Lehman: Next item is, I apologize here, I don’t think I quite got, we’re looking at 2 different items, and I think what I wanted to put this on is Mental Health Court. If we could put a little time with a presentation on that, and then go into Judicial Referee. We have Ken Kress here, who’s a member of the University of Iowa faculty, as well as a member of our Planning Council, but he’s here to speak as an individual today, and give us some background on Mental Health Courts.

Stutsman: Pat, can we discuss this, if it’s not on the agenda? Mental Health Courts?

White: Well, if it’s related to Judicial Referee or State Mental Health Proposed Budget, yes, otherwise, no. Ken could do a presentation under Reports from the Public if it’s not one of those agenda items. So, there’s certainly a way to hear what he has to say.

Lehman: What’s the feeling of the Board? I don’t know what Ken’s time schedule is?

Thompson: The Judicial Referee question is one that needs to be addressed today, and is on.

Stutsman: The only reason I’m hesitant is because, I always feel the agenda is to announce to the public what we’re going to discuss. And if there’s people that might have some interest in a particular item, and it’s not specifically said, gee I wanted to come to that Board meeting, not just in this particular issue, but in any issue. So that’s my only hesitation about.

Lehman: Well, I did not get that labeled correctly.

Stutsman: Yes.

Lehman: I take full responsibility for that. I don’t know what your schedule is, if you’d rather come back next week, Ken?

University of Iowa Faculty Member Ken Kress: If it’s possible to speak today, I would prefer it. It seems to me that mental health courts, since they will have effects on the mental health court budget, could easily come under that topic, under the County Attorney’s interpretation.

Lehman: OK. What’s the feeling of the Board?

Neuzil: I’d like to hear it, but if the others…

Lehman: OK. Well, maybe we proceed with the Judicial Referee first?

Neuzil: Sure.

Lehman: And then when we get into the next item, the State Mental Health Proposed Budget Revisions, we could address that.

Thompson: Yes, we’ve had correspondence asking, well, to go back. As a budget management technique, the court system had a budget shortfall earlier in the year, and deleted their funding for the judicial referees for mental health. And I think that’s caused some problems in the court process, and we have people here today to address that, but it’s been suggested that for the last quarter of the year, the county could pick up the cost of that. I believe it’s about $8,000 for one quarter, and then, beginning July 1st, it’s back in the State budget. So the question that we need to resolve is, do we want to pay for the last quarter of the year? I see Jay Stein back there, he’s the person who up until recently was the judicial referee.

Stutsman: I think Veda Higgins, too, had some…

Thompson: Veda Higgins, the Mental Health Advocate. Ann Lahey from the County Attorney’s office, and Elaine Sweet here, so I think…

White: I assume that’s why Judge Hibbs is here.

Thompson: That is Judge Hibbs. Oh, OK.

Lehman: I don’t if any of you would like to take any turns, come up and give some clarification as your area is affected or addressed here. You might re-identify yourself for the public.

Mental Health Advocate Veda Higgins: I’m Veda Higgins, Mental Health Advocate for 12 years. I’d like to introduce Jay first, because he could explain what his role was, up until October 31st, 2000.

Lehman: OK. Good morning, Jay.

Former Judicial Referee Jay Stein: Good morning.

Neuzil: Good morning.

Stein: The jurisdiction for involuntary mental and substance abuse commitments resides in the District Court, and Chapter 229 provides that the District Court can hire an individual, who has to be an attorney, to be the judicial hospitalization referee, who then exercises the District Court’s jurisdiction in those specific areas. For 20 years last past, that’s the way it worked. The procedure is that individuals wishing to commit a family member or a friend, or an institution wishing to commit a patient for involuntary treatment of mental or substance abuse, has to file an application. That application then has to be reviewed by the court; if it’s approved, then orders are issued, a hearing is set up, someone needs to preside at that hearing. After the hearing, if the person is committed, there’s interminable reports that have to be responded to with orders by the court, and all of that was done by the judicial hospitalization referee, and not the District Court. As Ms. Thompson has indicated, the position was de-funded when the Judicial Department discovered a shortfall in their budget, and all those duties then devolved back to the District Court, because there was no judicial hospitalization referee. The effect, I think, was deleterious to both consumers and providers, not that the District Court isn’t quite capable of making the decisions; they’re all very talented people, and I don’t care who knows that I think that of them. But I think there was a certain economy, because one person was in charge. Now, the District Court assigns it, I think, on a weekly basis, or perhaps, I don’t know, but I think that’s right. So you had a different person who’s running the system every week. So that makes it difficult, I think, for providers to know exactly what the rules are, because there’s a lot of subtleties involved in how outpatient commitments are going to be handled, that sort of thing. So there’s not quite the continuity that there was when one person was doing it. There is a problem generated because, when a referee makes a decision, the appeal of that decision, if a patient decides that he or she wants to do that, is sent to the District Court, which is set within 10 days; it’s fast and efficient. Now, if a patient disagrees with a decision that’s been made about him or her, that has to go right to the Supreme Court, and that’s a much more expensive and ponderous process. The other problems that are perhaps generated are, if you’ve got one person doing it, he or she can be, perhaps, more creative than a judge who’s only going to be there for a week. You can, for instance, at a hearing if you’ve got somebody who’s saying that they’re willing to receive the treatment, but maybe needs some encouragement, you could continue the hearing, and say, well, if you complete this on a voluntary basis, then we can dismiss this, that you would, upon notification. But a person who’s only going to be there for a week probably is going to have more difficulty doing that. I tried to put a lot of information into not many words, and if I generated questions, I’d be glad to answer them.

