 Good morning. This is the Vermont House Human Services Committee and it is Wednesday, March 17th. And this morning's first half of this morning's meeting, we are talking with alcohol and substance use disorder the arm of the Vermont Department of Health, as they share with us. Their request for information as it relates to redesigning their proposal, which we're now just hearing about their proposal to redesign service delivery. And that will be the first part of our morning we're also going to hear some testimony from providers. Welcome everyone and welcome Kelly and Cynthia and I'm not sure how the two of you want to do this is this do you both want to be. I'll leave it to you. Okay. I do know that, given us a very there is a PowerPoint on or slides on our committee webpage that I guess you're going to share some of us, some of it with us and I, we've had a back and forth that you wanted to let us know what is current. That's appreciative, but we have lots of testimony. So that's brief, because we want to know is so we can give you input as to our reactions to your, what you are hoping to do with you. Okay, thank you. Great. Hi, my name is Kelly Docherty and I'm deputy commissioner at the Department of Health, and one of the areas that I work with his eight up and I think that correct I did put together pretty comprehensive slides, just recognizing that I know that there are some new members on the board who may not be as familiar with the eight up system of care. I'm not going to go through all of those slides comprehensively but a lot of them were just there for your reference. But I think just sort of level set level setting sort of what the system is now would be good groundwork for talking about the system redesign. So I'll go ahead and share my screen. And I'll see that. Yep. And I just need to I'm going to stop my video for a minute, and I'm going to pause my sharing because I need to get it to the presenter view so bear with me for one moment. Having a technical issue there with me for a second. That's okay, we all have them. Can you still hear me. I can't see you all now that I'm sharing now that I'm now that I'm doing this so if you you may be doing it but we don't see it. Yep, here we go. All right, now you're saying it. Now we see it. Great. Okay. So like I said, I'm just going to give a brief overview of the division of alcohol and drug abuse programs at the Department of Health. You can see. I won't read this for you but our mission and principles basically to prevent and eliminate the problems caused by substance misuse. So we work with a wide variety of organizations and we recognize that substance use disorder is a brain disease and requires a public health approach. And I'll leave that there for now. This is just the structure of our work so you know the division is a part of the Department of Health it wasn't always that way. Years ago it used to be its own entity but we are now recognizing that this requires a public health approach ADAP is part of the health department. You can see our structure here we have a budget of about 55 million in the ADAP division alone and we give out over 300 grants a year to various community partners across the state. We have a pretty broad and deep infrastructure with a lot of expertise in the science of prevention treatment and recovery. And in addition to this well it's mentioned here we have prevention consultants in all 12 AHS districts across the state. We have local boots on the ground through our health department district offices doing the work of prevention in communities and working with partners. Not going to read this to you but this is just sort of the various categories of work that we do we fund which we're going to be talking about a lot the treatment system prevention intervention services recovery. We work with partners on enforcement and regulation and we look at policy and procedure development and do a lot of professional development and education for substance use professionals in the field. This I just wanted to illustrate just sort of that this work doesn't happen in a silo with ADAP we actually partner with other departments within the agency of human services, as well as other state departments and agencies. The agency is a comprehensive system that that we work within and partner a lot with our fellow state government partners. Just for some context, you may already know this but alcohol is the most commonly used substance by Vermonters H 12 plus and actually our numbers in Vermont are not that great. And you can see alcohol, we've got tobacco past month which has steadily declined over the years and marijuana which we're seeing creep back up, which is a concern fewer than 5% compared to the 60% of alcohol fewer than 5% of Vermonters used cocaine or opioids in the last year. So for very good reasons we talk a lot about the opioid crisis and, you know, it is something that needs to be addressed and continue to be focused on but I just wanted to give you this context that it really is a minority of the substances that we are that folks are using. So let's just illustrate sort of the, the full spectrum of work that ADAP does in collaboration with its community partners and providers, we do a lot of health promotion and prevention, and again intervention treatment and recovery. I wanted to talk a little bit about our prevention work. So we work to change people's knowledge attitudes and beliefs that impact substance use. And one of the takeaways for this slide is that if you take nothing else away is that there is no one strategy approach for all individuals or communities to prevention. We really need to take a very community centric approach because what would work in one community may not work in another and each community has its own sort of assets and resources to work with so we can't really have a blanket approach to prevention. And prevention programs can save a lot of money, as well as a lot of health consequences of substance use. This is our Vermont prevention model which you may have seen which is basically the socio ecological model where whenever you're talking about prevention. It's really important to work across all levels of this model, because just focusing on individual behaviors or individual not knowledge attitudes and beliefs is not going to change the culture that supports substance use so an example I always like to give is in the tobacco world. Some years ago we made it unacceptable and illegal to use tobacco in public places so we worked at the organization level and the community level and then we worked at the policy level to increase taxes and do other things that actually help to drive our tobacco rates down tobacco use rates. This is basically the SAMHSA PDSA cycle that they use for for development of prevention programming. So we use this in our work. And it comes from SAMHSA which is the substance abuse and mental health services administration and I apologize my cat is knocking things off my desk. So we had like I mentioned our prevention consultants that are in all of our district offices that work in their communities that we also do some work with school based prevention grantees. This is at the supervisory union level and not even all schools and the supervisory unions that we fund participate. And you can see there's a lot of gap here and you know that the reason is is that this is grant funded largely federal. We've seen a decrease and it's not really secure funding from year to year. And then this is our regional prevention partnership grantees, and we used to have seven, but our funding went down from 2 million to 1 million so we've been, we haven't been able to fund as many prevention partnership grants as we had in the past. And these are just some of our prevention campaigns we do a lot of messaging as I'm sure you're aware at the health department. The, a lot of these are very targeted messaging so these ones on the right. So you may not have ever encountered these messages because you're not the target audience so they are very targeted toward people in specific populations. So, a lot of digital campaigning that will target people who may be a greatest risk. I'm sure you're aware we have the fairly new substance misuse prevention oversight and advisory council that was formed in 2019. It started meeting in October of 2019 and is really replaced the opioid coordination council. It replaced the Vermont alcohol and drug abuse council and it replaced the evaluation review board to really have a consolidated focus on prevention that was not substance specific. So, so this council provides advice to to you all and to the administration on policies and programming to ensure that prevention is included in policy. And go through this really quickly so another focus of our work is intervention and harm reduction. So this is sort of like secondary prevention. You know we talked about primary prevention in the last section, these are services and programs that help people who may be struggling with substance use, and, you know, can help lower their risk, or intervene to, you know, maybe increase substance use so one you might be familiar with is IDRP it used to be called project crash. This is the impaired driver rehabilitation program that ADAP has run for years although now we have a newer curriculum. And this is something that we expect to have an increased focus on with the marijuana, you know, marijuana market coming and, you know, sort of preventing and intervening in impaired driving. These are some of our intervention services across the state and harm reduction services we work with our syringe services programs across the state. And there are a lot of alliances that have some of them really sprung into action as a result of the opioid crisis but have continued to work in their communities and broaden their scope. And these are some of our messaging and materials around harm reduction and reducing stigma. So really trying to get the word out about naloxone. You know, some safety messages, and, and our Vermont help link which I'll talk about briefly in a moment. This is a really exciting process progress project, the rapid access to MAT. So, this is now in every county, it started in Washington County, and what it does is it connects people. It connects these systems to enable us to provide MAT to people much more quickly than had been in the past. So some emergency departments when people come in and are either come in because of an overdose or come in and you know disclose that they are using opioids. Some hospitals can induct them on to buprenorphine right then and there and then make the connection to their local hub to continue services. Some emergency departments work directly with their local hubs to get medication to people quickly so