 So good morning, everyone. Welcome to the advisory board. So this is, we're really excited at the three-mile care board to take up this topic today. And in a minute Susan will identify the panelists and talk about what we're going to be doing this morning. But this is a topic that we at the three-mile care board take very serious in that we will not just pay lip service to parent between fiscal and mental health. And so having this type of feedback this morning from the advisory committee is going to be very, very helpful. And before I say too much, I did want to recognize someone in the room who just came back from getting a national award. Sam Lisch, you want to stand up? I was just honored in Washington and received the regional one award for the outstanding work that he has done. So thank you, Sam, for everything that you do. Thank you. So the three-mile care board in Title 18's chapters 220 and 222 does have a lot of statutory duties when it comes to mental health. And that was expanded actually in Act 200 this past year in making it very clear that mental health is on the same footing with physical health. So at this point, I'm going to turn it over to Susan, who will introduce our panelists. We're on a type of timetable because we did take the feedback in the last meeting very seriously where the advisory committee members didn't feel they had enough time. So panelists are going to be kept to that strict time limit and we'll move forward from there. Thank you, Mr. Chair. Before I introduce our panel, I wanted to give everyone an overview of what the agenda looks like today. We're going to start out hearing from our panelists who I will introduce shortly. And they're going to be giving us an insight from their perspective on what they feel are the biggest issues around mental health in the state of Vermont. And then we are going to break out into groups with the panel discussion, those from 1010 until 1110. And then we will be breaking out into three separate groups and the topics of the groups. And you should have received all of this information beforehand. We'll have one group on workforce and education. We'll have one more group on capacity and need for beds. And then the third will be on access and quality. That will start at 1110. I want to have Melissa Miles and Marissa Melamed and Michelle. Please just stand up. So I'm going to have these three staff members will be in different areas of the room. And that's how we'll break out. The room isn't perfect, but I think it's big enough that we can separate out and then help facilitate some work groups. We're going to ask one person from the work group to then share out the answers to the questions that we presented to you. And then you'll report that back to the group and to the board. I want to remind folks that we're going to have surveys for you of the meeting. And please ask you to fill this out today. We'll have someone at the door collecting these on the way out. We really, really need feedback from you so that we can make these meetings as valuable as they can be, both for you and for the board. So without further ado, I will go ahead and introduce the panel. So I'll start with Melissa Bailey, who is the commissioner of the Department of Mental Health for the State of Vermont. Next to her is Julie Tessler, who is Vermont Care Partners' executive director. And then next to Julie is Dr. Susan Deppie from the Society of Veterans in Colt, New York, Vermont. And next to Dr. Deppie is Dr. Mark McGee. He is the chief medical officer at Battleboro Retreat. And next to Dr. McGee is Dr. Rick Burnett. And he is a psychologist in the Stowe, Vermont. And last but not least is Devin Green, his vice president of government relations, Vermont Association of Hospital and Health Systems. We tried to make this a very broad group. We had to cut it off somewhere. But we really did want to bring in different perspectives that we hadn't heard in the past and trying to cover as many bases as we possibly could. So unless you have anything else, Mr. Chair, I think we can turn it over to the panel. And I think we should start with Melissa. Sure. Thank you. Good morning, everyone. So I'm going to start at a very high level, because I think that it's important to recognize that the Department of Mental Health's responsibility really span a very broad continuum. When we were reorganized out of the health department, statutory authority expanded to include the mental health of all Vermonters. And I think that the department has continued to sort of fine tune what that actually means for them, what their role should be in the mental health of all Vermonters versus their previous role that was primarily focused on just the most vulnerable. So I think it's important to first talk about mental health on the continuum of health conditions. Many individuals experience a mental health issue sometime in their lifetime, whether it's dealing with anxiety, depression, or any other issue that any one of us on any given day may struggle with. Some people reach a level that a mental health condition may become more impactful in their life. Their condition may reach a point of meeting the threshold of a diagnosable condition. And some, but of course a smaller number, become very ill from their mental health condition. And it's extremely impactful on their life and their well-being. All of these conditions are treatable, some to a better degree than others, all impact a person's life and each have overlapping and unique needs and needed responses to them, including treatment, social service supports, family supports, medication, and the list can go on and on. So we're talking about a group of individuals that are dealing with a mental health condition, their needs are just as unique as their diagnosis and their presentation may be. In order to best address the continuum and the responsibility of the Department of Mental Health from the most vulnerable, but also looking at the mental health of all Vermonters, we must continuously look at responses and treatment from these different lenses. So just as some