Stutsman: I understand the validity of having a referee do this. It makes a lot of sense. What really concerns me is that this is going to be a County mandate from now on, that the State doesn’t have any money this year. I understand projections are even worse for next year, so if the County agrees to pick this up, I just would be willing to bet my salary, we’ll be picking this up next year, too. It just bugs me, it just really annoys me that, on one level the legislature wants to cap our budgets and put us under a property freeze, and on the other level they put something like this on us. It just annoys me like I can’t describe.

Stein: Well, please don’t put me in the position of defending them.

Stutsman: I know.

Stein: And I think you have a valid concern. I think one of the aspects that ought to be looked at is whether or not having a referee would save more than the money that you would put into it. It may be that there isn’t going to be money for referees, too. I don’t know; it’s all in the hands of the legislature. The County, when it’s funding, I was always impressed when I was doing this that the largest item in the County budget is Mental Health and Mental Disabilities; it’s bigger than roads. If you can save hospital days for a patient, and I noticed that Mr. Kress, in his presentation, indicates that it’s like $1200 a day at University Hospitals, and $450 a day at the Mental Health Institute. If you shave some of those days, it doesn’t take long to make that money back. I can think of times when it was recommended to me that a person ought to go to the Mental Health Institute, and just because of having had that experience for so long, I could say, I’m not going to do it, because they won’t be there but 1 day or 2 days, and I don’t see the reason for that. But again, I think you raise a valid concern, about whether or not the Court is going to come back in the next fiscal and take this back away from me.

Thompson: The difference I see, Sally, is that we’ve talked about this, picking up various aspects of state funding many times, and we usually decide that we would pay, but we wouldn’t gain anything in return. I think in this situation, Jay makes a good point. If we can use our hospitalization days more effectively, we might save more than we would spend by paying for the referee, even though we’d be picking up a state responsibility. Could Elaine or somebody talk to that point a little bit more? How much does it save to have the commitments done efficiently?

Mental Health/Developmental Disabilities Director Elaine Sweet: It saves in a number of ways. From a consumer perspective, we’re seeing that… Since this change, we’re seeing that the system is less responsive to the consumers’ needs. We’re also seeing increased costs to the county in commitment-related fees, attorney fees, court costs, we’re seeing more appeals, because the first level of appeal is now the Supreme Court, rather than to the District Court. Commitment-related costs are mandated; they’re not… We don’t have a choice with regard to paying their, those fees. They’re mandated by state laws, so the more those commitment-related fees are, the more costs are incurred. The hospitalization fees, too, in Johnson County, you’ll hear me talk in a few minutes about the budget proposal. In Johnson County, a lot of our commitments go to University Hospitals. We don’t incur the costs to the same degree as a lot of other counties do, but we still have the commitment (inaudible), the cost of the state mental health institutes and the private hospitals where (inaudible) persons are committed. I had my staff pull some information on the, what we’ve been seeing in the last few months. We’ve been receiving attorney fees, one was over $1,000 for one commitment; another was $700. Prior to this change, we were seeing per case fees in the neighborhood of about $200 per commitment. We also have 3 or 4 appeals that are pending to the Supreme Court, and we’re now being assessed fees for those appeals, even if they’re dropped, those registration and filing fees. So the number of costs, both from the human and the consumer perspective and from the financial perspective, are significant.

Harney: Does that first level of appeal change, whether we have a judicial referee or whether it goes through the court system now?

Stein: It does.

Harney: Is that mandated the way it is?

Stein: Yes. If a referee hears the case at the beginning, then it is mandated that your appeal is to the District Court. You can appeal that to the Supreme Court, but that was rare. Now, it is mandated that if the District Court hears it in the first place, then you must go to the Supreme Court with your appeal from that decision.

Harney: I see.

Judge Hibbs: Can I add to that? I’m Judge Hibbs, and I was the presiding judge in Johnson County when we had a week’s notice that this change was going to happen, and so had to come up with a process to follow this. One of the differences that hasn’t been mentioned yet is that we have our court reporters. Anything the District Judge does there is a record of, and while it is what we call a Denoble Review on an Appeal, and it was when it was from the hospitalization referee. In other words, it’s a brand new hearing; you take facts again. Now, we have to have that record, so that it (inaudible) Supreme Court on the first level of the appeal. So, earlier, there would be an appeal of, say from Jay’s decision, it would come to me, perhaps in the District Court. We would have a hearing at the Courthouse; my recorder would be there. The record would be prepared, and if there an appeal, it would go to Supreme Court. Now, there is no intermediate appeal; there’s no appeal to the hospitalization referee. So every appeal, there would be a record, and there is a cost associated with the preparation of that record, the transcript, that has been submitted to the Supreme Court, because they don’t have a factual hearing. They rely on that record, so that may be one of the costs that Ms. Sweet was referring to. It’s different. I’m not certain that the number of appeals is more now; that would be left to people that keep those records, but I know that there is, I think now still pending, 2, to the Supreme Court.

