          I'm sure you've heard a lot about that over 

17          time today.  I think the most important thing 

18          we would ask to you remember is that you've 

19          heard a lot of numbers, but I think it's 

20          important to remember there's lives behind 

21          those numbers.  For the DSPs, of course.  But 

22          for people with developmental disabilities in 

23          many cases, when they don't have that person 

24          available to them or they have high turnover 

                                                                   326

 1          rates, really their lives are being put on 

 2          hold.  They're really not able to participate 

 3          in their communities as they would like to.  

 4          They're not really able to hold down jobs 

 5          that they would like.  They're simply not as 

 6          successful as they would like to be.  

 7                 So we just stand with Be Fair, and we 

 8          really ask for that to be expedited to solve 

 9          that issue.  There's also real risk to 

10          safety, dignity and well-being, you know, 

11          with these current numbers.   

12                 Transportation I know is a difficult 

13          issue, and we certainly don't have some sort 

14          of a magic spell, but I do think it's 

15          important for people to understand that 

16          throughout the state, for people with 

17          developmental disabilities, their options for 

18          transportation are vastly limited.  

19                 Even in our case, our office -- we 

20          share an office with OPWDD, that has been 

21          very generous in giving us office space.  A 

22          couple of years ago in Buffalo, our Buffalo 

23          office, the paratransit line was cut.  So 

24          even for us, the Self-Advocacy Association, 

                                                                   327

 1          we no longer have an accessible office 

 2          through paratransit.  So we are using remote 

 3          sites and exploring other alternatives.  But 

 4          I think that's a good example of how bad it 

 5          can get.

 6                 Another thing is for people in rural 

 7          areas, they really don't have any options.  

 8          So when you combine these staffing 

 9          shortages -- who may be their only line to 

10          sort of transportation community 

11          integration -- with the fact that there's no 

12          public transit for them, it can lead to 

13          tremendous isolation.

14                 CHAIRWOMAN YOUNG:  Thank you.

15                 MR. ACKERLEY:  Thank you very much.

16                 CHAIRWOMAN YOUNG:  Thank you.  I think 

17          self-advocacy is extraordinarily important, 

18          and we appreciate you being here today.

19                 MR. ACKERLEY:  Thank you very much.

20                 MR. PERRIN:  Thank you.

21                 CHAIRWOMAN YOUNG:  Next we have 

22          Executive Director John Coppola, Association 

23          of Substance Abuse Providers.  

24                 Thank you for being here.  

                                                                   328

 1                 SENATOR KRUEGER:  Hi, John.  When 

 2          you're ready.

 3                 MR. COPPOLA:  Good afternoon.  I want 

 4          to just start out where I left off last year.  

 5          When we came here last year, we asked for a 

 6          significant increase in commitment to 

 7          prevention treatment and recovery.  And we 

 8          predicted that if we didn't do that, there 

 9          would be a continued upward trajectory of 

10          record deaths and overdoses, et cetera.  

11                 Well, that's exactly what happened, at 

12          least the latter part of that.  We had a 

13          record number of overdose deaths in 2017.  

14          And I know that each one of you has a 

15          personal awareness of one of your 

16          constituents who lost somebody to an 

17          overdose.  There will be a record number of 

18          overdoses in 2018, and there will be a record 

19          number of overdoses in 2019.  People who know 

20          about health trends are saying this.  And 

21          what hasn't happened is a massive infusion of 

22          resources. 

23                 I want to correct the record.  Last  

24          year I believe the Governor at some point was 

                                                                   329

 1          talking about the commitment that was being 

 2          made to the opioid crisis, and I believe he 

 3          used the number $213 million, a substantial 

 4          number.  If you look at the chart in my 

 5          testimony that lays out local assistance -- 

 6          and I would strongly encourage the Finance 

 7          and Ways and Means folks to take a look at 

 8          the local assistance budgets over the course 

 9          of the last five years and ask a very simple 

10          question:  How much money did we commit to 

11          OASAS for prevention, treatment, and recovery 

12          services in the communities across New York 

13          State?  You will not see anything remotely 

14          resembling the number $213 million.  

15                 And I don't know that the Governor 

16          frankly was representing that that was the 

17          case.  I think the Governor was simply 

18          describing that based on the influx of people 

19          into our system, that is essentially how much 

20          resources were being consumed by the system.  

21          Okay?

22                 So if you look at the local assistance 

23          dollars over the course of the last five 

24          years, we have barely kept pace with 

                                                                   330

 1          inflation --

 2                 ASSEMBLYMAN GUNTHER:  Are you on 

 3          page 2?

 4                 MR. COPPOLA:  Yes.

 5                 ASSEMBLYWOMAN GUNTHER:  Okay.

 6                 MR. COPPOLA:  Yup.  So we've barely 

 7          kept place with inflation.  It's less than 

 8          3 percent from year to year to year, okay?  

 9                 So again, I do think it's not a 

10          misrepresentation to say that $213 million is 

11          being used to fight the opioid crisis; that's 

12          simply because of the demand of the people 

13          coming into the existing system.  

14                 And the thing that you have to ask 

15          yourselves and think a little bit about is 

16          you are acutely aware of all of the changes 

17          that were necessary when we moved from 

18          fee-for-service to managed care.  People were 

19          buying electronic health records, people were 

20          hiring billing clerks.  

21                 You have to ask yourself the following 

22          question.  If we weren't keeping pace with 

23          inflation, which is for your utilities and 

24          your healthcare costs and everything else -- 

                                                                   331

 1          so if we weren't keeping pace with inflation, 

 2          and if these programs had to buy electronic 

 3          health records and if they had to hire 

 4          billing clerks, how did they possibly do it?  

 5                 Well, it cannibalized existing open 

 6          positions.  So you're going to hear in a 

 7          little bit from our prevention friends in 

 8          New York City, and I was shocked when I heard 

 9          this.  Fifteen years ago, there were about 

10          500 prevention specialists in New York City 

11          schools -- and we did a survey statewide, 

12          similar numbers for upstate -- 500 prevention 

13          professionals in the New York City schools.  

14          Today, there's 280.  Well, 220, or 40 percent 

15          of the workforce, went poof.  

16                 Now, that's in part because the 

17          federal government walked away from 

18          prevention.  But I just want to reiterate the 

19          point very simply, that there has been barely 

20          enough money to keep pace with inflation, 

21          much less giving the commissioner of OASAS 

22          the resources that she needs to deal with the 

23          pandemic.

