 So pepper, I guess he wants you to go first Good morning. I'm sorry. We're a little bit late senator Baruth on his way to senator Senator Benings in court again. I know I wish he'd get out of court So we could tend his medium judge Anyway, all right James Pepper from the Department of State's trains and sheriffs This is clearly a very complicated area of the law The gaps in the system I think that Chittenden County dismissals the Windsor murder case Exposed for I think the public what the state's attorneys have been trying to Ring the bell about internally for a number of years That there are significant gaps in this public safety gaps I should say in this intersection between the mental health care system and the criminal justice system. I Asked Peggy to post a memo that one of our deputies wrote 2018 that really crystallizes some of these gaps or that exists in the order of non-hospitalization in the criminal justice system Okay So the the gaps that I the gaps that are identified in this memo and that I'll just talk about today is that Department of Mental Health is concerned with treatment of the individual. They're not directly concerned with public safety risks Both of people in their custody nor should they be The lack of adequate bed space In Variably means that there's tremendous pressure The image Wax the ability to adequately supervise people who've been downgraded to orders of non-hospitalization There is no Provision in the law that allows the image to notify the state's attorney or the victim When a person in their custody is being discharged or downgraded after a 90-day period and then there's other issues From hospitalization to non-hospitalization or from non-hospitalization to community care either one From from the downgrade to community care to the non-hospitalization or to just the not seeking the right So anytime there's a downgrade There's protections that happen within the first 90 days that include notice But after that Public that there was a hearing and the state's attorney in Bennington County went to the hearing 25 30 years after the murder of the Plant manager at ever ready How did we know that I mean I knew that because it was in the local paper I'm a little confused about how we would know about that if we can't provide notice well, there's a provision in the current law in Which you can actually see on page three of the bill which says that state's attorney shall be given notice 10 days prior to a Discharge the Supreme Court has subsequently said that that applies during the first 90 days, but not afterwards I don't know when the esteemed For all but it precedes him so that may be Remember I don't I don't know why that was made public perhaps, you know some of the other Yeah, I don't I don't know either. So I'm just curious as to how Well, I mean, I'm and I don't know the specifics, but yeah, no, but right it's I mean Really, there's a severance that happens when they when there's a commitment order and Between the kind of mental health and the treatment aspect in the criminal case This is the the goal of the bill quite frankly is why I've heard victims is one the lack of notice the knowledge and number two was the fear that that person is still dangerous to them or to their family members and That that What was keen out of obviously the shipping cases are different from the Windsor case And that's the shipping case the charges were dropped. So there was And that makes it even more confusing to try to deal with but you know, I Don't I would like to have a bill But I I don't care what it looks like Just I think it needs to address those two problems And I think that is precisely where the state's attorneys are I think this bill S-183 S-183 in its current form It proposes solutions to those issues They're probably deficient and I'm sure there's other witnesses today that are going to explain great detail Why they're deficient or make hurry well part of it in the Genesis was discussions last fall with these former states So a lot of it came from there and I don't have it I don't think any of the sponsors the bill have an ownership over the solution We just wanted to bring forth something to get the discussion rolling to see what we could do to improve the situation particularly for victims That and I'm glad to hear that because I think that there's actually a lot of agreement on those issues around notice Particularly, you know when someone is found incompetent to stand trial and Then they're committed to the Department of Mental Health There's very little notice the state's attorneys after that 90-day period if if they're being discharged And that that's a charge it can be refiled and you know, that's If the person is then confident you know the state's attorney should be put on notice to do a competency evaluation and Rebring the charge. I started nitpicking and you weren't finished with yours but Well, I'm nitpicking I want to concentrate on one thing you said and that's the lack of beds Which is what I've heard from a number of other folks is that if somebody is taking up a bed Who's a forensic patient who doesn't really need that treatment? We're taking a bed away from somebody who? May not be a forensic patient So that's another problem particularly in the light of the lack of bed space for That we have in the state so that's another problem that is Wasn't planned as far. I don't think the sponsors considered that but what also came up and I'm Cory Gustafson is going to speak to it. I think literally run evidently Medicaid is phasing out payment for forensic patients, which means it'll all be general funds The next couple of years, but I don't know what we need to get more detail on that But that does make a difference in how we look at that. Yeah, and it's my understanding as well I mean to say that The lack of beds is driving decisions is an overstatement. I would say but it certainly I think has to be playing it a Role in the decision-making about whether to move someone into community-based care I think fundamental to our position is that there's inadequate supervision of someone through the designated agencies when they're in On an order of non-hospitalization I'd be happy to talk, you know about the specifics of the bill You know, I heard from David, you know, he chose three year initial initial commitment order mostly because Mental illness can wax and wane over time and can be episodic and He really wanted to ensure that there's adequate supervision of an individual before any sort of Discharges being considered That Could be I mean it would be that three years would be consistent with Kind of the least restrictive setting necessary so that could be Order of hospitalization or non-hospitalization Pepper does the does the waxing and waning Is there data that Is being drawn on for the three years for that or could it be two years? I I don't know specifically why the three years was chosen other than you know, there was some talk about in New Hampshire You know, kind of what other states are doing. I think Three years was chosen because David Cahill felt that five years would probably be not be something that the legislature would approve and he thought maybe he'd start three years and see where we go You know from 90 days to three years and that There's no magic to any of that. Yeah, that's that's just my concern is that we're we're Three months to three years, which seems like an amazing jump if I Take the point about wanting to see a patient over a span of time Three years when they've been found innocent by reason of insanity or not guilty Seems contradictory Are they no longer a danger to themselves or others That's not part of the I mean somebody could be 90 days it could be 25 years No, I get that but I mean at 90 days. They're not They're not let out. They just have a hearing, right? So I mean in miniature it's like the argument we're having over life without control right well in human house System you have hearing every six months now Reviews yeah, yeah, it's every there's a review every periodically Did it turn away the juvenile should stay? We still be Talking about is really where the rubber meets the road and this Is at what point? You know if DMH is saying or a clinician is saying this person's no longer in need of treatment at what point do You rely on a criminal court judge or a victim or anyone to say okay, but there's still a public We need some supervision over them and then the question then becomes they remain in DMH supervision Or do they move to another suit well you? Inadequate supervision from local mental health agencies yet and by that I mean the designated agencies Right not DMH So the designated agencies Person released from DMH Right the other questions I mean for us again the I Mean the notice question is central to What we would like to see Change the law notice to the victim whenever there's a termination or a downgrade and You know that would offer the state's turning the opportunity for more about public safety aspect of the case So I you know again I Don't think anyone's wedded to the language in S183 But I think it does the solutions that propose it's more important I think to look at the gaps that they're trying to address not necessarily How they're close how this bill closes those gaps? I can say that the memo that is being delivered is written by one of our deputies who works very closely in this area of the law and He was on an order of non-hospitalization study legislative study And proposed this this Kind of state the issues Proposes some solutions And it's all contained Question So our Convict our people found Incompetent to stand trial in things other than murder and homicide So Are we talking about anybody who is Founded competent to stand trial by Because of Mental incompetence Or are we talking about only those they have That I have here that we're talking only about murder homicide people, right? And I think this bill was designed specifically to address the situation in a Windsor Which is not even competency. It's really just people are not guilty by reason of insanity for murder or attempted murder which I think There's a there's a jury finding first that this person did this crime beyond a reasonable doubt And then there's a question of whether they're absolved of liability because of their sanity and so you know, I think for David Cahill that's kind of the pinnacle of the public safety interests people that are committing murder and yet They can't appreciate the criminality of their acts So we're talking about people who were found not guilty by reason of insanity That's what the homicide or attempted homicide board Incompetent to stand trial. We're not talking about that in this bill. I'm talking about it though. Yes I'm talking about that is that that's another gap that right, right, okay So in this bill though, we're it's only those very narrow very very narrowly addressing a very Increasingly rare situation Shouldn't say increasingly just a very rare situation. Okay Okay, oh, I'm sorry. I was gonna say You you phrased it as they were they were found to have committed the act but then they were found not to have liability because of their illness you know that to me seems an important finding the jury and one that can be frustrating I think for The prosecution can be frustrating for for the system in general But it seems like and I remember David Cahill's testimony and oversight It seems like an attempt to sort of Say well, the jury should have should have decided that some years And and really to my mind once that decision is made the person is more a patient is more a medical case So I'm personally not disturbed by the 90 days But I understand the desire to increase that but three years seems a long time for somebody who's found not in your words Have my ability for the crime well, but they did decline right but this says No less than three Yep And it's not necessarily that we're looking for a punitive Response we're looking for supervision It's not it's not we think that this person should spend some time in jail It's that we don't think that there's adequate supervision of this person When he if they're downgraded from an order of hospitalization to an order of non-hospitalism And I I see what you're saying. I guess the difference between the hearing at 90 days and the hearing that three years Would be zero it would still be medical professionals sitting down and making a determination The only difference is that we're saying we're not going to draw on your expertise for three years Right, and I actually I think you'll hear from other witnesses I think even with that three-year initial commitment order there would still have to be reviews throughout It's what they couldn't be they could be downgraded. They couldn't be the commitment or couldn't be Thank you The commitment they could be down there You're still being in the custody of the Department of Health, but it could be in How can they be in the There in the community Oh Is that an order of non-hospitalization? But the general is now managing his portion Record math laria defender general When this bill came up or the draft of it in the summer we Said about doing some research and I passed this through a Pelican vision. This is actually an area of the law that was regularly in court I actually you know you hate to declare yourself an expert in any particular thing, but I was involved in some of the more High-profile and difficult Mental health competency and sanity cases that had gone to trial in Vermont over the last, you know 20 years or so and the thing that I have found routinely is that The vast majority of lawyers have no idea what they're talking about when they talk about this area and Everybody else knows less than they did and And as a result, it doesn't surprise me that when the proposal came forward It's almost as though Dave Cahill sat down and wrote a wish list of what he would happen without doing any legal analysis at all and my appellate division was Very excited at the prospect of this bill potentially passing Because they would love to up their win percentage in a in a significant way For all of the constitutional violations that are contained in the bill And I'm going to go Down the night tried to have like nine pages of stuff I wanted to talk about but I've basically been able to Get into about Large large print so that I can see it about two and a half pages and I can list The various elements of the bill that are not legal under the United States constitutional law and Vermont constitutional law Okay And