Lehman: Ken Kress, did you have information on that?

Kress: Yes, I wanted to add and clarify something about the costs. Ordinarily, and I say this from experience, because I do defend respondents in these cases, and under Mr. Stein being the judicial hospitalization referee, ordinarily, unless there were exceptional circumstances, the lawyer would not charge more than 3 hours at $50 an hour, or $150 for a case for the referee. If you then appeal to the District Court, you would have essentially the same circumstances; that is, you would have a maximum of 3 hours working on the case at $50 an hour, unless there was some bizarre circumstance in the case that required more work. So, both the initial case and the appeal would be $150. If you go to the District Court, and then you appeal to the Supreme Court, the amount of time that it takes to write a Supreme Court brief is quite a bit more, and could easily be at least $1,000, or $2,000 worth of time, in addition to, obviously, driving down to Des Moines, rather than down the street to do it. But I think in addition to the costs of lawyers that should be taken into account and the cost to the consumers in terms of quality of life, there’s also…if an appeal comes through sooner…because the District Court will take an appeal within 2 to 3 weeks. The Supreme Court might not take it for 6, 9 months. There may be additional time during which the person is under treatment, which is costing the County. But finally, and I think this is something which might be easily missed, of course, is that because the Judicial Court judges are doing these cases rather than other cases, the backlog in terms of other cases is going to be longer. Therefore justice in those cases and all of those costs need to be taken into account, in addition. So I think there’s a lot of hidden costs that one wants to take into account when one thinks about the value of adding the referee, in addition to the kinds of virtues that Mr. Stein talked about, about creativity and the value of having just one person who both the consumers, providers, and lawyers can talk to.

Lehman: OK. Thank you.

Hibbs: One other thing that I wanted to add, just for your information, so that you know. When this came about in November, when I was here, I looked to see what other districts were doing, that were similarly situated, and some of them that were larger. And I did check with Polk County to see how they are handling this now, in the face of no hospitalization referees. We have tried very hard to keep the same schedule that Jay followed, so that 4 days a week, we’re going to the hospital, the VA, or Oakdale, or someplace at the different centers. In Polk County they do hearings 2 days a week, with a possible 3rd day, and they do those at the Courthouse, or County building, so the Sheriff transports the patients there. We opted, on a short-term basis, not to go with that process, and to try and follow what Jay is doing, but I wonder what other districts are doing. Also, Linn County (inaudible) agreement with regard to their hospitalization records. You’re probably already aware of that, but I wanted to share that with you. That just happened very recently.

Thompson: In our packets this morning, we have a sample 28E of the one that Linn County used, and on the back of it is one that I believe was Pottawattamie County. So, other counties have taken this on, and for good reasons. Ann Lahey is the person from the County Attorney’s who often brings these cases. Maybe she would want to say a few words, too.

Assistant County Attorney Anne Lahey: I guess if I was going to address this issue, what I’d say is that we would love to have Jay back in the worst way, because he did a splendid job, and I know would do it again, and I think it, overall, was a little bit of a smoother system working. I think the judges have done a wonderful job under bad circumstances, as Judge Hibbs said, almost a drop notice. Jay was just given the word, and a day or 2 later is basically out of a job he had done extremely well. But, as far as the cost, I think it’s too early to say. In reality, I don’t know that there should be any more, at least in the initial stages, attorney costs, for the hearings. The Supreme Court appeals, we probably did about, because I do them, about 5, at least, a year, anyway. I think there probably will be an increase in those, and as they said, there should be, there probably will be added costs. I think the bill that Ms. Sweet talked about, the $1,000 bill, was actually an appeal that was done while Jay was still doing them, to the Supreme Court, that they had gone through the District Court stage, and that was an attorney who, obviously didn’t overcharge and never does. I think some of them would tend to have higher bills on appeals to the Supreme Court. I don’t know about the increased costs at this point and time. There probably will be some, but I don’t know if we can really say at this point and time. We don’t have…because we have University Hospital here, we don’t have the…don’t have to pay for…we can use state papers for the hospitalizations, so I don’t think those costs are put forth to the county. Unfortunately, we have a lot more commitments here, because we have University Hospitals here. But as far as the costs, I think as far as giving a line item type thing of increased costs, I think it will be anticipated there will be more. Obviously, as Judge Hibbs has said, it comes to the point, and I think there has been some discussion about this…

Hibbs: Yes, I’m not saying that’s going to happen.

Lahey: Right.

Hibbs: I’m just saying that’s the experience in other counties and, obviously, as we’re asked to do more and more, we look at ways that we can try and be efficient and meet the needs of the community in all kinds of ways.