24                 Quickly on the Governor's 

                                                                   332

 1          recommendation of a surcharge, $127 million.  

 2          And I believe a number of you asked questions 

 3          of the commissioner and others, you know:  

 4          Well, where's the $127 million?  Well, the 

 5          reason why you are asking that question is 

 6          because you don't see it in the OASAS budget.  

 7          It's not clearly articulated, right?  And 

 8          what we don't want to do is take $127 million 

 9          from the surcharge, put it in the OASAS 

10          budget, and then shuffle $101 million out the 

11          door to go pay for something else -- and then 

12          say we just took $127 million as if it's new 

13          dollars.  Okay?  

14                 So again, I'm just asking you to 

15          please keep an eye on the real numbers.  And 

16          the Ways and Means and Finance staff can kind 

17          of look at these numbers and let you know 

18          that they're very real.

19                 I just have a couple of additional 

20          points I'd like to make.  The executive 

21          director of NASW was here a little while ago 

22          to talk about licensing issues.  The Governor 

23          put something in his budget that would 

24          continue to address a very significant flaw 

                                                                   333

 1          in the social work licensing bill.  

 2                 There's a reason why it's been 14 

 3          years that it hasn't been enacted, and the 

 4          reason for that is that it was way beyond 

 5          what was initially conceived, and there was 

 6          very little awareness about how significantly 

 7          implementing that licensing statute would 

 8          impact the workforce in addiction programs 

 9          and mental health programs, et cetera, 

10          extraordinarily highly regulated environments 

11          where people in recovery and people with 

12          lived experience can work and practice as 

13          part of larger teams.  

14                 And what we don't need is to have the 

15          State Education Department implementing a 

16          statute that is seriously flawed and 

17          significantly -- and we will be displacing 

18          thousands of people working in addiction 

19          programs if we just let those exemptions 

20          sunset, right?

21                 So we're not talking about putting 

22          people -- making them do diagnoses.  That 

23          scope is a serious problem.  OASAS, OMH, and 

24          others have documented it, and it's really 

                                                                   334

 1          not fair to sort of suggest that the 

 2          workforce which has been doing addiction 

 3          treatment for years under a highly regulated 

 4          environment is somehow incompetent and 

 5          somehow OASAS and the other state agencies 

 6          are abdicating their responsibilities by not 

 7          hiring nonexistent licensed professionals, 

 8          okay?  

 9                 So I just strongly suggest that you 

10          don't just dismiss this because it's been on 

11          the table for 15 years.  There's a reason why 

12          it's been an issue for 15 years.  It's 

13          extraordinarily difficult to fix, but I think 

14          we can come up with a solution better than 

15          displacing people from the addiction 

16          workforce at a time when we can least afford 

17          to do so.

18                 Just one final point, and that is that 

19          as you contemplate -- and again, we need you 

20          to make a serious commitment of resources to 

21          address this pandemic, and I ask that you 

22          seriously think about the existing 

23          programs -- it's not just about putting up a 

24          new clinic here and a new clinic there.  

                                                                   335

 1                 And Christy talked about the workforce 

 2          crisis that we're having, right?  We have to 

 3          make an investment, and most of my written 

 4          testimony speaks about strengthening the 

 5          prevention workforce, strengthening the 

 6          treatment workforce, and strengthening the 

 7          recovery workforce.  We've got to take care 

 8          of the existing infrastructure.  It's not 

 9          okay that for years we have failed to keep 

10          pace with inflation with our allocation, in 

11          the midst of the death and addiction 

12          associated with the opioid crisis and the 

13          ongoing addiction to alcohol and other drugs.

14                 SENATOR KRUEGER:  I'm going to ask you 

15          to sum up.

16                 MR. COPPOLA:  Yeah.  So one final 

17          point is we did commission a workforce survey 

18          with the Center for Human Services Research, 

19          and there's a number of the findings in my 

20          written testimony.  And they really just 

21          demonstrate that there is a decreased ability 

22          to deal with the existing demand for services 

23          that is being caused by turnover and by the 

24          inability to fill positions.  

                                                                   336

 1                 And frankly, I think I mentioned it a 

 2          little bit earlier, that some of those 

 3          positions have been cannibalized and we'll 

 4          never see them again unless, you know, you 

 5          come in and really -- but, you know, I would 

 6          end with the following question.  What is it 

 7          going to take?  

 8                 What is it going to take for you all, 

 9          for the Senate and the Assembly, what's it 

10          going to take for you to just do something 

11          dramatic to deal with an issue that's quite 

12          dramatic in and of itself?  Like, what's it 

13          going to take, you know?  It's going to be a 

14          record number of deaths again.  What's it 

15          going to take?  

16                 We'll work with you in whatever way 

17          that we can to address this.  It's tragic, 

18          it's horrible, but we have to do more.  We're 

19          not doing enough.

20                 And on the very last page is a graphic 

21          illustration of the juxtaposition of flat 

22          funding and elevated level of overdose 

23          deaths, and I think the red line for the flat 

24          funding is a little bit on the generous side.  

                                                                   337

 1          It probably should be a little flatter than 

 2          it actually is.

 3                 SENATOR KRUEGER:  Thank you.  

 4                 Question?

 5                 ASSEMBLYMAN GUNTHER:  I just want to 

 6          say that I agree with you 100 percent, and I 

 7          think that we're not addressing this crisis 

 8          the way that we should.  And I think that in 

 9          my opinion, we need everybody on board that 

10          is on board today, and a lot less people I 

11          think are going into social work and becoming 

12          CASACs.  

13                 It's a very difficult program, and we 

14          need more beds, we need to do more long-term 

15          care for this issue, and hopefully we'll be 

16          able to do something about it.

17                 MR. COPPOLA:  Well, just thank you for 

18          all that you guys do, and I really appreciate 

19          your service to the community and for, you 

20          know, the questions you've asked and the 

21          consideration you give this.  

22                 I think the Legislature is more 

23          knowledgeable about addiction today by far, 

24          unfortunately, for reasons that are really 

                                                                   338

 1          tragic.  But I really appreciate your 

 2          engaging with us on this.

 3                 ASSEMBLYWOMAN GUNTHER:  There are so 

 4          many people that get to the point where they 

 5          do want recovery and they've been long-term 

 6          addicts and they've been through it once, 

 7          twice -- but sometimes, as you know, it takes 

 8          three times.  

