 Well, welcome this afternoon to the house healthcare and education's MIDI joint testimony about an extremely important subject in Vermont, and that is mental health and mental health funding in our schools. So, um, representative Helen and I will co chair this and we will watch the time because we do have floor at three, but we want to make sure we get presentations. I looked at the first presentation and I'm excited of what you all put forth. So, I think what I am going to do is I'm going to ask everyone to fold their questions and I'll break periodically so that we can make sure we do get through this. So, so again, thank you everyone for coming and I'm going to turn it over to the chief just one quick thing for those of you coming in. Those there are a couple of reserves each over there, but they are unoccupied. So, feel free to use them. Great. Thank you. Good afternoon for the record. My name is Laurel on land and the director of the child lesson family in it at the department of mental health and with me is my colleague Mariana Donnelly. I also am at the department of mental health. I coordinate school mental health. I believe in arm secretary who she of education will be here as well. Great. And I just want to say for everyone that is looking online. The presentation is under how the appreciate his name that we're going to be looking at. And then if we can also put it on the screen that would be the phrase. If I can do this. Great. So the person we wanted to talk about. Oops. Sorry. It's moving on me is success found six school mental health. Medicaid. I know we were here last year and we talked some about it, but I figured it would be good to do another review of it. There are some slides that I might go a little faster through and if you want me to go back and cover the detail we can. But I think for the just foundational knowledge success found six is the name of a Medicaid program. It's delegated to the Department of Mental Health. It was actually authorized by the Vermont Legislature in 1993 with the intent to reduce the cost burden to education and the state by leveraging Medicaid for services to Medicaid rules. This is a particular program that is under the Department of Mental Health and it is about the establishing partnerships between the local education agencies and the designated mental health agencies. So this is Medicaid that flows through DMH to our designated agencies to provide services in schools through a contract with the local either supervisor union or school. And then they bill Medicaid the school or the supervisor union pays the match. So they'll pay the state dollars that we've been can use to leverage the Medicaid federal share of that Medicaid. And I know I said I was going to get questions, but I think it's important for the education committee. Does everyone understand what a designated agency is? Okay. Great. Great. And we have some representatives who are here today and they'll probably talk more about that as well. So I think the important thing to note here is that the Department of Mental Health has a funding authorization under Medicaid. So we have a total Medicaid authorization that we can spend under. And then it's the local decisions between the school and the designated agency that drive what are those local contracts? They make the decisions. The school or SU supervisor union is deciding what are their needs? What is it they want to purchase from their local designated agency? They engage in a local contract. And then the designated agency provides us information about all of their contracts, what the FTEs are for, and what is the associated Medicaid for those. And then we have a contract with our designated agencies to authorize that Medicaid to be spent. Sometimes what the local school or supervisor union is looking for is not something that can be covered by Medicaid because it's either for a non-Medicaid or it's an activity that's not a covered service under Medicaid. And so those local contracts might not just be about the success beyond six services. There might be other activities that the school is agreeing to fund with other sources beyond Medicaid. We only have information sent to us about the success beyond six Medicaid because that's what we need. So that's kind of the core of how is this structured and what is it doing? And I'll get into a little bit of kind of what are the strengths of this, what are the limitations, and then some information about the dollars, the detail of what's happening. So this was my attempt to kind of summarize what I want to talk a little bit about. We at the Department of Mental Health and with our partners at the Agency of Education and then our local entities, we want to leverage Medicaid as much as we can to provide school-based mental health services to students. And so that is what the success beyond six is allowing us to do. We have had some challenges in doing that, partly because of the pandemic and partly because of work force. So I'll share some of those numbers. But I think that the strength of this and why it was authorized back in the early 90s is because it really does bring together these two local partners in a system of care to say together, how are kids doing in the school system? What is it that can be brought forward from the mental health experts in the community? And how can we have this provided under the allowable coverage of Medicaid? And then what else can happen beyond that? What are the other resources that the school system might bring to bear? And then with that partnership, the Designate Agency can provide both the school-based mental health, but then they also have that link to their other continuum of services that are available. And so there can be a connection with the psychiatry services, if needed, or the community-based services, and then a coordination of what that care looks like across the school and the community. Of course, that can happen with other providers in schools. They need to coordinate with other service providers that are working with a child and family, but there is an ease to it when it's within the same agency. SuccessFound6Medicaid covers a broader range of services than, say, a private provider coming into a school and billing Medicaid directly. Under a private provider, they can bill for therapy services in school. Under SuccessFound6, we are authorized to be able to allow our Designate Agencies to provide a broader range, including some of the specialized rehabilitation services. That's a Medicaid-covered service term. What that really is about is the service coordination, the skill development. It's not just about a one-on-one therapy session with a child. It really is helping them build their skills and be able to go back or remain in the classroom. And so the services this covers is a range of clinical services, behavioral intervention services, assessment, treatment and planning, but also teaming, being able to be a part of that school team, and doing the planning for that child and providing input about what's happening from the mental health side and hearing about what's going on academically. So it really is an integrated approach to supporting students. They can also work with families. So there can be that home-school connection that these programs offer. And then, as I said, there's that link with the broader system of care. They can support things like coordinate service planning under Act 264, et cetera. Limitations. You know, as I said, we're trying to maximize as much as we can the flexibilities under Medicaid. We have some alternative payment models that are helping us to do that. It still is about Medicaid enrolled students and Medicaid-covered services. And with some of these alternative payment models, you know, we'll have a monthly case rate for a school-based clinician where they have to serve a minimum number of students and providing a minimum threshold of services. With the increasing need among students, what we're hearing from the designated agencies is they have more students with more needs. And some of those students they're providing services to, but they're not hitting that threshold of service to actually draw down the monthly case rate. So the numbers that we get from how many students are being served might not be, they're probably an under-representation of how many students the clinicians might actually be interacting with during the school day. And I'll say, of course, we would love to know that total number. I'm sure you all would. I think some of the designated agencies are tracking some of that, but the challenge is how much administrative requirements do we have for the reporting. And so we're requiring the reporting related to the Medicaid that they're billing and providing. But I just, I wanted to note that. So there's, we're trying to have a broader breadth of impact, but we don't always know what that breadth of impact is. And that's part of what I was talking about in the right-hand side of the limitations about the threshold requirements. It also, they can't bill for activities where they might be providing some general consultation to educators about management within a classroom or about particular student populations, whether a grade level or subpopulation of students and their needs. If they're doing some training or consultation on specific mental health topics, if it's not about a particular student, they can't bill Medicaid for that. Sometimes that might be an activity that the school wants to purchase the whole, right? And maybe they'll use their other available funding, title funding, or other options, but it's, those aren't covered Medicaid activities. Medicaid also doesn't typically cover prevention activities. So the students have to have a diagnosis that they need to be able to bill under that diagnosis. So just to kind of give a picture of what the parameters under having Medicaid be one of our solutions to address the mental health needs of schools, it is a really important tool. We want to maximize it as much as we can, but it can't be that thing, the full solution to what we have. Other components that are somewhat challenging are the administrative requirements. There are higher reporting requirements, standards, and documentation for the designated agencies and providing school mental health services under this than say a private practitioner might have. And then, as I said, we only track the success down six component, not everything that's provided related to school mental health in schools. Just a quick question. Is any kid who's on Dr. Dinosaur considered Medicaid trouble? Yes. But do they need to have a diagnosis? Yes. To bill Medicaid. Okay. Get that. There's a child who cannot access learning because of behavior, whatever. Is