Lahey: You bring the patient to the courthouse; I think that is very unfair to the patient. We do that in cases where there’s no beds at University Hospital and they have to go to the Mental Health Institutes. But it’s more of a necessity type thing, and I just really think that’s terribly unfair to the patient, especially the limited capacity we have at the courthouse, because in a sense, they are somehow not purposely, but obviously, it’s a public building, and they’re seen, unfortunately, by people, when these are supposed to be, pretty much private matters. I think, if it came to that, I would certainly be in favor of the county funding it, but I have concerns too, as much as I want Jay back in the very worst way, is that the County is going to get stuck. I think the reality is that they probably…this is a short…or, I mean I think if this would be a short-term measure, it would be great, but I think it’s unlikely that the state may pick it up back in the future, especially if the counties take it. The other, I think, consideration, is that Jay only does them during the daytimes. He certainly more than earned his salary; in fact, I was surprised that, at what he…when it was went public with this, I mean it was public before, but I wasn’t aware of what he made, and I was…thought, gee, he doesn’t make that much for all he does, because obviously I would be in a position to know, probably more than anyone, what he does, to a certain extent. But, there’s also emergency hearings that are (inaudible) or a judge, the judges have been picking up those, along with magistrates, resident Johnson County judges have been going out to the hospitals at all hours of the night. Anything after the courthouse is closed is considered an emergency, if a person needs to be put under a…what’s called a 48-hour hold. So they’ve been picking them up. In the past, the system was, that Jay would have backup referees appointed, I think Tim Grady did the majority of them, and also if Jay had a conflict, which didn’t happen very often, with one during the daytime, or was gone out of town, or something. And so there would be added costs for those if the system was put back in place. I just wanted you to be aware of that, that we’re probably talking about more than $8000 to get back to the status quo that we had it before.

Thompson: Well…

Lahey: But it was an extremely good system.

Thompson: If a person is committed to the Mental Health Institute, that’s $450 a day, and then they appeal. Do they have to stay at the Institute until their appeal is heard?

Lahey: No.

Stein: If they were put under inpatient commitment the appeal doesn’t necessarily put off treatment. They may be required to stay at the hospital while they’re on appeal.

Thompson: So if the appeal takes longer, we would have to pay for more days.

Stein: Well, that’s true, but at least when I was doing it, the hospital was not holding on to people just because an appeal had been filed. They might say you’ve recovered enough to go on out-patient treatment, or something like that.

Lahey: I was just going to say, once in a great while, an attorney would get what is called a stay order from the District Court, when the District Court was doing the appeals. Now, I imagine it would be harder to get a stay order from the Supreme Court where they were able to stay treatment, where the order says do not treat this individual pending the appeal. In that case, it’s very unlikely that the person would improve and would be in the hospital longer, if that happened, although in reality it might be more difficult to get stay orders from the Supreme Court. Obviously, that usually isn’t in the patient’s best interest, but if they’re obviously pushing it, and the attorney is feeling they have to ask the court for it, that could hold it.

Thompson: The Mental Health Institute is probably the mental health service that we offer, so Jay’s comment about shaving off days, if he can shave a few days off… In fact, it would only take 71 days shaved off to pay the amount that we pay the referee for a whole year.

Stutsman: But commitments to University Hospital, too, is possible, through State papers? They all….

Thompson: No, some people get State papers and to U Hospitals, so we don’t have a cost for those.

Stutsman: Right.

Thompson: It would be the mental health cost that, if we could cut those, we’d save money.

Sweet: May I? A lot of our commitments are made to University Hospitals that University Hospitals the transfers to others. They don’t stay there for a long time. The State papers are for those initial dates only. Another clarification is that the State does pick up part of the rate for State hospitals, so we don’t pay a full $400 a day there. It’s approximately half that we pay.

Stutsman: Where will the money come from for this, for these commitments? Does it come out of your budget, Elaine?

Lahey: The commitment-related costs come out of my budget.

Stutsman: OK.

Sweet: The court costs,

Thompson: But if we paid this, we wouldn’t pay this out of the Mental Health budget, I don’t think, would we?

Stutsman: Why wouldn’t we?

Lehman: It’s come out of…

White: I don’t know where you would get it.

Thompson: Well, I don’t see (inaudible).

Stutsman: Yes. I was going to say, to me it’s a service for persons with disabilities. I would say it does come out of Elaine’s budget.

Sweet: I believe this is being discussed at the State level, because the intent of Senate File 69 was for all mental health costs to be paid out of the mental health budget. And I think there’s a lot of discussion on the State level, because every county is having these same discussions regarding the referees.

Thompson: There’s nothing in these 28E agreements samples that addresses that.

Stutsman: How many of these commitments do we have a year in Johnson County, on the average?

Lahey: A lot. About 300 and some, I think.

Stutsman: Oh, my.

Stein: More than 300, I think.

Lahey: Yes, probably more than that, yes.

Hibbs: We do about, what, about 8-10 hearings a week. That would be the hearings during the daytime. It varies from week to week; some are less and some are more than 8-10, but that’s, I think, when they figured it out, I asked for some numbers, and that’s what…

Higgins: Could I point out a couple differences I’ve noticed? Jay always ruled right after the hearings. He made his decision right away, and some of the judges are doing the same and some are not. Judge Hibbs makes a decision right away. When the decision isn’t made for a day or 2, when I’m meeting with the patient, I don’t know if they’re under commitment or not; I don’t know if I’m appointed or not, so it makes it difficult for me to explain their status. When a decision isn’t made right away, the hospital is calling Patty Covington, the mental health clerk, right away, and myself, because they’re uncertain about the status of the patient. Jay also explained his decisions to the patient, which was very helpful to them in understanding why he made it. So that’s one difference. Another is, because of our longevity I guess, Jay and I got real good at reading doctors’ writing and recommendations, which isn’t always…

Dr. Chris Okiishi: We try very hard.