our goal is really we say three days or less our goal is 24 hours and in many cases that can happen from first point of contact to first medication dose. Really making those connections so that we can break down barriers, connecting people to recovery supports in the emergency department as well as a big piece of that to start building up somebody's support system. And then Vermont Helplink was launched almost a year ago right around this time last year, which is a support center at the phone number and a website where people can get information resources and get connected to services related to substance use. You can see we launched in March of 2020. We saw a little spike in April, May. This is the phone calls and then these are our website visits which have really skyrocketed we know that people are struggling right now with COVID and substance use. And again, alcohol is the primary substance of concern for people contacting Vermont Helplink. And we also partnered with DMH to we're getting mental health resources available through Vermont Helplink for people who work in healthcare, recognizing that those folks have really been had a lot of challenges over this last year with COVID. Finally, treatment. I think this is where, you know, folks are most probably interested right now. So, ADAP has a preferred provider treatment system that has 25 providers and over 30 locations statewide. And this is just sort of a snapshot of what's there. These are our preferred providers. So this is our preferred provider network. So we have all kinds of providers we have nonprofits and for profits. They're all paid the same through ADAP and held to the same standards. So we certify these providers. They have certain treatment standards they have to meet. And as distinguished from DMH, like we have a wider array of providers. So we don't, in the ADAP world, you can see that most of our providers are not designated agencies and we have eight designated agencies that are part of our network. And one thing of note with the substance use treatment system is that there are no catchment areas. So unlike DMH, so as a consumer, I can go anywhere to get substance use care. I don't have to go to the provider that's closest to me. I can see anyone that I want in the system. And these providers because they're certified by ADAP and they are held to our treatment standards, we have an enhanced Medicaid reimbursement rate that they that they're eligible for. So obviously this isn't all of the substance use services available in Vermont. There are private practitioners and those kinds of things, but this is our ADAP network. So a little bit about our certification rule and sort of what that process looks like. And most people, there are many people who don't seek treatment for substance use disorder, mostly because they don't feel like they need it. I wanted to highlight this just because it's more than just making services available in the community. We have to do a lot of work to sort of highlight the benefits of treatment that treatment is effective and it works. Because we, so it's more than just making sure the services are in communities, we really need to promote them and and encourage people to seek treatment if they need it. So the preferred provider system has become obviously again for good reason very focused on opioid use disorder. So most people seeking treatment, even though we know alcohol is a much bigger problem in terms of the number of people who use it. Most people who enter treatment are seeking it for heroin or other opioid, other opioids. And then this just illustrates the growth in our hub and spoke system. So it's grown every year since 2012. And, you know, we're serving more and more people. And with COVID treatment providers really turned to telemedicine and telephone for outpatient services you can see last year in January and February it was 0% of non hub services provided to Medicaid through telemedicine and it just shot up with COVID, which is great that they were able to transition to make those services available. And then very quickly recovery so we work with the 12 recovery centers across the state we provide them with financial support and technical support. And they're all independent. They're their own independent 501 C3 organizations. So, but there is a recovery network that, you know, helps provide support to, to these organizations so we work closely with them. And these are just some of the services that are available at recovery centers. We provide a wide array of services that are available. And you can see in 2020, again, lots of remote recovery services which can be really challenging for people because it's all about that personal connection. But the recovery centers were able to pretty quickly with COVID switch to remote services. Here's where we're going to talk about the system of care redesign that's one of our new initiatives. Some other things that we've been working on is co locating MAT and syringe service programs so you're I'm sure you're aware of the Howard centers program safe recovery and in Burlington where they are syringe service program but they also have a prescriber so they can connect people right then and there with treatment. We are working with other syringe services providers in the state to be able to offer that same model and other places. We are actively working on overdose prevention and harm reduction campaigns, particularly in light of increased overdoses during COVID. We've been giving out specialty community action grants to address overdose prevention, and we continue our workforce development work. I think everybody has the most interest I hope that I hope that you could understand me I feel like I'm talking really quickly but I wanted to just lay that groundwork does anyone have any questions before I move into the system of care redesign section. Okay, my question when you go through your slides is to start with the, why, what is what is what is the purpose of the RFI. And who, who did you get input from, in terms of the system of care redesign, and where was legislative direction. Yeah, so you, Madam chair have read my mind because my first slide is why are we doing this. So the, the system of care redesign there were a couple of different avenues through which this became something that we wanted to pursue one is that really the system of care for substance use, other than the addition of hubs, you know, the hub and spoke system for opioids. There really hasn't been any change in the delivery of care over the last 30 years. And there's inconsistent access across the state and inconsistent quality of care across the state. And there's also workforce instability so it's really hard for providers to recruit and retain staff. So some of this work started under the opioid coordination council, there was a lot of work done through the OCC, where they examined the system of care, talked with stakeholders and identified sort of what the strengths of our current system was, where the gaps were, especially with respect to transitions of care. We often lose people when they move from, you know, one level of care to another and it was identified that there really needed to be a stronger coordination of care for people in SUD treatment. Some folks have multiple case managers. The system is not necessarily easy to navigate. People weren't, we heard loud and clear that people didn't know when it when they wanted to seek treatment for themselves or loved one, they weren't even they didn't know where to go. And it's not an easy system to navigate and again it was set up many years ago pre opioid crisis. And the hub and spoke system despite its success has really fragmented the system in some way. So, you know, we've got that system sort of overlaid over this other system. So, so we really want to focus on better coordination of care, better transition of care. So, the goals of this effort. This is where we'd like to end we don't know how we're going to get there yet. That's the purpose of the RFI. But we want all Vermonters to have equal access to a core set of evidence based services. We want one treatment system that is agnostic of substance. So in other words, you know, we have the whole hub and spoke system that is really focused on opioids but there isn't really a system that's designed to cover all substances. We have enhanced care coordination to include the physical health care system, co occurring disorders and recovery services, and a seamless system that's easy to access and navigate and includes all of the, the different areas so the intervention, co occurring recovery care management, and eventually a value based payment structure to incentivize a higher quality of care and outcomes for Vermonters so we already are in a value based payment structure in our hubs and in our residential programs, but not for outpatient programs. So, and we don't have, you know, when we think about these goals, we don't currently have the infrastructure to make this happen. Some programs are very small with very small staff. And one thing that I want to just make really clear is through this process we have no intention of destabilizing the DA system so we, you know, want to work within our existing resources and just provide a better system for Vermonters to access substance use services. So we've already covered some more goals. We really need to reduce the duplicative effort on behalf of the client. So sometimes clients are going to multiple providers getting multiple assessments depending on whether they're, they might have, they might be getting opioid treatment they might be getting some other treatment for another substance they might be have mental health issues. And that more efficient recruiting and retention of high quality staff, including competitive wages and benefits which I think that all of our providers would agree is a challenge and a reduction in administrative functions. So these are all the things that are in scope for this redesign. So we want to take all of these services and really make them more coordinated. And these are the things that are in focus in the RFI I don't know if you had a chance to read the document I did put a link in the presentation. One thing we're not including in this right now is prevention. And the reason for that is that we have like I mentioned earlier the substance misuse prevention oversight and advisory council. And we, you know, that council is very active in doing its work and we don't want to get out ahead of that council since it is the designated body that is supposed to advise the state on prevention. So we've been working very closely with the agency of human services central office, including blueprint which has moved from diva to a just central office. The spokes are part of