This doesn't go really in the order of the bill But it goes into an analysis that a lawyer would look at the bill in Making decisions about it the first unconstitutional part of this is it this creates a Quote of a public safety hearing All right, the US Supreme Court in case called Addington versus Texas in 1979 Said that if you have an involuntary commitment procedure You can't just look at the state's concerns about public safety You have to balance it with the rights of the defendant in the case and what they're What they're interested in in being released given the status of their health at the time The other thing that that's so that's the first issue the second issue is essay 183 unconstitutionally puts the burden of proof on the proponent of release in fact the state and this is a case called Jackson versus Indiana in 1972 case the state has the burden Must always have the burden of proving that the person is in continued need of treatment under the definition And that Under the definition that I can talk about later But that the proof has to be shown by clear and convincing evidence which leads me to the third constitutional violation that This bill has an unconstitutional standard of proof It talks about preponderance of the evidence with the burden being on the person seeking to be released Basically the moving party in fact the state has the burden of proving as I said in Jackson versus Indiana and and that that standard has to be by clear and convincing evidence It's a constitutional due process standard But the fourth issue Is this unconstitutional mandatory minimum commitment of three years? Jackson versus Indiana again Talks about due process requiring that the nature and duration of commitment Relation to the purpose for the individual is committed. So if they have a mental illness that waxes and wanes if they are Involuntary either treated voluntarily or involuntarily and they are no longer a danger to themselves or others Their their release has to be available to them or they have to be held in the manner that is the least restrictive environment given the status of their Their mental illness Good question, there's a case called O'Connor versus Donaldson that was in 1975 and there's a Vermont case state versus mayor that was in 1980 case and What they did in these cases they took evidence about The amount of time where you could reasonably expect to have somebody Received some amount of treatment and be subject to review like there would be enough time for a change So they based the 90 days Although it's not perfect in every case that 90 days is actually a constitutionally Determined amount of time based upon evidence that they had at the time Where mental health cases? Show improvement with treatment during that period of time now it might not work And in fact, there's another issue here, which is it is not a mandatory minimum All right, it's a mandatory maximum before you can have review All right, so the 90 days if somebody was Couldn't go better immediately in 30 days that could be an early petition But you can't say even though we have an early petition. We're holding 90 days the nine the mayor case in Vermont talked about They use some some nice Latin language that always drives people crazy, but basically what it says is indeterminate does not mean That it is You talk to the statute talks about indeterminate amounts of time But the stat but it was established as 90 days being based on evidence a kind of a therapeutic period where review would be determined And if the condition that subjected the person to commitment no longer resists or exists then you have to hold them in a Civil confinement that is the least restrictive alternative given their current situation There's this never been challenged And I can tell you why it's a very similar thing that if this bill were to go through in Vermont I'll take a Detour for you. I we have a list of defense lawyers. We have 300 and something people on it and I put a Question out to me said look how many of you folks have ever had a Attempted murder or murder case that went to a jury verdict that resulted in Not guilty by reason of insanity. You know what the number was? zero And I'll give you an example one of the renowned cases in Vermont was one that I tried in Rutland in the mid 90s And there's a long history that is I think confidential, but there's also the public side of it I tried the one of the Ron Bean cases in Rutland and He was charged with kidnapping and I think of originally attempted murder and and the like we did a 10-day trial and And I was using insanity defense This will lead to two other issues that you'll you'll see as we come through this Experts on both sides. Everybody agreed that the guy had a major mental illness the question was Competency and there was an issue of sin competency at the time of trial whether it's common actually go to trial And then there was the issue of sanity at the time of the offense and there's some lurid details in the offense, but the bottom line as we tried this case for 10 days and Lots expert testimony expected the jury to be out for some amount of time When the jury went out I actually I got in my car to go through the Burger King Which is about five minutes from the courthouse at that time and while I was in the drive-thru I get a call on my cell phone that said hey the jury's back. I'm like, huh Well, they must agree quickly. Well, I guess so I come back there. I'm not he's guilty on everything guilty on every single thing During the trial by the way We had multiple requests for competency evaluations, which were taking place We had doctors who are still working in the system now who said yes, the man is actively psychotic But the standard is so low for competency To stand trial that we can't say that he's incompetent to stand trial because he knows who you are He knows you're in a courtroom. He knows he's being charged with stuff And even though he's actively psychotic during the trial We're the you know, we had people disputing this on both sides, but The the psychiatrist He said no, he's he's competent to stand trial This is a guy while I was trying the case. I was surrounded by A u-shaped table With black draping around it and during the trial. He was handcuffed behind the council table and shackled so he couldn't move All right, and during the trial he was calling out to things he was seeing in the courtroom Which were obviously not there dragons and devils and various things and and shouting out and barking and doing various stuff like that and We were behind there so that you know, he was chained up so that the jury wouldn't know that We were covered by the black draping so the jury wouldn't know That he was chained up during the trial But you can hear clink clink clink all the time in any event The couple of things came out of that case Because it was appealed right he was guilty on everything And it was appealed and two things came up Number one is that you can't it wasn't established at the time in Vermont, but you can't raise an insanity defense without the consent of your client It's the client's choice not the lawyer's choice All right There are a subsequent case and that's the state versus being case. There's another case state versus tribal went up and down a few times also And I advised the lawyer who was doing the case at the time I said, I don't think you can do this who also tried to diminish capacity case Contrary to the wish of the client and also fine and in that case was also fine You can't use a diminished capacity defense or a sanity defense if your client is found Comvident to stand trial they have the choice whether or not to raise or waive those Those defenses Which is strange because if they're No, it's not Component to stand trial if they are found competent to stand trial They make the choice about whether they can do diminished capacity at the time of the offense or sanity at the time of the offense All right, which is interesting was interesting to me when a guy was actively psychotic yet confident to stand trial but making decisions about whether or not he was going to raise an insanity defense or a Diminished capacity defense That I've been said two weeks after the trial I was walking down the street in Rowan And there was a guy who worked in stockbroker's office who happened to be on the jury And he makes a point of coming across the street and grabs my eye And he says Matt Matt you did a great job with that case the other day. I'm like Well, thanks. I didn't quite didn't quite feel that way because you know the guy's looking at You know life sentence and stuff and he's like yeah, he goes that guy was crazy. We're never letting him out Well, you wonder why an insanity defense by a jury in the collective memory of 300 and something lawyers and I tried hundreds of cases over the time that I was trying cases and I did big cases Did thousands of or hundreds of DUIs, but they were you know, I did murder cases. I did sex cases I did all of the kind of the worst stuff that you can you can think of Richard Rubin has been practicing a lot for 50 years When does insanity raise itself insane at the time when This the court's expert says, yeah, that guy was insane at the time When the defense expert says, yeah, that guy was insane And the state doesn't have anybody to say he wasn't but that's that's when it comes back to the reality That is the reality as a reality as a state senator When you have the public Concerned about dropping charges against three individuals by one state attorney, and then you have the Windsor case That's the genesis of a bill. I Have no ownership. I don't care what the bill looks like as it comes out of here But I think we have an obligation to address the concerns of the public Regarding public safety when those cases are done like that I don't I'm not here to criticize the state attorney in Chittendon County For dropping the charges. I as I understand that she felt she had no choice, right? And and I respect that but the the public Sees it as you know, somebody got away with murder or attempted murder. They're wrong Well, I want to point out a couple of things Well, I actually want to point out something in your bill that actually shows why people don't seem to get this stuff Right in the in the preamble statement of purpose of the bill right Throughout the bill there are various places There's all right this bill proposes to establish a three-year initial commitment period for persons adjudicated not good guilty By a reason of insanity for homicide or attempted homicide You know what homicide is? Killing of one person by another person Homicide is not a crime Murder is a crime All right, and we go through when we go through murder has certain elements. All right Well But it's a it's a term of art it means something different in the law So when you go through and there are portions in the bill that talk about a time of homicide attempt There is no if you go through our bill or a statute there is no crime of homicide What people see is the result they see the homicide and they are appalled at that And they feel like there's no in their mind. There is no difference between a homicide and a murder But the law recognized difference between a homicide and a murder Okay, a murder is a crime a homicide is the act All right, so All of all the homicide describes as one person killing another Justifiable homicide. There's homicide by people who are who are mentally ill and insane at the time Which we don't hold them responsible for under the law because they're ill There's homicides when a two-year-old finds a loaded handgun and mistakenly shoots a brother mother Whatever it is. Okay, and so you have one person killing another person, but we don't hold those people Responsible because of their mental development because of their mental illness because of whatever their particular legal status is at the time Whether it is a murder Requires other elements and it includes a mental state All right, both first-degree and second-degree murder or aggravated murder And so What we're really talking about people is people who are who have illnesses We can't appreciate the consequences of what they're doing and that it renders them not legally responsible For what they did. This is what the senator was talking about earlier When you flip over into that world You have to be able that you're talking about the civilly confining people not criminally confining people and that Confinement has to be reasonably related To the time of treatment required to remedy the condition that led to the confinement that is the mental illness and our statute to comply with the US constitutional interpretation of that as defined as in the state be mayor and Citing Jackson versus Indiana and O'Connor versus Donaldson Uses a 90-day review period because that is therapeutically the amount of time that is reasonably related to determine What is necessary for people to? Address mental illnesses The I Understand what the public is concerned about and when I'm done with telling you what I only have one more major thing that I'm going to talk about with what's wrong constitutionally with the bill and That is that This unconstitutionally seeks to create separate civil hospital sort of a separate civil hospitalization process for mentally ill people tried to murder or attempted murder and In violation of the equal protection class There's a case again Jackson versus Indiana Which talks about treating defendants who are adjudicated not guilty by reason of insanity dissimilarly To other defendants by least the protection class so you can't carve out The acts and say we're going to treat these particular acts differently then if you're found not guilty by reason of insanity then the other than any other crime and The You know this so I understand the public's concern about this and there are and there are issues that need to be Addressed and I'm going to give you some suggestions. And if you have any questions, of course Yeah, so for just that last piece of So if we put in everybody that's coming out that's been toward ordered into Is that cover that piece if you put everybody who everybody that went into Facility And made so that everybody coming out Before the could be discharged Persons with you do have to treat similarly situated people similar way so if they have Major mental illness and they are put in an order of hospitalization because they're a danger to themselves or others You have to see all those people the same way Okay, I don't think you want to do