Higgins: I think your writing is good, but a Judge couldn’t read a doctor’s recommendation and misread it, and terminated a commitment on one of my patients, one of my very few who happens to be dangerous. I caught it, brought it to the court’s attention, and that order was set aside. But if I wouldn’t have been at the right place at the right time, I don’t know if that could have happened. And the patient receives an order for termination of the proceedings also. Jay is just so familiar with all the cases, and so when he reads reports, he knows what questions to ask, or he knows what they might be recommending for that particular patient. Another point is, we have less continuity. After hearings, I would many times bombard Jay with information about individual patients, and maybe someone was getting ill, and I would say what I was doing to seek them out, or that there might be a pickup order for re-hospitalization. Now, with a different judge every week, or sometimes every day, I might prepare that person, but they probably aren’t going to be presiding when a request comes from someone, and then they don’t have the background information. So, that’s some of the differences I’ve noticed. The judges are doing a very good job; it’s just, they’re not familiar with these proceedings, and they don’t know these patients and these cases. I’d like to call on the doctors I’ve asked to make a comment. Is that all right?

Lehman: Yes, please.

Higgins: I’m sorry, did you have any questions for me? Thank you.

Okiishi: Thank you very much.

Lehman: Ken Kress, maybe you’d like to…I see you had your hand up; maybe you want to clarify…

Kress: I just wanted to make a comment on one of the things that Ms. Higgins was saying, which is, if the decision is made immediately, and the patient had been up ‘til then refusing to undergo treatment, as soon as the individual’s committed, under the code, the hospital or the facility in question, the doctors have the right to require them to take treatment, and they get better sooner. If we wait a couple more days and we’ve an individual who’s refusing treatment: A, they could be getting worse, and it’s a longer time before they start treatment, and as they get worse, of course, it’s going to take longer to bring them back to the status they would be in. So it is very important to have a decision made as soon as possible, which is why the code says that the hearing should be 5 business days from the application. The other thing is that, I think it is very important to have someone explain the grounds of the decision to the respondent, the potential patient, as Jay Stein did on many occasions. I hope you’ll forgive me that on occasion I would say to my client that I disagree with the court’s decision, and I think that we could win on appeal. And, to my amazement, quite frequently they said, I feel I got a fair hearing; I’ll stay in the hospital. I think that the way in which Mr. Stein conducted the hearing, showing great respect for the patients, and explaining to them why it is that he found that they needed to stay in the hospital, and the grounds of his decision, were a major part of this. There’s a lot of empirical research showing that if people feel they’ve gotten due process, they feel a lot more comfortable with an experience in court than other ones.

Lehman: OK. Could I ask for a clarification here? If we were to sign an agreement, here, it’s for the position and not necessarily for the individual, Jay Stein. We’re always cautioned against funding a position and not necessarily an individual, although in this case, we assumed Mr. Stein would probably be the appointee, at least for the short term that we would fund, the remainder of the year here.

Stein: I would like to say that everything that people have brought up, I don’t think it’s that I was given a better education to do it better than anybody else. I think that all of the benefits that have been discussed today would happen no matter who had the position.

Lehman: OK.

Stein: The long-term knowledge, and that sort of thing, and the continuity, I think those are more important than the fact that I was doing it or any individual that would be doing it.

Lehman: I just wanted to clarify that we’d be approving payment for a position, not necessarily Mr. Stein, although we would hope…

Stein: That’s exactly right.

Lehman: I guess my feeling would…

Stein: That’s exactly right. That’s exactly right.

Thompson: The model 28E agreement states that we’d be reimbursing the state for the costs of having this, and they would appoint the person.

Lehman: Yes. So, I mean, there’s a possibility that things wouldn’t be status quo. OK. Do we have some of the doctors that wish to, maybe, yes, do a little clarification here, on their end, and perspective? If you’d like to introduce yourself, please, as the Auditors…

Okiishi: Thank you. I’m Chris Okiishi.

Dr. Julie Phillips: Hi, I’m Julie Phillips.

Okiishi: We’re both residents in the psychiatry program, so we are the doctors that are called upon to testify and present at the vast majority of these cases, and we’ve come to know Mr. Stein very well, and the other judicial hospital referees, both in our county and then from counties around the state, and have seen how counties work that have judicial hospital referees versus counties that have magistrates that are doing this. I think it’s an enormous service to the residents of Johnson County, and then those individuals that are spending time with us in Johnson County, to have a judicial hospital referee in place for their care, for the simplification of maintaining their rights, and also for maintaining the ability to provide care and keep our community safe. Things that we have seen in the absence of a judicial hospital referee are: individuals trying very hard to provide the same service, but not being familiar with the mental health system, not being familiar with mental health diagnoses, not being familiar with testing, and then other types of things that are requiring lengthier commitment hearings, lengthier time for individuals to get the care that they need, and quite frankly on many times some misunderstandings about what is required for individuals and could be in the best interest, or the types of things that can be offered. We are quite alarmed at proceeding; it’s thrown our system into disarray. The idea of us going down to the Courthouse and being present there, then would take several hours out of our day from the hospital in caring for the individuals, which will lengthen hospital stay. There’s no way around that, and incur more costs both to the individuals from this county and from other counties, as well as to the hospital. It is a wonderful thing that they have continued to come to the hospital and work with us, and be able to do that. We would be much in favor of this program continuing.