the blueprint system of care so we work closely with blueprint on that. But we've been meeting with the secretary and the deputy secretary around this idea of the system redesign for a long while now. We've been working with the department of Vermont health access to. We've been working with them, their payment reform team, although I want to emphasize that right now we're not talking about payment reform right now we're talking about the system, the delivery system. And we've been meeting regularly as well with the Department of Mental Health. So all we're we are working closely with our state partners we can't do this in a silo. And we are very aware of that. And these are some of the stakeholders so ADAP staff actually conducted interviews with a lot of our stakeholders around to sort of get the low hanging fruit around what did they see as the strengths and challenges in our current system. These interviews were conducted between September and February. And, but I want to stress that this was not the only opportunity for these entities to provide input that was just sort of the preliminary sort of conversation like what off the, you know, off the top of your head is. Do you see as our strengths and challenges. So I have a link here to the RFI was posted on the 26 and responses are due on April 29. Basically, how this process worked is those interviews that I just talked about. In addition to the work of the OCC, there was a lot of information gathered and we heard many themes in that through that feedback. Again around coordination of care. Assess needing a system that's easy to get in and navigate that's person centered where people can, you know, go to one place. What we did was we created the RFI based on those themes that we heard. So this didn't come just, you know, from ADAP's head, it really came from the stakeholders themselves. We did excuse me, I'm sorry, excuse me, we have a question from Representative Wood, and I just noticed it and it was probably from something earlier that you had said. Thank you madam chair. I'm just, you know, so actually it's been it was very helpful for you to kind of go over the current system briefly and the way I'm hearing you describe it. It sounds like sort of a patchwork quilt of all these things that knit together to form a system. And as you're looking forward, are you looking to, I'm familiar with in some parts of the agency and human services. There's a system where there's you know particular catchment area and if you're a person who has a need for that covered area so in this case it would be substance use services. You would go to that one place and then they would either provide or arrange for the provision of other services for you, you know whether through contracts with other agencies or direct referrals. Are you envisioning something like that or is that kind of really the purpose of this RFI. The purpose of this RFI I want to really stress that we do not have a preconceived idea of what the system is going to look like. So the purpose of the RFI is for information gathering only. So we're inviting. To respond these to share ideas on what a system could look like. So there's no commitment, you know, we're not committed to any other than our goals which I stated earlier. We're not committed to the system looking a particular way per se. What we really want is to generate ideas and to hear from from our current providers and others what a system that meets those goals could look like. So and I also want to let folks know that if somebody doesn't respond to the RFI. I mean that if we eventually put out an RFP that they can't respond like responding to the RFI is not required it's it's like an invitation. And so it. What I'm gathering then that that you that the department had a hypothesis that they're there needed to be some change and you went out and you did all this, you know all these interviews and information gathering, and the result of that. And I don't want to put words in your mouth but this is sort of what I'm hearing taking away from what you're saying. The result of all of that information gathering from from people who utilize the system from people who have been providers in the system from advocates all that. The result of that was that that feedback was that there needed to be some changes and you know the goals that you outlined previously. The groundwork for that so I guess what I'm wanting to confirm is that what you heard from all of those people that you talked with is that there needed to be change is that accurate. Yes, I would say that's accurate and I'm going to see if Cindy wants to add anything because she actually conducted some of those interviews herself. Am I on. Yes, you are really. Good morning Madam chair and committee and first of all I'd like to thank you all for inviting us to do this because this is such important work and having the opportunity to do this presentation is really important. Yeah, I did do a number of the interviews, mostly with the recovery centers and the treatment providers. And there were very clear themes on the areas that needed to be changed people were pretty excited about the opportunity to make these changes and like Kelly said, the themes really revolved around person centered care easy access, having the services coordinated and workforce development was is always identified as an area we need to work on retaining staff being able to pay staff well. A question and maybe that people are misreading the RFI, but it appears to many people who have connected with me that what the department is looking for is a source. The responsibility for the system that in fact you are looking for someone, an entity outside of state government to be the coordinator to be the lynch pin, or to be responsible. Madam chair that is a misunderstanding and the RFI. So that is certainly an option. What we did with the RFI was we definitely put some categories in there, but it's not that is again I just want to reiterate that we have no specific model that has been predetermined. Cindy, do you want to speak to that in the RFI. Just to confirm what you said Kelly is that different I like during those interviews. Many people had different ideas of how the system could work and be coordinated. An example of that would be, we had one entity describe how cancer treatment is provided, and that there is a team and identified team and so when an individual needs treatment. They are assigned to a team and that team are the only group of people that they see and they all work together very very closely it's very coordinated and they get all their care with the same people all the time. Someone else talked about expanding the model of the hub and spoke so we have the hub and then the intensive coordinating treatment with the, and then the spokes that people can move into for lesser levels of care when they're more stable so we have different models like that the people suggested. So the purpose of the RFI the way it was written is to have people respond to different ideas like that to see if people have done it before and how did it work because we don't know we don't have the answers to this so the purpose of the RFI is to generate more detailed ideas and thinking than we did in those initials interviews the bear and they were that they were not long, and they were just the beginning of this process. And we did send the draft RFI before it went out out to all the stakeholders so that they could provide feedback on the RFI before it was released so there was opportunity for our current providers to give input on the RFI and we did make some changes in response to that. And that's helpful that you did that it's unfortunate that you do not see the legislature as a partner. And that in fact you do we were not part of the stakeholder group. Okay, so this is sort of our current work plan and timeline. So we started this internal planning last January. And again we did our interviews the RFI was actually posted a little bit earlier than this it was posted on the 26th of February. And again responses are due April 29. And our vision is that whatever the new service delivery system looks like that it would begin in January of 2023. So we'll follow the same process as in the past. So, you know providers can, you know, will be engaged in the process. Often what we've done when we've done big initiatives is our provider network will identify representatives to bring information back to the larger group. From all types and levels of care so from, you know, residential and outpatient, you know, recovery centers. And if we do decide to put out an RFP for this work. We're going to coordinate closely with our legal folks because they'll come a point when, when anyone who's potentially going to apply or submit a proposal to the RFP, you know, would have to sort of not be getting sort of inside information I don't know a better way to say that but so we'll be working closely with our legal folks on that. And that is the end of my slides. So I'm looking forward to a conversation or answering additional questions. I'm muted madam chair. You think I'd learn. Thank you very much. We have a series of questions, one from representative small and one from representative Whitman represents small. Going back to the last slide that you were showing it says that the RFI responses are due by 429 20. In fact, wondering what the actual date is. I'm sorry, it's 429 21 I apologize for that. I just can't seem to let 2020 go represent Whitman. Thank you madam chair, and thank you deputy commissioner darchy for the presentation the overview, all the work that you're doing really appreciate it. A couple questions that I have since now I guess it is our turn to be the focus group is looking at. The way in RFP goes out because I understand from reading the RFI, one of the options you're considering is a vendor to be the service delivery coordinator, which would be a significant change. Two parts to my question is similar to the way that we have the prevention advisory council within state government. Would it be possible for us to do treatment and recovery that same kind of work in these kinds of changes within the state. The second question is if we do go with an RFP for a vendor. Would our current ACO be able to put in an RFP for this scope of work. I'm sorry, the current what you broke up there for one care would one care be able to put in an RFP. I would imagine so but I think that we're it's really premature to think that far down the road Cindy I don't know what your thoughts are but you know again the service coordination piece again was an idea that came from the providers and so that's why it's in the RFI but it's not predetermined that will will go with that. And it likely, you know, we could have proposals and fun