 We were talking about sort of the peripheral question of what we will end up having to deal with directly by way of brick and mortar. And a lot of folks have come in to talk about placement of mental health patients. We are having the conversation to let anybody talk to us that would like to talk to us. The first thing we're going to do is go around the table, these committee members, and introduce themselves. And anybody who is subsequently coming up to testify if you could have the seat where Sarah Squirrel is currently at and then announce your name and what your position may be. And just to remind you all, we are being recorded. So even if you don't like the decisions at the impeachment trial down in Washington, D.C., we kind of try to keep the record as clean as we possibly can. So, Cheryl, we'd like to. We're not going to talk in key terms. Yeah, we'd like to look around. Cheryl, hook and roll. I think Matt has a granddown. And I'm Joe Betting from Caledonia County. I'm the chair of this particular institution's committee. Sarah, we invited you in to begin the conversation and please take it away. Yes, well, good afternoon for the record. Sarah Squirrel, commissioner of the Department of Mental Health. And Morning Fox, deputy commissioner of the Department of Mental Health. So yes, the committee requested an overview of vets, kind of the status of vets in the state of Vermont. We actually just submitted a report that was a comprehensive overview and analysis of vets made across the state. The committee didn't necessarily ask us to do a full walkthrough of that report. However, we did provide it to you so that you could take a look at it. And what we'll be testifying today is a summary of residential vet capacity across the state of Vermont, as well as inpatient capacity, just to give you a sense of what it all looks like and how it fits together, especially as we look to kind of advance the appropriate facilities to support the overall system of care. Of course, given that it's Mental Health Advocacy Day, this is a nice opportunity for us to underscore the significance of need and the urgency to ensure that when Vermonters need the right care at the right time, that's absolutely essential. So the legislative charge that we had for this report was really to look at an analysis of vet needs, looking at rural locations across the state of Vermont, historic occupancy rates, an analysis of access, barriers to access, barriers to discharge. Also, it asked us to work with individuals who are either currently receiving services at some of these settings or maybe previously had in these settings. Sarah, if I can interrupt you. Yes. Are these the reports we're referring to? Yeah, so you have the PowerPoint is what we're going to be walking through. That is the full report. We aren't going through all of the content in that report because that would be another hour of testimony. We're trying to give you the high level view of the system of care so that you walk away having a good sense of where beds are and where needed capacity is. So this is kind of a hybrid of looking at residential beds as well as inpatient beds. So if you keep looking through going to adult residential settings, we're going to kind of walk through within our residential system of care what our current capacity is in Vermont, how we define that level of care and how people access it. So the first level of care that we're going to focus on is group homes. We have 19 group homes across the state of Vermont for a total of 151 beds. One thing that's important to consider with group homes that they are more in line with long-term care. So when we think about our intensive recovery residentials or recovery residences or other residential step-down capacity, they're designed to be more transitional. Group homes are actually for individuals who need extended care and possibly long-term care and will be living there for long periods of time. They're licensed facilities. They are available to individuals who are enrolled in our community rehabilitation treatment support program. So they're connected to the Department of Mental Health in a designated agency because they're enrolled in a CRT program. Individuals who are serving group homes do require more intensive treatment. So if they could be served in a less restrictive community setting, we would certainly like to see that. But for some individuals, they need access just 24-7 ongoing care. Group homes also include skill-based training, daily living skills, access to a kitchen, living areas, treatment supports, medication management, and supported counseling. Some individuals are on an order of non-hospitalization and under the care and custody of the Commissioner of Mental Health. So moving on, the next, I guess, tier in terms of our residential system of care in the state of Vermont are what we refer to as intensive recovery residences, otherwise known as IRRs. We have six of these residences across the state for a total of 47 beds. This level of care also includes our peer-run program, which is the Superior House, which is offered through pathways. Essentially, this is frequently utilized for step-down from hospital level of care. So typically, individuals who are in our inpatient setting who are not able to transition directly back to the community, the intensive recovery residents provide step-down care for those individuals and they have an anticipated length this day between six and 18 months. One thing that's important to remember about intensive recovery residential versus group homes, group homes tend to be accessed from the community level, meaning that your local designated agency is likely making the referral to the group home for you and there are more localized resource. Intensive recovery residentials are actually designed to be a state-wide resource for those primarily who are under the care and custody of the Commissioner of Mental Health. So when we think of IRRs in terms of geography across the state, we take geography into consideration, but they're accessed by anyone in the state at any given time who simply needs an intensive recovery residence, whereas group homes tend to be accessed through your local community mental health agency. So each of them can... Yes, ma'am. The peer-run program, you said, is run by pathways. Yes. So is that just then only offered in those counties where pathways is established? It's one specific location. So it's one actual intensive recovery residence that is run by pathways that is peer run. And that's a level of programming that some individuals really flourish in. And are referred to and has been very successful. Act 79 actually required us to put into place what would be considered a hospital diversion program that is peer run. And so Tira is our peer run diversion program, if you will. And where is that located? It's in Burlington. It's the only brick and mortar home, if you will, that pathways runs. Everything else that pathways does throughout the state is with individuals in their individual apartments. So this is the only program. Intensive recovery residences have a pretty robust array of clinical staff that are on site. I know, second spring, which is one of our intensive recovery residences and leadership from second spring is here today. But they also have skilled nursing staff on site. They're working on transition skills, daily living skills, et cetera, medication management. Of course, the goal is to transition individuals to least restrictive lower levels of care as quickly as possible. I'll just keep on moving until somebody stops me. One thing to keep in mind also in terms of how we think of the management of the system of care and flow is something we talk a lot about. How do we ensure that