Senate Finance Subcommittee Issues Testimony From Nevada Department of Health & Human Services

WASHINGTON, May 12 -- The Senate Finance Subcommittee on Health Care issued the following testimony by Stephanie Woodard, licensed psychologist and senior advisor on behavioral health at Nevada Department of Health and Human Services, at a hearing entitled "The COVID-19 Pandemic and Beyond: Improving Mental Health and Addiction Services in Our Communities":

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My name is Stephanie Woodard. I am a licensed psychologist and serve as the Nevada Department of Health and Human Services, Senior Advisor on Behavioral Health. I also serve on the board for the National Association of State Mental Health Program Directors and the NevadaBoard of Psychological Examiners.

I am humbled and honored to have the opportunity to testify before you today to discuss how the COVID-19 pandemic has highlighted the critical role of crisis services and Certified Community Behavioral Health Clinics and our opportunities to build strong, resilient communities throughout the recovery.

Inadequate access to critical behavioral health infrastructure has long contributed to Nevada's struggles to address the behavioral health needs of the population. Nevada's vast geography combined with workforce shortages, insufficient access to critical health and behavioral health resources, and high rates of uninsured and underinsured have been amplified during the pandemic and contributed to the disproportionate impacts of COVID-19 across communities in our state.

When compared to previous years, in 2020 Nevadans experienced higher rates of depression and anxiety. Emergency room admissions for overdose, suicide attempt, and suicide ideation all increased over the course of last year resulting in the highest number of admissions in the past decade. While overall deaths by suicide decreased, the suicide rate rose 25% in youth and young adults age 8 to 24. Additionally, opioid-related overdose deaths increased 44% with synthetic opioid overdose deaths accounting for more than 50% of the overdose fatalities in Nevada. These data underscore the urgent need to address substance use, mental illness, and suicide, they help us to understand the magnitude of suffering occurring in our neighbors, co-workers, children, friends, and family members, and they provide an imperative to act.

Informed by the body of knowledge on disaster behavioral health, Nevada's COVID-19 Disaster Behavioral Health Response and Recovery Plan, established in May of 2020, used a population health model focused on promotion, prevention, early intervention, continuity of behavioral health care, and access to recovery supports. Our Certified Community Behavioral Health Clinics, suicide prevention crisis hotline, mobile crisis teams, and crisis stabilization centers provided the necessary foundation for Nevada's plan.

Nevada's Comprehensive Crisis Continuum of Care

National guidelines developed by the NASMHPD, SAMHSA, and the National Council were valuable tools as we developed a coordinated crisis continuum of care. Essentially, a coordinated system of crisis care ensures that when individuals are in crisis, they have someone to talk to, someone to respond, somewhere to go and the services and supports are based on best practices. These guidelines have been the road map for the crisis system in Nevada statewide, and regionally, over the past 3 years.

Nevada completed assets and gaps mapping in July 2020 and found significant gaps in the capabilities across continuum of care, however, knowing the gaps in the system has led to strategic use of federal funding through CMS and SAMHSA to respond to community needs for crisis services.

Crisis Call Hubs/Care Traffic Control

Crisis Support Services of Nevada is part of the National Suicide Prevention Hotline, meaning no call goes unanswered. Through grant funds we have been able to increase staffing on the crisis line to increase in-state answer volume, decrease wait times for callers, and begin to ready the system for 988 in July of 2022. Nevada has pending legislation to establish a fee and a fund to support the implementation of 988 by July 2022.

Mobile Crisis Services

Ultimately, overutilization of emergency services within EMS and Law enforcement has resulted in costly use of critical public safety resources with lengthy wait-times and a mismatch of intervention to support the individual. COVID-19 grant funding has been used to divert children and families away from emergency rooms through the expansion of children's mobile crisis teams. We plan to further this work with the new supplemental funding through the American Rescue Plan Supplemental Block Grant funding and the enhanced FMAP through Medicaid to sustain more mobile crisis teams across the state.

Crisis Stabilization Centers

Prior to COVID-19, on any given day an average of 90 people would be waiting in an emergency room for an inpatient psychiatric bed, the vast majority of whom were underinsured or uninsured. We expanded funding for uncompensated care to 24/7 crisis stabilization centers through federal grant funding in order to provide an alternative destination for individuals in crisis and diverted from emergency rooms.

Statewide expansion of mobile crisis teams and crisis stabilization centers is planned with new supplemental funding through the American Rescue Plan Supplemental Block Grant and enhanced FMAP for sustainability for mobile crisis. A new Medicaid rate for crisis stabilization centers is expected to result in cost saving to Nevada over the long term. The recent infusion of federal funding is necessary in the development of essential infrastructure however, it is insufficient for long term sustainability. To bring the entire crisis continuum to scale, Nevada, along with other states, will need guidance from CMS to ensure these services are sustainable into the future. For states to be successful in rising to the challenges 9-8-8 presents, collaboration between SAMHSA and CMS, as recommended by the Medicaid and CHIP Payment Access Commission (MACPAC), will be essential.

Nevada established Certified Community Behavioral Health Clinics through the SAMHSA CCBHC Planning Grant in 2016 and the Demonstration Grant in 2018. Nevada's investment in CCBHC's through the Demonstration Grant, Mental Health Block Grant funding, and the CCBHC Expansion Grant has resulted in nine CCBHC's under the Medicaid State Plan.

Over the course of the Demonstration, CCBHC's have increased access to critical safety net behavioral health services including 24/7 crisis services, while lowering costs of care and improving outcomes. CCBHC's success can also be measured by the relationships the clinics have with the communities they serve. Collaboration with law enforcement for community-based crisis intervention has reduced unnecessary incarceration and emergency room visits. Expansion of services into schools has increased access to care for students with behavioral health needs. Comprehensive case management and peer recovery supports better address social determinants of health and increase engagement in care. Cost-based reimbursement has enhanced their ability to recruit and retain qualified behavioral health professionals in competitive job markets despite workforce shortages across all regions of our state.

In addition, while many behavioral health providers experienced significant challenges in maintaining operations over the past year, Nevada's CCBHC's were able to pivot quickly to expand telehealth services and offer hybrid services to individuals for in-person care. We anticipate continued CCBHC continued success and look forward to onboarding an additional four CCBHC's under the most recent SAMHSA expansion grant.

Nevada expresses our gratitude to Senator Stabenow, Senator Blunt, the National Council, and countless other who have supported the CCBHC model and expanded the Demonstration until 2022.

Opportunities and Solutions

* Collaboration between SAMHSA and CMS, as recommended by the Medicaid and CHIP Payment Access Commission (MACPAC), will be essential for states to fully leverage Medicaid to sustain the crisis continuum of care.

* Looking ahead we would encourage SAMHSA to work closely with state mental health program directors as they administer the Expansion Grants. CCBHC certification requires state time and resource and is essential in ensuring all clinics qualifying as CCBHC's meet the rigorous certification criteria.