proposals from multiple entities I don't think that we're we're not looking for one statewide entity. And then I guess a follow up is that if it were not to be one care to go with another vendor, would there be something within the RFP to determine how they would coordinate with one care and with the state because that just seems like an additional entity within the sort of communication coordination transparency. Yeah, I think that we would definitely want to coordinate with with one care. Thank you. And go ahead, Madam Chair. So follow up to your question representative Whitman and Deputy Commissioner, you said that the idea of system coordination came from the, the stakeholders, the people that you checked with. What was the idea of the system coordination out outside of state government, or a private entity is that what came out of the stakeholder group. I've never deferred to Cindy on that since she was part of the interviews but I think one thing to remember is that our current treatment system is they're all private providers so it's not like the state is is doing that work directly but Cindy go ahead. And that what you said is is accurate there. There is no intention to have go outside to a different entity that we currently have. I'm not saying we wouldn't do it but we don't have that's not the plan. We have to wait to see what comes in from the RFI and, and pull our stakeholders together and start the process we really don't know what this is going to look like. Thank you. Sorry, sorry, represent Whitman, please continue. No, I suppose my the next appropriate question would be, will we get to see the RFI responses on April 29. Sure, I don't see why not great. Yeah, I do want to add it will take us a while to depending on how many we have their it's pretty lengthy RFI so it'll take us a while to put the information together, but sometime after that information is going to be shared. Yeah, people are very curious to see that. Okay, I appreciate it. Representative Wood. Thank you madam chair. So I, I'm curious so the, so the, the, the RFI seems to be seeking, you know, potentially additional service providers, as well as an entity or entities because I just heard you say that you're not necessarily committed to, to one statewide entity. I guess that that manages or service delivery coordinator issue referred to it. So I guess what I'm trying to understand is what where do the resources come for that role of service delivery coordinator coordinators. I'm not aware of the existing resources that the health department has so I'm not aware of any additional appropriation. And so, you know, naturally I think service providers are thinking or maybe thinking that the resources may be coming from existing providers that are being made to service providers. So, you have the opportunity to maybe dispel that or to, I'm just curious where the resources coming from, if you end up with an RFP that, you know, makes this, you know, significant delivery service delivery change. I think that remember one of our goals is increased efficiency in the system. And so we imagine that there could be, you know, savings just from a lot of the administrative, you know, work that is happening now also. So we are we will consider a value based payment structure for outpatient services so there could certainly be savings to be gained from that. If we move in that direction. And again, I'll ask Cindy if she has anything she wants to add to that. No, I think that we have no intention of reducing the funds go to the providers. Okay, so if you if you're not going to reduce the funds that go to providers, and you don't have an increase in appropriation, even if you do go to a value based payment system let's just say if you go to a value based payment system that is not going to reduce funds to providers that means that value based payment system would utilize your existing resources I'm unclear really that where you get the resources to, to, you know, enter into, you know, a contractor contracts, you know, for them. What looks like the management of the system, but I understand that seems to be a misinterpretation. You know, go ahead, Cindy. No, I was just going to say that that's a really good question that we have ourselves. And we have not started at all to talk about payment of the system payment reform we're not there yet we're currently just gathering information about the system and how we could do better how we could provide services that are as a you know meeting all the information down the road we're going to start to talk about payment reform but we're not there yet so we we haven't addressed that. We don't have the answers, which is representative would and committee. We asked diva to come in and talk about the payment reform process and we're told that they would not come in. So, we'll either have them come in at another time, or whatever but that request was made and a decision was made, either by the commissioner of health or by the secretary that diva would not be coming in. Yeah, and I think that just echo is. Go ahead. Sorry. Madam chair. Dan, hold on. I think Kelly wanted to say something. I was just going to say, I just want to echo what Cindy said that we're not looking at payment at this point. So I don't know if like diva wouldn't really, I don't think at this stage would have much to to contribute because we're really just looking at the delivery system at this point. But eventually, we would look at payment. Okay. Representative noise. Thank you, Madam chair. Do you know the percentage of individuals who seek sub SUD who are on Medicaid, receive their insurance through Medicaid. Do you have. I'm going to ask Cindy to answer that one. I don't know that off the top of my head. We do have that we'd have to get back to you on that I don't have it off the top but we do have the data on that. Okay, number of Medicaid individuals who are seeking treatment. Yes. Okay. Thanks. Be interested to see that I saw that you had reached out to an FQHC and I know that they have a different billing rate with Medicaid so just interested. What the percentages. Thank you. Sure. Yeah, we can get back to you on that. I can respond to the FQHC is also an ADAP preferred provider so we pay them the ADAP rate. Cindy, you've gone or else everybody has gone. No, I can hear. I'm seeing. Oh, can everyone else hear Cindy? Was it me? Yes. Oh, okay. Okay. Just to clarify for the FQHC, it's in Lamoille and they are an ADAP preferred provider. So their behavioral health services for substance use is actually paid through ADAP with ADAP rates. It's not through the encounter rates. Thank you. Yeah. Thank you. Thank you. Thank you. Thank you. Representative Whitman. Thank you, Madam chair and deputy commissioner and Cynthia forgive me because I can't help but think ahead, even though I know that we're waiting for the RFI results. I really appreciate and I really support them and agree with them and I love the fact that you're putting focus into this, but especially along the value based system. Is that something that you could conceive doing in house, I guess, within ADAP and I guess with all of the goals as well to what extent can you see while we still don't know the responses of the RFI. But to what extent are you already doing some of this work within ADAP and to what extent can you see the possibility of completing this work without an outside vendor. So, we've already done some payment reform within ADAP for like our residential treatment programs, for example, and also with the hubs. So, you know, we have already undertaken some of that work. So I think it's, you know, something that we would be prepared to do. Cindy, any. No, I agree Kelly. Thanks. Appreciate it. Thank you. Our chair had a computer connection problem so she is logged off and is going to try to log back on so just want to check in with members to see if there are further questions for these witnesses. Okay, I'm not seeing any hands raised. So, I guess, Cindy and Kelly you're off the hot seat for now. And we very much appreciate you coming in and sharing the background sharing, you know, the as as represent Whitman said, the goals of what this process is and, and, you know, frankly putting a spotlight on it we, we appreciate the needs in the state and so we might differ on the process to get there I think the goals that you outlined are common goals for all of us. So, thank you so much for being here. Okay, and they're starting having to switch my screen. Our next, our next witness is Chad bigger is Chad. Yes, I see you Chad. Welcome. And Chad is the executive director of recovery house and welcome to the committee and we appreciate any thoughts that you might be able to provide on what we're looking at in terms of this system redesign for substance use disorders. Absolutely. And I think the representatives of this committee for inviting me today. I have a little bit of background if you're unfamiliar with recovery house. I'm sorry to interrupt I should have I should have indicated if you could just introduce yourself for the record it's sort of a formality we have so that people who are listening know who they're listening to. My name is Chad VJ. I am the CEO of recovery housing. The recovery house has multiple programs, the serenity house grace house. We operate the public and ebriate program out of Rutland and Addison County, and we operate a small office based MIT program. We've been around for about 49 years. So we've seen a lot of change, and and I welcome the opportunity to discuss the changes that are being considered by the state and ADAP. So again, thank you for inviting me. It's important to know that I'm very much in line with the goals that this RFI is seeking to answer the idea of improving quality. And the idea of addressing gaps that we have in our system of care I think there are some gaps that need to be addressed. Certainly, but there are some concerns. But the language of this RFI, the idea of putting out a request for information related to finding a service delivery coordinator, and the key objectives being related to cost effectiveness. So our concern here is, is, is a large private entity going to come in, offer reduced cost of providing this administrative work, and and not have any connection to Vermonters. And that that I have and I know that Deputy Commissioner spoke about the idea that they're just considering options. But I think if is if it is an option to outsource that work. I think it would be appropriate to really consider what sort of ties the entity has to the state and the population that we serve. In addition to that, the RFI indicates that you can apply to be both a service delivery coordinator and a service delivery provider. I think that opens the door for some potential conflicts of interest. So