Phillips: I’d support Chris in everything that he said. I think it’s important, once again, for the patient to be considered here. If they have to go down to the Courthouse, like what was brought up with Judge Hibbs, it would be breaking confidentiality. These are not open hearings, people would know if they’re walking in with the Sheriff, what they’re there for. There’s a potential for that, which would be a detriment to the patient. As well, if we ever had questions… When I was an inpatient resident, it was very easy to call up Jay Stein or Tim Grady or the other judicial referees and ask, what would you recommend in this situation? Is this something that we need to look at transferring outpatient commitment to inpatient commitment? We would be able to get a hold of them very quickly without incurring really any further court cost. We wouldn’t have to approach the Clerk of Courts, and then go through that process to find out what to do in certain patient situations that we could pass off onto them.

Okiishi: The other issue is the after-hours care that was mentioned. That is pretty crucial to us. If you imagine, you have someone who is having an acute mental breakdown in the emergency room, and how important it is that we get expedited responses from the court. It’s taking up to 3 to 4 hours now for a magistrate to be found and brought in, when Tim or, at times, Jay, would arrive in 25 minutes. It is clogging up the emergency room; it is resulting in, and it will result in a loss of life at some point, in that these individuals cannot be treated unless it seems to be an emergency situation. People are escaping; people are causing problems and difficulties for themselves in ways that were not, before.

Phillips: The only way we can secure patients if they are an acute threat to themselves or others in the emergency room is through the use of physical restraints, and/or chemical restraints, which may be avoided if we were able to get them to the floor in a much more timely fashion.

Lehman: OK. Questions or clarification? That kind of helps explain what the clinical part is. I guess I had a question, maybe, for Elaine. Does legal settlement enter in, is that a factor in this issue?

Sweet: It would be if it weren’t paid from the MH/DD budget. Then you could (inaudible).

Thompson: Now, I’m doing this as a court cost, not as a treatment cost. Isn’t that why it was under the court to begin with?

White: Yes.

Thompson: So, if we had to pay it, it would be out of one of our court funds.

White: As I said before, I don’t know where you’d pay it from, and I don’t claim to know Elaine’s budget well enough to know whether there’s room there, even if you decided to do it.

Stutsman: I agree with Elaine. My understanding on Senate File 69 was any cost related to mental health, regardless of…

Thompson: Treatment.

Stutsman: No. Any cost related to mental health, services treatment, whatever was out of that budget. Because I think the Legislature, when they proposed Senate File 69, didn’t want counties saying, OK, we’ll put that in the Mental Health budget, but actually we’re going to fund this here, and this there, and, actually, the capital had no bearing.

Thompson: Well, why did the state fund this to begin with, then?

Sweet: Yes.

Stutsman: I don’t know. I don’t know…

Sweet: I think that was the intent of Senate File 69. In practice, though, I think there are some exceptions, and this may well be one of them.

Stutsman: I don’t think they caught it before, to be perfectly honest. They never thought about it…

Thompson: If we put it on for a vote next week, we’d have time to research that.

Lehman: Yes.

Stutsman: Yes. And I guess I’d like to know what other counties are doing, too. I would like to make some calls to see how the counties are handling this.

Lehman: We’ve got 2 problems. One is short-term, for the rest of this year, and then we, next year, re-addressing it with an agreement. Am I correct?

Thompson: Yes.

Stutsman: Yes.

Thompson: And I noticed this 28E specifies that it ends on June 30th.

Lehman: Yes. So, do we have consensus from the Board to put this back on next week for some action?

Stutsman: Yes.

Lehman: Maybe have some more information on the questions we’ve brought up today as far as legal settlement.

Neuzil: If nothing is done by Johnson County, because obviously, the state has found that this isn’t as important to them, what happens?

Okiishi: I just have to say that Johnson County is an unusual place, in that this is where the University of Iowa is. That’s why we have so many commitments that come through here, is because this is where the hospital is. People from other parts of the state relocate to Johnson County because of the availability of mental health services in Johnson County. So, I think it is in the interests of Johnson County to continue this program because of our high number of commitment cases.

Neuzil: Oh, I think it’s very important.

Okiishi: Yes.

Neuzil: Again, what happens if we don’t?

Lahey: It just continues as it is, with the judges.

Neuzil: OK. Thank you.

Stutsman: The services is being provided, it’s just not as efficient as it was before.

Neuzil: Right. OK.

Lehman: Yes.

Okiishi: Which means people suffer.

Lehman: OK.