that with people who are you know charged with You know retail theft and well We can treat violent offenders differently from People who exhibit violence can't you in the criminal system. What about mental health if you're in a mental health system? If you are adjudicated not Criminally responsible now you get into a different area of law and you have to go through the process of determining If you have the same That doesn't make any sense Well, it is if you have the same mental illness the same process occurs With all due respect man, that's You can disagree with Disagree with the US Supreme Court in the Supreme Court that would make that ridiculous finding that somebody who commits a retail theft Should be treated the same as somebody who can commit some murder that would mean we would civil simply confine people that you know We see them every day here in Montpelier You know our significant mental health issues are in the community and we would treat them the same as we would And what and you start to make a determination whether or not they are a danger to themselves or others Right, but that's absurd It's not a certain for a lot It's an absurd I Defies common sense Defies common sense is just like saying that because somebody has a concussion They're more likely to murder based upon Aaron and then this then the general public. I mean, it doesn't make any sense Well, no, I know but that but that's the same type of idea It's not the same idea because the issue is Somebody committed a retail theft. Do you have any evidence that they were a danger to anybody? When you when somebody commits a murder or homicide, I did it myself, didn't I? The you have some evidence that they are a danger to themselves or others by their actions So it's not the same the issue is those factors what occurred is a Fact that is going to be determined Helping determine whether or not they were a danger to themselves or others and that's a big that's a huge difference Can I follow up on that just a little bit? So if you're it isn't whether they It's if they've been Judicated a danger to themselves or others then they have to all be treated this that's that's under a Hospitalization order a non hospitalization order right all those people in that so we have that's the question Next question. Do you are you should be should it be a non hospitalization order should it be a hospitalization order and and then We're gonna in the question is are you a danger to yourselves a present danger to yourself or others? And then the question is what type of treatment are you going to be receiving you have to be treated in a manner consistent with What is necessary to cure you? You know something consistent with whatever your? Mental health or disorder is and you have to be held in a manner That is the least restrictive environment given your treatment status Right because we have a lot of people who have mental health issues who are not under either Who are not under non hospitalization orders? I'm anxious to hear what you think suggestions Well the first and easiest thing to do Would be to allow Victims and their families when someone will be placed in the community on order of non hospitalization Give them notice through the state's attorney's office and their victims advocates or by mental health Or through a mental health case worker aside That to me Is it you know, they know what's going on? You know that by the way in the team case The case was dismissed So it just like the ones up in Chittenden County So don't get her misapprehension there, but when that comes up it does seem you know Listing you when she was in Vermont in that the hospital here when we had a hospital Would routinely call me all the time and In any event I Actually, I believe as well that one of the issues is that the mental health system is Not designed in the same way as the correction system, even though they're all under the agency of human services To follow people around But for the very few people who fit in the category of Your homicides or attempted homicides that Are in the in the mental health system? I Think it would be appropriate to create a small number of mental health case worker position Charges with keeping closer track on individuals who are formally charged with murder attempt murder and are being released on non hospitalization orders or subject to Potentially the discharge even if it's a matter of you know chatting in on them because As has appropriately been said Mental health laxes and waves it a lot depends upon you know if If you were on medication or not on medication or if your medication needs to change or if you develop a toxicity to medication over time And other other factors that I'm not really qualified to talk about because I'm not a doctor But we know that people go through like we all do in our own mental health episodes There are stressors that that make us more volatile And if we have to get on a regular basis Then then that could that could help To me that those two items really get at What you're trying to get at without Violating people's constitutional rights and without upending the entire system with As I as I've indicated it's it's not like they're these cases going in trial and juries are finding people not guilty by result Insanity the only time we've ever ever see those is when there's no counter evidence that they are anything but insane at the time of the and There are two ways that happens one is by agreement, which is what the state's attorney chitin County did and the other is The way that Dave Cahill did it with the county, which is there's no We just throw in front of the judge and the judge has nothing But that evidence to rely upon in making the decision to That the person was insane at the time Juries don't respond well to this type of evidence for the exact reasons anybody even you know the chairs Position on you know, you can't treat murderers differently than other you know You look at it go. There's a dead person or more than one, you know, it's a problem We understand that response But you can't you know, you can't kind of leave it to the mob to make that decision because the decision is Invariably emotional as opposed to legal I wanted to talk a little just a little bit about section section to And I just it talks about in that in that section that there's going to be a study or new ODG psychiatric support services or fun I don't know what that means because we don't really do any psychiatric support We just we have a line item in our budget that is other personal services that a lot of different things investigators Experts Transcripts There's a lot of things kind of included Whether it's equal access to Equal access to We routinely see people popping up on the other side of cases that are the same people we hire That's you know, if it's a matter of the state's training needs more money to hire experts You know I mean, I know what I do when it when it comes down if there have been times and And I think I brought this to the attention of the legislature at the time But during the crew cases there was a lot of psychiatric evaluation going on for two different people and two different giant cases And that stressed our budget at that time but it is not That was an extraordinary those are extraordinary cases an extraordinary time And I would expect to have extraordinary stresses on the budget because of them Normally we're in good shape, but I have no problem obviously with doing that just as long as there's not not some belief that we provide psychiatric support services Because that's that's the way the that second section is written we what we do is evaluate provide the information To the attorneys and they decide with their client what they're what they're supposed to do The the the other side of the other thing about this kind of the undiscussed I'll put the room is the whole competency to stand trial issue because that's Not part of this, but I think it's what a lot of people Are Concerned about as well because the the case the most recent one that was brought back by the Attorney General's office Didn't end up being a sanity case in a big competency case now It would have probably been an insanity case if it had gotten that far Right, but you know one of the things that we find is with people who have mental illness They don't want to be found insane at the time They will they do not want to pursue sanity defenses or diminished capacity defenses and So you actually get kind of dumped into the silo Competency Matters instead of the confidence excited things instead of the sanity side of things and I Think that's why they're so few copies of that That's not my question My question was I know that this doesn't deal with competency to stand trial, but I Was really struck when you talked about the guy who was sitting in the courtroom Seeing dragons around and yet was found competent in stand trial So do we need to change would that happen again today? Okay, so do we need to change the Bar for what is how we find that's a long that's had a long standing And evolving and evolved legal rule The the standard for competency to stand trial in a criminal case is really really low There's a famous here the Colin Ferguson case in New York City where the guy went and shot up Yeah, the the insomniac standby console against his wishes in that case He described the fact that Colin Ferguson was a found competent to stand trial Given his mental illness was all he really had to know is the difference between an orange and a Volkswagen bus and What is it different? You know, it's just it doesn't take much to be competent court who makes the decision About whether somebody's company can stand trial often times It's against same kind of thing is as sanity, but you have experts do evaluations the court makes a determination ultimately Oftentimes though when it's very obvious the parties agree the state defense agree Thank you very much any comments on the forensic portion study. No Thank you The next witness is And I will urge other witnesses who are scheduled at 1030 That you are welcome to talk about the bill, but obviously it will undergo significant change So as frequently happens I And maybe For the record morning Fox deputy commissioner Department of Mental Health Thanks for having us I think what Karen and I would like to do is go through some of what we heard this morning trying to help clarify some things from the department's perspective As well as then kind of get into some more details around the actual proposal and So one thing I wanted to start with was there was a fairly robust conversation Order of hospitalization and orders of non-hospitalization Being under the caring custody of commissioner and sex like that And so we thought it might just make sense for a state just a few minutes just to explain that process And and what that looks like and so People can be under the caring custody of the commissioner of the Department of Mental Health in two fashions one is under an order of hospitalization Which is pretty clear and understandable that means the person To a hospital and they're under the caring custody of the commissioner. It's an involuntary status The other way that someone can be under the caring custody of the commissioner also an involuntary status is through what's called an order of non hospitalization and basically that's an order that says You're a person who has met the statutory definition in order to be ordered hospitalized The person has to meet the statutory definition of a person in need of treatment and then placed on that order of non-hospitalization Quite frequently. They're also a a patient in need of further treatment It's it's the most common route to an order of non-hospitalization in our state is after an order of hospitalization Not always, but that is the most common And so person is placed on an order of non-hospitalization They have met the statutory criteria of being a person in need of treatment I eat they have a mental illness as a result of that mental illness They have been a danger to themselves or others when they're being placed on order of non-hospitalization they're seen as Not needing hospital level of care anymore, but are still in need of further supervision from a psychiatric standpoint in order to Try to help the person maintain and remain connected within treatment In order of non-hospitalization Will look like Many many other Court decisions or conditions of release from a court or something of that sort where basically will tell an individual These are kind of the circumstances and the guidelines if you will of your order So while you're in the in the community you have to x y z you know thing and typical things in order of non-hospitalization that are An individual will continue to take medications as prescribed Or we'll meet with their providers on you know when the providers schedule You know meetings things of that sort Might be that you live in a particular place Or live in a place that's mutually agreeable between yourself and your community providers So In fact most of the people who are under the care and custody of the commissioner at any given time Are actually out in the community And so most people who are under the care and custody commissioner are actually on orders of non-hospitalization as opposed to orders We just want to kind of Just to level set so that people understand that if if an individual Begins to Falter not do as well Maybe start to not take medications or doing other things that Would see to be seen as quote unquote a violation of their order of non-hospitalization Then the providers can basically through the department petition to the court to revoke A person's order of non-hospitalization That's not necessarily an immediate thing When someone's you know probation for example Is is being revoked that's a much harder faster pull if you will Whereas revoking an order of non-hospitalization It's a petition to the court. It's a court date being set And testimony being heard And so it's a longer process and generally the results of a revocation of an order of non-hospitalization Resulting just a few possibilities one the order of non-hospitalization could be amended Maybe there just needs to be a change in order to help someone kind of get back into compliance with their order Frequently and the most common result is The seeking of an order of hospitalization as a result that this person is you know Not engaging their treatment not taking their medications and thus The state is looking to revoke their order of