 9                 And at this moment in time the 

10          difficult of getting inpatient stays is 

11          unbelievable.  And I said before, I called 

12          for hours and hours and hours.  And, you 

13          know, and I knew because of being a nurse -- 

14          and I worked at a detox unit when I was 

15          younger -- and being a nurse and working with 

16          Catholic Charities a lot that, you know, at 

17          least I knew what to do.  

18                 But for people that it's a new thing, 

19          and it's becoming new to so many families 

20          across New York State -- we have never seen 

21          young people involved, robo-tripping, all 

22          these kinds of things.  It's just different 

23          than it was before, or maybe because of 

24          social media we're just more aware of it.

                                                                   339

 1                 MR. COPPOLA:  And Assemblywoman, if a 

 2          secret handshake is necessary, I know it in 

 3          every single region of the state.  And I have 

 4          the exactly same experience that you do.  

 5                 I was trying to get a 23-year-old 

 6          woman who had an alcoholism problem into a 

 7          treatment program on several occasions.  Time 

 8          number one, waiting lists every place that I 

 9          knew.  Time number two, waiting lists 

10          everywhere.  Time number three, her father, 

11          who lives in Albany, put her in the car, took 

12          her to Buffalo, and she found a bed in 

13          Buffalo.  Right?  

14                 So this is really -- you don't forget 

15          that experience.

16                 ASSEMBLYMAN GUNTHER:  No, I don't.  

17                 And also I know that -- I mean, there 

18          are some bizarre things going on in the world 

19          that I think we should be aware of, like if 

20          somebody is stoned or high.  But some people 

21          actually, I have heard now through the 

22          grapevine -- they actually shoot up to get an 

23          admission into a hospital.  And I'm sure 

24          you've heard that.

                                                                   340

 1                 MR. COPPOLA:  Mm-hmm.

 2                 ASSEMBLYWOMAN GUNTHER:  You know, 

 3          because they'll take you when you're stoned, 

 4          I guess, and not when you're not.  So people 

 5          actually do it one more time.  And it is 

 6          absolutely true, because I work with a lot of 

 7          people in that community.

 8                 MR. COPPOLA:  Yeah.

 9                 SENATOR KRUEGER:  Thank you very much, 

10          John.

11                 MR. COPPOLA:  Thank you.

12                 SENATOR KRUEGER:  Stephanie Campbell, 

13          Friends of Recovery New York.

14                 And then for people watching the 

15          lineup, to move down closer.  After that, 

16          DC37.  After that, Coalition of Provider 

17          Associations.

18                 Good afternoon.

19                 MS. CAMPBELL:  Good afternoon.

20                 SENATOR KRUEGER:  Thanks for being 

21          with us.

22                 MS. CAMPBELL:  Thank you so much.

23                 ASSEMBLYWOMAN GUNTHER:  You're so 

24          happy after waiting so long.

                                                                   341

 1                 MS. CAMPBELL:  I know.  It's so true.

 2                 My name is Stephanie Campbell --

 3                 ASSEMBLYWOMAN GUNTHER:  This is a 

 4          half-day.

 5                 SENATOR KRUEGER:  Don't listen to her.  

 6          We're very early today.  We're fine.

 7                 MS. CAMPBELL:  Oh, good.

 8                 (Discussion off the record.)

 9                 MS. CAMPBELL:  -- and as the executive 

10          director of Friends of Recovery New York, I'm 

11          honored to be here at today's hearing to 

12          discuss how we can address the public health 

13          crisis of addiction here in New York State.

14                 As you may know, Friends of Recovery 

15          New York represents the voice of individuals 

16          and families living in recovery from 

17          addiction, people who have lost a family 

18          member and folks that have otherwise been 

19          impacted by this scourge.

20                 The stigma and shame that surrounds 

21          addiction has prevented millions of 

22          individuals from seeking help, and 

23          FOR New York is dedicated to breaking down 

24          some of those barriers to access to addiction 

                                                                   342

 1          treatment, healthcare, housing, education, 

 2          and employment.

 3                 But more importantly, my name is 

 4          Stephanie Campbell, and I'm a person in 

 5          sustained recovery.  And what that means for 

 6          me is I haven't used alcohol or drugs in over 

 7          17 years.  And that's allowed me to be the 

 8          mother of two beautiful girls, one who 

 9          recently graduated from Sarah Lawrence 

10          College, and one a teenager in her senior 

11          year of high school.  

12                 It's allowed me to be a partner, an 

13          employee, a taxpayer instead of a tax drain.  

14          It's allowed me to save the state of New York 

15          millions of tax dollars because someone made 

16          an investment in my recovery.  And as a 

17          result, I went from being a homeless street 

18          kid in New York City to having a master's 

19          degree from Columbia University and New York 

20          University.  

21                 So instead of bouncing in and out of 

22          jails and institutions, I advocate for folks 

23          that have been impacted by this illness.  And 

24          I know that you folks know that heroin use 

                                                                   343

 1          and prescription opioid use are having 

 2          devastating effects on the public health and 

 3          safety of New Yorkers.  According to the CDC, 

 4          drug overdoses, as you know, now surpass 

 5          automobile accidents as the leading cause of 

 6          accidental death for Americans between the 

 7          ages of 25 and 64.

 8                 And since I've begun this work -- the 

 9          first year I was here in 2015, we were losing 

10          about 129 people a day.  That number jumped 

11          the following year to 144, and this year it's 

12          174.  So as John Coppola just said, and other 

13          folks have said, this is not going away.  

14          It's going to continue to increase if we 

15          don't address it the way that it needs to be 

16          addressed.

17                 And so the surge of people dying from 

18          this crisis continues to rise.  And given 

19          right now the $4.4 billion shortfall that the 

20          New York State budget is facing, we must have 

21          a steady revenue stream of critically needed 

22          funding for prevention, for treatment and 

23          recovery services that are desperately needed 

24          to address the greatest public health crisis 

                                                                   344

 1          this nation has seen in generations.

 2                 New Yorkers have been fearless in 

 3          taking on previous epidemics, like HIV and 

 4          AIDS.  And I worked -- I sank my teeth into 

 5          advocacy early on in ACT UP and, you know, we 

 6          saw a real change that happened not only here 

 7          in New York State, not only here in the 

 8          United States, but globally when we took that 

 9          epidemic seriously.

10                 So we wholeheartedly see that it is 

11          time for the drug manufacturers who 

12          contributed to this public health emergency 

13          to cover state expenses that are associated 

14          with the epidemic here in New York State.  