we're moving people in a timely way through different points of care as appropriate? Our department of mental health care management team, which is small but mighty, facilitates the management of these individuals and is kind of managing the referrals based on clinical readiness to access the intensive recovery residences. So just so that you're aware that DMH has a significant role in managing the step down of individuals from inpatient to access this level of care and also of course looking at discharge as well. So that we can ensure that we're transitioning folks and that new individuals can access the effects. So how small and mighty is this group? Our care management team, we have a care management director and we currently have three care managers who are in the process of trying to fill in the fourth position. But for many years it's been a four person staff with a manager. And working very closely in collaboration with our IRR partners. The next residential tier of facility and support that we have is the Physically Secure Recovery Residence, which this committee is well aware of. The Middlesex Therapy to Community Residence was designed to be a temporary facility post-hurricane Irene built to using FEMA funds. Temporarily cited in Middlesex to serve as a step down. The intent was to ensure that from our highest level of care, which is our level one beds across the state, which at that time we decentralized. So Vermont State Hospital closed. We have 25 beds at BPCH, 14 beds at the Brattleboro Retreat, and then six level one beds around the Regional Medical Center representing individuals with the highest acuity of need. It's essential that we have a secure residential where they can step down to given their height and acuity and safety needs. 98%, 95% of individuals step down into the Middlesex Therapy Community Residence from a level one bed. In order to be placed at MTCR, the individual does need to be in the care and custody of the Commissioner of Mental Health. And I'll let Deputy Commissioner Maureen Fox speak to this, but there's a special court order by a judge that also needs to happen in order to access this level of care. It's really quite common that an individual who's going from a hospital to an intensive residential that they may be discharged from the hospital in order of non-hospitalization, which has them remaining under the care and custody of the Commissioner, but in the community. However, in order to go to the Middlesex Facility, it's not a May. It's a has to be. That's in statute. That person going there has to be under the care and custody of the Commissioner in not only in that circumstance, but the order of non-hospitalization has to speak to the fact that the individual needs that heightened level of security so that we're not looking to have someone in a locked facility other than those who really need that type of facility. So part of the legislation kind of envisioned that a court and a judge would have to weigh in on that piece of that need for that level of security. So they have to be discharged from a hospital on an order of non-hospitalization that speaks specifically to their need for that level of security. And folks, this committee table are well aware that we are on our way to the expansion of our physically secure residential, expanding the capacity to a 16 bed physically secure residential facility with the capacity to perform emergency and voluntary procedures, if indicated. This is an essential and top priority of the Agency of Human Services, as well as the administration is essential to expanding our overall continuum of care. And of course, the facility at the current middle sex was designed to be temporary. So with this critical that we have, this level of care, especially as we look to expand our level one capacity in the state of Vermont, which is also urgently needed. We'll be talking a little bit about level one. Our level one beds run at about 99% occupancy all the time. So when people ask me the question, do we still need these well new level one beds at the bottom of retreat? Absolutely, yes, we do. We also need to ensure that we have appropriate step down capacity. And any given time this analysis is articulated later in the report, we have 10 to 15 individuals who are currently in our inpatient system of care, that if we had a physically secure residence with the ability to perform emergency and voluntary procedures, we could transition them into this programming. Currently, those individuals remain stuck, if you will, because our seven bed capacity is just not adequate, which of course backs up the whole system and we end up with individuals waiting in the emergency departments because all of that essential level one capacity is full. So just to give you a sense of how this all kind of links together in terms of our continuum of care. Anything to add to that? Okay. The next slide, this is just more of an overview of who our designated providers are. Many of the levels of care that I just indicated are managed through community partnerships with our designated agencies, our designated hospitals, specialized service agencies, and some are state owned, such as the state secure residential programs. Like second spring, that's actually a collaboration between Washington County Mental Health, Clara Martin Center and the Howard Center. Is that correct Scott? Yes, it is. The next slide shows provider capacity. So this is just intended to give you a sense of how many beds in each of these areas. You can see within our designated agencies, we have adult crisis bed capacity. We're not necessarily diving into that level of care, but just so that you're aware, we do have adult crisis bed capacity in the state at the designated agencies. Youth crisis beds and the adult intensive residential beds that we were just talking about those IRRs. Our peer service agencies, we do have a two bed peer run crisis center that's run through ELISM, as well as the Saturia program that we mentioned before. We have our physically secure residential that the state runs with seven beds. And then on the right column, these are all of the designated hospitals and the inpatient capacity that they have. So that level one capacity, as I mentioned, is distributed between BPCH, the retreat, and Rutland. We have non-level one capacity, which is our greater inpatient capacity across the state. We have an additional 156 beds and additional inpatient capacity. CBMC having 14 of those beds. Rutland Regional Medical Center has 17. UBMMC has 28. The Wyndham Center has 10 beds. I will just note that the Wyndham Center opted not to pursue designation status to the Department of Mental Health this year. They can still accept voluntary patients that can still continue to receive care there. But involuntary patients can no longer be admitted to Wyndham Center. And my sense is that is a direct result of some of the strategic challenges that they're looking at right now is their connection to Springfield Hospital. The term peer run, I'm not familiar with. Can you flesh out what that is? Yes, so it is essentially a peer run facility or program is one that is run by individuals who identify as having lived experience. And that when you look nationally at other programs statewide, it's a very effective programming structure. It's a structure that many individuals who are seeking care seek out and request and can work very well for some individuals. How many of those do we have? One. And that was a requirement of Act 79. Is that a brick and mortar or state owned building? No, this is owned by, I don't know if they own the building or actually rent the building, but it's a part of the pathways program. We help find that program but it's not the brick and mortar piece. It's