I would like to see an entity that isn't providing any sort of service to the population. That's just my thinking in that regard. I think it would be a piece on the service delivery coordinator entity. I think it would be important to, as the Deputy Commissioner pointed out have some sort of community centric approach where we need to recognize that the needs of, let's say Rutland County are different than the needs of Chittenden County. Having those individual relationships with the area providers I think is critical. Thinking about how this opens the door to privatizing the work and bringing in larger entities. I think about the value based payment possibilities and opening the door for providers to put up proposals to do service delivery. Are we opening the door to large national entities to come in and provide care to to our population. I think there's some thinking on a national level that if you scale substance use treatment and reduce overhead costs that it's more cost effective. I think we run the risk of losing quality of care. If we if we if we leave that door open. Just some some thoughts that I have with that. Recovery House is also in an interesting position where we're going through as a residential entity we're in our going into our third year of payment reform, where we are receiving episodic rates versus a daily bill to rate. So we're seeing the perspective of this value based payment. But I'm also reading the language in the RFI that is cost effectiveness. To me, I think we need to address the idea that, you know, we have to consider what cost effective and what's what the costs are of treatment, you know, thinking about workforce development in the addiction field. It's pretty frightening. The amount of people that are in the fields either aging out due to retirement and the lack of people interested in becoming licensed professionals. I think we really need to focus on, you know, providing appropriate wages. And I think ADAP and Deputy Commissioner for pointing out that fact as well that we have to address the wage situation within the field. And so the question that I have in my work in responding to the RFI is how can my agency be in a spot where we work to control cost and not necessarily reduce costs to a point where we're unsustainable. Those are our primary concerns with the RFI. And so that that was what I had wondering if anyone has any questions. Sorry, I was talking and I was muted. Thank you, Chad. And my apologies for mispronouncing your name. So totally appreciate appreciate you saying it correctly. Are there questions for Chad with regard to his comments or any other thoughts that you might have committee members with regard to how that might intersect with the RFI as we see it. I have I have a question and then okay represent Whitman go ahead then I'll ask my question. Thank you madam vice chair and Chad. Thank you for being here today. My question is the idea of coordination within the rest of the system of care. To what extent do you feel connected coordinated within that kind of continuum in current state and to what extent are you working with ADAP and kind of communicating within the larger system. The RFI when you mentioned the larger system are you speaking specifically about substance use or the healthcare system in general. I would let's start with substance use. Okay. So my organization operates for anyone across the state. So I think we have a really good relationship with all the providers and recovery centers around the state and we're open to furthering those relationships. We have a good position there and as far as our relationship with ADAP. I've appreciated our relationship that we have with ADAP. Whether it's the guidance on the administrative end or the guidance and recommendations that they put forth on the quality and as well. I think it's something that if if the state besides to move in a direction where they outsource that coordination. You know we'd have to rebuild a brand new relationship. And I think we would lose something that we've had with ADAP. And I guess a follow up for the next step is as far as co-occurring say mental health concerns, emergency room referrals. Is that something that you have a lot of sort of lines of communication coordination currently? That's something that we're improving as we speak. So the state issued the community action grants, the linkage to care grants specifically. And here at Recovery House we've set aside some beds specific to opioid overdoses. And so we're generating this fast track from emergency room to serenity house through this grant and some case management efforts. In the hopes that folks will get transitioned to us the same day that they're at the hospital and stabilized of course. Great. Thank you. Representative Bremsted. Thank you, Madam Vice Chair and I sure you don't want to go with your question I was going to wait to raise my hand so you would feel comfortable asking yours because I am. That's okay go ahead I can stick mine in. Okay. Yeah, thank you so much for your testimony and for being here today. I am. I'm just curious. What do you think about that one of the things that ADAPs told us at the very beginning is that it's really been 30 years since they've done any sort of redesign. And as someone who works in the field is that concerning to you and as you look at your colleagues maybe in other states do you see them delivering the care in a, in a way that would make you think maybe it's time for the health department to think about a redesign. That's a great question. I think if we're not constantly changing, we run the risk of being stagnant and I think quality of care decreases as a result. The issue in looking outward is that I've been in this position for about a year now. And what I'm seeing in other states is that there is a large swath of money makers in the addiction treatment field that is equally as concerning as, you know, anything that is out there so my concern is that, you know, if we change in the wrong direction, and it becomes something more about money. You know that I think that will have unintended consequences on the quality of care. As I said, I think it's important to acknowledge that the cost for delivering treatment have increased. And that's something I think for future conversation within the legislation. In regards to appropriating more funds to substance use treatment specifically. So, just one quick add on to that then were you included in the discussion the focus group discussions or where any of your colleagues included in that. Absolutely. Actually, Cindy was the one who interviewed me it was really great conversation. You know, I am one of those who are excited about the idea of making positive change within our care system. It just, I felt compelled to share the concerns of, you know, privatizing care. You know, I'm, I'm very supportive of hearing hearing that I just wondered as I think big picture so this is, this has been very helpful. Thank you. Thank you. One of the things that I am curious about is the sort of this the coordination role that's that's being looked for in this RFI or you know information about possible aspects of that and and you spoke to coordination and and the positive relationship that you've had with ADAP at the health department. So, what do you do you see. So that's coordination between you and the state, what do you see, or do you see gaps in how to coordinate services. At the local level, you know, among different service providers who might have different different might provide different services than you provide so I'm thinking about sort of like the web at the local level. How does that work for you now and how do you feel like the system works now in that regard. I think that's one of the gaps that the state is looking to address. And I'm interested in addressing that as well. The idea of linking people to care, you know, treatment is accessible. But how do you get those who are in need to the treatment that they need. I know that we've increased our efforts around the state to help out with that linkage. And I think part of my idea of having this service delivery coordinator interact really with specific areas is, you know, to address that that idea that every area, every areas web is different and providers interact differently. I think it is something that we can improve on the case management in between levels of care. And I'm looking forward to addressing that certainly. Thank you. And I see madam chair is back her internet problems I don't know if they're solved but at least temporarily she's back so I will, you're muted madam chair. I'll turn it back to you. Thank you. Thank you. And thank you committee. And I apologize to deputy commissioner for needing to. I didn't need to for being Internet issues. Representative McFawn. You have your hand up. Thank you madam chair. Please excuse my lateness coming into the program. I too had computer problems. Yes city and today. But I know there's a guy out in the post over there now I can see him. So that may be it. Happy St. Patrick St Patrick's data everybody. I never would have known representative. I didn't think you would but you have a nice lovely green blouse on today. You're very good Irish woman today. I have one question. If something is working pretty well. And with some tweaking, it'll be much better. And you get that information from all the people in the field. And the question is this. Why as part of this. RIP or whatever it's called. Why is it on the table that this successful program could be administered and operated by somebody outside of the state of Vermont or somebody other than who's operating it right now in the state of Vermont. Because we're doing pretty well. And I heard all kinds of allocates throughout the years about how well Vermont's doing so. Why is that even on the table. That's my question. To get to the. Maybe. Okay. So Cynthia or Kelly, can you. Respond. Yeah, I can respond to that. So in some areas we are doing really well. You know, I would say, you know, the hub and spoke system is a model that, you know, has really been looked to nationally. But we don't have a system that is as responsive to other substances of concern. And also, you know, we're not looking for like an outside entity per se to come in and, and, and take something over, you know, we would be working with our preferred provider system just like we do now. So I think that there are areas for improvement and chat. I appreciate your acknowledgement that there are areas for growth. And I think that we should always be looking to for ways to make the system better for the people who, who need it. I could follow up madam chair. That's what I mean. You're asking for information from the field. You get that, and you improve what