15          And we see that proposed surcharge, which -- 

16          language is everything, right?  So we really 

17          see this as an opioid stewardship fee, is 

18          what we're calling it, to expand support 

19          services to address the pandemic through new 

20          prevention, treatment, and recovery programs 

21          that will effectively address this public 

22          health emergency.

23                 And I just want to say that, you know, 

24          part of my recovery process was from 

                                                                   345

 1          prescription drugs.  You know, and there's 

 2          many of us, there's thousands of us across 

 3          the state who I've talked -- you know, some 

 4          of them I've talked to in recovery talks that 

 5          we've had who have said, you know, "I 

 6          relapsed, you know, on prescription drugs.  

 7          My doctor didn't know."  Right?  And it's not 

 8          that they don't care, but the overuse of 

 9          these prescription drugs has really created, 

10          you know, part of this pandemic.

11                 So, you know, I just want to reiterate 

12          that we see this surcharge as a clear message 

13          not only to manufacturers that they too have 

14          a responsibility to pay their fair share, and 

15          for its recognition that additional funds are 

16          needed to stem the tide of this devastating 

17          epidemic.  But we feel strongly that the 

18          state's first priority for these funds must 

19          be the needs of OASAS prevention, treatment, 

20          and recovery.

21                 And I also want to say that we want to 

22          see that this not -- we don't want to see 

23          this passed on to the consumer.  And there's 

24          a way to do that.  There's a way to have 

                                                                   346

 1          conversations in which, you know, the right 

 2          appropriations are made to the right people.  

 3          And so we certainly support that.

 4                 So as a person in recovery who 

 5          continues to hold her illness in remission, I 

 6          see this proposed opioid stewardship fee as 

 7          the way to holding those who contributed to 

 8          this crisis accountable, while reducing that 

 9          demand.  

10                 As individuals continue to struggle 

11          with addiction with no end in sight for 

12          grieving families who continue to lose loved 

13          ones to overdose deaths -- and I can't tell 

14          you folks how many people I've buried in the 

15          past two years alone.  You know, how many 

16          funerals -- and I know you guys have gone to 

17          funerals as well.  

18                 It's -- it's -- it's time.  It's 

19          really time.  You know, addiction --

20                 SENATOR KRUEGER:  Could I ask you to 

21          summarize, to wrap up?  Sorry.

22                 MS. CAMPBELL:  Oh, no.  Thank you.  

23                 It doesn't discriminate.  You know, I 

24          know that we have Senator Brooks here from 

                                                                   347

 1          Long Island.  You know, we've got a wonderful 

 2          THRIVE Recovery Center that's doing 

 3          extraordinary work, they're facilitating 

 4          referrals, mobilizing resources, and linking 

 5          individuals to community supports.  

 6                 We must continue this work.  We need 

 7          more recovery community outreach centers, we 

 8          need more recovery community organizations, 

 9          more peers that are engaging with folks, 

10          family support navigators, and youth 

11          clubhouses.  It's really time to stop 

12          investing in the problem and start investing 

13          in the solution, which is recovery.

14                 Any questions?

15                 SENATOR KRUEGER:  Any questions?

16                 ASSEMBLYWOMAN GUNTHER:  Thank you very 

17          much.

18                 SENATOR KRUEGER:  Thank you very much 

19          for being here today and for all your work.

20                 DC 37 Local 372, Kevin Allen and Donna 

21          Tilghman.  Did I get that right?

22                 MS. TILGHMAN:  Yes.

23                 SENATOR KRUEGER:  Welcome.

24                 MS. TILGHMAN:  Thank you.

                                                                   348

 1                 SENATOR KRUEGER:  Whenever you'd like 

 2          to start.

 3                 MR. ALLEN:  Good afternoon, everyone.  

 4          Good afternoon, Chairwoman Weinstein.  Thank 

 5          you for inviting us.  On behalf of DC 37 and 

 6          President Francois, we thank you so much for 

 7          listening to what we have to say.

 8                 We're representing a group of 

 9          1.2 million school students.  SAPIS provides 

10          work in the following areas:  School 

11          programming, clubs, leadership, mental health 

12          awareness, peer mediation, classroom 

13          presentations, counseling services -- which 

14          is at-risk counseling, group, and individual 

15          sessions -- drug and gang prevention, and a 

16          host of additional mental health services for 

17          a variety of conditions.

18                 These counselors help children keep 

19          their focus on remaining learning-ready 

20          through the use of coordinated and 

21          collaborative proven methodologies to cope 

22          with the myriad of societal pressures that 

23          detract them from their daily work in life.  

24                 We're excited that we seem to be a 

                                                                   349

 1          unique group that counsels groups from the 

 2          letter A to the letter Z.  We counsel 

 3          children from the letter K to the number 12.  

 4          We're excited about that.  In a community of 

 5          over 1800 schools, which incorporates 

 6          1.2 million students -- if you do the 

 7          numbers, that breaks down to 6,000 students 

 8          per SAPIS.  In reality, each SAPIS provides 

 9          direct classroom lessons and counseling 

10          services to an average of 500 students each, 

11          with services available to only 325 out of 

12          over 1,800 schools.  

13                 We're passionate about that because 

14          just look at what we see on TV, just look at 

15          the daily grind, look at what the influx of 

16          social media has done with the students that 

17          we work with.  That's why we provide that 

18          means on an ongoing basis, and Local 372 

19          SAPIS are employed to bring that research.  

20          SAPIS have consistently implemented 

21          evidence-based programs with fidelity.  

22                 In addition, SAPIS are used to support 

23          schools during crisis -- unfortunately, one 

24          of the recent crises that we talk about is in 

                                                                   350

 1          the Bronx, in the Urban Assembly School for 

 2          Wildlife Conservation, when that student 

 3          unfortunately died due to an incident.  SAPIS 

 4          counselors was one of the groups that came 

 5          and that was called less than one half hour 

 6          after getting the information that that 

 7          happened.  The reason why I can speak so 

 8          passionately about that, I was one of the 

 9          staffers that was there, that were on the 

10          scene.  

11                 The result of that is priceless.  The 

12          result of that is catastrophic to a 

13          neighborhood, to a school, and to a 

14          community.  

15                 For the past three years, the Assembly 

16          has allocated an additional $2 million, and 

17          that has provided the funding for 

18          approximately 25 additional SAPIS positions.  

19          Together, these 25 SAPIS are able to provide 

20          prevention, education in the classroom, and 

21          direct counseling for approximately 

22          12,500 at-risk students and their families 

23          who would otherwise not have the support that 

24          they needed.