that kind of the first kind of flag? Yes. And then, unless they come in with a diagnosis. So it's kind of access to learning or interrupting other kids learning of those the kind of what The key here is addressing a student's mental health needs so they can access their learning. That is what it's about. And so the decision to have a student receive school-based mental health services through the designated agencies, it really is driven by that need. And there's often a educational support team who might be meeting and talking about student needs and deciding what resources within the school do we have available. There might be some brief interventions that a clinician can provide and that's adequate. If they need something more intensive, that'll be part of that team planning. Oftentimes, especially when we talk about the more intensive behavioral intervention supports, that is driven by an IED, an individualized education plan. But some of these students have an IED or they receive a five or four plan and some don't, but they have an identified need right now that people are concerned how it's impacting them. It might not rise to the level yet of special education and this might be able to help maintain so that they don't need to pursue that. Great. Thank you. I think there was interest in this committee about what this looks like around the state and so this was our attempt to show kind of over time. So you'll see in the bottom the fiscal years from 2020 through 2024, how many schools had in the blue any success beyond six contracts and then the gray bar is specifically school-based clinician contracts. And then it's listed under public schools and supervisory unions with the percentages of how many have that type of contract or agreement. So there have been a little bit of a decline from 23 to 24 in the supervisory union level and public schools. Well, in the supervisory union related to school-based clinicians, as well as just any success found six with public schools, there's been a slight uptick in how many schools have any type of success found six. So that could include the behavioral intervention, the one-on-one intensive support with students. So just wanted to kind of show what this can look like over time by getting to any questions. Is it possible to get the data by public, by the district, and I'm probably not using the right education analogy, I apologize. That's right, I mean school districts, it depends on the region. We do have it is what we're trying to represent in here is sometimes the contracts are at the supervisory level directly so that a position could switch between schools. And other times it's directed to the school. If it's either scenario, we counted it under the supervisory union, but they have it somewhere, whether it's at the district level or the school level. This I wanted to show the change over time of what our Medicaid authority was. So how much spending are we allowed to spend in success found six Medicaid. And then what the designated and so that's green, what the designated agencies budgeted, meaning what they were planning to provide based on their contracts with the schools that's in blue. And then the orange is what was actually built. And you can see kind of how that has shifted over time and a real drop off really since pandemic between what was budgeted and what the actuals were from 2020 and current. And I think that's really largely driven by workforce certainly during the pandemic it was also driven by closure illness, you know, not having either the individual health provider or the student available to provide the service so there's a definite gap there that we want to try to address because we want to maximize as much as we can. So the other thing that's important to know is when I talk about where there are agreements or contracts that's that's again the contract that was planned that's not necessarily what's filled and available and I think that's some of the challenges that our school partners are experiencing as they they might have an agreement with the designated agency that the da can always actually find a person to provide that service. And the school has a mandate, especially if they're a student receiving special education to meet that need. Laura we have a couple questions. I just want to make sure that I am understanding this correctly. The actuals for let's just say FY 23 is a little over $50 million. Had there been the available resources mainly the phone with manpower. Excuse my terminology there. We authorized up to $70 million. So 17 million dollar gap of available funding for mental health. So it's about 72 million total across the state. And I think that year we were budgeted around 67. So in a perfect world with perfectly staff. We could have provided another $18 million worth of services. And just to add to that and can you also for the record. And I think the corollary and why this started conversation started at least part of it in how said is that when that's happening it doesn't mean the need has gone away at the LEA level. And so that is largely probably being that gap is being funded by education fund. Dollars that have more flexibility and can be used as we talked about yesterday. I think all the testimony days are flowing into me that you know we have more. Districts that are that are choosing to pay full freight and not take advantage of success beyond sex. None of which is good. But I just just to kind of connect those dots from what we talked about a little bit yesterday. And I think it's important to come back to that statement and drill down more into it. Speaking of drilling down I wonder if you can just borrow maybe drill down a little bit into the Medicaid authority and talk a little bit about what's in that line doesn't include our match. And then in addition to their under like maybe the budget is that include the amount budgeted for any of the purchasing of outside contracts etc. What's your opinion. So thanks for the question. So the authority is the total Medicaid dollars that are approved which is a combination of state and federal. So to be simple one dollar of Medicaid is about depending on what our F map is the federal share 60 cents federal and 40 cents state. So this is the combination of those. And the actuals is that same combination that was able to be built because service was provided. And the service includes and I have another slide on this. I think further down but it's our behavioral intervention services are clinical services and then our search programs concurrent education rehabilitation treatment are therapy schools that are run by a dozen agencies. So you might be familiar with the Baird school team garden school Washington County choice programs Lairway school. And that's the D.A. budgeted line. Yes. Yes. So everything and that's the six you said it is Medicaid. Yes. There's no component of SB six that's not Medicaid. Succession six is the name for the Medicaid program. Yes. And can't. I think school districts that were providing some mental health services outside of set success beyond six were able to draw down Medicaid. Yes. Different Medicaid. Different Medicaid. Different authority different spending authority that is school based health service Medicaid which I think we'll talk about a little bit later. Okay. Not the same. Yeah. It is. It's complicated. It's complex. So. Yeah. Yeah, this was I'm sorry. Yeah, go ahead and then more and then we're going to keep going. I'll be previous slide. I'm sure it's a little while. But the limitations of all of the program. Yes. Yes. And the first one is Medicaid enrolled students. That doesn't mean that a non Medicaid student in the school can't get help or doesn't. So what I can say is if there's a need for just a very brief intervention, they can get the support. If it's a need for an ongoing support, it's likely the school will need to either provide that through one of their own employees. Or include more funding in their agreement with a designated agency to cover that non Medicaid students. Okay. This is only for Medicaid. Absolutely. Okay. The sex is success beyond sex. Yes. Well, okay. Great. So this was to demonstrate what the changes in the federal Medicaid assistance percentage has been over time. During the pandemic, we got more from the federal government than we had to in our share of that Medicaid dollar was reduced. It has gone back up for fiscal year 2524. Excuse me. And then what is the dollar amount of our on the left, our dollar amount of our state match share that we paid based on services provided in Medicaid. Build that. This slide I want to put some caveats around because we were struck by the, this is showing the number of foods served in success found six Medicaid by fiscal year. And certainly we were noting a reduction during the pandemic years, and then fiscal year 23 numbers were recently shared with us and I was surprised to see it. So we are digging into this. We have some questions about whether there's some data accuracy. We know that there was with one of our agencies that we've been working on with them. But we're also hearing that there have been reductions in contracts. So I, I didn't want to take it out, but I also want to put some copyouts around it because it is, it's notable. Reduction in contracts between the schools or supervisor union entities. Correct. Question question. Yeah, I know you haven't dug into it very deep that because the need has dissipated or because the work staff isn't there. The support. It's a great question. I actually, I don't know that I can answer the why behind why contract shifted. What I'm hearing is some of it's about the ability to be able to fill positions. Some of it is desired to pursue it through a different means. I do want to note, especially with the answer funds that the educational pandemic relief. Those are federal dollars that were available to schools and federal dollars cannot be used to match federal dollars so they could not be used for success beyond six. So it's possible that some success found six contracts reduced while the school had access to the answer funds and purchased it. Perhaps also directly with the designate agencies they just funded it differently or perhaps with someone else. So, can you, we, I promise we'll get to it. Okay, these are the slides. I don't need to go into detail, but I did want to note. But that additional monitoring is that the state does with the designate agencies for the success and six mental health program. As opposed to what other school mental health programming might have for oversight. So we do program monitoring and fiscal monitoring. There are standards that they need to meet documentation requirements for annual reporting requirements to us. This is part of