White: I want to put just a bit of a context on this, in terms of budget policy. I don’t disagree with anything I’ve heard anybody say this morning. When this was announced, I described it as horrific. As it’s carried out, I don’t think it’s been horrific; it’s been problematic, and it would be better to go back to the old system. But I think there’s some very significant state/county policy considerations here that really haven’t been touched on much this morning. My understanding of why this has come about is that either there was a huge miscommunication between the judicial branch and the legislature, or a breakdown in management somewhere at the state level in the judicial branch. This has been characterized as needed because they didn’t have adequate funds for health insurance for judicial branch employees. You well know, you’ve been trying to manage major increases in health insurance, and foresight and budget planning does that. It didn’t occur, here. Whether it was the fault of the legislature, or the administration, or the Supreme Court, I don’t claim to know. But faced with that, then, the Iowa Supreme Court judicial branch made a decision that mentally ill people were not a priority for them. That’s where they chose to cut, and I think that was a misguided judgement on their part. But they made it. I think, for example, it is unconscionable, and that’s the word I’ve used, and so I don’t apologize for or regret using it today, that is part of the reaction to this judicial branch budget problem. They decided to lock the doors of the Clerk’s Office in the middle of the afternoon. That would not happen if the Clerk’s Office were still a county office, as it used to be. That just isn’t the way we treat people or do business. But that reflects the budget and policy analysis that’s been made by the judicial branch in response to this budgetary problem. I think this is a very slippery slope. There is no doubt whatsoever the system would work better if the referee were back in place, better, more accurately, quicker, although all of the comments about delayed decisions and contact actually may be more criticism of judges than it is the absence of the referee. There’s no reason that people handling these can’t be as available or responsive or prompt in decision-making as Mr. Stein was. Maybe one of the things that needs to be done is, where that’s problematic for judges, somebody needs to go to them and make the same sort of pitch that was made today, about how that’s being problematic. I’d even feel a little differently if we knew the state funding was coming back on July 1st, but we don’t. At this point, I just think it would be a mistake. I know how tight your budget is. You know what you’ve cut out. You postponed delivering Sheriff’s deputies to the Jail because you didn’t have money in this budget cycle to do it. You’ve postponed doing lots of things. We just had a discussion about pressing County space needs and the absence of money to do it. It’s a modest amount, but for the county to start picking up judicial branch costs, where there’s been a miscommunication or mismanagement or poor planning, I just think would be a mistake, notwithstanding that it would be a short-term gain in terms of service delivery. Sally is absolutely right. Legislators in Des Moines are telling us, our reserves are too big, they need to be cut back, that counties across the state are not capable of making budget decisions, so we need to impose more limitations. Now, they haven’t done it yet, but it’s going to be a very close vote in the next couple of weeks, to restrict your budget authority even more.

Stutsman: I agree with what Pat says, and I fully recognize that the system worked beautifully before with the court referee. I just know, come the 1st of July, they’ll say, see, counties picked it up. We knew they could do it, they would find it somewhere, not to worry about it any more, that they recognized the system needed to continue to be funded the way, or to continue to be work the way it did. And so, we will fund this forever. I just have that…

White: It risks feeding in to those legislators who think we have too much money sitting around.

Stutsman: And unfortunately, it’s the, our clients that get caught in the middle, and that’s what is so repulsive to me, that we’re faced with these budget decisions, and there’s the client.

Lehman: Bob Welsh, you have some input?

Welsh: 2 factors. One is, Sally was just saying this, I would hope you would make this decision not just on, OK, whose responsibility is it, and is this again being just the state dumping something down on the County, but take into account the persons at this point. But I heard, and I might have been wrong, is I think I heard Elaine saying, this is what I think, the point that Carol was making, is that this position would basically pay for itself and be a cheaper way, and so, I guess the person I would have you ask is Elaine, is this an expenditure that can fit within the mental health budget? And if so, it seems to me like that’s a win situation.

Stutsman: But the problem is, is that that budget is just getting more and more tight every single year. And sure, it’s cost effective, but the best solution is for the State to continue to pay for this, so we don’t have to tap already tight dollars to pay for another service that the State should be paying for. We had information from the Governor’s office, from ISAC, saying that we’re not going to get as many State dollars to put into our mental health budget. That’s one of the places that they’re going to cut. So not only are we getting reduced funding from the State that they agreed to, that they were going to put more State dollars into our mental health budgets, but now they’re asking us to pay for more services out of a budget that’s being reduced. It’s really distressing.

Welsh: Is this the most cost-effective way…

Stutsman: The most cost-effective way is for the State to continue to fund it.

Welsh: Well, within, for Johnson County, I guess, that’s why I think you’d want to check that out with Elaine at that point.

Sweet: I don’t believe that’s an easy yes or no answer. As Pam indicated, it’s too early to really put some firm numbers to it, to say definitely one way or the other. No, there’s not room in the MH/DD Services Budget for that. We’re projecting overspending this year, and the next agenda item talks about the proposed cuts for next year. So no, the money is not just there waiting to be used.

Stutsman: The problem is, is that sooner or later with our budget, we’re going to have make decisions about people not getting funding, because the budget is capped and so we fund this unfortunately at the expense of something else. That goes into my decision making process with this too. Trying to meet everybody’s needs and not at the expense of one population over another.

Thompson: I think that the potential for some cost savings is probably there and it might meet or exceed the amount to do this. To me the compelling factor is the benefit to consumers. I think the point at which a person is being committed is extremely stressful. The way that’s handled kind of points the way the future treatment is going to go, what their future well-being is going to be. I think some things you just do because they’re right and this would be one of those things for me.