                                                                   351

 1                 For us to be able to maintain the 

 2          current number of employees, we are asking 

 3          the Assembly to maintain this $2 million 

 4          allocation in the 2019 budget, and for the 

 5          Senate to contribute an additional million 

 6          dollars to support the hire of an additional 

 7          12 counselors.  

 8                 We thank both the Senate and Assembly 

 9          for their expressed support and recognition 

10          of the 1.2 million students taught in more 

11          than 1800 schools.  The resources and the 

12          services that SAPIS offer to help keep pace 

13          with adverse societal pressures -- suffice it 

14          to say that New York City schools need to be 

15          safeguarded for that funding. 

16                 While there are limited state 

17          resources, which we all understand, New York 

18          State has always been a leader in 

19          prioritizing opportunities for the children.  

20          Local 372's goal is to partner with the state 

21          in making a smart investment in the qualities 

22          of life for both New York students, their 

23          families, and communities at large.  Of 

24          course we look forward to working with you to 

                                                                   352

 1          make this possible.  

 2                 Again, we thank you for the 

 3          opportunity to come before you on behalf of 

 4          DC 37, Local 372 of the New York City Board 

 5          of Education employees and the 280 Substance 

 6          Abuse Prevention and Intervention Specialists 

 7          that are on the ground each day looking and 

 8          working for that change, all about children.  

 9                 We will answer any questions that you 

10          have.

11                 SENATOR KRUEGER:  Thank you.

12                 So any questions?  Any questions, 

13          Assembly?

14                 MR. ALLEN:  Thank you very much.

15                 SENATOR KRUEGER:  You did explain it 

16          beautifully.

17                 MS. TILGHMAN:  Thank you.

18                 MR. ALLEN:  Thank you.

19                 ASSEMBLYMAN OAKS:  Thank you.

20                 SENATOR KRUEGER:  Thank you.  Thank 

21          you both for being here today with us.

22                 And our next testifiers -- don't lose 

23          your list -- excuse me -- Coalition of 

24          Provider Associations, Winifred Schiff and 

                                                                   353

 1          Barbara Crosier.  And then getting ready to 

 2          line up next, Association for Community 

 3          Living and then Supportive Housing Network of 

 4          New York.  

 5                 Good afternoon, ladies.

 6                 MS. CROSIER:  Good afternoon.

 7                 MS. SCHIFF:  Good afternoon.  Thank 

 8          you to Chair Gunther and to all our friends 

 9          in the Senate and the Assembly for your 

10          ongoing support of all of our issues and for 

11          hearing our comments today.

12                 ASSEMBLYWOMAN GUNTHER:  Thank you for 

13          being so patient, all of you.

14                 MS. SCHIFF:  No problem.  

15                 MS. CROSIER:  Thank you for sticking 

16          around.

17                 MS. SCHIFF:  I'm Wini Schiff, of the 

18          InterAgency Council of DD Agencies, and this 

19          is Barb Crosier from CP Associations of 

20          New York State, and we're today on behalf of 

21          COPA, which is the Coalition of Provider 

22          Associations. 

23                 COPA consists of five associations, 

24          which are the Alliance of Long Island 

                                                                   354

 1          Agencies; CP Associations; DDAWNY, in Western 

 2          New York; IAC; and the New York Association 

 3          of Emerging and Multicultural Providers.  

 4                 And before we get into our comments, I 

 5          want to just say how grateful we are to your 

 6          support of our #bFair2DirectCare living wage 

 7          initiative.  Thank you so much.  

 8                 To give you just a small context for 

 9          the reason -– you know, for our asks, in each 

10          of the past five years the adopted budget 

11          contained increases to Aid to Localities 

12          spending.  But because of midyear reductions, 

13          each year it was less than that, the spending 

14          was actually less.  For example, last year 

15          there were $88 million less spent than the 

16          year prior.  And even though this year the 

17          proposed spending is $151 million higher, the 

18          cumulative spending over the past seven years 

19          has been $53 million less.  

20                 In addition to that, we have not 

21          received a Medicaid trend -- except for a 

22          1.2 percent increase two years ago -- since 

23          2010.  

24                 And we did get two increases that 

                                                                   355

 1          we're grateful for.  In 2015, there were two 

 2          2 percent increases just for staff.  And then 

 3          again this past year, the two increases for 

 4          our direct support professionals, which are 

 5          absolutely necessary and, you know, still is 

 6          our biggest priority.  

 7                 But at the same time, all of our costs 

 8          are rising, and so providers are in more and 

 9          more of a precarious situation financially.

10                 From about 1993 till 2010, we got 

11          Medicaid trends every single year.  Now it's 

12          been eight years that we have not received 

13          any kind of an overall trend.

14                 In addition to that, rate 

15          irrationalization, is what we call it -- 

16          because it's based more on an idea than on 

17          actual costs of providing services -- have 

18          created a situation where there are no 

19          surpluses for any of our programs.  And so 

20          programs that lose money, like clinics, 

21          Early Intervention, and other services for 

22          people with the most significant needs, are 

23          actually closing because they're money losers 

24          and we can't afford to support them because 

                                                                   356

 1          there are no more surpluses to do that.

 2                 Getting right into something that 

 3          you've heard before, which is our request to 

 4          actually give us the payments toward the 

 5          living wage more quickly.  So in the 

 6          beginning, we had asked for $45 million every 

 7          year for six years, to bring us to the living 

 8          wage, which is $17.72 downstate and $15.54 

 9          upstate.  But based on new data that we have 

10          collected, our vacancy rates have gone up to 

11          14.4 percent, our turnover rate is up to 

12          26.7 percent, and programs are really 

13          suffering.  So we are asking for the original 

14          plan to be sped up and for $18.25 million to 

15          be added to this year's budget for the next 

16          installment.

17                 So just the other day -- on Liz 

18          Benjamin, actually -- I know you had heard 

19          that SWAN, which is a statewide parent 

20          advocacy network, joined the 

21          #bFair2DirectCare coalition, and Barb DeLong 

22          and Pat Curran were on there talking about 

23          our worsening crisis for staff.  And Barb 

24          said that she's been given 45 staff hours for 

                                                                   357

 1          support in their home per week, and she's 

 2          only able to staff 10 of those hours.  So 

 3          that's pretty telling.  

 4                 I'll turn it over to Barbara for 

 5          development.