not owned by the state. Is it not funded through the Capitol building? And there is one other, the other peer run program has the permission to do the two bed crisis bed at Rochester. The VA Medical Center has 12 inpatient beds. These of those are specifically designated for veterans. And the brought up or retreat of course, in addition to the 14 level one beds has 75 beds. And then when we look at our child and youth capacity in terms of inpatient, we have 30 total beds statewide. All of that capacity is at the brought up or retreat with 18 beds for adolescents, 12 beds for children. There is an additional program across the lake, CVPH, which is a child and adolescent inpatient unit that is connected to the UVM health network. We have been very hopeful that we could continue, that we would begin to be able to access some of that capacity given the challenge that we have with youth and children waiting in EDs. We have been having some challenges in terms of having children and youth going across state lines and how our respective legal statutes do or don't agree with one another. So that is something that we're in the process of looking at and trying to better understand because it would be wonderful, particularly for children and youth who might be in the northern part of the state of Vermont, not to have to travel all the way to the brought up or retreat, but could simply access care just across the lake that we had had some barriers to access in that capacity. Is this a facility that is part of normal care? It was at Champlain Valley Physicians Hospital, which is a part of the UVM health network. And it's located, what's actual town? It's in Platsburg. Yay! So the next slide is designed just to give you a visual of the continuum of care from most intensive to community-based care. At the top, you'll see our level one inpatient facilities. The 45 beds are general inpatient hospital units, intensive recovery residences, our mental health crisis beds, group homes, transitional stat housing. This would be programs like the MyCAD program that has been an incredible model that the Howard Center actually started, which is actually pairing more independent apartment living with services and supports on site. So it's kind of creating capacity for some independent living, as well as having some tuition and services on site. How are you? I was testifying in another, I'm sorry, just to start. Okay, well, just to pull you out on where we are, we are doing a high level overview of the analysis of residential bed needs that came out of the World Health Task Services requirement. We are not doing a deep dive into the full report, but just providing enough information to give the committee a sense of our capacity in terms of inpatient and residential beds. At the lowest level, or least restrictive and community-based, we're looking at shelter plus care vouchers, which is independent living that also has services attached. So that gives you kind of a sense and overview of inpatient and residential capacity across the continuum of care and what that means in terms of intensity level. Number of slides are we on for Senator Ryan's? We're not numbered. We're not numbered. Okay. We're at the MAP thing. We have a lot of MAPs. Maybe like SNAPs. So we always make sure to throw in a couple of MAPs back up. The staple on the right-hand side, huh? There you go. Left-hand tip. Opportunity for growth. A little dyslexic in the temporary. There you go. Starts with you. You should be a specialist. We wanted to give you a visual sense of where residential capacity sits across the state. So this first slide again shows you where those group homes are, those intensive residentials. I do apologize. It's a little small to read. You can certainly see areas where we have not as much capacity as we would like. It's also important to remember that some of this capacity is statewide, like the intensive recovery residences, whereas group homes are much more community-based. But certainly something to think about as we go forward, because this begs the next question is if we're willing to invest in additional resources and capacity, where would our money be best spent? What does that look like in terms of community and geography? Do you have a companion map for your patient numbers are distributed? Like for instance, if I was to say Essex County, are there any patients in Essex County, or so how many? We would have the number of residents in the programs. I guess it depends on, they're talking about numbers of, like say in Essex County, number of CRT individuals from Essex County or individuals in our residents. When I come to think of, where should the brick and mortar be? Knowing where the population is that's going to be utilizing these buildings, it's kind of helpful. I don't know if you've ever developed that kind of a map. So in the rural health care bill, or the rural task force bill is as well, we ask for that, we ask for what the needs were to provide county and locations. Yes, and we did an analysis of from your county of origin, where are you going in terms of accessing care? So we do have that data in here that you might be asking for a slight deeper dive on that data. We do have information of, people who are, for instance, we have some 500 folks who are involuntarily hospitalized in a given year, roughly. We can tell you from which counties, how many from each county, that those individuals come from, place of things of that sort, which would use some indication of the needs in the back of the local communities. So in a more general direction, do you have numbers of people that you service throughout the year so that we can see? Yes, we do have that information, but there are other. And we are going to be looking at some occupancy numbers later in the report. I'm looking at that as well. The next map essentially combines residential and inpatient beds. So you can see kind of geographically across the state, where our residential capacity is and where our inpatient capacity is. And this is both children and adults. The next area I want to bring to the committee's attention is planned capacity increases. Vermont has made significant investments in extending our capacity across the continuum of care. We do have the 12 new level one beds that are scheduled to come online with a bottle borough retreat, sometime between June and August. Again, I talked a little bit about the occupancy rates of our current level one beds being at about 99% at any given time, thus justifying the significant need, knowing that's the highest acuity of individuals in the state of Vermont. Also, when you think about emergency department wait times, the length of stay for individuals who are on an involuntary status or under the care and custody of the commissioner of mental health have the longer wait length of stay. It averages about 3.4 days versus involuntary individuals whose length of stay is about just under a day. So again, thus indicating where we're seeing the backups in the emergency departments, this level one capacity will be essential to alleviating that as we go forward. Longer term, the UVM Health Network, CVMC, is in the process of planning to construct 25 new inpatient beds. The Department of Mental Health has been working closely with them. Again, in the spirit of our 10 year plan that we also presented today as we look at integration of mental health services within the broader healthcare system, it is excellent to see one of our larger healthcare providers come forward and prevent providing more additional inpatient capacity in the state of Vermont. They are looking at those 25 beds in terms of tiers. So tier one, tier two, and tier three, which would indicate acuity at this point were an initial conversations