you're doing now. Right. That's my question. Why do we, why are we even considering somebody else, other than who's doing it. Yeah, I apologize. We are not considering someone else at this point. We're, we're not even there yet. We're the purpose of the RFI is for anyone to submit ideas on what an improved system could look like. Yeah, so that's the whole purpose is to collect information. We're not assuming that the people who are currently providing services are not going to be providing services anymore. That's not the intent. Okay, good. Thanks. Representative noise I'm not sure if your question is for Chad or for Kelly but we're sort of having a round table discussion, I guess. Yeah, it may, it may span a couple people but just in the presentation earlier it said that 96% of the popular people don't seek treatment. Is your goal to get under the, you know, do you hope this change will get more people to seek treatment. And so that was like a pie chart that you presented earlier so I'll just like to answer that. Well, I think that's one of our goals right now, even in our existing system because we know that there are a lot of people who could benefit from treatment who aren't getting it. So we do an awful lot of outreach and marketing. We have our new Vermont help link which the, you know, the goal of that was to make accessing treatment and other services, more accessible. So I don't think it would continue to be a goal. I don't think it was the driving force, but it's, it's sort of an overarching goal that we're working toward all the time. And just to follow up, do you have the capacity if more people were to come forward looking for help. Yes, I think that there is capacity in the system and we would ensure that everyone who wanted treatment would be able to get it just like we did with the hub and spoke we expanded it. And as more people were looking for treatment we work to expand that system and I think we would do the same for other outpatient services and residential representative noise if I might add to that. That's one place where the role of the legislature may in fact come into play, because to expand the system, we're going to have to pay for it. And that kind of thing. Committee, what I might since our questions seem to be too many of the people who have spoken thus far but we have not. I believe we've not yet heard from milling from Melanie or Jack Duffy. Why don't we hear from two other preferred providers. And then we can have more of a discussion, because we are. And we have half an hour plus, maybe close to 45 minutes but. That we hear from Melanie who's the executive director of the Clara Martin Center. Thank you madam chair and committee for inviting me to speak today on behalf of Vermont care partners, which is made up of the 10 designated agencies and six specialized service agencies. As you said madam chair. My name is Melanie I'm the executive director of Claire Martin Center. I also serve on the board of central Vermont substance abuse services in Berlin. I've been the executive director for one year at Claire Martin Center but I've worked here at the agency for 29 years and various different roles. My first 10 years was clinical work and then my other 20 was in various management roles from HR, a director to operations to quality assurance so my strength is in that aspect and kind of this RFI touches on a lot of those different experiences that I've had in the field. I come here as a representative of VCP of the designated agencies so I'd like to just quickly touch and make sure I touch on the high points that we as a system wanted to acknowledge here. And then I'll speak on just a little personal experience here at Claire Martin Center in rural Orange County. So I know time is of the essence so clearly Vermont care partners and our network agencies are committed to both mental health and substance use disorder treatment. We've been partners in the field for many years. In our work we serve over 15,000 unduplicated Vermonters in the last five years. In our substance use disorder programs alone 80% of our comprehensive service designated agencies are preferred providers so eight out of 10, which is a third of all of the preferred providers in the state. Clearly the largest hub in the state the Chittenden clinic is a Howard Center program. There's a lot of data. Julie Tesla has available for you if you are interested some of the key points we wanted to make is the ADAP system restructuring must be considered in the context of the larger health delivery reform, taking place in Vermont clearly as part of the mental health service system we've been part of value based payment reform and have had some success in that area. As providers of not only substance use disorders but also mental health and developmental disability services, the VCP network believes that any restructuring of the SUD delivery system, including quality assurance service expansion, contracting and oversight must align with the internally coordinated with the rest of AHS, and especially with the efforts of Dale and DMH. I think one of the things we feel is that we have a strong working relationship with those state agencies, and would love to build upon that and the structure that already exists to improve the care. I think, you know, as a remontor I appreciate kind of the opportunity to step back and look at our system, and is there a way to do it better and appreciate ADAP efforts around that. But I think we speak of not wanting to reinvent a new system but really work within the systems that we have and some of the strengths that we have clearly there's areas for improvement. And that's something I'm passionate about and really work within our workforce and support our workforce that is so their treasures, and we need to retain them at a time that we need them more than ever right now. And I worry about the instability of a major redesign at a time with COVID, our numbers are just still going up. We haven't hit the peak nor do we expect to hit the peak for some time so as I digress a little bit but a little personal about as we discuss some of the changes here. So clearly aligning with some of the other state agencies that rather than virus gating the system. Alignment would enhance opportunities of integrated and continuous care with people with really complex needs and those that have co-occurring mental health and other health conditions. I think that's the other touch point that I personally just want to speak, having been in the field for so many years we've been working on the co-occurring model with ADAP with SAMHSA for several years. And us here at Clara Martin Center really embrace this. I don't think I can be an effective community mental health center. If I don't provide substance use services and address the co-occurring needs of our populations. So many people whether they're personally dealing with a substance use disorder and actually meet a diagnostic, the family system and the community is impacting it that you can't do this work without having a basic understanding of that. So building upon the integration the co-occurring model is something that I've been passionate about. I think our organization has been passionate about that. At a time that fiscally you know my CFO is relatively new to us he's like why do you do this we lose money, but I can't do the work in a rural area where there aren't a lot of providers if I don't train my staff to have a basic level of understanding of substance use needs. Because you know used to be it was a hot potato and you referred them out. I don't have that luxury. Let's be comfortable and train my workforce so that we can handle this internally so that we don't get caught in the gaps where we lose people to services. I also add with the value based payment that we've been working on with with mental health. I think it really does apply some of the same common measures apply to substance use services, you know, engaging them, you know within one to five days we're working towards same day access and the engagement once they've been in this in the in the system. So I got a little excited on a few of these bullets but let me get back to some of the talking points. So we have demonstrated, you know the success at working with diva with payment reform, Dale and DMH and one care so I know one care was a question that you folks had. So we have been trying to address the health of all Vermonters in those relationships. We do have some concerns that ADAP had conversations with some individual stakeholders. The process did not involve system level planning and input and was not iterative where it build upon what other conversations were happening. The RFI indicates the ADAP is looking to bring treatment and recovery services under management by an outside entity. I think that there seems to be a little appetite for state general fund dollar increases for the system. I know this was discussed about within this committee. And I think that that's a concern, I think especially around the service delivery coordinator, you know, I think the service delivery services we all are looking to do that better. I think it made us nervous in terms of the coordinator role and where does that money come from? Is that money going to come from care? As we talked about, there's no new monies into the system. So we share that concern that was discussed earlier. And I think, you know, I think finally, I think you folks have a copy of this talking point. You know, we support, you know, no reduction in direct service dollars. We surely are focused currently on immediate access to care. We surely are looking to build upon the peer recovery services available to support treatment programs. We do that both with substance use and mental health. And that meaningful outcome measures align with outcomes and mental health and the general health care delivery reform process. And finally the intercept framework model. We look to encourage to continue with involvement with corrections where we're also involved with those folks. So we've looked forward. I think Cindy came to our VCP meeting recently and had a good conversation. I think back in November, when we started these hearing about these stakeholders meetings, I think we did get nervous. And I think they've done a good job to try to kind of calm us down. They weren't looking to outsource to an external out of state provider to do some of what ADAP does and take those monies out of care. I think my concern is we've seen sometimes that happen. And once it gets too expensive, they leave. And then we're left holding the bag and taking care of our Vermonters and making sure they don't fall through the cracks. So I think that's been my experience from a historical perspective that I worry about as I as I listen