non-hospitalization One of the issues that that has come up is that when that gets to court if that person in that moment Is Not meeting the statutory Definitions of a person in need of treatment It's possible and it does happen that the judge will say but they don't mean hospital level kind of person near treatment level right now and so the revocation does not Does not happen the person remains in the community Or if the judge finds that they do meet that that criteria and the person is then or the hospitalized Yes, but what led to the bill The governor asked the Attorney general to look into the cases that was in Chittenden County and then we heard from The state's attorney and winder county with concerns about what had happened winder county in terms of Lack of notice when the person was Leaving although he he did get notice Informally I don't know what was illegal or what but that was I'm curious about You know that situation in Chittenden County Despite the governor's intervention appears nothing changed One of them died in the meantime So can you speak to that how that I'm not not necessarily those three those cases but how you deal with victims who call and want to know what's going on with so and so or So it's important to remember that the department of mental health is a covered entity We are a health care provider. So our job is to provide mental health care to people in our care and custody That's federally protected information under HIPAA. And so If we do not have a release, um, we don't share information on someone's personal information But the law does allow exemptions If this if this bill were to pass with an exemption to allow you to notify victims So for example Um, there is a kind of a catch-all provision in HIPAA that does allow if um, if a law otherwise requires But my understanding is across the country that that's it's not as simple as the legislature passing a law That it still has to be consistent with HIPAA and it still has to meet the requirements. So, um, obviously, we don't have language in front of us that I can look at but I think the agency of human services is certainly concerned about Making sure that we are meeting our requirements under HIPAA as a covered entity There's a private road of action if you violate someone's copyright. Um, and also, you know, there's there's pretty heavy sanctions from the federal government Should we violate these things? Protected health information. So that's certainly something that we are very concerned about and try to be very sensitive to So does the governor have suggestions? So Well, I think there's a Well, I mean, yeah, seriously. No, no, I I'm asking that question and I'm not trying to it's not a trick question. I'm not trying to trick you up the governor You know expressed Deep concern about what happens in Chittenden County He went as far as asking the attorney general to look into those cases um We all know where that went So my question is does the governor Or the administration that better have said the administration does the administration have a proposal to address the concerns I think one of the one of the things that we are looking at is around the concept of The department of mental health when it's in criminal court department mental health does not have party status very not Involved when it's in the criminal court system And so one of the things we'd like to try and see if there's a possibility of Is how can the department have party status while the state's attorney is remaining As part of the case as well and That that could provide an avenue possibly For some of those things like victim notifications inside I think it's a piece that will have to be discussed. We have to do a Would the administration Or if you don't know just say we don't know would the administration oppose some form of victim notification I would have to say I don't know Well, we had a plan to put something into the bill that would address victim notification I I it's my understanding my my belief that the administration Does have uh as i'm thinking about some of the different various meetings I have had around this topic Victim notification is a piece that they're looking to try and solve I think the the question is through what path I think that's on everyone to think about I think one example is the Human health system which allows us to notify victims of juvenile crimes, but they're Why didn't it be a criminal offense if they revealed the information? The Yeah, the aerobol system as well extremist protection orders here. We have a bill here When the governor vetoed the bill, but not I don't think because of that, but there was an exemption there who are Medical professionals to consult with law enforcement when they felt their patient was a danger to themselves or others So I I think there's a general interest in this committee anyway and Trying to provide some notice to the victims in here and the defender gentlemen's comments So anything that you have to offer to contact Eric I didn't mean to senator wait So when people are on orders of non-hospitalization Do we have Enough community resources actually in our designated agencies or elsewhere to actually provide What we need in terms of Working with the patients or do we need to beep up our community I'd like to just remind the committee too that the the supervision that The staff at the community provide for individuals who are on an order of non-hospitalization is treatment-oriented and the supervision is to Work with an individual to help them remain Engaged in treatment to As in an effort to help they are there them remain stable and stable in the community and so So that's the work that they do from that kind of supervision if you're talking about do they have the resources necessary to provide Public safety type supervision That's not a resource that that's not even an area of expertise that they Could engage in I'm not sure that they're different Do we have enough to even provide the the treatment? The people need Because we see our mental our designated agencies are so strapped sure that I don't know that they can I think it's tough in general. I think you know, you know, I would look to You know folks from from our care partners and others, you know You're represented as the agencies to speak a little bit about that But I'm like case managers and the folks in the community. They have large caseloads There are at any given time roughly 300 people On orders of non-hospitalization in the community That are being monitored by Our community designated agencies. So that's a significant number of folks And I think it's important to remember that mental treatment can't mitigate all threats Treatment providers are there to provide mental health treatment They can get addressed depending on your antisocial I'll do it No, I'll do it I'm sorry They were telling me there was a germinolous class out there Wow, there's a germinolous class out there That's all about his kid So people can be a danger to themselves or others for many other reasons other than their mental illness And so, you know, really when someone's on an order of hospitalization or an order of non-hospitalization The mandate, the statutory mandate that DMH has been given is to provide mental health treatment So that's really what we're focused on And another statutory mandate is to do that in the least restrictive setting So again, that's something that we're focused on and making sure that we're doing As far as the studies The department of mental health is well versed in Engaging in various studies We've been asked with many studies over the years And so we are adept at managing that So I appreciate you being having that It's not an issue In your business document that I read it I particularly note that the Vermont is an outlier, not nationally in regards to the terms of our lack of forensic systems I think that's important and also Love to know more about the Connecticut psychiatric security review board Which sounds like something else that You know, it's one of the witnesses who will be speaking later this morning Will likely be able to speak directly to that I think a lot of us have long Been concerned of the lack of forensic unit in Vermont that it does take away from It creates a lot of problems and we've been getting away with it quite a while It's coming back the longest The department We agree that you know, that's something that's been on our radar Long as I've been you know with the department now, which is going on seven years I hate to step on senator Benning's toes There is a facility that according to the governor's budget is closing But we're saving three and a half million Is available We'll talk about why I argued we should have had 50 beds back in 2011 Well, whether we should have or should But can you You said somebody's going to talk about tonight. Yes, that's good. Yeah My right. So you really like to let us know I Love the jury. Yeah. No, that's fine We'd like to just address a couple of pieces That were in in this bill And it kind of loops back to this this conversation so As far as the three-year initial commitment Make minimum You heard the federal Speak earlier about the need for treating individuals in the least restrictive environment That we have both federal mandates as well as Vermont statute to treat individuals in the least restrictive environment possible for mental health needs and the contemplation of a three-year a minimum of a three-year commitment Flies in the face of the department's ability to treat an individual At least restrictive environment and so That just that in and of itself brings up concerns for us in that it potentially places the department I think I said something similar to this back in July-August when joint justice oversight committee met To first talk about this that having a a minimum of a three-year commitment Puts the department in an untenable precarious position of either being in violation of this law or in violation of federal statutes federal regulations and So someone's either going to arrest us or sue us in the end Could you just clarify the Precise Conflict? Sure. Yeah, we have in the state law with act 79 codified in the state law the department of mental health was Provided treatment in the least restrictive environment and the funding stream that pays for the federal Medicaid funds that are Supporting the the state hospital as well as much of our patient facilities receive federal money The cms regulations also state that An individual in order to be in a hospital must Be actively receiving treatment must need be in need of actively receiving treatment if they are not in the Abactively receiving hospital level in care. They must be discharged Or the goal has to be to move to that next lower level of care In order to treat someone in quote the least restrictive at least forceful environment. So it's the minimum itself Producing Correct, but and saying, you know, if it was a minimum of two years still would rest in the same same conflict And such and so that that puts us in into this piece and As far as being in this kind of position where We're down one way or the other But do you agree that the minimum of 90 days we currently have It was does not violate that Because of what the defender general is talking about It could be up to two years. It could be up to I mean I'm going back to the maps and then we'll test them out a little bit, but The up to is the thing that's missing So if if you're talking about the language changes to an up to three year commitment Because the important piece is that the treat the treaters the psychiatrist Says no longer need and treatment need to be able to have that ability to But actually a reality it could be up to 50 years Well, if you set up two The person who is If the department feels that the person is in continued need of supervision That supervision could be up to 50 years. There's no Per limit. It just needs they still need that service Am I correct in that one the current system? So I mean I'm wasn't being I know People like to take anything the politicians say and use them against them in a court of law And I love that about the system. I see what's happened to poor bernie and poor elizabeth and poor joe No, it just it's incredible. So what I meant was There's no limit to how long somebody could be held Based upon their need for continued treatment, but if the burden is on you not on them You might say could be asking me like I'm in order of non Yeah, the burden's on you to continue that hospitalization or whatever and that is how it's currently set up The burden is on us to reapply to the court to say this person is Meets the statutory definition of a person and you have continued the question then becomes Your competency to determine how long that person needs that Goes back to max comment that if for mental health case worker decisions to provide services in the community That might include making sure the person's still taking their medication or if they're not That's an interesting concept. Uh, it's a it's a new proposal. Uh, first hearing of it, but uh, definitely wrote it down Not like the governor supposedly yesterday to embed mental health workers in our State police parents, right? But how would how would that? I'm trying to figure out how that position would be different than the case manager that's working with We need more case managers because it's the case manager that would be saying to turn working with the patient We don't need separate positions to work Apart from the case managers that are I don't understand how that those positions would be integrated into the care of the Of the person with their case manager Maybe math can explain that to me later But I think that the idea is that somebody has that responsibility to continue I think part of that that conversation then comes back to what we're speaking about earlier, which is Let's say in someone in the community They're violating their order of non-hospitalization in some fashion Not meeting with their providers or something of that sort But in all honesty are doing well And not in need of hospital level of care Then what? Well, that gives the case manager would determine whether they I guess my my concern is from the department's perspective going into an order of non-hospitalization seeking a revocation of that Order because the person is violating that order, but not necessarily a person in need of hospitalization What do we do with that individual? Do they remain in the community from the order of non-hospitalization? So