but have some sense that they're tier one from a clinical acuity status would align with our level one acuity status. So what that will mean for us as that new capacity comes online in our system of care, what will that mean for other areas of the system? Will we continue to need that additional capacity? Will there be areas to think about other different levels of care? But that certainly will give us more flexibility. One of the things I would also note about the 12 new level beds at the Bartleboro Retreat, individuals at that time were actually thinking strategically about as new capacity comes online, would be able to repurpose those 12 new level lump beds for maybe a different level of care. So they're being designed to be flexible, meaning that they could be potentially transitioned to maybe geriatric psychiatry, maybe more intensive residential, if that's what we need at the time. But we are trying to be thoughtful about capacity overall, trying to ensure that we're maximizing our investments in these capital expenses, and certainly the 12 new level lump beds represent a significant capital expense or investment on behalf of the state of Vermont. Of course, we also have our 16 bed physically secured recovery residence, which is also a significant capital investment on behalf of the state of Vermont, and is essential in terms of the continuum of care, which we would consider more community-based care in terms of it being a therapeutic community residence. It is not impatient if you have a hospital level of care, but serves as a step down. But again, we are moving in the right direction in terms of ensuring and scaling up essential capacity across the state system. So the next few slides get into more of the detail of the analysis, and I am happy to walk the committee through these slides in the interest in time and other individuals who are here to present. We're also happy to come back and do a deeper dive, but I guess I would defer to the chair. I think probably given the time, we're gonna have another conversation about this is the plans coming to fruition and we want to update some of the brick and mortar is doing, I just wanted to comment on somebody that farthest reaches of Essex County. Probably has to travel well over a hundred miles for the nearest root home facility, but I don't know if that's just the way things grew up, or we've decided there's just not enough need, was there any rationale behind that? I think individual, but root homes are primarily run by the designated community mental health agencies. Some community mental health agencies have moved forward to building that capacity within their catchment area, if you will, and some have not. I don't know that that's necessarily reflective of needs. Certainly that's something that we look at and some of the analysis is the rate of individuals who are utilizing root homes. One data point that is on the next slide that I'll bring to your attention is that Lemuel County, which would be Lemuel County Mental Health, has the highest percentage of individuals in root homes. They also have one of the largest root homes. So it's just interesting as you look at what's available in their community and how folks are utilizing it. And then the other side of that, look at the highest utilization of intensive recovery residences. In Wyndham and Windsor County, that utilization is much higher than some other counties. And again, they have two intensive recovery residences in that area. So that's more analysis that we'll be doing. But yes, to your point, there are certainly areas where access to a local root home, you may not be able to access that in your community in certain regions. Certainly some individuals do move into root homes in other areas. They actually become a client of that respective designated mental health agency. One slide that I would bring your attention to, which is a few and because I think it tells an important story about some of the capacity investments that are already underway. Is this slide here? I don't know, I apologize, I better not remember. That's the one right there. This is involuntary patients residential level of care needed upon discharge. That's our second reliance. So what's important about this data point is that we surveyed all of our inpatient hospitals for six months, essentially asking them the question because what we really want to understand is what is the unmet need in the state of Vermont in terms of discharge from inpatient? So we essentially ask them, four individuals who were trying to move out of inpatient settings, what is the residential level of care needed at that time? Whether it's accessible or not, and you can see here very clearly return to former independent housing. This clearly articulates that just housing in general remains a continued barrier to actually moving folks out of our inpatient settings. The intensive residential also rose to the surface in terms of a need area and then the physically secure residential with EIP capacity. So that again just gives a sense of what is the unmet need and then a further slide gets into some of the barriers to discharge. One of the other things I would note with this data set also looks at occupancy rates in our group homes and our intensive recovery residences group home occupancy rates are just very close to 100% all the time, give them the long stays in our intensive residential. We're actually seeing a slow down in admissions but an increase in length of stay indicating that folks are likely getting a little bit stuck in those intensive recovery residences. So we just have to keep looking further down the system of care in order to really alleviate and manage flow as best as possible. And of course to ensure that we're serving individuals in all these restrictive settings as possible. So I'll stop there. Just one quick question about your account for the number of people served. Yes. Are those unique individuals or are they not babies in person? Which slide are you referring to? Referring to a lost page. The number was 2,000 or 2,300 or 2,800. Yes, those are all the individuals that we currently serve in our CRT programs total. And then we, so out of those 2,800 individuals then we did a breakdown of how many of those are being served in intensive recovery residences and in group homes. Which indicates that a lot of the individuals in our CRT program are actually being served successfully in the NEP. It's a small percentage that are accessing these residential programs. Great question. Okay, thank you both. Yes. Do you want me to give a quick overview on suicide prevention in terms of what's in the governor's recommend and then I'll let our other good partners talk about some of the great work that's happening. I'm happy to hear that because we're switching gears to that subject right now. So if you'd like to lead into that, that's wonderful. Wonderful. So of course, Vermont continues to grapple with the impact of suicide in our state. It's something that we want to ensure more resources for suicide is the second leading cause of death in Vermont for ages 15 to 34. And certainly for our young people, this is reflected in the Vermont Youth Risk Behavior Survey where St. Pyro rates of hopelessness, despair, depression, that number is even more alarming for LGBTQ youth. Vermont is poised to expand our suicide prevention efforts. We put forward some initiatives. Those have been supported by the administration and are reflected in the governor's recommended budget for FY21. We really try to take a multi-pronged approach to how we were looking at suicide prevention across the state. Strategy number one is to expand our Vermont National Suicide Prevention Lifeline. When I first started my job as commissioner, I was