 6                 MS. CROSIER:  And I'll just quickly 

 7          summarize.  

 8                 As development and particularly 

 9          residential development for people living at 

10          home with aging caregivers is continuing to 

11          be a severe problem, we recognize that there 

12          is additional funding in the Governor's 

13          budget, but most of that is spent before it's 

14          even allocated.  And then we also have 

15          concerns about actually seeing some of the 

16          additional what would be $120 million 

17          all-shares actually go out the door and be 

18          spent.

19                 There's concerns about families are 

20          unfamiliar with the new residential request 

21          wait list and the certified residential 

22          opportunity list; concerns about how 

23          backfills are maybe being inappropriate, that 

24          people who really -- because there's an 

                                                                   358

 1          opening, that's the only place they can go.  

 2          Or that's what they're offered, even though 

 3          it's not necessarily an appropriate placement 

 4          for the individual, and that they're no 

 5          longer being supported in places that are 

 6          person-centered and really most appropriate.  

 7          So we would ask that.

 8                 Mark mentioned telemedicine.  And 

 9          Assemblywoman, you also asked about it.  We 

10          think that telemedicine is critically 

11          important, particularly for individuals with 

12          developmental disabilities.  We think it can 

13          provide much better quality of care and 

14          significant Medicaid savings, particularly on 

15          the healthcare side.  

16                 There have actually been several 

17          pilots that have been funded through PPSs and 

18          BIP grants that showed that 86 percent of 

19          emergency room visits could be avoided with 

20          telemedicine.  So that's far better care for 

21          an individual with a developmental disability 

22          not having to be transported to the emergency 

23          room.  When we are in the emergency room, 

24          emergency room physicians tend to admit 

                                                                   359

 1          individuals with developmental disabilities.  

 2                 So it's a huge cost savings to the 

 3          healthcare side, and we think it is much 

 4          better quality of care for individuals with 

 5          developmental disabilities.

 6                 What we're asking for is that there's 

 7          language in the budget for the Office for 

 8          People With Developmental Disabilities to 

 9          promulgate regulations.  We're asking that 

10          that be emphasized and that the office does 

11          promulgate the regulations allowing 

12          telemedicine, particularly in our residences, 

13          but also that there be some funding for 

14          agencies that don't have either Article 16 

15          clinics or Article 28 clinics that can access 

16          funding through the healthcare facility 

17          transformation fund in the health department.

18                 The other thing that we're asking for 

19          is that for telemedicine -- in our clinics, 

20          we get an add-on, because it's recognized 

21          that it takes longer and more staffing to 

22          treat an individual with developmental 

23          disabilities than it does a typical 

24          individual in our like Article 28 clinics.  

                                                                   360

 1          And so we're asking that a similar add-on be 

 2          included in the telemedicine rate to be able 

 3          to bill through Medicaid.

 4                 SENATOR KRUEGER:  Thank you.  I'm just 

 5          cutting you off because you're at zero.  

 6                 Does anyone have any questions?  

 7                 ASSEMBLYMAN GUNTHER:  No.  

 8                 And I think you make a great point 

 9          about the telemedicine, because diagnosis of 

10          a child with a disability or an adult with a 

11          disability is so much different.  They 

12          exhibit pain differently.  

13                 And also the transportation itself 

14          sometimes -- as you said, it's not just one 

15          person, it's two to three people doing the 

16          transfer, so it's very, very costly.  And 

17          really you need someone with a specialty in 

18          DD folks.

19                 MS. CROSIER:  Right.

20                 ASSEMBLYWOMAN GUNTHER:  I think it's a 

21          great idea.

22                 SENATOR KRUEGER:  Right.  Thank you.  

23          Thank you both for testifying.

24                 MS. SCHIFF:  Thank you.

                                                                   361

 1                 MS. CROSIER:  Thank you very much.

 2                 SENATOR KRUEGER:  Our next testifier 

 3          is Antonia Lasicki, Association for Community 

 4          Living.

 5                 MS. LASICKI:  Thank you.  

 6                 Good afternoon.  Almost done.  How are 

 7          you?

 8                 SENATOR KRUEGER:  All right.

 9                 MS. LASICKI:  So thank you very much 

10          for the opportunity to testify today.  My 

11          name is Toni Lasicki, and I'm the executive 

12          director of the Association for Community 

13          Living.

14                 ACL is a statewide membership 

15          organization of not-for-profit providers of 

16          community-based housing and rehabilitation 

17          services for more than 35,000 New Yorkers who 

18          have been diagnosed with serious, persistent 

19          psychiatric disabilities and who have been 

20          functionally impaired by those disabilities.

21                 I am going to read parts of my 

22          testimony, but I've crossed out an awful lot 

23          of it, so it's like a summary.

24                 Today I will be speaking on behalf of 

                                                                   362

 1          my organization, ACL, as well as the Bring It 

 2          Home campaign, a statewide coalition of more 

 3          than 200 community-based mental health 

 4          housing providers and advocates, faith 

 5          leaders, residents, and their families. 

 6          You've heard from Harvey and from NAMI and 

 7          from others about the Bring It Home campaign 

 8          today -- Christy Parque as well.  We're 

 9          working to bring better funding for better 

10          care to New York, and we strongly urge you to 

11          include adequate funding for our critical 

12          mental health community-based housing in the 

13          final New York State Budget.

14                 New York has historically been a 

15          national leader in mental health healthcare.  

16          Under the leadership of both Governor Andrew 

17          Cuomo and his father Mario -- and with the 

18          support of the New York State Legislature, 

19          including many of you listening today -- 

20          New York set new national standards to care 

21          for and protect people with psychiatric 

22          disabilities.  However, despite building a 

23          breadth and depth of mental health housing 

24          opportunities that is unparalleled in the 

                                                                   363

 1          nation, the state has not kept its promise to 

 2          adequately fund these housing programs that 

 3          care for the New Yorkers who most need our 

 4          help.

 5                 For more than 25 years, mental health 

 6          housing providers have received few increases 

 7          in their funding, and most of those increases 

 8          that were provided went to New York City, 

 9          Long Island, and the Lower Hudson Valley, 

10          because the state just wouldn't make enough 

11          money available.  So it focused on the units 

12          that would literally imminently fail without 

13          immediate help. 

14                 In bad years we've been told that 

15          there isn't any money, and in good years 

16          we've been told there wasn't any for us 

17          either.  Within the five models of housing 

18          programs, only three have received increased 

19          funding since 2009.  So out of five models, 

20          only three have received anything, and only 

21          in restricted geographic areas. 