our agency reviews are chart reviews that we've conducted on a periodic basis. And then the monitoring of the finances related to success around six. As well as part of the reporting requirements are outcome measurements. And so these are the examples of things that we asked our designate agencies to report on so that we can track. How many students are served how many FTE is and what roles they are in what schools. What are those payments for the Medicaid portion of success found six. And then they all conduct an annual school satisfaction survey and we get those results. There are some additional in a reporting for the behavioral intervention program. And then for any student. This is newer within the past year or two. When receiving success found six services. The designate agencies complete the child and adolescent needs and strengths tool. And then that's reported to us on the students. So we are tracking impact on the student and their particular needs. We are trying to get those up and live on our website. They're available. So there's been some. We're working through some things with the agency of digital services, because this is student data data and wanting to make sure that it's aggregated, de identified and allowable to have on our website so we should. This was just a way to try to visualize. I believe especially the education committees play with the multi systems of supports that we have here in Vermont and across the country really. It was this was a visual to try to show what is the role of the school districts and often the community partners across those tiers and what that looks like in school mental health. And then how does that translate to those three kind of core categories of success beyond six programming that are listed up top. So the universal supports and services which is really like what do all students need. There can be some component of our clinical services because of that alternative payment. They're able to participate in the MTSS planning teams and schools to provide a mental health expertise. I will say that the capacity of those clinicians to do that kind of work has been minimized because of the students need more students having need and so providing those kind of quick points. That is still something that we're trying to prioritize and support them in doing. And then for those that the tier two supports which is what are students who might have some risk or some brief identified needs, how can success beyond six connected those. And so that's some of the behavioral support services that can be provide as well as clinical. And then for those few students who have more intensive identified needs what can be provided to them. That's where the ongoing school based clinical services can happen in terms of one on one supports through the behavioral and then off our alternative independent therapy of schools and also address those. So just a quick visual on that. This, we're giving a little more detail than we did last year to try to get at some of the different structures for how school mental health can be provided. I'm just thinking about, you know, there can be an internal approach to this and integrated a co located coordinated, and we tried to provide a brief description and then what are some of the considerations of that so internal is really the schools are hiring people directly. They're an employee, and they can provide the supports to schools there's ease of access for students. They may have resources to be able to then pursue insurance reimbursement, including perhaps school based health services or perhaps less likely commercial. There is more administrative oversight, they might be able to contract for some clinical supervision for that role. And then there's an option of integrated which can look like our success plan six programming or other partnership with the community mental health partner where there's a direct partnership and it's happening within school. There's co located where some schools open up space, and they might open up space physically for a private therapist to come in and then that therapist bills insurance directly, or they might open up space for a telehealth service to occur. So it's coordinated where it's just the schools are referring out to the community and there's obviously less access ease for students with that. Okay, I think we had talked about this document a little bit last year, I do want to say we are in the process of actively reviewing and revising it because there are changes with ESSA funds no longer being available. So I'm going to make sure it's an accurate reflection, but we don't have the final update draft yet. So, I think we can talk through what isn't here with the intent was behind this. This came out of some collaborative work across agency of education department of mental health and our partners at the division of, excuse me department of mental health access, Eva. And where we really wanted to help schools understand what the range of funding is to support different mental health, social emotional activities in schools and so this document was way to capture what are those different sources and then from the lens of a school or a supervisor union, asking a question about is this about a tier one, you know universal support a targeted support here to or more intensive support and then based on questions that you ask there's a flow chart that can help guide towards potential changes that a school or district that's for, and I'm going to hand it over to you. Sure. Yeah, you could click on link and hopefully I hope it'll show it. I think this was also sent as a separate document so everyone should have access to this I think that was sent this morning. Just just get the power. So it might be we have the PowerPoint on our. Okay, perfect. She can click on and I'm going to do that and then I'll reach share my screen. Okay. And while you're doing that, Leslie, do you want to ask a question. Thank you. I come from the South Eastern part of the state and at a meeting with our superintendents, and there was a lot of frustration that's pressed about mental health programs, and they felt they weren't getting supports in the third page. And that was required to use education funds to pay for medical services. So I bring that up to spare on the table. So we can understand the stuff that people have been mentioned to agree that they want to get what they need the local BAs. So that they had to be since I say education, but we did the moving learning from kids that needed it. So there was a lot of worry and wondering where we can have we had a conversation. That is why we're here. So keep bringing that up. Yeah. I think, you know, as a department, we're always glad we have been invited to go and meet with both the school district representatives and the designated agency leaders around school mental health and have some of these conversations to understand what what are the challenges what are the concerns and see if there can be some things sometimes it's misunderstandings or things are communicated differently. So that is something that we're glad to support because we do, like I said, we want the success found sex Medicaid to be leveraged as much as possible. We know that there has been turnover across our agency system there might be, you know, just different needing to rebuild some of those relationships locally. Yeah, I'm wondering how you can get back to us about that because I've been saying it looks pretty tense. So, so Leslie that's part of this conversation and will as we move forward will whether it again as a joint or separate we're going to continue that conversation to build up. Thank you. So, again, everyone. Yeah. As Laurel said this was a joint effort with a variety of stakeholders, both state and then also in the field so we had representatives from the designated agencies as part of this collaborative work and then also a limited number we kept trying to get more but a limited number of our school districts that worked on this and the idea was we started this right at the beginning of COVID or maybe even right before COVID. And the idea was not so much to message there's all this money available for mental because as you'll see a lot of these pots of money are definitely already spoken for, but to actually let, you know, provide some assistance to the field both DA's but also certainly to LEAs about there are some other creative ways to use these funds that maybe you haven't thought about and so I just want to clarify that that was that was the goal for this and so there are several funding sources that are our agency of education identified. We've already talked a lot about success beyond six and so hopefully if you didn't understand that program Laurel did a fantastic job of sharing that. We do have and this came up with representative I think Austin or well, or was it plus about the school based Medicaid funds. Yeah, it was representative of us. And we have Jess Robinson here or we did I don't know if she's still on virtually and she can talk a lot about this program. It's using a different but it's using a different pot of Medicaid. That's allocated for a certain set of special education services and it's, it's a little bit confusing when you start to kind of try and keep all these different pots of Medicaid and then federal funds distinct but that's also why we put this together because we thought it would be useful for the students to actually have this. And then of course we have the local budget, the state education fund, and then we have title one funds. These are the primary set of federal funds for education. We provide assistance to students who are at academic risk for, you know, as the main goal, but if the cause of their academic risk can be related to social emotional learning challenges or mental health issues, then you districts and schools can use title one funds to support students in that, in that situation. We have local and state title two funds, a different title. These are under US Department of Education, and these are for school staff to lead to improved instruction student outcomes and again this may also include professional education in SEL and mental health. We have title three, which is our supports and services for English learner students. So the theme here with these title funds is that they're all education based. The issue must be is there an impact on academics for the student. And if that impact can actually or students and if that impact does include something related to social emotional learning mental health those kinds of topics you can leverage these funds. Now, these are the core academic support funds for districts. So as I said, most of them are going toward academics already and so there's not