getting a lot of phone calls from the National Lifeline because they were concerned that we had the lowest in-state call response in the nation. So at the time, that was a little bit embarrassing given our focus on health and supporting our Vermonters. So this additional dollars to support the National Lifeline will be essential. Essentially how other states utilize this, it's a national call number. I think they're actually moving towards getting federal approval for it to be a three-digit number, which will be wonderful. Those calls typically come into your state and are managed by maybe crisis centers, local crisis centers that are trained that can then get that individual directly to the right resource at the right time. Vermont's in-state call rate was very, very low and essentially our calls were getting bumped out of state. We're actually being answered by folks in New Hampshire, which then, of course, you risk dropped calls. We're relying on an entity in another state to understand our system of care. So this funding will allow us to support three of our programs to get additional training and resources and capacity so we can increase our call rate from a 0% in-state response rate to a 70% in-state response rate by 2021. That will be partnering with Northwest Counseling and Support Services, Pathways Vermont, and 2-1-1. So very excited about this opportunity and support for individuals who are trying to seek care. Strategy two is expanding zero suicide in Vermont. There are many leaders in this room that will talk about zero suicide and its incredible systemic framework for bringing more training and workforce development across the state. We've been able to pilot it in some regions with our designated community mental health agencies, but we have not been able to scale it up statewide in a way to really impact the social, the optimal social impact that we wanna see. So this will allow us to scale up zero suicide statewide, partnering with the Center for Health and Learning that will be supporting that implementation. I would also note that zero suicide also has a component of training that's related to support for veterans as well. That is another population that we're very concerned about and I know the administration was concerned about. Strategy three gets to that, which is expanding programs and supports for older Romaners and veterans. Suicide risk is often coupled with social isolation. We worry about particularly our elderly Romaners who may be isolated or at higher risk. So one of our upstream suicide prevention strategies is to expand the elder care clinician program, which is run through the Department of Aging and Independent Living to better support and have that reach to veterans so they can get the care they need when they need it. So that's kind of the array of suicide prevention efforts that are being supported and are a part of the recommended budget for FY 21. Thank you for opening with my good. I believe Senator Wyeth is on that as well. Yes, thank you for your sponsorship. You'll be. Do you know how many mentally ill patients are incarcerated? There is a high representation of individuals of mental health, mental health challenges in our correctional system. I don't have the number off the top of my head. I should say with respect to that question that in judiciary we are talking about that question. One of the concerns all along has been somebody with real mental health needs should not be in jail. We all understand that traditionally we have had a situation in this state where that was the place of last resort when there wasn't anything else available. But we've come to recognize that's not the way to go. So we're having that question resolved but not inside of this committee. Just so you know there's a lot of other committees and a lot of other conversations going on but we are aware that that's a problem we're trying to address. That was part of the Justice Oversight Committee work that we did over the summer of the fall. And so it's a jointly introduced bill from members of health and welfare and judiciary that's being worked on in judiciary and we'll maybe look at it a little bit in health and welfare but it's really a critically important issue. When the other committees figure out who needs to be where, they tell us and we pick up and figure out how to build it and that's essentially what I want to do. That being said, this will take time as everything does. So in the meantime, the monies that are being appropriated in this budget, will some of this be going to corrections, mental health services have been corrections or is that money set? In terms of the suicide prevention? In terms of any of the new programs that you're... So the capital dollars that are going to support the construction of new facilities is for the 12 new level of beds as well as middle sex. But as far as the money that you're looking for for suicide prevention, will any of that be going into corrections as well? Not at this time. To be an appropriations question. It's a big discussion. It is. Okay, that was the lead in. Yes, thank you very much. And there's a lot of other folks here that would like to give us some words on the next suicide prevention issues. I had food afternoon, Richard. I understand. Have you ever testified before, committed before? Yes. Okay. Please, go ahead. I'm a CRT client, but also I'm a total, I'm a total correction. That's why I'm here to say, I'm a employee in Montenegro. I started working at the Branson School where I worked until 1992. We began to work with corrections in 16 years. Before we were to be corrections along to the program, the class halls and the citizens. This in-match program showed the best side. When I started, it was like one for an urgent caring from a brand, a brand-tank school, that we have to call it sort of like on our expected. But then that's the concept on it, not the brand itself moving well into that, and we will on that. The other day, you never knew what to expect. The more it started to be bottomed off, it didn't need to work. You had to be consistent and walk all over it. And throughout six months, it got you easier to be consistent. The hard-core job was obstacles that did not lie to the rules. And bringing cons around the time of the officers was a great step, they're not conforming to themselves. Some brought in cars and cigarettes for a hundred dollars. Things got worse our times. Spent more time in the jail than with the family. The cons of tires, especially if they were at 16 hours and had four or five men drive home. No matter how effective it was back a few hours later, which only did about four hours of sleep. This is why we cannot retain staff. Men of staff were medicated by using alcohol drugs themselves to deal with stress. On my days off, I drank heavily and just wanted to sleep, especially when I worked at Blocks Rounds. It was hard on the young family. By the way, I'm buying a new house of cars, it's all a problem, and there wouldn't have to be happiness. It didn't not work that way. We'd go into debt and rely on our work time to survive, even working out today. At 45 years of corrections, I had my first suicide count, not only because of the job and family stress, which is one of those that's why the course was worse. Also, I was embarrassed by a friend of Bill who landed up on the slideboard where I spent a week. I thought that after a week, I could return to work in my day. It was even harder. The root feel of the laptop and the volume of some staff is like a hell. I said, well, after removing up Moran's correctional, let's turn on more respect. However, with more responsibility, the more I drank, the more it goes on to threaten suicide, and then it went to hell as well, which is the one