we will be The bill If you have suggestions to contact there I just also wanted to know that there's a supreme court case for 1999 That's on point Olmsted, which talks about the unjustified placement or retention of people in institution constitutes a form of discrimination Based on disability. I'm sure it's something That if legal later dr. Bt got to speak about they would So just wanted to put that out there that you know putting this kind of artificial time limit also not only goes against I would say state law federal law, but also It sounds like no one's contested that And I think the the other piece that we wanted to just make sure and comment on was around Having public safety hearings Again the language in here speaks of basically After presenting the case that the judge feels that you know the person is no longer a danger And the department is seeking a discharge and the judge would then say okay We move forward But if the judge felt that we did not meet that burden And that the judge still felt that an individual posed a threat To public safety that the judge would stop the department from that discharge That comes back to that same point I was bringing earlier that by having a judge say you have to stay in the hospital But a doctor saying but they don't need to be here Puts us in that again in that untenable position of either violating this law or the federal regulations and federal laws Kind of guide us Well, um, I'll say again I think we appreciate the the tenor and the kind of direction if there are suggestions for eric or katie And redrafting it's appreciated from the department Effort to kind of work together here. Yes, something that addresses the problems that So we're going to take a break Southern part of the state We have somebody who traveled all the way from marlington, but he stays here from time to time That's in the southern part of the state for those of you who are not familiar with the southern part of the state So commissioner Interim commissioner Baker Good morning. Good morning. Good morning. It's good to see you all So you My third week. I'm still here, sir How many days left? I'd have to check with my voice I'm making track of it. I'll let you do our second Um, we're I know you're you're busy with a number of other issues, right? And but we're trying to And these thoughts from the department of corrections, and I know you have an mo you or the department channel of the long-standing issue People by default at the your department Frequently would be more appropriate Supervised by other department Correct. So, you know looking at the bill, you know Correct, I see is is very interested in participating in a conversation around the issue of doing folks Who have acute mental health issues? And where they where they should be housed and You know the position of corrections is that you know meeting with medical staff yesterday and getting briefed up And I'm probably about an inch and a half deep under something To this point. I did spend some time with the medical staff yesterday The medical team gave me up to speed on The services they were providing facilities and the number of games. This is not accurate. It was just They would estimate the folks that are dealing with the mental health side would estimate That we probably have in our population now probably 50 folks Who have acute mental health issues That at a given day prior may not have been inside our system So my My advice to you is from corrections point of view As you start Going through this bill and trying to figure out how to deal with the issue that's in front of you Is that you know, our prison system is not the place to have folks That have acute mental health issues for a whole host of reasons Um, primarily yes, you could Build in a system where treatment was built into that process but You know inside our facilities The day-to-day operation of facilities is about security of facility And then the support stuff that comes along with that and it becomes challenging to blend in When you have a high need person That needs that high level of treatment And uh, you know, so for us Having that population to blend it into our existing system Would be a real challenge and i'm not sure we'll be in the best interest Of the individual who needs the treatment We have an estimate on what the average number of people in this condition and position are When you say condition you mean acute acute and yeah, I so often they're in your bed space. Yeah I think you know, the staff told me we we probably howls right now about 50 folks that they would consider Acute need acute care So I can't give you, you know, what that would average out to out to be but you know, that was the conversation as of yesterday Are many of them being held that you may not know, but I wonder if any of them are being held without bail and they're not sentence population My sense of the conversation This is where I was My sense of the conversation yesterday senator was it was sentenced by I know that there are a number of people nationally there is studies that indicate That people with significant mental health problems who are held in prisons because of Whatever crime they're the ones that are held the longest As compared with the rest of them that are held on bail conditions Now there are obviously there are some people who are held without bail because of a murder charge or whatever and they're You know, they're they're know they're going to get time served or whatever And so they're not that concerned but in the And generally those that are held the longest are those with mental health problems because there's no other places We're correct And that's a sad use of our corrections beds Yeah, and that's really what I'm talking about Especially as we you know as justice reinvestment moves forward and we start thinking about Rethinking the way corrections operates in the state You know that that just makes I mean the population we're dealing with I've heard you know We've talked about this in the short time I've been here. The population we're dealing with is very challenging You know with between the opiate issues and you know, sometimes it's hard to figure out Is it the opiate issue that drove the mental health issue? Is it the mental issues that drove? The the opiate issue is hard Hard to deal with And so the population that we're dealing with Inside the facilities looks much different than it did five or seven seven years Eric, I wonder if there's a way of working with the council of state governments Instituting the stepping up provisions That they have is that it's a county The problem is in the stepping up program is a county program that it provides Work to try to keep mentally ill out of jail who are charged and then they Um the county's because the county jails and you know because we're a unified system It becomes the galt institute. There is a mental health court in chippin county at things still But there's nothing anywhere else in the state And it seems to me that we're missing at least From a policy standpoint that we should be looking at better ways to deal with this problem Even before and so I know that I brought that up at the board meeting in savannah and said that they were working on something for I think it was Could you yep They're here today. We're gonna come check on it too. Okay. Yeah, we're have our working group this afternoon Senator that gives our final working group Follow-up on something like that So I I as part of this bill. Yeah, I need to get clear on different terms. So when you said that There are approximately 50 people in prison who are needing intensive care mental health care That's different than the population that's under that's been Not found guilty because of reason of insanity and are under the supervision of the commissioner of mental health so that None of those 50 are these people Correct because they're already in prison. So we need mental health services for them But that's a different population than we're talking about in this bill. Okay Years ago when we were over at springfield at the health center to confuse it further There were people who had significant mental health episodes And the staff at springfield were trying to get them into A mental health facility temporarily to deal with the With the episodes And the difficulty one of the difficulty was if they got better While they were waiting they didn't get the I mean it just was The logic wasn't there and they were Frequently assaulting staff and other things Because they weren't being dealt with appropriately and so I think The corrections developed a mental health unit at springfield I'm not mistaken and again, you know, I know you're I know there is a facility there right right and we tend to But that's that's not this group that we're talking about in this bill, right, correct But but my point is that I think the group you're talking about in the bill Takes it to a whole new level Even above with what we're dealing with now which Again, our system is not it's not the place to try to You know assist those folks with their challenges And against senator what I get I have to be careful because again Um, I think I think I answered it right for you because the difference between Someone that's found insane priority going to trial and someone who You know, uh was insane at the time of you know deemed insane at the time of defense I'm not really clear out all that language right sitting here right now. Okay. Yeah I get that. Thank you I mean, I think the hard part is, um You know granted these people are in the prison system But in fact, if there's absolutely no place to go it's safer for them there and it's safer for the party I mean, we've got to figure this thing out. It's terrible. We've been on it for years And we can't figure it out Or we could maybe figure it out, but don't have the money Well One of the ways that other states are dealing with if I just mentioned that is to Diverting people before they get into the criminal justice system Into mental health courts or other vehicles Yeah, you know through chitney county. I guess you got a shot at it. If you're any more else, you don't Yeah, I mean those those hospital meetings you go to them and they they told horror stories of First of all, we got to get the sheriff to give the person a ride if it's if it's uh, Other than the person willing to go voluntarily And then the bed gets shut off at nine o'clock or the bed is held for them to get the patient there for several hours Right, I heard that till like nine in the night and then the bed We heard that yesterday. There's seven I believe that they're around for a retreat. That's the policy that they You mentioned it We have the Expert on the retreat. Yeah, you know the patient the patient mixes bad. So they want to take the patient so right I mean I understand that but You can't put a 17 year old who's um Going crazy The issue was the sheriff was late getting there It was after nine o'clock and they said no, we can't take because they can't do an Appropriate assessment and admissions process, you know, they see the problem started in the hospital the night before In the local hospital in 94 And then they finally find a bed for the person. I think this is the wrong witness Yeah And this isn't connected to this bill Are there any other places of no places for people to go, but thank you commissioner. I appreciate it very much. Thank you So now you you've solved everything for us Thank you. Thank you. Thank you Thank you Here from uh, dr. Ribbon The dr. Bolton are both here They came from brattle bro, and I don't know if they want to come together or separate They talked to each other. Oh, you're from middlebury. Well, I was told that you were both from brattle I know where middlebury is I Very good. Um, thank you so much for uh, giving me the time to speak with you Um, and share my thoughts about s183. Um, my name is simcha raven I'm a forensics psychiatrist. I live in putney Um, I'll share a little bit about my background I Putney. Yes, honey, you know It's out of this world. Yes, regarding We've already talked about good swimming holes. I won't give directions. Yeah Um, I serve as the president election of the vermont medical society Those of you who don't know senator white lives in putney. That's why all the pay no attention Is just continuing Um, important important geographic distinctions I I also serve on faculty at Yale university school of medicine and the division of lawn psychiatry for the past five years and My clinical focus and specialty is working with individuals with mental illness and violence history Um, and or criminal justice involvement And I've worked in a number of different settings in vermont in massachusetts And the vermont medical society has identified forensic mental health as a priority And we share your dedication to improving forensic mental health services and infrastructure in vermont Um, so i'm a forensics psychiatrist. I'll tell you a little bit about what that training is Um, it means I trained as a physician Then pursued four years of residency training at harvard medical school to become a psychiatrist Uh, a specialty which focuses on cognitive psychological and emotional health Um, I completed an additional year of training specifically in forensic psychiatry at Yale university And forensic psychiatry is a specialty that focuses on a number of different things It's kind of a large umbrella care of individuals with mental illness and justice involvement Violence risk assessment and also psychiatric evaluations for courts The topic of s183 strengthening forensic mental health infrastructure in vermont is so important and timely I'm so deeply grateful to your committee for taking this for taking this on This work on this vital issue In my work with level one patients in vermont, um, and I've been at the Brattleboro retreat in various different roles, uh over the past several years Um, currently a senior medical director prior as interim chief medical officer Um, but my colleagues and I have recognized a number of areas where we can improve our systems of care For people who experience mental illness and have criminal justice involvement Um, and I have a number of comments on the proposed bill I can also, uh, outline a bit my Experience with the Connecticut psychiatric security review board Which is a model that I I think is a useful one for us to look at So my first comment is actually on the three-year proposed initial initial commitment period And I have some concern about that, um, for