to the some of these concepts that are out there. And where reality is versus the process, you know, we'll see where this goes. But anyway, it's just interested in being part of that conversation. I think I touched on some of my touch points locally here at the agency. I think workforce is something I absolutely just want to reinforce, you know, I am committed to taking care of my staff so they can take care of Vermonters at this time of great need. And anything I can do to provide them the stability. I want to do. We need them more than ever and we are losing people in the field, whether it's compassion fatigue, retirements. And just a plug I'd put in here that anything we do retains those workers and doesn't add new positions and takes away from, you know, we don't have a lot of trained workforce to hire. So I think you folks know that that's a barrier we we face. So get a little excited there. You know, hopefully that touches on kind of our perspective and where we sit right now. And really just look to build upon some of the infrastructure we already have and build some of the strengths we have to address where we might need to improve. All right, Melanie, thank you. And committee why don't we hold our questions or comments and let's hear from Jack Duffy CFO of Valley Vista. And then we can continue our discussion. Hi, so this is Kevin Hamill on the vice president of Valley Vista I'm filling in for Jack today. And I know Rick to Stefano is also trying to log in right now because he wanted to address you but since you're all waiting I will step in here. Thank you is we have, we do not have people enter the committee room without knowing who they are. So there is a person who was trying to get in with no name, but with just a phone number. So, if that is him. If you can, we have asked them to identify themselves. So please do you go ahead. Number ending with 499 that would be Rick to Stefano the owner of Valley Vista. Okay, looks like he was just let in. Okay. So, who is testifying on behalf of Valley Vista. Rick, please go ahead. Rick, you are. You are muted. You are still muted Rick chair. Can I add a note. If Rick has not testified via phone today that it is a simple star six to unmute to participate via zoom. Thank you. Rick, did you hear that star six will unmute you. You can still be muted. So, until I see the unmute and someone starts talking. Let me open it up for more questions or comments representative Greg war. Yeah. Do you want to jump in quickly. I can so I can head in I got an appointment here. All I was going to say is what I said in the chat is that it sounds like I understand all the concerns don't give me wrong but you know the RF RF, RFI process, I mean to me is kind of like brainstorming you're getting all your information, and you're putting it on the table and you never start a brainstorming activity by saying these are the things we can't do. You get everything on the table and then you go through them and say why, why or why not they won't may not work. You never start a process like that by saying we're definitely not looking at this option. That's definitely not a good brainstorming or request for information type process so it sounds to me like they're moving ahead in a good direction. We'll get all the information and I'm sure they'll look and we'll look and all the stakeholders have a chance to look at what they found, and then go through and start saying okay well this has some good components. This one we're kind of questionable about, you know, etc. So that's just my my point. Thank you. Thanks for a great war. And I understand you need to step away for a bit. I do. I will be back. Bye. Are there other questions. Now we have a we have both Kelly and Cynthia as well as Chad and I think we lost. Oh, we do have Melanie. So we have other folks as well. Kelly this is maybe connected to the RFI or maybe it's connected to our current system. Unlike, unlike my understanding and I could be wrong, unlike the mental health system, unlike our physical healthcare system. Currently, the ADAP contracts and has as preferred providers out of state for profit provider. And which is, I believe a shift for the state of Vermont to contract with for providers for healthcare. And how did we come into that and what is something that is up for a question as to whether or not similar to other systems that we have that are nonprofits. Right. So, and I Cindy will have more of the history of how those providers came into the state, but I can tell you that anybody who's in our preferred provider network. They're not being treated to the same treatment standards as, you know, any other provider and they're also paid the same way. So, you know, they're they're not being treated any differently than than the other providers but Cindy can speak to how some of those entities with the process was when they came into the state since that was before my time. I think our first was when and that was put out to bid I believe again this was before my time I was working in the state but not in ADAP. And then Bart behavioral health who runs a number of our hubs. They it was through an RFP. So we did RFP the hope services and they won the contract the last hub we opened was up in St. Collins and it was the same process and they were chosen as the entity. Have it up go same thing they it was for a hub through an RFP. Thank you. Thank you. I see that Rick from Valley Vista has has come back on and I think we'll be able to hear you and so, Rick, thank you very much. Please go ahead and. Okay. Can you hear me. Yes, we can. Okay, good to be heard so sorry I was trying to press pound six for ever didn't work I just hung up and dial back in it seemed to work so. Jack Duffy was going to join this call was a bit more prepared for this. He had an unexpected emergency come up and was not able to do it called me and asked me if I would jump on happy to do so. You know, basically, I think that overall this group probably knows that Jack and I were the initial folks at Valley Vista beginning services in 2004. We sold the company 2017. After some difficulties with the owners that bought Valley Vista Meridian behavioral health we had some communications with Health Department, Cindy others and we ended up buying the company back in May of last year. So we've been operating less than a year at this point through obviously a very difficult year with with COVID. You know, we had a lot of years of experience prior to that. And are glad to be back and I think that we came back to a facility that was in very tough shape staffing wise. Certainly COVID had taken its toll but the company was already and was not doing a very good job in my opinion. Looking back on what they were doing running the company and we kind of felt this really was our legacy we started the company in 2004 and wanted to come back and bring Valley Vista back to the quality that we believe it was when we left in 2017. So for that I apologize. We think we sold the company some good people who were all fired about six months later was basically a financial decision. They were being funded by a group that decided that they weren't performing well enough from a financial standpoint and pretty well cut them off. And they did a lot of what I would call damage to the quality of programming that was being offered in Valley Vista at the time. And I know that I think the health department folks would agree with that and we're back on track now it's been a tough tough time trying to rebuild many of our licensed staff members left. We lost almost all of our managers fortunate we were able to bring back our CFO and a few other folks that did stay on. Kevin Hamill who's been on this call is overseeing the clinical nursing and medical program. Kevin's a registered nurse with 20 plus years of experience myself and Jack are regularly at the facility and trying to make some some good changes in a rather tough world. And I guess that you know just quickly you know we ended up you know with a very very poor census when we started. We have 99 beds total between virgins and Bradford. We have 19 bed women's facility in virgins. We have 80 licensed beds in Bradford. About 20 of those are women's beds. The remaining beds are male beds. Meridian gave up the adolescent unit while we were away. So there is currently not an adolescent unit there. Our census was in the 20s when we returned we've been averaging about 50 to 55. Now it's been difficult to bring patients in in this environment. We also had about a COVID in the building in November, which reduced our census to four. We were not able to admit for 17 days we had nine positive cases of COVID amongst our staff none were involving our patients fortunately. We've been helped out in a very nice way by the health department and testing and so far so good we've done a pretty good job keeping COVID out of the building we're testing every patient before coming if they've not already been COVID tested. Our census is about 50% occupancy as I say we're admitting about 100 to 120 people a month right now. And it's been very, very difficult to maintain financially with that kind of a census. Fortunately, the assistance money from the state, the federal monies and some PPP money has allowed us to keep the doors open. We're trying to navigate and get used to the new payer system, which is an episodic care right now, which is something Jack and I were certainly not used to. We're finding it very difficult with the rents we have to pay for these buildings to be able to maintain and quite frankly are very concerned when any kind of relief money is ended, whether or not, you know, just on census alone, 50 patients will not pay the bills at Valley Vista and keep it operating. So we're very concerned about that and certainly have been talking to the health department Medicaid about some payment reform issues. We really believe that without some major changes, it'll be very difficult to keep these 99 beds or operational going forward if funding from the federal and state were not to be available to us in the future. I mean, I guess that, you know, right now our mix is about 80% from our Medicaid patients. We do have other third party insured patients in the building. We are trying to grow that census that certainly helps because we're being paid about twice the rate from the third party insurance as we are from Vermont Medicaid. We also have contracts with a couple of the managed care companies in New York state, namely Fidelis and CDPHP, and we're being paid about 40% higher rates from out of state Medicaid than we are Vermont Medicaid. So growing some of that business certainly will help us keep the doors open going down the road. One of the things that we're really very concerned about right now is that we have