I'm talking about. I was at a work for about six weeks, and when I returned, I was put on a mandatory visit. In 2003, I was transferred to Marble Valley for a split on a third shift. It was more difficult because there were more inmates and staff that started to get used to it. I had to get accoladed with more. Well, I didn't take the paperwork. We had a screening test initially surveyed to see where they would be put out based on if there was suicide. The amount of incapacity of people that came in were also difficult to deal with. With all the stress I'd go on in the morning and drink until I could fall asleep, I switched from trip to schedule the next three years while drinking and using my prescriptions all in meds to pull it off, meds are harder. I was allowed to take care of myself. I didn't care what I looked like. My uniform were dirty and I was sparring out of control and deep in debt. My family was in my job in marriage. In 2007, I had a violent suicide. I was in the hospital for five months. It was the end of my career. Over a six in a period of time, many officers like me could not do the stress and that's suicide terms themselves. In most times, I've known four officers that are currently in suicide. I hope to speak to correctional sides, to speak to officers about seeing signs of suicide, not only in the admit first act, that are overworked, stressed, I have no problems in that themselves. I need a place to feel safe in my taboo of getting help thousands of sensitive and emphatic but also seek out and want to help all of us not attempt suicide because I hurt your family, friends, first responders, and community. I learned and heard about NAMIC. I found our program and our own voices which has celebrated our first days and our personal success stories. Now I was helping all those I'll tell for myself. I now spoke with the Department of Health, team two in a police cabinet. It's the other one I can, so someone else and I go through what I've done before. I now have a job work as a first support specialist part-time, but there's a life in a tunnel to get help and help all of us move their experience of suiciding out there. Know the signs of someone you know of as suicidal and depressed, talk to them, they may tell you it's wrong. When you're suicidal, you don't care about anyone else. You just want to end the ban. I never told myself I'd just let a gun's in the house or I was drinking it. I was sleeping all over on the suicide line and now I come to watch the sport line which is a fun day, 24 hours a day to help people that are peers and who come past in the care. Richard, I appreciate you coming to share your story. Best of luck in the future. Thank you, sir. Thank you. I have Scott Eakus. Is it Eakus? Yes, I know that we're on the topic of suicide now and I'd like to talk about those initial pads. I just wondered, do you want to work with suicide? If it's okay with you and you have time to hang around, I'd like to keep the subject the same if possible. That's fine. Thank you. Pauline Torello? Yes, that's me. Good afternoon. Good afternoon. I'm Joellen Torello, I'm Executive Director of the Center for Health and Learning and we are a 501-3C that is a state partner to many initiatives that address priority health issues. In most recent years, we did a lot of work early on in chronic disease prevention. In more recent years, we were the lead designated agency on behalf of Department of Mental Health to receive two suicide prevention grants. They were originally focused on youth and when the federal grants came to a screaming halt, we wondered what we were going to do. So we created the Vermont Suicide Prevention Center, which is a public-private partnership with the Agency of Human Services. And I have to say, I think it's a really good model. I'd like to see, as I just caught Commissioner Levine in the hall, I'd like to see this develop something similar around our substance misuse and opioid prevention kind of problems. And the reason I think it's a good model is because the coalition is composed of representatives cross-sector, business, private, non-profit, healthcare, education, social service and also many people with new experience. So they are able to inform state initiatives and the state comes to the coalition to inform the coalition about directions and get input. We're able to move in parallel process. I think we've made some progressive progress on suicide prevention in Vermont in the last few years. And I think it's because we have a sort of a body moving in parallel process very closely with the state. So I did a little research on your committee to try and understand like how to gear this talk to your interests. This is where I say, uh-oh. Uh-oh. One of the things we've been successful in doing in the last few years is working closely with the Agency of Human Services and they've established a leadership team for suicide prevention. It's had some fits and starts, so to speak. Alison can speak to that better than I as she is a representative and co-chair now of the leadership team for AHS. But I wanna bring this up because you asked about corrections and so the Department of Mental Health has been the lead agency on suicide prevention in Vermont by designating us as the original grantee and then the money has flown through Department of Mental Health, the zero suicide money also. But on this leadership team are representatives from all the departments in AHS. So Department of Corrections, do they have a, okay, they have a representative. Department of Children and Families, for example, they have a representative. And I think that is going to be our best opportunity to elevate the discussion about effective suicide practices in those departments. So in other words, to get back to your question about corrections, we have a lot of momentum in Department of Mental Health but suicide prevention can't just sit on the shoulders of mental health. We have a momentum now in Department of Vermont Health Care Access with the blueprint and one care getting on board with zero suicide. Again, this isn't just a healthcare issue although healthcare certainly can shore up. Department of Corrections has a training for all of its workers and it has traditionally delivered that training. And there are still, I think, there's still a desire to think more strategically about suicide prevention and corrections. And that's true for Department of Children and Families as well. They have yet to train their whole foster care system, for example, in suicide prevention awareness and training. So let's see, suicide is complex, but here's what I can say that I think relates to your interest. An individual dies by suicide. And when they die by suicide, that has a huge, huge and traumatic impact, really for the rest of their lives on the family. The family lives in a community, children, the youth, the young adults go to schools, colleges, institutions of higher ed, and the parents or family members work in workplaces. So we cannot underestimate or undervalue the return on investments in putting good suicide prevention practices in place. And anything we do for suicide prevention is going to build the overall system of care. So we have had the opportunity to work with the designated agencies who have shown a lot of commitment to zero suicide and absolutely thrilled, really. Use that word, and I don't use it lightly, that the governor has included a scale up in their budget. And I'm hoping that will center for health and learning Vermont Suicide Prevention Center will be able to provide some backbone support. And backbone support is project management, it's training, it's resource development, but the work really goes on in the communities. And that's through our designated mental