22                 All of the programs throughout the 

23          state are stretched untenably thin.  For 

24          example, the Supported Housing program in 

                                                                   364

 1          New York City spends nearly all of its 

 2          funding on rent, which leaves little for 

 3          mandatory staffing, lease management, and 

 4          other obligations.  

 5                 With unreliable funding across the 

 6          state, our mental health housing system has 

 7          reached a financial breaking point.  And the 

 8          people who feel it are some of New York's 

 9          most vulnerable residents, who suffer from 

10          the disruption that staff vacancies and staff 

11          turnover create, not to mention to overworked 

12          supervisors.

13                 And I just want to respond to the 

14          commissioner for a minute.  She spoke about 

15          the $42 million that have been added to the 

16          state budget over the last few years for 

17          housing.  That sounds like a lot of money, 

18          but it really has to be put into context.  

19                 There's a certain model of housing, 

20          8200 units, that had gotten so little 

21          increases for 25 years that they had lost 

22          80 percent of their funding due to inflation.  

23          They literally got 10 percent in increases 

24          over 25 years.  So a chunk of that 

                                                                   365

 1          $42 million went to them.  They are now at 

 2          the point where they have lost 70 percent of 

 3          their funding due to inflation, even with the 

 4          investment that the Office of Mental Health 

 5          made.

 6                 The Supported Housing program in 

 7          New York City, Long Island, Westchester, 

 8          Rockland, and Putnam, also received a large 

 9          part of that $42 million.  That brought their 

10          rates up to, as the Commissioner said, around 

11          $17,000 in New York City.  Just to put that 

12          into context, OASAS pays $25,000 per year per 

13          unit.  New York City pays HIV-supported 

14          housing -- it's the same exact model -- 

15          $30,000 per unit.

16                 The new units that the Governor is 

17          putting online, the services will be $25,000 

18          a year because they knew these providers -- 

19          and it's these providers that will do those 

20          new beds -- these providers would not develop 

21          those at $17,000 per year for services.  It 

22          doesn't work.  It just doesn't work.

23                 I have a provider on Long Island who 

24          has two large facilities, 65 units in each, 

                                                                   366

 1          and he's losing $250,000 per year on each 

 2          building, and he has one staff person for 

 3          65 clients.  And to respond to Senator Young, 

 4          in terms of what's -- how steep is the step 

 5          down from a state hospital to the community, 

 6          those people who are staffed at one staff 

 7          person for 65 clients, that facility emptied 

 8          an entire ward of Kingsboro State Psychiatric 

 9          Hospital.  

10                 So an entire ward went into one of 

11          those facilities.  And they went from a state 

12          hospital to one staff for 65 people.  It is 

13          not reasonable any longer, and providers -- 

14          their boards of directors are now telling 

15          them, We cannot allow you to continue to do 

16          this.

17                 We have providers in New York City, 

18          they are losing massive amounts of money at 

19          $17,000 a year per bed in supported housing.  

20          It just doesn't work.  

21                 So I do want to be clear.  Mental 

22          health housing providers cannot survive under 

23          these circumstances.  They have reached the 

24          point where they'll be forced to reconsider 

                                                                   367

 1          renewing state contracts -- and some have 

 2          said that to the Governor's office -- and 

 3          without adequate funding they are going to 

 4          shut down.  Maybe not tomorrow, but it will 

 5          eventually happen.  

 6                 Beyond the moral imperative, taxpayers 

 7          end up footing a larger bill when our clients 

 8          fall through the cracks.  Without mental 

 9          health housing options, those with major 

10          psychiatric disabilities end up hospitalized, 

11          homeless, in nursing homes, or become 

12          incarcerated, often due to minor infractions.  

13          And I know I'm repeating what Wendy Burch 

14          said, but it's true.  

15                 Governor Cuomo made a commitment to 

16          combat homelessness, and he is funding all 

17          those new housing opportunities at an 

18          adequate and much higher services rate.  So 

19          my providers are saying to themselves, Well, 

20          why wouldn't I just turn back the ones I've 

21          got that I'm losing a ton of money on and 

22          develop the new ones which will be fine?  So 

23          that's the dilemma that they're all in.  

24          They're having board conversations all the 

                                                                   368

 1          time about this.  

 2                 So as we face the dilemma, we can 

 3          either become a national model for how states 

 4          can successfully protect a population that so 

 5          desperately needs support, or watch the 

 6          system collapse and become an example of what 

 7          can go wrong.  So it's time to make the right 

 8          choice.  And on behalf of all New Yorkers 

 9          impacted by mental illness, their families, 

10          friends, colleagues, and neighbors, we urge 

11          you to increase funding for community-based 

12          supportive mental health housing in this 

13          budget.  

14                 So we're mindful of the state budget 

15          environment that we have right now, 

16          obviously.  On the last page there's a -- the 

17          last page of my testimony shows what the 

18          financial need is by program type, and it's 

19          about $117 million that they need to 

20          stabilize approximately 40,000 units of 

21          housing across the State of New York.  It 

22          sounds like a lot of money, but it is 40,000 

23          units of housing that have been really 

24          neglected for a very, very long time.  

                                                                   369

 1                 But given the state budget environment 

 2          right now, what we're suggesting is that the 

 3          Governor's $10 million which he added to the 

 4          budget this year for these housing models -- 

 5          and how it's allocated hasn't been decided 

 6          yet, so our suggestion is that the Senate and 

 7          the Assembly support moving that $10 million 

 8          to the fourth quarter of the state's budget.  

 9          Then that $10 million would annualize to 

10          $40 million.  

11                 That would go a long way to helping 

12          us, and we think that the Governor might be 

13          more willing to make that move if the Senate 

14          and the Assembly put something in as well.  

15                 If the Senate and the Assembly put in 

16          $20 million, the $30 million combined would 

17          equal $120 million for the next year, which 

18          is exactly what we need.  We understand even 

19          that might not be possible, but if you match 

20          the Governor's $10 million and there are 

21          $10 million from the Legislature and 

22          $10 million from the Governor in the fourth 

23          quarter, that would equal $80 million 

24          annualized, and that would go a long way to 

                                                                   370

 1          helping us in the short term.  