a lot of, you know, it's not like we're coming here and saying, oh, there's like, you know, millions of more dollars that can be deployed. But we, you know, I think, I think districts actually that got back to us found this useful because they were creatively I hadn't thought about blending and braiding these funds. So we had an answer. Title four and title five are available as well. Title five is really a special program that's for our highest need rural schools and interestingly, the schools we get the list out to the field but they have to actually apply directly to us and for those funds. It's going to make it weird. It'll happen. I mean, everything else right comes through the education agency, but this one is a little different. I'm kidding, by the way. It is now pretty much expired but as you know, we had a whole. We were required in terms of our state set aside and as we're leas to put some funds into social emotional learning and related topics that were, you know, obviously a big component of students ability to be resilient in the face of the pandemic. But those funds are, we're on the last tranche of spending those, then there are, I'm not going to go through all of these because that's just boring for everyone but there's a variety of different special education funds as well. Again, the idea there would be is does the student qualify for an individual individualized education plan and if so, is something going on with respect to mental health with emotional learning and then those funds could potentially be deployed. These are essential early education grant funds that can also be applied. And then we have some other state funds that we identified, which are the extraordinary embarrassment is typically linked. It is linked with special education as well. So I'm going to, there's a lot of us that could actually talk about this so I'm going to actually just flash forward and I invite, I invite committees to take a look at this if you want to do like a really deep dive. The, this I think has been really helpful, which is kind of a flow chart for decision making about what funds could match what kind of need a student or a group of students has because that's the other thing some of these funds have to be allocated at the individual student level. Some can be used for groups of students. And so it's, it's a lot to really keep in mind and that's why we set about to to try and provide some clarity around this. And the first one is for universal or targeted supports so that largest level from the school perspective of the pyramid which is what can we, how can we deploy these different funds for resources to help mental health, help with mental health and social health for all students or the next level up would be a smaller group of students. And then what types of resources and kind of resources are available for that level three from the education perspective, which tends to be more the bottom of the pyramid for our Department of Mental Health colleagues because it is more that individualized intensive work. And with the title funds, so take title one, a school gets a lump sum based on a formula, not based on a level of need. No, correct. What this guy does doesn't give that anybody access to any more money, but just clarifies how that money can be used. Yes. The other thing I would note is we, this was important to us because we have had a lot of turnover in terms of local district leadership, both of the superintendency and then also in some of our key positions so if folks have been doing this for a long time in the field they might have seen this as a yes we already know this but we're really meant it as a chance to get everyone on the same page to clarify some misconceptions if there were some about what funds could be used for and so forth. I guess I wanted to make sure that we noted and this came up in testimony in this body. A couple days ago I think is a question about how much of school districts total funds are being spent on mental health. I think it would be very hard for us to get that in a quick way. This is an approach that we piloted with one district and it took them a fair amount of time to get us to this place because they started with the Uniform Charter of Accounts but the Uniform Charter of Accounts is still at a pretty high level when you take a look at it and so they had to dig deeper and make sure, okay, this really is going to, you know, this particular position that's in this bucket really does go towards social emotional learning or mental health and for our purposes for this we actually combine those together because a lot of our work has been together has been framed around that social emotional learning and mental health are really on a continuum. So if you're actually helping students with their skills and their understanding of healthy social emotional development it will stave off mental health challenges or it should stave off mental health challenges later on. That's very simplistic and it's not the sole answer but that has been a lot of what we're working with. And my good friend Laura would say and it's not just about the skills, it's also about deploying those social emotional behaviors which is a really very important point that I'm always clear to note. Okay, so this is just one example then trying to put this down. So, just to clarify a little bit more this district. Did you get to talk about Project Aware yet. Okay, so that's coming and Project Aware is a really awesome state grant which we can hopefully have time to talk about. But this district culled through all their finances and basically by the financial fund, they actually mapped out like okay out of all of our LEA local budget, our state education funding. Here's the amount that's actually covering SEL, social emotional learning or mental health in any way it could have gone students and could be fresh learning it could be going to staffing those kinds of things. But the same thing for Success Beyond Six, those different titles I told you about then there's some other funding pots to Act 260 Best is a state funded program that allocates the funds to the school districts and provide some professional learning with state contract. You can see that right off the bat this would be outdated because it's got all three. It's combined the three S or pots into this this was this was done in calculations are probably 2021 because the report was finalized in 2022, but I thought. So the bad news is we don't have this on every district, but it might we could we could we could engage in this so otherwise what we're left with is we're kind of piecing together really what's going on and part of that is because what's happening is really at the local level. So to this point. So in this graphic if you can actually go. Yeah, well actually the one that's very clear that this supervisory union, supervisory union is. Education fund dollars for mental health versus Success Beyond Six. Yes, and I think that's that's what we want to get to at each supervisory level so I don't think we need as much of the title to and everything else but but what is the total dollar spend on mental health in our schools social muscle money and what is coming from Success Beyond Six and what is it coming from other sources and and from this you can say that you know the local budget is really a large chunk of the other sources and why in each of those districts or supervisory unions I apologize is that happening and it's going to be I think has to be done at each supervisory union level but if we're leaving $17 million on the table for Success Beyond Six understanding that that's just for Medicaid. We have to somehow put that gap. So is that possible to get to. I think that we certainly want to hear testimony from the field of education about the lift that that would be. So I think we don't have that we don't have access at the state level to that level of detail about how the education fund is being used, because those decisions are really at the local level. We have uniform chart of accounts information so we do have FTE numbers but that's only part again of what's being done so I think Laurel has shown we do have that for Success Beyond Six. I think the big piece is really digging into what at the local level are those funds being spent on good budgets probably have that already. The line item somewhere probably I mean they're likely I mean but then look at something like professional learning like you might have a line item for professional learning and that's got all everything in it. So I don't want to give the impression that this would be an easy walk in the park. And that's why quite honestly we thought about, you know this was kind of a small pilot and we thought about, hey should we, you know maybe think about requiring this and then and then COVID like continuing so this kind of fell by the wayside but I think it's a really, and I understand about the issue about title, but I also think that they are important to put in here because they can be deployed and so I mean I'm very eager to hear again from the field in terms of what they think would be useful. And I think that is our goal is to have a second, and I'm just going to let the question maybe a little bit differently I'm wondering Laurel if it's possible to understand from the success beyond $6 level, where everyone is, and for those that are below average I mean, you know some metric, start with those supervisory unions to say well why is there, and I'm not saying we need there's there's obviously a root cause here whether it's staffing or something else. So, where can we start that conversation so we'll have the subsequent by saying testimony with educators and then can circle back to this. Do we know what percentage of kids in school are Medicaid covered. I have to go with depends are they covered you know there's different. There's different. I mean that would be more. That's not really our, we can get back for you through other state channels. I mean one simple way is how many, how many kids have Dr. Dinosaur. And for the school based Medicaid, it doesn't come to one to one, like it's not like that so that's why I was also pausing because there's some group work and that kind of stuff but I do think that we could get that largely from diva or the Medicaid or even. I understand every Dr. Dinosaur covered is diagnosed with something that would qualify for success. Right. Can I just want to do a check reel here because of timing and so I see there's quite a few agency of education. People on the schedule are they here as the experts. If needed to be or they testifying we have and Jess and Tracy. Do you want to that's a great question and they're here largely as experts to answer questions, but if you would