insanity equities Um, I think that the need for inpatient psychiatric hospitalization Or community-based treatments should be informed by clinicians That, uh, it's highly individual what each, uh, individual person or in this case Insanity equity would need clinically And a blanket commitment Um, I It's would be Both complicated and confused the role of physicians in hospitals um, uh My concern and this this this comes up from time to time is when somebody has improved to an extent that they Can be transitioned to the community Um It essentially makes jailers of physicians and hospitals to hold them when they don't require the treatment, uh, the treatment context any longer So it's practically and ethically very complicated To have someone particularly committed to a hospital Inpatient context when they could be transitioned to the community particularly with with support Um And that that break, yes Yes Completely different position I understand that position and that's quite frankly the the law that we have now yet We heard testimony this morning from the defender general That a lot of people who go through a jury trial are found guilty Yeah Because the jury doesn't want to see them out on the streets And I suspect a lot of the reason that we might have 60 Or 50 people sentence population with acute mental health issues Is because this idea that the mental health system can't adequately protect the public So you have and I completely understand your position as as a physician and you know, this person is now even though they may have committed a horrific crime Is now a mental health patient and it's no longer a criminal That's you know, that's how our system works. That's how we've developed it But in reality, we have this other problem going on So that I just need to point that out I agree with you entirely and I've uh experienced that sort of gap that if someone No longer needs treatment. We don't have a mechanism for Either monitoring their safety in the community or additional specialized supports For people who have demonstrated violence when they are symptomatic with mental illness. I agree with you entirely and I struggle with that Um, actually my next point was really how we struggle with that Um, I'm sorry, maybe I don't Oh, no, I agree with you and I think that's the crux of the problem Um And puts clinicians in a difficult position because when we're treating people in an inpatient context And we say, okay, this person could progress to the community Especially for people who have demonstrated Violence when they are symptomatic with mental illness I believe they do need oversight in the community. I think that the Connecticut psychiatric security review board is a good model for that. It is an independent An independent board That is neither mental health clinicians nor corrections And the position that we're left in now is sending people into the community with Without the clinical specialized clinical support and without that kind of oversight Um So I think that the the point where we need more resources is not and more time is not necessarily in patient setting Though some people may Need to be in an inpatient setting for long periods of time. Um, that's an individually determined Um The psrb structure I think is one that could be really inform us And the psychiatric security review board in Connecticut and only Connecticut in Oregon have that kind of structure Is a state agency to which the Connecticut superior court commits people who've been found not guilty by reason of insanity And that's all insanity equities Which are usually for Serious offenses But not exclusively homicide And they review the status of these individuals regularly While they reside in a hospital And in the community and oversee Their movement in the community and increasing autonomy As their treatment needs change And generally oversee release from the jurisdiction of the psychiatric security review board And that board is composed of a number of different people representing a number of different disciplines Attorneys representatives from probation and parole victims advocates Mental health profession professionals. There's a psychiatrist and a psychologist And member of the public So I think that's a model that may that would help inform us Um and something that that may be helpful for us to address where I I think the A lot of our difficulty is in People's oversight and access to robust treatment Uh in the community who have been found not guilty by reason of insanity Do we have that model in In our packet and we don't but I just do the Peggy can google it. There's a whole mission our board members and staff Okay, it's going to do that. And reports victim information training. Yep. Okay. I'll Actually Peggy, maybe you could That's it's the portal Connecticut dot gov Well, I think you've just googled Connecticut psychiatric review board that Has a mission statement that might be helpful to start with To protect the safety of Connecticut citizen by ordering treatment confinement or conditional release A person's acquitted of a criminal mental disease or the effect And as the what is this idea after review board? I think that would probably at least get us there here I don't know how to make that print You can make it print I have a few other comments I want to make sure that you've got the right resources To research that I I wanted to comment S183 outlines that the court would assess an insanity equities risk to public safety And I wanted to make a note that forensics psychiatrists and psychologists have formal training In performing violence risk assessment Which is a process that involves clinical interview review of records and Use of standardized instruments And I would recommend that a clinicians violence risk assessment inform the court's Risk assessment of an individual that that's a very helpful and comprehensive Process that forensic psychiatrists and psychologists undergo to look at violence risk I wanted to bring up another issue that Has been discussed a bit this morning in the discussion of orders of non-hospitalization and that process And that's a mechanism for re-hospitalization Of individuals particularly of individuals who have been found not guilty by reason of insanity These are individuals who demonstrated for the most part have demonstrated that when they are symptomatic with When they have symptomatic mental illness that they become violent and aggressive towards others so it's a very narrow and specific population Um, and I think we need a mechanism To re-hospitalize this narrow population more quickly Than the order of non-hospitalization, which is a long process allows for And a mechanism for these individuals to have hospital evaluation and treatment Uh, even when they don't reach threshold current threshold for involuntary and patient treatment This is a very narrow population Who we know by definition has exhibited violence and aggression Um, and uh In that vein, I wanted to make a comment that Um, in my work with people who have been found not guilty by reason of insanity Which is both of assessments and clinical work treating individuals who are in sanity equities I've um Worked with people who have had uh, essentially are Um, been found NGRI for a range of offenses Not just a homicide or attempted homicide But arson, rape, attempted rape, and I think that Defining the population for the purpose of this bill, bill more broadly Would be would be logical given But there are other serious offenses that I think would people would benefit from greater treatment resources and oversight And my last point is on the forensic care work group Which I think is really a wonderful idea and I thank the committee for this What I would Recommend is to have resources allocated to Assembling this work group so that we can have robust input From individuals who have expertise In other models that can inform us And that that would Create I think a process And a report that would be Really enormously helpful for us, isn't it? You stand important for Vermont According to one of the documents we got from the Department of Mental Health Indicates Vermont is unusual and that it has no forensic Facility you think that's a endurance in your work. I do. I do. I think that specialized Hospital environment for people who are broadly defined as forensic patients So people who have been found not guilty by reason of insanity People who have been not confident to stand trial specifically And then often people who are in corrections but need a treatment environment that can only be found outside of corrections That having a forensic hospital or forensic unit That's specialized in that treatment Is unusual that we don't and would be a real benefit to Vermont if we did Do you know traditionally Other states that's under the Department of Mental Health and the Department of Corrections? Um, I think it varies I think that having that contextualized within mental health rather than corrections Makes sense given that It's an area. Uh, it's a treatment facility And we need to especially when people have been found not guilty by reason of insanity. We're looking at ways to safely treat individuals and Support them Both in the hospital and in the community, which makes communities safer Senator white do you have any sense and this might be an unfair question for you, but The number of people we're talking about because When um, senator benning asked the commissioner How many people in our prison system needed mental health care? It was about 50 and then We were talking about how many people are, um A significant mental health. Yeah And then when we were talking about earlier about the number of people who are being held, I think It was about five I mean, what what what number are we talking about here that we need Some kind of a unit for so I can distinguish that that's a separate separate population of people who are in corrections Right so symptomatic that they need intensive support. Right. I can't speak I apologize that I can't speak to the number of people who Seek the insanity defense I I know that in a given year, there are approximately two to three hundred people who undergo competency to stand trial evaluations Though most of those people are in the community and those evaluations are done in the community I can't speak to the precise numbers Do you see a problem intermeeting those who are cookies from The need of mental health secure facilities Because of the way they've come in to be a threat to others or to themselves Um clinically, I haven't seen a specific. I haven't seen a robust issue or a problem with having A mixed population of insanity equities and people who are struggling with significant mental disorders And without criminal justice involvement Clinically people people often need the same kind of treatment in the hospital The difficulty comes when we work Dilligently to support people in the community and transition them To have the kinds of specialized supports to do risk assessment To look at what kinds of supports people would need in the community and put them in place Thank you so much. Appreciate your testimony. Thanks. Thank you. At least a nice day to try And to you. Thank you so much. Thank you. Dr. Um Middlebury, yeah, well actually it's anasin I shouldn't know where I live. Well, it's somewhere near middle So actually my Addison town 22 goes through I'm on 17 which goes down by the bridge. They blew up So my needs peg I'm a psychiatrist. I'm a forensic psychiatrist. I Glad way for me to have a night tonight for not going to the whole thing But I my first job was a Brooks one at the SH In 2005 I went back and did a forensic fellowship in massachusetts And since then I have worked both in public mental health, which is what I've been doing until last may And I do do these assessments that we've all been talking about Confidence insanity assessments And I don't I just want to say didn't know to anything that Dr. Raven said I think that But I want to point out something to you that that I think the committee has has ferreted out We have a gap In our system of care We have our department of mental health Which holds non-coercion is the highest good. That is a that's a good thing And We have This system that places in people over ngri or incompetence to stand trial Swearly into our public system. Now. I was the doctor. I was working in power Czack Washington County too So it is so it is those folks and those resources which have been caring for the people Who are found incompetent to stand trial or Not guilty by recent insanity and who are in the community Which is A lot of them because we don't have a lot of resources in patient resources I want to support that you will need Facilities that are unhooked from treatment because there are people who continue to be dangerous Even when they've maxed out their treatment that may be a threat. That's a threat. Maybe a forensic facility We may not be able to get treatment funding for them But I also want to point out because my view is the community I've been sitting in the community for a lot of years and that's where I think We We do not have a robust system That oversees those folks with these special needs Some states Fold it into the public mental health Some states as we were hearing Valerio was saying there would be another another stream or another way to oversee these folks I'm certainly in favor of victim notification But I recognize I can't do that because of HIPAA Maybe maybe another Agency or a method would be There as well. So I think that the This expertise this looking at treating people in the community is is a place that we really need to be Others we have done some things right Maybe not meaning to but we do not Incarcerate or lock up people in the hospital when they're found when they're not Incompetent to stand trial for misdemeanor. We are not going to be Holding people too long But we fall down in Helping people in the community So I would I would advocate as putting our hands on thinking about how how do we do that? How is that going to be? How how do we achieve that? Those skills in the community to help because just taking one thing that dr. Ravin said When I would have a patient for whatever reason Doing things in the community that were scary and dangerous and we would put a revocation in There's a delay and it didn't always work We let me just say People with mental illness the fears that they're all dangerous that is not true But there are a subset of people who have been dangerous and have proven to