very difficult patients trying to commit to Valley Vista, especially since the void with Brattleboro kind of ending their detox services December 31. We're seeing many, many more requests for patients who are too psychiatrically impaired for Valley Vista, but no other place to go. They don't qualify to get into a mental health facility. They're not sick enough for them, but many of them are too sick for us. We try to admit as many of those as we can. We find out that we, you know, are successful with some and some we need to discharge, but once they're there, it's extremely difficult to discharge them to a inpatient psychiatric facility. And that's a real big concern of ours right now. It's a lack of services to move people to a higher level of care when they need that really, really difficult without the Brattleboro retreat being able to accommodate the detox needs of the patients coming through the door, continuing need for detox services. That's certainly been a big problem for us. We were also finding that right now to operate these facilities compared to when Jack and I were here for the 14 years. Nursing costs have skyrocketed for us. We can't find nurses in the state of Vermont. The pay if we do find them has gone up about 30%. So we're having the staff with temporary nursing, agency nursing at the rate of 100 plus an hour. Guarantee them 48 hours a week. We're talking about nursing costs right now for three nurses right now in the building that are traveling nurses is just about our entire nursing budget. So that's something that we really see as a threat to our continued existence going down the road. And the other issue is the recruitment and hiring of L. A. D. C.'s license alcohol drug counselors, which really right now is just about just a snow and out there and we're we're increasing the amount of pay. Certainly what we see has happened and certainly great thing for the state of Vermont, the blueprint, but the blueprint has changed the rate of pay for L. A. D. C.'s has increased the rate of pay substantially for L. A. D. C.'s. And we're having a really difficult time competing with the Monday through Friday schedule of a blueprint of counselor in the Matt program or hub. And it's, you know, there are our operation is 24 seven. And it's made it extremely difficult for us to to hire and bring staff in. We're trying to do what we did in the past train our own, but we're certainly lacking in licensed alcohol drug counselors or licensed mental health professionals. We're also finding that the amount of psychiatry we need in our buildings right now with the difficult patient population that we're taking in is not something that we feel is in the current rate, the episodic care rate. And to afford psychiatry, the amount of psychiatry need in the building. We certainly know that we'll be struggling down the road with with with that being able to happen. We do have some psychiatry now we're trying to recruit more psychiatry. The reality is that our patients require a fair amount of psychiatry, a fair amount of medical co-occurring issues as well. We do have a full time family practice nurse who is seeing most of our most of our regular sick call type or medical issues in the building. And then we have a medical director who's a internal medicine doc by training and addictionologist for the last 25 years certified addictionologist board certified. And we are able to take care of the majority of the medical issues going on the building at a fair expense as well. So, I guess what I just said is that, you know, we have some major concerns with the number of co-occurring mental health and in our substance abuse population the dollars associated with nursing with ledcs with mental health professionals with psychiatric staff is really, it's really something that we really feel needs to be addressed for us in the really inner future for us to continue to exist when some of the relief communities go away. Rick. Thank you. Thank you very much for one filling us in and talking about sort of the history of where Valley Vista is now and some of the struggles and how you are addressing them and how you bought back the company in order to bring it back to where it was. And for part of what we are trying to understand better now today is the direction or the request for information in terms of system redesign that the department that ADAP is engaged in. Were you part to do or anyone in your staff participate in any of those focus groups or stuff that that they had done in the feedback? We did not. I'm not sure if Kevin was on any of those calls, but I did not participate. Jack has had some participation and reviewed much more of that than I have as executive director in the building. Yep. Thank you. Thank you. That makes sense. Committee. Do you have any questions or Rick in terms of Valley Vista or Chad in terms of recovery or or Melanie or for that matter for Kelly or Cindy as it relates to ADAP? I think this is our opportunity. Representative Whitman and then Representative Noyes. Thank you Madam Chair. One of the themes I've been thinking about is the substance agnostic system. Especially looking at the sort of a claim that the hub and spoke model has gotten while being opioid specific and some of the numbers that Kelly introduced about alcohol use being another big concern. So a bit of a naive question. What is a kind of inpatient equivalent to medically assisted treatment for people with alcohol substance use disorder? To what extent do different organizations, Rick, Chad, Melanie feel that they have the capacity to be substance agnostic be able to meet different people's needs based on substance? Well, from the point of view of Valley Vista, we'll tell you that as much as we see opioid use disorder being a big part of what we do, we're still treating alcoholism, detoxing for alcohol and are able to accommodate the needs of any drug. We were seeing all kinds of different substance use out there, but still the patient who's admitted for alcoholism, alcohol detox is still a regular patient and a regular part of what we do at Valley Vista. Thank you. Chad, you wanted to add to that? Yes. Similar to Valley Vista, we offer alcohol detoxification. And I would say that we are absolutely substance agnostic, whether it's alcohol, cocaine, opioids, amphetamines, whatever it might be. And certainly they're providing treatment. As far as the MAT side of things, we are linking folks to, you know, some medication options for alcohol, continued medication options, whether it's Naltrexone, Vivitrol, Antibuse and so forth, as well as linking folks to the opioid side of MAT as well. Thanks, Chad. Representative Noyes, oh, sorry, Melanie, did you want to add something? Yeah, I would just concur with that, Representative Whitman, that we do offer the full continuum regardless of substance, whether it be MAT, alcohol, smoking cessation. It's probably just the different hot levels of care, but the substance itself we can treat. Great. Thank you all. Representative Noyes. Representative Noyes, are you having internet problems? Am I the only one that sees him as stuck? Oh, are you back? He's back. You're back, Representative Noyes. You were stuck for a while. Sorry about that. Little, yeah, sorry. Yeah, just had a quick question. What is the average length of stay inpatient if someone were to go to Valley Vista? Valley Vista is the average length. Rick, could you answer that in terms of... Yep, yeah, I'm happy to. Average length of stay at Valley Vista would probably be a 14 to 17 day length of stay. And, you know, obviously not every patient stays the time we want them to stay. We do have a rain of about 18% against medical advice, discharges, occasional administrative discharge. But two to three weeks would be the average length of stay. 14 to 17 is probably what most patients end up staying. And what does that cost? The cost, or what are we reimbursed for that? Reimbursed, thank you. Well, our good point. Reimbursement rates, I don't have those various buckets in front of us. But in the episodic care rate currently, there are qualifiers for different rates. So we're reimbursed as little as a little over $3,000 for some of those patients. And then some of those who meet some of the criteria around homelessness, around co-occurring issues, medical issues and whatever that rate could go up by several hundred dollars. But probably I would say if we looked at it overall, Jenny, you might have a better feel for that if you're on, but it's somewhere in the low to mid threes for that entire stay. So if we average out the length of stay, I'm sorry, this is Jenny Gellman. I'm VP for Valley Vista Finance. Our average daily stay is about 226 for a Medicaid patient. That's what the average, it averages out to be daily. Right. Obviously it does not cover costs. Yeah, it's not, it's currently not covering costs of Valley Vista. That's for sure. Thank you. Thank you. And I want to ask Cindy or Kelly, if you have any final comment you'd like to leave us with today. I'd like to thank the committee for your time and for inviting us. I think that, you know, as with everyone, we've, we've been a little focused on COVID and it's really great to be able to come and talk with you about this really important work. And we'll certainly keep you updated as the results or the responses to the RFI come in and we'll be sharing those with you. And if we can come back for a follow up at some point, we're more than happy to do that. So thank you. Well, and thank you very much for that offer. If we forget to ask you, and you think we should have, because you're doing things that are exciting or new or whatever, please, please invite yourself and say, you know, we have something to share. We certainly will. Thank you. Rick or Melanie or Chad, do you have any final comment you want to leave us with for today. I would just like to thank you as well. And Kelly and Cindy as well for participating in this important conversation about a important need for our, our communities. And that we provide, provide good care, most effectively, most efficiently. And so I appreciate ADAP and this committee's support to looking at this on behalf of Vermonters. And thank you. And I guess I want to thank all of you who have participated because I think you have helped me at least and I think the committee to maybe understand what the purpose of the RFI is. Not really what the understanding is in the community. And if there's any undercurrent of what the community had understood that is the unstated expectation to have heard our concerns and our questions about that. So thank you. Thank you all very much for that. And committee I would suggest that we take a 15 minute break until and we're going to change subjects at 1115. So, thank you all very much.