like to hear more about school based Medicaid that's Jess. Okay, and then I think the we did have a small set of slides on the. So a survey annually and as part of our baron MTSS monitoring work and there are some relevant questions from this last survey that I thought that we thought would be useful for the topic today. And I think Tracy is with us. Why don't we do that and then we'll do a couple minutes of questions and then I want to make sure that our DA partners that are here have time to testify. Chair Conlon one thing I would note as Laurel's figuring this out is that. It's I think it's hard for schools to know if students are qualified for Medicaid and because part of that has to be the parent has to sign off so it's just a caveat, but we can get that information. Or maybe a more of a non school question but just a population question. Maybe even by county. Also, I have to note for the record, I have no idea why Laurel put my name first, because Laurel did all of this work. So, not. We appreciate all of you to undersell. Now I'm embarrassed. So, is Tracy available to talk through these. It's not. Tracy appears to be maybe she's just on mute. Looks like she's on mute. Well, why don't I get started and because I know we're pressed for time and then Tracy can jump in if she would like. So, these are from all of our schools and we have a really excellent return rate. So, you can see the top 5 mental health supports that are provided in school year. Counseling and guidance services. These are so we have a 2 year comparison here. So, from 2022 to 2023, those counseling and guidance services actually went down a tiny bit. If I'm reading that. Right. And the other pieces that are going on and this I think gets at some of the work that I was talking about around. Breaking apart the ed fund and that because there's a lot of different types of supports that are going on. So restorative approaches. Helping students understand that when you're unkind or let alone actually hurt someone, it's not okay. And here's how to actually repair and restore your relationships. Tracy, can you talk now? I am I could not get off of on mute and show my camera. But now I'm here. Thank you. So, I'm Tracy Watterson. I am the assistant director of the student support services division at the agency of education. I'm also the program manager for Vermont multi tiered systems of support. And if we can go back, thank you to that slide. Heather said this is an annual collection. That's part of state statute. We receive responses from school principals about their school. And in this past survey, which we collected the information in the spring, we had a 95% response rate. And so you're going to see that reflected in a few data slides to follow. Today I tried to highlight three questions in particular that we ask in regards to mental health. And the first one you'll see is asking about which types of supports are available within your school to support students with either mental health or socially emotional help. And we noted in our survey that there was not a change in the top five from last year to this year. So that's something to note. If you're interested in seeing either the questions for the survey or the full survey itself, which is linked to the previous slide. We do an annual report where we collect all the data and give us sort of a state of the state representation. So those are both available on our website. So the next slide shows a question about asking for if your school has a memorandum of understanding with a local designated agency. I will say that this is a yes-no question, so we don't ask about what that looks like, you know, why you do or don't. And then for the third slide, these were the top five out of 20 choices that represent both mental health and social services, how things are funded. And I just want to make a note that we asked what were all the funding sources that you use. So even though you'll see a large percentage for a local budget, it could be that someone chose more than one. But these are the top five that have been reported to us this past year. I'm going to pause there. Yeah, no, this is great. This is really helpful. So if you go to the middle slide that you showed us, I mean, I think this gets to our question that we were trying to figure out is who is not working with a local DA and using success beyond sex. So is it an anonymous survey? Or do we have that answer? I do. So it's not anonymous. I know which principles have responded. And we use this information in two ways. One, we, when we share the report, which shows state level data. So if you see that on our website, it's not going to say which school answered what. It's state level data. We encourage schools to look at their information because when they submit the report to us, they have a copy for themselves and the superintendent is cc'd on it. So they can compare what's happening in their school with what's happening around the state. We can also correlate a school districts data to provide to the superintendent if they want to have that broader picture more easily. And then when we provide technical assistance to a school, we will refer back in to this survey as one of our data points and supporting them, whether it's mental health or, you know, really anything about their system because a survey is very broad to get a picture of what's happening throughout the school. Thank you. I would just note this is asking a principal of the school. And so they might not have the district or a school graduate level. Thank you. Thank you. Yeah. We do have the information by school and by SU success found six. It's just, it's too much. Would you do you think that that information would be comparable to this. I'd be interested to see how it obviously the question is if a school district doesn't have an MOU with the DA. That's a lot of letters. Yeah. Yeah, somehow we have to get to that point. Okay. And I think some of the design agencies to answer that from their experience because we know, I mean, there were some letters to our two agency and department about concern about the strict fully canceling all of their agreements with the design agency. You know, we talked with them and tried to understand what's going on behind us. So there, it is a local regional, you know, driven decision. And it has once. So before we open it up for a couple of questions was that either you have anything more. We just had two last slides. What was really just trying to highlight some of the work that we're trying to continue to do across our two entities at the state level. Really trying to enhance more guidance around social, emotional and mental health, including universal screening for social mental health guidance around that and technical systems or professional development. So we, there's a toolkit that's available online that school districts can look to and then coordinate other efforts and then we project aware, which could be a different. Brief information here, but we've got a second round of that grant the MHS now the grantee and partnership of agents. And Tracy, did you have anything else? I apologize. I might have cut you off. Well, I was just going to share some of the resources on that slide about enhanced partnerships. We have, if you look at the, I think it's the, let's see. Thank you. The second bullet, the AOE webpage for social, emotional learning. The other items on this slide are on that page. We were just trying to highlight a few. So if you're curious, that's a place to go. There's probably, I don't know, five or six different topics like resources for parents resources for educators, et cetera, funding sources. And then within each topic, when you click on it, there are additional information. So the collaboration with department of mental health and agency of education is just really strong. We have a social, emotional wellness team that we meet together monthly. We're working on project aware together working on Act 112 together, which is also focused on mental health for youth. So just a lot of exciting collaboration going on between the two agencies right now. Great. Thank you for sharing that. It's important for us to hear. So couple of minutes of questions, because again, I want to do the DA. Is Daisy, do you still have a question? Thank you. I guess this is for the share. And the last thing back on the planning slides. And at C6 is such a big, there's too many of that. It's a complicated thing. And for all this wonderful things that it does for students, including my kids, it is really complex. So looking at some of the other ways that we fund school based mental health supports. And thinking about the current state of youth in Vermont. And their needs for this. I'm wondering what other funding mechanisms are you looking at knowing that we are in a new general crisis. And I'm a big fan of our surgeon general and I don't I'm sure you're familiar with this 2021 report on the new general crisis. And shortly after that, the bipartisan safer communities act, you know, the largest mental health funding that had been interpreted in 50 years. The majority of that $1 million was for using all in schools. And I thought the innovative thing of that was a huge portion of that was not for mental health providers or VA system, but it was direct for school districts. So I'm curious, sitting and where you were sitting at that time in the leadership role a what portion of that bipartisan safer communities act. Are we seeing in in this pyramid right now. And thank you for the question. I'm going to bring you directly to the leader of that initiative, who is and born and narrow, who is on there and could you do a high level on what we're doing on on. On that fund. Sure. So, it was a little bit hard for me to hear your question. Can you repeat the very last part, just the question itself. Can you tell us about what portion of your projects are related to the bipartisan safer communities act. Sure. So actually, all of our projects are by definition, they have to be so the bipartisan safer communities act allocation to Vermont. I'm saying off the top of my head, I'd have to look it up, but it was around $4 million. And we had a competitive grant application process and we awarded those grants to, I believe, 18 school districts across or supervisor unions across the state. Basically, everyone who almost everyone who applied was was awarded. Not every single one. And by definition they had to prioritize in our in our competitive application we had them prioritize how they were going to address SEL mental health needs with these funds. We specifically ask them to coordinate with other funding sources that they already had like project to where like title like S or like success beyond six to talk about