health system, some of our independent providers, and through our healthcare system. So individuals are suicidal and they enter a system somewhere. They enter it in the mental health agency, they enter it in the hospital, emergency room, they enter it in the primary care office, and all of those places have to be short up in order to have the skills to assess, to screen and identify, determine if they're low, medium, high risk, and then to get them to the next point of care. And if there isn't a good warm handoff, so to speak, with protocols, that's when people get isolated, they feel alone, their hopelessness takes over, and they end up resorting in some crisis moment to a firearm, a poisoning, a suffocation, whatever it is they choose to end their life. So if we want to deter that, then we have to shore up our people and shore up our connections in those systems and limit access to lethal means when a person is at high risk. So your institutions are composed of people and it seemed to me as I was thinking about this, people need self-care, whether they're the people working in the systems who experience a lot of impact on the delivery of care to complex needs. And they are then at high risk, so all of our correctional facilities, all of our healthcare workers, all of our, you know, and then the people in the systems, ideally we can do as much as we can to create cultures of health. I just sat at the table, got a big hug from a survivor of suicide who has been part of our coalition. She said, I started yoga. And I was like, yes, that's wonderful. Well, there are actually a lot of fairly low cost. And yes, it's costly to train our staff and to ensure integrated staffing solutions. But, you know, fresh air, vitamin D, there's been large scale studies done on that role of vitamin D in institutions. It's actually considered an evidence-based practice. Yoga, mindfulness, meditation, things that teach us how to regulate. And this is how we can move it upstream safely well, and also at the same time support the recovery of the people in the institutions. So our prevention protocol is very important for institutions that they all have protocols in place how to prevent a suicide. And sadly, we really need postvention protocol. Protocols for how to respond when there is an event because of all of the ripple effect. And we have exemplary policies and protocols at templates that people can adapt to their institutions. We just need to continue to make progress on getting those introduced, adapted, adopted, and implemented. The last thing I would say is what we are learning about suicide is that there are subpopulations that are at highest risk, or higher risk. So we know veterans are at higher risk because of all that they experience. And because the culture does not encourage health seeking. Older men, middle-aged men are actually at very high risk. Allison just shared some data, most recent data is that the highest demographic in Vermont most recently is 25 to 55, so our middle-aged people. So GLBTQ, people dealing with GLBTQ, people experiencing domestic violence, all the co-occurring factors. So each of those has its own risk factors and its own protective factors and its own cultural considerations for delivering service and creating a healthy environment. I'll stop there, but I'm happy to take questions. And I will say that what we do is build out partnerships with agencies, organizations to bring capacity to address priority health issues. And if there's any way that we can support efforts in the future, that's why we exist. So thank you. Thank you. Any questions? Thank you. I don't know if there's anybody else that wanted to speak on this particular subject. Not, I guess Scott, you're up to the plate. It's a residential. Thank you. I'm really good, thanks for being patient. All right. Thanks for coming and thanks for being patient. Absolutely, thanks for having me, really appreciate it. I'm Scott, I guess I'm the executive director of the collaborative solutions corporation. Sometimes people call the entire organization second spring, which is fine. We do run the second spring programs. How long do I get in? A couple hours. Well, it depends on whether you want to have a very upset committee. It's very small, I guess. Probably like 15 minutes, something like that. Well, it would be, if you're gonna weasel it into 12 because I have another group coming in at 2.45. All right, let's try it. So I did provide the committee with some people work here that gives us summary for those who aren't familiar with our programs. We have 27 beds, so of the Intensive Residential program Sarah was talking about earlier. There are 47 of those, 27 of those are at Collaborative Solutions Corporation. It was originally founded to accept people out of the Vermont State Hospital that we had severe and persistent mental illness labels, like schizophrenia, severe bipolar disorder, schizoaffective disorder. And we still play an important role in that kind of flow. People come out of the designated hospitals, typically type one beds, into our care. We have a very close relationship with the DAs, but we're not a DA. Come by our different houses. We have a house in Williamstown that has 16 beds. We actually have another one in Williamstown with three beds and one in Westbrook with eight beds. I wanna highlight the level of clinical care. So the difference between us and the group home is that we offer really, we reach towards a hospital level of care, of intensity. So we provide, oh, there's me in front of the map. Good, thank you. So we provide on-site psychiatry. We have a primary care advanced practice nurse who's responsible for the primary care needs of our population, which you may know has dies on average 10 to 25 years early due to primary care type issues. We have daily nursing care, 24-7 on-call by both ND, RN, and a clinical specialist, case management, psychotherapy, vocational rehabilitation. Creative Arts Therapy is our most popular program. We used to have a music therapist. Now we have a drama therapist. People love that. Substance use disorder treatment, peer support, and we coordinate with scores on off-site providers. The impact that we have on the system is something about this chart on slide 10 is similar to one of the slides that Sarah showed. Just, we're basically always full. Once in a while, we'll dip down a little bit, but for the most part we're always full. A lot of the room in between us and 100% is because people may go to the hospital for a few days, or maybe discharged, and then we're waiting for someone to take that bed, but basically we're full-ish. You can see that it's tremendously cost-effective when you look at slide 11. Those figures are a little bit outdated, but we're still south of $900 per bed day, and I believe VPCH has gone up to $2,700 per bed day, but I know these numbers are directly from VPCH, so in 2017, they were at $24.66. You all noticed that our cost per bed day has come down significantly. The reason for that is because our census is up. So it used to be that we didn't have as many bed days, so the divisor was a smaller number. Now, we're full all the time, so that's why our costs per bed day have come down. Can I ask the coverage of length of stays? So we're geared for about nine months, but it really varies dramatically individual to individual. They were between three years, sorry, three months, and even like a couple years. The reason that we've been able to be so successful, and this is really what I would like to end up building towards the end of this talk, is that we were created at a time when the S8 Vermont State Hospital needed to reduce its census, and people got, people who lived experience, not many Vermont psychiatric survivors, people who