be dangerous where we know that The standards the best standards say a quick response to a higher level of care and then continue on your treatment So there's a lot I think fighting on a lot Because we don't have anything and I'll end by saying That's why I would really advocate for a good study. I know it sounds like it's the answer to everything and money is tight But we really have an opportunity In our state to look at what we've done, right? How how we got there What we choose to do in our unique state and how we see things We're beginning to think we need to think a little differently on how we've traditionally Went out to go after this problem And listening to both of you the first thing I have is a reaction is we don't have enough of you And that is part of parcel of our problem But we also have a very limited ability to raise money to go after this problem Traditionally, I've seen people lodged in hospitals I've seen people lodged in prisons They're both in the same category of someone who is either a danger to themselves or other Doesn't matter whether they've been Crying or not They are in a cute new position And we have them located in different areas where we don't have the ability to maintain people of your professional status To address what their needs are Last night I got a call from a guy who has been Leave he said 26 years as a nurse in the hospital And he quit because he could not believe how people were being treated in the hospital as well intentioned As they are and they do service a something of the need The bottom line is hospitals are not equipped to deal with this problem in the way we should be looking at If we create a place for all patients who are in need Because they are a threat to themselves or a danger to others And there's no problem intermingling those who are acquittees with those who have just come into the system through a mental health crisis It seems to me we might be able to concentrate the limited resources we have In order to have it properly staffed with people who know what they're doing As opposed to the traditional way that we've been doing it which is Putting them in the nearest place we can find and hope that we can get enough money in each one of those places To address their problem I don't I'm the chair of institutions. I'm the brick and mortar department and I'm trying to figure out With what little we have how to get the right people in to do the right treatment at the right place So I thank you both for coming and I'm just Batten around in my own head with the best way out of this Senator white So just to follow up on that in addition to the facility. We also need More robust community for people who are on non-hospitalization orders I don't want to leave here like a Pollyanna What I don't want to be a Pollyanna here, you know, we all know we need more robust community We just had a budget address yesterday that No new taxes no new fees Tell me how we're going to do that when we have to make up And the budget also relies on just counting here seven and a half million dollars that the legislature may not agree with Three and a half cutting woods Eliminating wood side maybe we'll agree. Maybe we won't two million dollars on sports betting Two million dollars on kino and you know how well that won't last time introduced kino So, I mean Let's be realistic here in this environment that if if We are it is what it is and we need to we need to Have our resources spent more wisely. I think too If we can but senator benning's right. We don't have enough of you And if we If I say I would suggest that When we have people that are incarcerated Because we haven't figured out a better thing to do with them while they're awaiting a determination of whether they're guilty Not guilty or not guilty by reason of insanity We we are doing this service to them and to the public if they could just as well be held if there was a Some supervision in the community or wherever else That's that's how you spend money more wisely in my opinion You know, I I I've raised the issue. It's not a mental health It's a actual disability case but one in bennington that they should have known Would have known Was going to go wrong, but instead we just let him turn 18 and age out of one system and Now he's waiting You know, he's he's being held in rutherland On the lack of bail after assaulting a family member And how do you make sure that those community services are available for him? That the family will be comfortable in having him back And avoid not a mental health case It's a disability case, but that's Bennington Yes, I'm telling you because I I my first job was a state hospital and we Treated we treated people on ee entry when there was an observation and I would advocate for observation again That meant that the judge could send someone for so many days Sometimes it's helpful. I get that we don't have the resources And that's one funding stream. This is back in the day and I think That that's being a brick and mortar person I hear that and we can mix those people to some extent maybe you're going to have some people say well There's problems, but we can The problem is this funding issue There are going to be those folks who are Are legally covered Who have treatment needs They say they're treated, but again, this is I'm trying to unhook We have some some public safety oversight And that Personally, I think the doctor could use some help With that getting some either either hearings or a public review board But they need may need to stay longer than what Is narrowly defined as a cute treatment or defined as a cute treatment. So it it it's a it is a puzzle It's a huge could be done in the same facility though, couldn't it? It could because different we had the different floors were certified and uncertified at the state hospital I mean intermingle on the other hand those folks with Those people who are simply violent criminals Would you both agree that's not the direction you want to move in? Not if they're not mentally ill that becomes I mean that so That's also a moving target. I mean I would I would defer to dr. Ratton too, but Um criminals it every person has a story and Some of them are going to be mentally ill and some are and What we consider to mental illness for reasons of insanity in 1994 is different Than it is today So things change. Thank you both dr. Dr. Thank you for coming today. I appreciate it Oh Emma Harry harrigan, I'm sorry. It's started coughing in the middle of your introduction Emma represents the Vermont Association of Hospitals For the record Emma harrigan director of policy analysis and development for the Vermont Association of Hospitals and Health Systems I think a lot of the points that I was bringing today Hovered adequately by the state of Vermont the deputy general even the state's attorney and certainly dr Hobbit and dr. Bolton, but I just want to reiterate that we definitely recognize Why the bill was taken up this year? There's definitely a need for more transparency and accountability when working with forensic mental health patients We do believe that models that connecticut Arizona and oregon have Psychiatric services review boards can infuse the right level of transparency and accountability into the system and also provide a place for For victims rights rights in the whole process and provide a structure to to make sure that everyone's receiving the right level of service And that the public feels adequately protected. So To that degree, we definitely support the language In the bill looking for a study of the forensic mental health system of care and looking at the connecticut psychiatric services review board We think that a lot of good could come from And also reiterate what dr. Robin said that Having the right level of resources allocated to the department so it can bring in an independent perspective would be really helpful Where I really want to focus today is impacts. Um, there's been a lot of discussion about People waiting for mental health beds, community resources, and so I just wanted to provide a little more context to that Currently in vermont, we have about 10,300 Patients waiting in emergency rooms each year for mental health services individuals visits So i'm not sure how many are the same people coming over and over again, but yeah That would be a high percentage of models It is and it's growing each year We see changes about every year two to five percent growth in the number of visits coming to emergency What's really alarming is the amount of time they're waiting. So from 2015 to 2018 The amount of days that people are waiting in emergency rooms for mental health care has grown 87 percent From 2010 it's grown 348 percent So it's it's a problem and I think There are two you say waited you mean they're waiting in the hospital emergency room Okay, thank you So there are two primary bottlenecks in the system of care right now for inpatient care. The first is we just have more demand Then we have supply so we have 10,000 people waiting a year About 5,000 get into inpatient beds and we estimate 10 to 20 percent of those people waiting Would have gotten into a bed if one were available and they just get better by virtue of waiting so long and they leave Potentially coming back later So we have a very high demand the other issue in the mental health system of care Is that we don't have enough supply on the back end. So we have people waiting in hospital beds Not being able to access the next level of care. For example, if you have an elderly individual with With psychosis, they no longer meet hospital level care, but there's no nursing home That's willing to take them or able to take them that person waits And so those waits really contribute to people waiting even longer to get into And so for context for each year That someone takes up a bed. That's 30 To 61 people each year that we cancer who are waiting in emergency rooms. So we're very concerned about any kind of process that I don't want to say this We want processes that optimize length of stay to what is clinically appropriate So we want people in hospital beds For the right reason at the right time And any time that we have policies or lacks of resources that create bottlenecks where people can't That's less people we can serve and more people to wait in emergency rooms. So just by that concept any process that Defines hospitalization That's not defined by treatment need is a concern for us When somebody goes to emergency, are some of these 10,000 visits people that Come in and Treat it and go home afterwards or go somewhere else afterwards or they all end up staying in the emergency room until There's a bed and a psychiatric So now all of them are Ultimately going into an I would love to have more A better understanding of the 10,000 visits and the waiting list and the waiting time that this Creates in our hospitals. I mean, we all hear it from our hospitals our local hospitals um in maddox bennington just started our Program for adult for young toddlers Which replaces the going to the emergency room? That's called hawk. I think it's 125,000 grant from Not sure department mental health one care one of those one care one care and you know that it has The promise of keeping those young kids out of the emergency room And you know hopefully it works, but I'm wondering how many of those that do we need to seek some alternatives to Like that for other populations I think we do So all of those people What I get really concerned about it when we and this has nothing to do with this bill particularly since you brought it up When we talk about people needing that are waiting in hospitals I get very concerned that we immediately jump to the conclusion that we need more level one psychiatric beds Because all of those people don't need level one psychiatric beds Those are acute beds that are not meant to be for a long term what we need is A different level that's worth in my opinion. That's where we need beds not more level one So if I can address two points, um of the 10,100 10,300 people we have waiting a year We know there are about 5,000 to 6,000 who go into inpatient here Um meaning level one or some kind of any patient okay Yeah, level one is a very very very small subset. So that's we know that we also know From data from the department of mental health and people who are held in the custody of commissioner That there's a percentage of those individuals who the term would be called walking off papers Where the crisis abates the person no longer needs to be held against their will In an emergency room or in another location and they they can leave the hospital or leave that setting And that can be anywhere from 10 20 a year and also we know from some initial studies by uvm and trying to figure out How many beds to build in central romant there is also a significant percentage of people not in the custody of the state Who leave because they wait they wait long enough for inpatient care where the immediate crisis goes away and they leave Going somewhere else that other place. We don't know. So there's definitely a need for those There's definitely a need to make sure we have the right number of beds to capture people Who truly need the care at that time and also the right number of community resources to help people when they leave the emergency room Or leave inpatient psychiatric care to make sure that they don't have a rehospitalization. They have a good outcome And then because this has been a point of confusion in other committees The beds that cvmc is constructing are not going to be all level one beds So there is hopefully some capacity being built in the state within the next couple years That'll address the needs of more than just the most severely acute Yeah, I just I've always get very nervous when we talk about beds and immediately A great number of us Jumped to the conclusion that that means level one beds, which Okay I think most of my other points were covered by others I just want to reiterate that the need for psychiatric hospital care needs to be clinically determined And that we are required by both the ethics of our physicians and federal participation rules to treat people as patients first So all hospitals in vermont including the vermont psychiatric care hospital And the brow where we're treated are certified by the centers for medicaid and medicaid and medicare services Which means they have to follow federal conditions of participation That also means that given the new Structure of our medicaid waiver in vermont, and I believe in is