how they were going to do that so that so that they would make most effective use of them. So, we approved a lot of different kinds of projects. So, some of them were straight up clinical services. Others of them were more family engagement family outreach. They're trying to get kids to come to school trying to understand the, in some cases anxiety and other things that are preventing them from coming to school and to address those in a whole school process some of them were for SEL curriculum. So, so we had the gamut a wide range and there is a website which I will look up and put in the chat that explains each of the projects and what they're going for but every one of them has some SEL mental health component. So, I understand that can you repeat again how much money came into Vermont from the from this. It was around 4 million I can get the exact figure in a second and put it in the chat. And for the record that was Dr. Anne Bordenero, who is our division of federal education support program. Yeah, sorry about that. Thank you very much and I apologize so and I will say my committee we use first name so I apologize but it's not the norm here. Any other questions before we move on to the DH. What's the process for what happened in a school again, determine that someone needs help. How does that happen? Where does it come from the future, does it come from the student, does it come from a parent. How does it, how does it manifest itself so that you then give them the service of the community. Probably above. And so that's the real core of what multi tier systems of support is all about. So it's really making sure that everyone's on the same page there's whole specific set of components or multi tier system of support, but typically, for, like, if a student were struggling and hadn't already been identified as needing services under an IEP or a final. What do you mean, could be academically could be acting out in the classroom could be. The opposite of acting out could be like very introverted and not really responding and not making close friendships. So all kinds of ways that would be considered potentially at risk for a close adult who's working with that student. They would districts have under a QS they have an MTSS system they have a referral system to make sure that students get the right kinds of resources they need. Sometimes, if it is counseling or clinical services that's needed. And that is happening right in the school through school based clinicians, which success beyond six does pay for is very talked about, and then some are funded in their direct employees of school, well, they can be direct employees either way. It's really complex. So the other thing I would say is there are more short term teams education support teams that are not solely focused on academics but that tends to be if a student is struggling and some regular supports that meaning struggling academically or socially and if the regular supports that we're getting as part of just stopping taking a moment really working closely with that student are not working then they would get referred to an education support team, which they meet regularly and that's what we're going to be talking about. So we're going to be talking about this weekly Tracy, a water son has a lot more details than me on this, but there are a variety of ways that students actually should be in the system getting identified as needing additional supports resources conversation. So can I apologize. So we really need to get to the days and we're going to hear from the educators at a future one so if you hold those, that'd be great. So we're going to do one more question sorry to make Catherine and then we're going to move to the days. Yes, I was doing digging for the bipartisan bipartisan safer communities act and the part of that document. The documentation was released by the Department of Ed, gave estimated numbers of school based mental health professionals projected to be hired using those investments and it said that Vermont was projected to have 16 new positions. Do you know what the final count was for that last year using that grant funding. I have to look to am. I don't I don't know if that report is I'd have to look at that. It's through it's through the department US Department of Education. It's on her website. Just, I don't know. To my knowledge, I don't, I don't think that they required us to actually hire new positions. I mean, again, and if they weren't we'd have to we'd get that information from the LEA. It's not a requirement was just an estimated number of how that money would be used to address this need. And so they went state by state and said they estimated based on the grant application that said these figures are estimates generated by grantees through their donations for federal funding. So just seeing how that actually shaped out. So I see in and came up and you have a short answer or can we send this to you in an email and get an answer from you. Yes, I was actually tracking down the other on the phone with someone else tracking down the stronger connections information so I missed the actual question. I'm sorry, was talking to my assistant here on I'm going to get a hold on the estimated number of new school based mental health professionals that were hired using monies from that act that Daisy mentioned earlier it said projected we would have about 16 based on our own grant application. So the numbers that we put for in our own grant so I was just wondering what the problem was. If you take a look I'm going to post in the chat now I found the information and I will see just by sort of adding up the applications, you know, the information in the applications 16 sounds high to me, but, but, you know, I'll take a look. Those are also proposed I mean these are budget grant. And so there's a distinction between actually being able to hire those and so I really want to be clear about that. Right. And some of them may be full time FTE and some of them may not. And that's why I'm asking y'all could just provide clarification. That's why I'm asking. Thank you. And I would ask anything that comes in the chat. Because that would be excellent. Great. Thank you both. And three of you very much and everyone that's online. And we have and or a diesel saying that right and Tiffany more I think you're both coming up together right. Great. So just to level set on time. We have to be on the floor three and we want to give everyone a chance so we can leave about 10 of that would be great. We are going to do another screen so you don't get through everything. You have a great presentation. I do want to make sure we get to the challenges and understanding from your perspective of where we are with using DA's and all the schools. Great. Yeah. So I'm Tiffany more and I'm the director of school based services here in Washington County and have been a part of Washington County school based services for 29 years and have built a number of roles in the agency in school based mental health. I'm Ann Paradiso on the director of school programs at Howard Center and I have been involved in implementing school mental health services since we got some. Welcome. And I were just saying when we were coming in and listening to the presentation. Yeah. So I'm going to jump right into some of the challenges and needs but also I think it's important to like what works well. Yeah. Let's do what works well. Some of the challenges and needs and then hopefully we'll have some time for questions. Yeah. So so there are a few slides in regards to the Vermont care partner system of care which supports the designated agencies statewide. And so there are a few intro slides. I know you have that power point. We didn't know that if we should spend much time on that and just get into kind of what our experiences are. That would be great. I think as I reflect on this in my involvement with the system, the partnerships have worked really well from when they first were implemented back in the early 90s. When they're fully funded. And I think what we have seen over the past decade is that the funding for the mental health system of care has eroded over time. Which has impacted our our ability is as eight the designated agencies to have adequate staff to be responsive to the needs of the community. When they're fully funded and I think what we have seen over the past decade is that the funding for the mental health system of care has eroded over time, which has impacted our our ability is as eight the designated agencies to have adequate staff to be responsive to school needs. And there's been a whole host of consequences that have come with that. And I think we've particularly seen it. It probably started maybe about eight to 10 years ago and the pandemic just expedited it. So, you know, that before I get into those issues, I just want to say when it's fully funded. It was an incredibly effective model. It was robust through like the early 2000s into the, you know, the mid teens, the partnerships were just really exponentially growing really innovative collaborative work together to meet the mental health emotional behavior needs of students in schools. And yes, I'm sorry. So when you say fully funded. I'm not, I think that would help. We need to understand that because we saw a slide that made it look like we have a number we can get to create a budgeted to that number. Correct. And then we're down here so explain from your perspective. Yes, but that means. Um, so this really talks about funding the designated agencies overall. So when we look at the full funding that comes into the agencies to support the costs for running those agencies that impact salaries. And we can look at over the past decade on average that annual funding increases been roughly 0.8% yet the consumer price index has been during that same period about 2.3%. So we it's eroded over time and why you can. It is interesting. I knew that question would come up. There is a gap about what's available. We have to employ staff to be able to draw those funds down. So the schools can pay us the schools to the extent they have their local funds and they want to work with us to to serve a student or serve a school district. We have to hire those staff that then are able to access those Medicaid dollars. We can't hire the staff. We don't have access to the Medicaid dollars. So that that's what that refers to. We'll speak to that quite a bit in the needs and challenges because I think it's just an overarching piece because there's a significant domino effect when you're not able to fill positions. And school systems and mental health agencies have the acuity of need that we're all, you know, struggling to to serve. And so just to speak to Anne's piece around, I would, I