knew what it was like to be in the hospital as well as actual providers of the services, put them around the table and had them figure out what do we need to do to make a really great situation system. And they teamed up with Second Spring. Second Spring South was the first IRR with 14 beds, and it's just beautiful. I run into people across the state all the time who were part of Earth and the organization. It's just beautiful. The heartfelt warmth that they have about that. I'll also tell you I get calls from around the country for, from systems of care who want to replicate what Vermont is doing. So my hat, I was in Ohio at the time, my hat's off too, but the people in the state of Vermont became welcome to this. No, our mission is to create caring communities where people seeking mental health finds hope, compassion, and excellent clinical care. I'm gonna start by talking about that word, compassion. Is everyone comfortable here? Imagine this happens to be the worst room in the building for air quality, rather than care for health, I'll assume this happens to be the worst room. I'll healthcare, I mean, it was really tough. Imagine if you weren't comfortable and you were expected to stay in a place for nine months. If you felt ostracized, people throughout the history of mankind with mental health issues have been ostracized and alienated and put over there, or worse. Okay, and what we've done with the state of Vermont has done is created a situation where we're inclusive. We have a community that has compassion, of course, people who have these diagnoses. All right, let's talk about hope for a second. Okay, at least several more minutes, so that's good. Let's talk about hope for a second. This is actually an important chart, this one here. It's number 16, and you can see that as people, before people enter, 54% of the people aren't even willing to vocalize that they want recovery. They're not even willing to commit vocalty verbally to doing that. And 10% of the people, I'm sorry, at discharge, 7% of the people aren't willing to verbalize that. Okay, in contrast, people who are still in the hospital waiting to come to us, 10% are actively involved in recovering, whereas at discharge, 42%. So you can see that people's commitment to a recovery way of life goes way up. And that's because they have hope when they come to us. So, to get to the crux of this issue, I wanna look at slide number 19. And this is something that I really would like to build on top of Sarah's presentation. If you look at that higher chart, look at 21% who leave us. 21% get discharged back to the hospital. That's not a bad number, considering where most folks came. Many of them came from spending a year in the hospital. So that's actually, we're fairly proud of that number. But those 21% are part of the flow, right? They're taking, they are in vows in psychiatric hospitals that we're apparently finding to be out of premium. So if we're looking to add building a new IRR, not the one that Sarah's talking about, which is involuntary, but if we were to really talk about increasing our capacity, the system capacity by building an IRR, the number one thing that I would recommend is solving that blue triangle by talking to people who are not feeling served, who's not feeling comfortable, who's feeling ostracized and alienated, even from our care. I tell you what, that's the worst doing in the world. We get so many that we relate to them and they feel like they're cared about and they stay and it makes a huge difference in their lives. When one gets away, we feel awful. So how do we reach those folks who's not getting rich? Well, just to look at the demographics, we have a dramatic increase in substance use disorder since we were born from 25, 80%, 85%. We have a dramatic increase in opioid use from 1% to 37% of our residents. Our residents are getting younger. That's slide 21. We have more clients with medical co-morbidities that are life-threatening. That's slide 22. So when we sit down at the table, it's gonna take more than just interviewing a few people at our residents, the people who are, by the way, willing to come down to the living room to talk. When we do surveys, we're talking about certain people who are willing to come down to the living room to talk. We need to talk to the people who are willing to come down to the living room to talk. And they're going to primarily be in certain demographics. Those with severe medical needs, this is slide 23. The LGBTQ community, dual diagnosis, substance use and mental health, significant forensic involvement, and those with a little diagnosis of personality disorder. So the takeaways are, the IRRs really work. They work from a financial perspective and they work part and soul. And doing right means funding those programs appropriately. More IRR beds is likely to legal less in-yard boarding and less hospitalization. But not just any IRR beds, what we're getting down to is the folks who are making that, even with the IRRs that we have. How do we actually reach in there and help them? So we have a, I have a whole minute left. We have a three-bed program that is a test case. It's called the Pierce House. Our first client was a gentleman who had spent almost his entire adult life in the psychiatric hospital over 15 years, most of the time in the psychiatric hospital. He's now been in our residence for three years with a total of two months hospitalized. That's magic. First of all, think how much it's safe. But also, what does it mean to him? What does it mean to his mom? So we can do those things, but he wouldn't have done that in a larger program. So I really want to suggest that to the extent that members of the committee are engaged in discussions about that, that we're really asking, one size doesn't fit all, especially with where we're at right now. And that's what I have for you. Thank you for having me and I'd love to answer any questions. So good, and we'll probably have you come in to our Health and Welfare Committee at some point. But I have a lot of questions about the funding, how it got started, what funding was utilized and what keeps you going, and what's the patient source of funding, how much is Medicaid, how much is other stuff. I think that's a big area for our consideration. Be happy to join the committee or answer questions by email or by email. Oh, so we'll sort of help. That's good. I mean, this committee might be addressing that too. And you're not a designated agency. So how do you get your clients, your residents? They're referred ultimately by the DAs through the Department of Human Health's collaboration. So it's a statewide referral pool to us. And is there like requirements like if they usually have a few beds and who does the determine who gets to get to. There's, yeah, that's a great question. It's a fairly intricate thing. We have a full-time position responsible for the ongoing dialogue with the psychiatric hospitals, and the DAs about who the next person is likely to be successful is and what is our next bed get open up. And then that person also collaborates with our clinical director and director of nursing, as well as if necessary, psychiatrists to make sure it's appropriate for people. We need a good bed for work. If you use a bed for work. Wow, we've got knowledge here. Scott, I appreciate your testimony. Again, dance along the periphery of where this committee is involved. Chinese Committee Health and Welfare is probably going to get involved. You'll make all the decisions. You guys, will we make all the decisions? Oh yeah, we'll come through this, yeah. But we appreciate you giving us the picture for the second spring. Thank you all too. Thank you, it's great. Thank you. Committee, we're going to take a 12, 13 minute recess.