 2                 We realize we'd have to come back 

 3          again and continue to try to get more, 

 4          especially now that I think we're moving into 

 5          a time of increased inflation.  We've been 

 6          relatively lucky because the last four years 

 7          have been low inflation, but we're probably 

 8          moving into a time when we're going to have 

 9          much higher inflation.  And so all of my 

10          program types, they're either at about -- 

11          they've lost either 43 percent to inflation 

12          to 70 percent to inflation.  So it's 

13          desperate.

14                 And the workforce issue.  We are 

15          running 50, 60 percent staff vacancy rates, 

16          and Assemblywoman Gunther heard just 

17          yesterday from a provider who has six staff 

18          people per week for a program, and they only 

19          have two hired.  So four are vacant out of 

20          six.  So that means the program managers and 

21          the supervisors, they're swooping in to cover 

22          shifts.  

23                 They usually have a group of respite 

24          workers they can call in.  Respite workers 

                                                                   371

 1          are going away because, you know, we're at 

 2          full employment.  So it's very difficult to 

 3          find anybody to do respite work.  So we're 

 4          wearing our staff out.  I even have a CEO who 

 5          does midnight shifts in one of her programs 

 6          in Ulster County.

 7                 SENATOR KRUEGER:  I do have to cut you 

 8          off, but I also want to thank you so much.  

 9                 And I asked -- I tried to ask these 

10          questions of the commissioner earlier today, 

11          but you were so much more articulate at 

12          laying out how desperate the situation is.  

13                 And I'll probably get in trouble for 

14          this, but you know what, I think your 

15          providers should say "We're not taking the 

16          $17,000-a-year contracts," and shift gears.  

17          Because it's crazy that we're paying $25,000 

18          under the new contracts for exactly what we 

19          need, we say we need -- the next testifier's 

20          going to tell me that too -- and that we need 

21          to be speeding along our increase in 

22          supportive housing.  And then you find 

23          yourselves being penalized so extremely for 

24          having been in the business of doing this 

                                                                   372

 1          important work for so long.

 2                 MS. LASICKI:  Yeah.  You know, our 

 3          providers are mission-driven, and they are 

 4          loath to give back beds.  They are loath to 

 5          do any of this.  They really want to 

 6          continue -- they have wait lists a mile long.

 7                 SENATOR KRUEGER:  Yeah.  Right.

 8                 MS. LASICKI:  They recognize that 

 9          reducing the number of beds in the system is 

10          a terrible outcome.

11                 SENATOR KRUEGER:  Right.

12                 MS. LASICKI:  So they do their best to 

13          not do that.

14                 SENATOR KRUEGER:  Are there questions?

15                 ASSEMBLYWOMAN GUNTHER:  We talked 

16          yesterday.

17                 MS. LASICKI:  Yes, we did.  Thank you.  

18                 SENATOR KRUEGER:  Thank you very much 

19          for being here.

20                 And our last testifier today --

21                 (Laughter.)

22                 ASSEMBLYWOMAN GUNTHER:  You get the 

23          Patience Award.

24                 (Laughter.)

                                                                   373

 1                 SENATOR KRUEGER:  -- from the 

 2          Supportive Housing Network of New York, is 

 3          Maclain Berhaupt.

 4                 Hi, Maclain.  How are you?

 5                 MS. BERHAUPT:  Hi, very well.  Thank 

 6          you so much for the opportunity to testify 

 7          today.  

 8                 My name is Maclain Berhaupt, and I am 

 9          the State Advocacy Director of the Supportive 

10          Housing Network of New York.  We represent 

11          just over 200 nonprofits who build and 

12          operate supportive housing throughout the 

13          state. 

14                 I mean, I really could just sit here 

15          and echo exactly what Toni just so eloquently 

16          laid out for everyone.  Just a couple of 

17          additional points I wanted to make that I 

18          think are important to the conversation.  

19                 You know, in New York City, where Toni 

20          mentioned the increases have occurred -- 

21          which were extremely modest, $500 per 

22          person -- HUD puts the fair market rent for 

23          an efficiency apartment in New York at just 

24          over $18,000 annually.  The current rate 

                                                                   374

 1          there is just over $16,000.  So while this 

 2          program 20 years ago was intended -- roughly 

 3          50 percent of the funding would go for 

 4          services and 50 percent for rent, it's not 

 5          even covering rent anymore.  So that's the 

 6          issue.  

 7                 You know, a few years ago we were here 

 8          saying, Oh, there's a couple of hundred 

 9          dollars for rent, and we're barely making 

10          it -- but now it's not even covering the cost 

11          of rent.  So something is going to give 

12          eventually.

13                 The other thing I just wanted to 

14          mention is, you know, the way providers are 

15          dealing with this right now is they're 

16          doubling up tenants.  And that's not ideal 

17          for any situation, particularly for this 

18          population.  And you know, again, the 

19          chronically low rates, you know, in addition 

20          to the doubling up -- we're watching 

21          landlords just refusing to renew leases now.

22                 So we're really in a dire situation.  

23          And we're urging the Legislature -- through 

24          the campaign, as Toni mentioned -- to work 

                                                                   375

 1          with the Governor, you know, to look at the 

 2          funding requests of the $10 million that was 

 3          put in this budget, put it in the fourth 

 4          quarter and then annualize it into next year 

 5          so we can really get the relief that we need.

 6                 And then the last point I'd like to 

 7          make, as Senator Krueger had mentioned 

 8          earlier, is that we advocated heavily for the 

 9          last three years to see these new supportive 

10          housing units come online.  There are 6,000 

11          over the next five years.  If we watch the 

12          existing units just evaporate -- because 

13          that's exactly what's going to happen -- 

14          we're not addressing the homelessness crisis 

15          as the Governor and the Legislature really 

16          intended last year by doing the five years of 

17          funding for these new units.

18                 So we would just urge you to work with 

19          the Governor to support the $10 million, to 

20          try to do some additional funding and 

21          annualize it going into next year.  

22                 So thank you.

23                 ASSEMBLYWOMAN GUNTHER:  Thank you.  

24                 SENATOR KRUEGER:  Thank you.  

                                                                   376

 1                 Any questions?  No?  

 2                 Well, then, thank you for being our 

 3          last testifier.  

 4                 And this officially closes the 

 5          Senate-Assembly budget hearing on Mental 

 6          Health.  For those of you who are used to 

 7          coming here every day of your lives, don't 

 8          come back until the 27th for the next budget 

 9          hearing.  

10                 Thank you, everyone.  

11                 (Whereupon, the budget hearing 

12          concluded at 3:49 p.m.)

13

14

15

16

17

18

19

20

21

22

23

24