Kress: I would like with all do respect to reduce the imprint that Sally wanted to make. If we fund it then the State will say the counties can do it and we don’t have to fund it. Obviously the question isn’t just what we do but what all of the other 99 counties do. Unless we’re certain that all of the other counties will follow suit or a great majority. It might be that there’s just 10 funding it and so the State thinks there is a small number we need to go ahead and do it. There’s certainly not going to come back saying we’re going to fund those counties that are doing it already. We’re either going to fund all or none. If we’re pretty certain I think your guess is right that they won’t fund it next year because the budget crunch is going to be even worse. Then I think the question really comes is it worth it to the County to do it given what the cost will be, what the savings might be, what the value will be to the consumers and the like. Also I wanted to make a point relevant to Pat White’s comment that the district court judges could be as efficient as a single person doing it. I don’t think that’s the case. They could certainly make the decisions right at the time and they could certainly respond to questions by people who are already committed though they might not have worked on that case so they have to look at the file and get some information. But a problem might also arise is sometimes an attorney or a doctor wants to talk to the judge in advance of the hearing. As I understand it frequently the judges are being picked the day before or the day of a hearing. I had an experience with Judge Hibbs, in which I called and wanted to find out who the judge would be who would be hearing a case that I had a question about and it had not yet been determined.

White: But Ken that too is a question of administration and priority setting. It doesn’t have to be that way.

Hibbs: But a trial is still going you can’t assign somebody if they’re still in trial and we don’t control the length of trials. Attorney’s and the doctors can’t just get right to these judges when they need to like they used to be able to do with Jay.

White: There’s no administrative reason, whether it’s the best way I don’t claim to know but there’s no administrative reason why someone can’t be designated to stick with this for 2 or 3 months and their schedule managed that keeps them more available. Ken there aren’t referees in every county. I don’t know how many there are.

Lehman: What’s the feeling of the Board here? We want to put this on. Legal settlement is the question I would like to know.

Harney: One of my comments would be the judicial referee I’ve seen it in the past first had. Jay did it wonderful in the past whether it be him or someone else. It was kind of expeditious to be able to move through the process going through him. However you are looking at the mental patients needing help and you are looking at due process… I’m really wresting with this because we have a process now where taxation is such an issue. People are taxed to the hilt. The State is turning their backs on it in many places. They’re cutting teachers. That’s dumping it back on the counties. That’s 8,000 this next quarter and 32,000 next year. It just keeps adding up. I’m not sure where we’re going to get the money if it falls under Mental Health. They’re already at a restraint now for dollars. The people who need all of this help, I just don’t’ know where we stop the tax dollars.

Lehman: Well I think its interesting this morning we approved 8,300 for calcium chloride on 2 miles of road, and here we are talking about the same dollar amount for quite a different issue but we’re still talking about safety. If you had them both laying there side by side which would you choose. You go through the budget and prioritize. The difficulty we have is when issues come to up week by week by week.

Harney: I don’t think there’s much question which choice we would’ve made.

Thompson: You can’t really spend…

Stutsman: That’s what the legislature did. They made sure we wouldn’t have to make those kinds of decisions. Roads in a separate budget versus mental health.

Thompson: So this will be on next week?

Lehman: Yes. Does the audience have direction of questions clarification of legal settlement was the one I wanted to know. I don’t know if there is anything else people wanted to have before they made a decision.

Neuzil: Well anytime obviously our e-mails are open, letters calls all of those kinds of things.

Lehman: We’ll put this back on the agenda if you want to attend next week.

Harney: I guess I do have one other question. I’m not sure who its appropriate to answer. It was mentioned that people are gravitating towards Johnson County for those services because of the hospital. Are they being claimed as residents of Johnson County? Are we able to bill that back to the other counties?

Lehman: That’s the question of legal settlement I was wondering about.

Thompson: In the past when the cost was paid by the state they didn’t care where they had legal settlement. But if we have to pay for it we would care. We would have to find a way to work that out.

Lahey: I think in answer to Pat’s question, initially you can although there is sometimes juxtaposition about who is the county of legal settlement. I think what happens unfortunately if your trying to fund Johnson County is that because they come here and they like it, there’s more services, they’re told about the services, there’s the psychiatric outpatient clinic, there’s obviously much more for them in Johnson County. There’s the emergency housing, there’s everything. They tend to stay here. I think you pick up more people that way.

Stutsman: I think too because of the University being here a lot of people come here with the intention of going to school and suffer some mental issues and then they are a Johnson County resident.

Lahey: We get a lot of out of state commitments too. Because VA is Illinois and Missouri. We’ve gotten a lot of Nebraska lately at the VA. We have quite a few especially at the University from Illinois show up there.

Stutsman: As they close more of these VA hospitals we will get more of those people coming here to this VA.

Okiishi: So we’ll just have to do a worse job with mental health.

Stutsman: Well no there I go back to the State needs to say this is not a Johnson County issue. I have no problem with these people moving here. It’s just that where are the dollars going to come from to make sure these people have the services that they need.

Lehman: Do we have direction to put this on for possible action next week?

Stutsman: Yes.

Lehman: Thank you everyone for participating.

(Continued in Part 4)