probably going to cover this Forensic mental health stays are no longer eligible for for medicaid matches. You say no longer you mean today or next year or We'll wait for the time But that's a concern as well for because every dollar that's a concern that came up once we were discussing this bill is that It changes the equation very much So So I think in that Realm we recognize that the flexibility we've had in the past to use medicaid dollars to pay for forensic mental health is changing And that there will be some need In the next couple years to likely develop some sort of forensic mental health capacity either inpatient beds or outpatient support services and just being really Plantful about how many of those resources we build because every dollar we have to contribute towards that means it's a dollar less We can match against medicaid to provide services for all Vermonters So I think that's and I'm I'm sure you appreciate the equation But that's best I think our concerns we recognize There's a need for more community supports to balance inpatient care and to assist in emergency departments And we want to make sure that that resource is there So making sure we have the right number of forensic resources is really important Thank you very much. It's a great timing The question My name is Ina Bacchus. I am the director of healthcare before Nice to meet you all. I don't believe I've testified in your committee before As I understand you're interested in a in a fairly narrow set of information and what I've prepared for you today is Is narrowly focused on the background and for During our discussions, I think many of us have felt for a long time And The part of that When we talk about a forensic unit, what on earth do we mean? I mean that The 50 people that Do we mean the people who have been found that may be a very small group In my view what was I about people who Not guilty by reading them sanity not Not confident to stand trial. There's been a court determination that While their behavior may have been criminal, they're not guilty because of one of those two factors And so what has been happening? In my opinion is they've been taking acute care beds away from patients who have not forensic and that's And most states Forensic care now there may be people who are currently incarcerated Who have The need for that type of facility that I'm not getting into today that could also You know, we heard when we were in springfield about a certain small group of people Who are incarcerated who see need significant mental health services But for whatever reason, maybe it's what matt described the jury just wasn't going to let them off And so they just found them to be guilty even though they They knew they were you know mentally ill so that that group may also but that That I don't want to get into today. I'm really talking about separating out that group. I just wanted when we that's what I'm looking at That's what you mean by printing. Well, that's the group that would no longer be covered by Medicaid. I believe Yes, I can describe to you. So maybe we should let you do the term. Okay. Yeah I'm sorry about that I'll provide some background about medicaid our vermont medicaid program and how institutions for mental diseases have been funded up to this point Talk about what is required by our 1115 waiver as it was renewed in 2017, which is a phase down The source of funds that we were using to cover Institutions for mental diseases and I'll talk to you also about the waiver that we received in Which provides for federal fiscal participation Using federal matching funds as a part of our medicaid program Rather than the source of funding we were using to cover a subset of Institutions for mental disease for persons with serious mental illness and serious emotional disturbance. So I'll describe it I'll talk about the limitations of that source of funding and the fiscal impact Medicaid prohibits payment for institutions two institutions for mental disease First services provided to medical individuals 21 to 64 This is a part of the medicaid program that's been in place since 1965 That is a standard of a federal medicaid An imd is defined as a hospital nursing facility or other institution of more than 16 beds That is primarily engaged in providing diagnosis treatment Or care of persons with mental diseases includes substance use disorder Historically in vermont we've funded care at imd's Using a managed care organization investment This was a stream of money that was made available by our first global commitment to health waiver Which the state received in 2005? It freed up money for the state to use medicaid funds in ways that were otherwise Not allowed by the federal medicaid program to try to reduce medicaid expenditures for the whole And one of the ways that vermont used these funds was to provide for treatment for individuals in institutions Since 2017 these funds which were previously referred to as managed care organization investments have now been Renamed as investments because vermont is no longer a state-based managed care organization model And these are still available through the term of our current demonstration waiver Which was renewed again in 2017 and runs through 2021 The 2017 renewal of the waiver Also required that vermont submit a plan to phase down Uh these expenditures for the vermont psychiatric care hospital and other imd expenditures that had been historically covered by this investment category We were required to submit a plan by december of 2018 and we did so The state was also required in the 2017 renewal to propose a lower amount of imd expenditures for calendar year 2021 We haven't done this, but that is not yet approved by the federal government. We are still negotiating what that Phase down amount will be for 2021 And in 2017 the waiver renewal required that investment expenditures be completely phased down by 2025 For imd for imd. Yes for imd The proposed phase down schedule is on the next slide to give you a sense of what the state proposed in 2018 For 2021 our proposal remains 95 phase down Again, that has not yet been approved. We're still negotiating that cms During this time cms made available. Sorry Do you mean five percent? In other words, yes, okay, we would still be able to use 95 percent. Yes During the uh interim years between when our 1115 was renewed in 2017 and now cms has made waiver opportunities available to states for covering Using medicaid dollars institutions for mental disease and and treatment there vermont was awarded a waiver for Insta we were awarded an amendment to our 1115 waiver So it's still the whole same goal commitment waiver package now with an additional amendment December 5th 2019 that amendment enables federal fiscal participation Which is different than this investment funding. It's medicaid agreeing It's going to pay for these services in vermont via this waiver For short term stays at imd for diagnosis of serious mental illness and or serious emotional disturbance How many imd do we have? We have The vermont Psychiatric hospital the lund home and the brown on borough retreat Stays must be 60 days or fewer with a statewide average length across the facilities of 30 days Correct This amendment that's that's one limitation of the amendment the average length of stay another amendment to this limitation excuse me to the amendment is the the coverage for forensic patients The waivers that cms has made available for institutions for mental disease Did not provide federal fiscal participation for for forensic mental health patients And cms defines four categories of patients who receive forensic psychiatric care Individuals who are awaiting psychiatric evaluation as part of trial Individuals who have been found incompetent to stand trial Individuals who have been found to be insane at the time of the crime Were tried and found not guilty by reason of insanity And individuals who are pre-education or have been convicted and are in doc custody Who developed the need for acute psychiatric care on either a voluntary or involuntary basis Give us some kind of an average regional I I do not but the department of mental health may have that information What was the question I click here four criteria that are laid out and there's no page number on here, but um It's page seven. It's very faint. I'm sorry. Yes, it's very faint Page seven has four criteria And i'm trying to figure out exactly how many people fit into this category Each one of those criteria on an average basis. So we have something to Look at for what the need is The the amendment also doesn't provide fiscal participation for care for persons who are otherwise Not vermont medicaid eligible So that could be a variety of circumstances where an individual is treated in a Institution but is not medicaid eligible including that individual being an out-of-state resident And it also does not provide as I said already care for persons whose lengths of stay exceed 60 days Very importantly all of these limitations are in place for the federal fiscal participation That's part of the medicaid program vermont is still covering All of this activity using investment dollars Where our investment dollars are still available for us to cover these activities today I know this question Yes So the length of stay for those That exceed 60 days It is does this is this only for the highest acute patient that we're talking about here the The serious mental I'm trying to figure out if Medicaid isn't going to be able to cover anybody who is in a Long-term mental health treatment, but they're not in that Level one acute Care is that what we're talking about here is the acute the distinction is not the level one or other care The parameters are strictly around the person having a diagnosis of serious mental illness or serious emotional disturbance And the persons stay being 60 days or fewer If we say 60 days or longer Vermont will continue to cover that using investment dollars For the near term It's after 2025 that we aren't allowed to continue or we may we have we may not be allowed to continue to We've been asked to phase do planning for a phase now We still have to negotiate The 1115 waiver the next 1115 waiver And everything on the table for that negotiation However, our current waiver document does say state of vermont We need to plan for these funds not to be available starting in 2025 Just out of curiosity. I noticed the phase down goes 75. It does. What's the thinking there as opposed to It seems as though washington was thinking more like a phase down that would get you closer to zero Is that not so the The phase down that was presented was done. So anticipating that vermont should Seek to have as many of these funds available to it for as long as possible So that we could actively plan for and engage in the next phase of system design That would be able to work under a scenario with fewer funds. I understand That's correct. It doesn't It doesn't make sense meaning you would think that you would incrementally go down to zero But this was proposed knowing that we need to protect those resources that we have available today For as long as we possibly can I guess the question would be is there a plan b If you get to 2025 and you've had 75% and now you're expected to go to zero That's obviously much bigger and all the low hanging fruit will have been collected So does that mean in 2026 there's a there's a plan In the event that it actually does zero out we we are We have more work to do on in order to plan for readiness for this phase down And that's something that the agency of human services is engaged in and particularly In partnership with the department of mental health In that planning and again A part of that planning will inform our next 1115 waiver negotiation Which will be beginning Very soon Very interesting that CMS somehow I guess figures that mental illness isn't part of our healthcare I mean because If some if you had to be in the hospital for a cardiac Incident you could stay there for Quite some time and Medicaid would cover it, but It's sorry I'm sorry You're wrong Yes The next chart which is on or the next page page nine. I'm sorry for the faint numbering Is a chart that indicates the fiscal impact of the receipt of this amendment and In I'll summarize by saying that the impact of the amendment is is that now We have a total allowable amount meaning Medicaid is participating in funding about 13 And a half million dollars worth of inpatient short terms days at institutions for mental disease That means that we still have a total amount that could become phased out We need to still face out if you will 29 million 29 We were previously in total funding 43 million of IMD stays With investment dollars. We've been able to move 13 and a half million of that roughly very roughly into Medicaid program expenditures via this waiver amendment And uh, the next slide is only for your interest if you're interested in under this is of interest For others in the building certainly But we have an investment cap and so this waiver also has an impact on the amount of space We have beneath that cap to make other investments Well Thank you very much I would summon it all this information, but Uh Today has been extremely helpful In saying to all of you Who wish to continue to testifying the bill stay tuned Because what you have in front of you for a bill is not going to be what you're going to be testifying about so What I would prefer to do is work with Have the committee work with katie and Eric redraft the bill And then get that out to everybody so that they can respond to what might actually hit The floor or a revised bill here So if you'd like to testify further on this issue or follow it, please do but if I could summarize where we're at Looks like We'd be looking at a study of where the remod should create a separate forensic unit You would be looking at Something similar to what not valerio suggested Uh, we'd also be looking at something like what happened in But kinetic insistent and then also some form of victim notification may be based upon what we've What we've done in the juvenile system so that it's not over notification, but rather a Notification to the victims or victims family I noticed somewhere. I think it was kinetic and they talked about the victims of media Who is the victim of the victims of media family? It's already defined in the kinetic statutes Those are some of the things I'd be looking at maybe And up to and not a And beyond all criminal activity not just Okay, great