would say that while it was very robust at the start, I would also say it continues to be robust. And so there has been a number of challenges that we've faced over the last number of years and I think some of those challenges again that we will speak to is around the, you know, increasing caseload the complexity of students that needs the staffing challenges. But despite all of that, there is still some relatively innovative practices that continue to take place. Because there's a collective desire to support the students that, you know, are developing youth within the communities. I do think that we have shifted. Again, as Anne had mentioned, certainly pandemic and forward, but even just around the cusp of the pandemic. One of the things that I do notice a significant change in sort of the, the collaboration or the workings between mental health and education is that it sort of has moved from a responsive system to a reactive system. And there's, there's a variety of reasons why that's the case. But when we together in our collaboration were able to work very responsibly, certainly in Washington County, we had, we have what is called the governance board and school leaders, some school superintendents, school administration, Sped directors, and our mental health partners would all come together once a month we talk about what are the needs, where are the gaps, what isn't available what are the resources that are available how do we leverage some of those how do we do more with less like and really have robust conversations that has shifted over the last number of years because school systems have these students that show up in their schools every day that needs service, and if we don't have stopping so it's become more of a shift in focus and pose for some challenge, but one thing I did want to say about what's going well before we move to challenges is, is, I know this funding stream feels really complex. But in the end, we, the DA's develop the service we forgot what it costs to run. We take the education portion which is, you know, a shift year to year but it's roughly 43%. And they get charged and this is at the simplest term. They get that's what they on the contract costs and then we in the DA system have staff that bill Medicaid that draw down that to make up the full the combination to pay for the service. And the simplest term that's what it is so for me when I think about where we go from here and how we continue to meet the complex mental health needs within the school systems we have a model that works it's been working for 30 years. It's a soft track right now but I feel like if the funding is there, we're going to get back on track to be able to take advantage of the really diverse and deep array of mental health expertise, working in conjunction with our education partners. So, that is just one mention I want to say it's when it comes down to like actually delivering it it is cost savings for the state to be able to leverage the federal Medicaid and have these contracts with school districts. But I think something that we do have going for us in Vermont and that we should take advantage of. You know, I can say a little bit more about the whole, the inability to hire staff and the insufficient funding we can offer market weight wages as much as we try. And then of course the workforce crisis has exacerbated things further over the past four years the DA's have experienced roughly 25 to 30% staff turnover. And yes, that in itself is hugely costly. And then, you know, on top of that we've, you know, there have been conversations about school districts contracting with private providers or delivering services through through the school employees. What they can say about that is that there are private providers. They can charge more, they can pay more they don't have the same administrative burden and some of this stuff was Laurel had talked about in her presentation. And so what we find is that staff might start with us, like the new grads I guess some great initial experience making their license and then they're off and running with a private provider that can pay them more. Back at square one bringing in kind of newer staff to the extent at this point they can even be, they can even excuse me even be hired. And schools also can be our competitors because if we is is it is our ability to respond has eroded as is to refer to the student acuity has just gone through the roof we all know this. There's mentioned shortly ago about that may have an obligation to serve these students and so if they the DA's can't respond they're going to go where they can get the service because these kids are showing up at their doors. And they have a legal obligation. And so they might go with a provider private provider and they might hire their own staff. And then that becomes a competition between the DA's and the school system and the, the, you know, the schools can struggle with the lack of funding flexibility. We talked about success bansits predominantly support students with Medicaid though there is some flexibility with the school based clinician work. The administrative burden can be a bear to schools and then, which, you know, it's the billing the documentation and all the reporting requirements we have a lot of regulatory bodies that we have to that we have to respond to and private providers don't have that. And so this is all added up to the DA's not being in a position to be responsive which I see in those figures that were shared I mean it's not a one simple answer. So those were some of the initial challenges did you was anything from that. Oh, I mean, I think we could dive so deeply into some of the things I just said, you know, I mean, I'm sure we can all appreciate that. But again, like I don't know if it would be helpful if there were just questions that we could agree we could then field. Yeah, I think one of the unfortunate things with with going from having had a robust program to one that's a little, a little less than it used to be is the fact that school based school can school hired people are there for the school services during school day, whereas when the DA's are involved that can be a full wrap around into the family work where clearly that has the most impact. I don't have a question I think I just was throwing that. You're mentioning that I was going to talk about that in terms of like what's working. I mean I think that when we think about the services that the DA's provide, whether it be in our local education or as a member of other child serving agencies, it really is looking at the social determinants of health, but we touch all of it, right. A significant thank you whoever's operating slides. When we look at the external supports in the community referrals that's not something that school systems are able to do when they hire private providers or they hire or they employ their own. The connections that the mental health age, it's like, we're like a conduit to a much greater system of care, whether it's pediatricians or dentals or economic services or housing or helping families like really getting into children's home and addressing the origin of where so much of the manifestation of the behaviors that we're seeing at school. Looking at all those environmental influences and how do we impact change in the family system as well as the individual student is school, then then has a ripple effect back into the community, but it, you know, I just think about some of those social determinants I mean like their housing right like their their community integration education food. These are all things that students are showing up in schools with every day in terms of some of these insecurities but also just the crisis and the chaos that's going on in their mind. And having that mental health system, you know whether it's through a school based clinician and or through a verbatim service and or one on one be I it really just opens up a number of supports, I do want to say the slide that captured some of your attention that world had presented looking at this past years are like fiscal year 23 or 24 numbers having dropped to 2,990. You know, I was thinking when I was speaking to you about the changes that I've seen moving from a reactive or a responsive to a reactive system. While we have seen in the last number of years, our alternative school placements are maxed their capacity with high referrals to them, any center based program are at capacity with high referral rates are one on one supports are, I think in Washington County alone I have over 30 students on a wait list waiting for a one on one, but our school based clinician positions have dropped by half. And so then what I look at that number I'm like because the number of school based clinician contracts have dropped drastically those positions can serve 8 to 12 students. With one clinician in a school that is a low barrier access to a system of care to high quality service and support is a phenomenal service in schools, and those numbers are dropping and it speaks to the complexity and the number of students that are in a place where they are just reacting to the the crisis that's taking place in their schools they've got these students that are in there and there are these high acuity needs and the clinicians has to do with not being able to hire not having staff we can't hire them we can't right we can't pay them they'll get hired out of school sometimes they'll come back because they're like like supervision lack of support lack of training, and we can do a whole piece on that we've got a lot of people are so many of our staff who've left on to the educational field who have come back saying, you know, some of these, you know, administrative burdens I didn't have when I was there but the things that I missed were training or supervision where the clinical supports was the access to, you know, professionals that are in the field the same level of expertise. Okay, so I think I saw tested you have a question. I did. Okay, and then Leslie, and then Serita. So, if a school is trying to, you know, a child has an issue, if they are on Medicaid, can I, if I'm the principal, I have a contract with success beyond six and I can also have the school Medicaid program right because if they're, can you talk to me about like, do I choose one or the other as a principal or is this a rated situation do I choose, I just choose success beyond six, or I choose doing it on my own. If a student has Medicaid and there's a relationship with the DA to contract for services, most would go the route of the of the success beyond six funding mechanism I think it's the most economically makes the most sense. If a student doesn't have Medicaid a school can choose to buy to purchase outright the services of a non Medicaid rate it's much more expensive. They can choose to do that, but they don't use different Medicaid stream. I'm not aware that they don't use a different Medicaid stream to purchase services. I think Jessica from since probably the best expert, it would need to be on an IEP. And I believe that we actually pursue our Medicaid first and the special education last. There's kind of this preference from the federal government about what we're tapping into. Okay, and then if a student's not on Medicaid, but they need this service, then the school has to go through it and they cannot go through success beyond six because they're not on a gate. And do we do we know how many of those students that I'm wondering if the reason why schools are contracting more if there are less kids on Medicaid. Then is that a part of the reason why the numbers are flowing differently. If we have more, if we have more kids that have mental health needs but aren't on Medicaid, then they can't use success beyond six. They can't use success beyond six for like the one on one individual contracts and some of those services that are provided by that but our like school clinician position. The mandatory positions allow for it like 8 to 10 identified Medicaid youth, but then that position itself has the capacity to serve the general population of the school. And the way that the funding is done for that position, it requires just it's like two hits per unit per client per month right and then everything beyond that can support the school at large so that can be non Medicaid can be classroom support that can be supporting EST teams and SST teams, it can be offering for this trainings and clinical supervision to education staff regarding youth who may not necessarily be Medicaid When I saw the reduction in my contracts services, I we have a program that provides one to one behavioral intervention interventionist staff that can go into the school partner with a student that's really struggling to attend class to participate to keep their behaviors under control to access their learning And after that program was budgeted for 43 contracts, which means the ability to serve 43 students, I think the most we hit during the school year was maybe 33, and it was totally related to hiring. So this year, we dropped the budget to 33 students, and we are at 27. We've not even been able to. So when I look at that, I think of it from a staffing perspective, the disk. And you talk about having a wait list in Chittenden County that you can own. We find that they only can ask so many times and they keep hearing we don't they don't have the staff we don't have the staff and so they they're, they're going where they can go to get those needs met. But I see it I see it as my lens is is the staffing crisis. And then, and the acuity is just like nothing that we've seen before and the pandemic really pushed it over the edge. Their schools are responsible for students that sometimes we can't even serve. They by the time they come to us they belong at a higher level of care and higher level care doesn't exist and they're back at the door of the lea, who is not in any better position to serve the students. It's, it's, it's a really complex situation right now between in the public schools. I think it's important I appreciate your offering a bit of clarity around that and when I say wait list, there's a wait list because we don't have staff. It's not that I can serve X number of students and so you, you just wait until one of those slots become available it's this it's a staffing issue. It's a staffing issue if we had a staffing that was available if we had the ability to provide them both in salary and as a competitive rate that some of our private providers are able to then we would have as much of a staffing issue as we, as we do, but the bottleneck piece I think is also important as and just mentioned. I mean the rise in acuity is significant is incredibly significant and students that we were supporting in schools or that we are supporting in schools that both schools and mental health struggle with these are students who were once in hospitals right in residential facilities and because there is a reduction in that and beds available. They show up in the public school every day. And so services, it's like the services are serving a different population now. And as a result, right, like we see all sorts of things around like turnover rates, and that's not just in DA systems I think one of our challenges also is that there's enormous amounts of turnover rates in our education system, both in our leaders, as well as our teachers, and certainly in our area there's a number of teachers that are teaching in classrooms who are not qualified teachers. And they're forced to hire unqualified staff, because they have to have the school has to function classrooms have to exist. And so there's this push pull right like mental health we want to work with you, but it's going to take forever for you to get somebody in and I don't have forever. So I'm just going to bring this person along. And that's our struggle. We have two more questions I just want to get to you. Just real quickly, just anecdotally, I'm hearing that social media plays a part or a large part in this mental health, the acuity and I'm just wondering, yes or no, you don't have to like going to man. What is the top two kind of difficulties that you see with kids in terms of the skills, what are the top two skills that you're seeing that kids need to access to be able to stay in the classroom and learn real quickly. Like, like emotional regulation right like their ability to control and regulate. I mean we're working with children every day who are so hyper vigilant, like they just live in a state of hyper vigilance. Based on, yeah, they're likely their environment that they're developing and whether it's in their home their neighborhood right like their community members. So I'd say emotional regulation for sure. And, you know, depending on where they're at many students that are in school have lacked their lagging and or have missed altogether critical developmental steps. Right. And so we're looking you know school systems mental health we're like filling in the gaps of developmental skills that have not been ascertained at 123 and four years old, just based on the influences of the environments around them, there's poverty and trauma and certainly social media doesn't help but there's many influencing actors to start very early on that that make it complex for students in public schools. Yeah. Thank you. All right. Topper last one. That's what it appears that you've identified the staffing problem. And that's wages. That's what you said. It's one component. Yeah, what's the other. They're not people like I think you know, this is important. Yeah. You said that that the staffing problem is based on wages. If you could pay more, you would probably be able to stop solve the staffing problem. It would help if there's a small pool of people and everyone's pulling from that same pool. We know that like we're not replacing ourselves as we're all aging the state doesn't have enough young workers. And so there's a small pool and everyone's competing for those workers and so they go mostly they are interested in the higher wage, not necessarily the benefits. And I think we have fairly good benefit packages in the DA's but that if we didn't know if we had to like really like take it down to one thing, we do see wages but there's also housing child we have people that want to come and work from out of state they can't come and work from out of state. And so if the housing thing is part of it, which we know. Yeah. And we're trying to work on that. So while we're working on that. But I want to get back to this. Point you made about the staffing issue. Higher wages would solve that. Is that what I'm hearing? Is that true? So I'm going to say one more thing. Burlington bagel bakery has a sign out front $25 an hour. That's more than we pay our behavior interventionist. I don't know the status of their staffing, but when, when, when people are seeing that and they're going to make less to go into schools. It's really complex and they're now they're going to spit and it's a much more difficult job. they're going to make less to go into schools. It's really complex and they're now being hit and spit. And it's a much more difficult job. We're hearing, we have staff at LEED that are be like, this is so many staff of mental health issues from themselves coming out of the pandemic and working with really complex students. So they're like, I can make more and pay my rent and have more left over at the end of the month. I'm moving over to the bagel baker. That's just one example. I think it would help. I mean, I think we've heard from the DAs and our committee for years and we've supported increases. You are not, the wages within the DAs are not at market rate. And so therefore, for this specific situation, if a school is in need for their children and they can go and get a private provider that can help, they will do that. And so there might be some competition between the DAs and the private providers in that. They may come to us first and we don't have anybody and they're like, okay, we're off to the next thing. And I'm pulling away. Right, they need, they just take care of the kids. They can have it, can they need support and help. The availability of staff. And when I say it's a portion, you're right. If we could probably drill it all the way down to that because then it makes a difference around quality of providers, right? We can get a higher quality provider if we're gonna be able to pay them more than McDonald's third shift. Is that fair to say we can't create more qualified human beings because they don't exist. So the next best tool we have available is to make it worth those who are around worthwhile to come and work at a DA. But what I would say is you're absolutely correct. But if they came on board and the wage and the salary was livable and they stayed with us, we can train and super we've done, we've trained a number of people and supervised a number and build the skills that we need them to have. We just need them to stick around and stay versus going to the bagel bakery because they're like, I can't live off this. Yeah. Thank you all very much. This was really helpful. I think it raised a lot of questions. If you can help comment. No, no, it was terrific. Thanks. Great, thank you everyone. I just wanna say that I'm sitting next to somebody who works in a public school, who works as a paper interventionist. And I say that we also need to thank the people who are doing work for us. So shout out Grapp Taylor. Yes. Thank you. Thank you.