examples, we run the Vermont Psychiatric Care Hospital and we also promote access to community providers such as the designated agencies, as well as promoting things that are like the crisis text line that are available for all Vermonters. First and foremost, I think a system that focuses on health promotion, prevention and early intervention will be our most effective while not pulling back from our responsibility of treating the most vulnerable or those that are really dealing with a serious mental illness. Just like addressing any health conditions, staying healthy and preventing illness should be our first response. So when asked what is the greatest issue in Vermont regarding mental health and substance abuse treatment and access, we feel that the Department must first think about how we're preventing and intervening early while not at all taking any of our attention away from our biggest responsibility again treating the most vulnerable. But to that end, and because we don't have a system completely set up to do that and because there are also, we'll be people who need more, we need to focus our efforts and our responses on treatment care, engagement and ways to help people who do have a mental health illness recover, live in their community and build resiliency skills. These approaches regardless of the more upstream or further downstream must combine treatment options with addressing the other things that people need like social determinants that I mentioned earlier. So without options to housing, secure food, safe neighborhoods, addressing loneliness and isolation, which has become more of a front and center in the conversation around mental health concerns, having a purpose in life, having job skills and employment, relationships and the skills to address all those things has to be a part of what our system focuses on. I just wanna highlight a little bit around children and families when I talk about health promotion and prevention, I think about it on the continuum and that can happen anywhere in somebody's life. But I am gonna talk a little bit about Vermont families and what they're facing. When we look at the adverse experiences, the most common in Vermont are income hardship, being separated or divorced, parent or caregivers own mental health issues and or substance abuse issues. And therefore, because of those concerns that families are facing, they struggle to provide their children with the environment in which they can grow and thrive, build resiliency and obtain optimal mental health and brain development. In response to these struggles, DMH has been looking at evidence-based practices. So we continue to look at things like parent-child interaction therapy, parent-child psychotherapy, ways that we can really get into families as early and as preventative as possible. Children do best when they're living with families that are healthy, their local schools, living in their communities and while at times residential and inpatient care may be necessary for a child, we'd like to keep that as short-term as possible. The same when we think about it for adults is that we want to move them back into the community as quickly as possible. So, although I know most of the focus and energy today is on the adult system, I did think that it was important to talk about the kid's system, so I'm gonna skip something to get right to that. We also see individuals with serious mental illness that come about due to genetic or other consuming factors as well as kids or adults who have thrown up in a family system that's challenged as the way that I've described earlier. So DMH's first priority is to focus on the crisis at hand, which is the emergency department in inpatient access. Working with legislators, advocacy groups, peers, individuals who are receiving services, hospitals and others to address the need for inpatient beds for individuals with the most acute needs. This should include identifying and addressing the reasons people enter emergency departments in the first place and reasons people are not discharging from emergency departments. And as we saw in the Act 82 report and the deeper dive that UBMC did, it was clearly that the social fabric, the social supports, the housing supports, those were all very impactful and contributing factors to why people were challenged to discharging and we can only make the assumption that in many cases that that's also a challenge of why they come to the ED in the first place because they don't have access to those services and supports. That's not to say that there isn't an absolute need and time for inpatient care with really strong psychiatric response but we can't forget about the social fabric that supports people when they're dealing with a crisis. Nobody fits neatly into any of the category or boxes that we have in our system so we need to continue to work with the other providers that could be the criminal justice system, schools, employers, the list could go on and on and again to describe individuals as fitting in it to any neat box would do it in justice to any one of us. Clearly people have unique needs and we need to figure out how to continue to work with that. So again, I just will highlight knowing that my time is probably running out that I think we need to focus on the crisis at hand, the emergency departments and inpatients but almost simultaneously or concurrent to that really focus on these other pieces that contribute to people's well-being both on the front end and on the back end so that we're preventing people from reaching and needing that level of care but we're also doing everything we can to assure recovery and resiliency so when people come back into the community they are successful in not needing that level of care again. So I think I'll stop there and rather than try to. Thank you. I'm Julie Tester from on-care partners and I really wanna thank the board for taking this up because from on-care partners' perspective mental health, some serious disorders are just part of healthcare and if we're gonna achieve the goals of convenient costs addressing healthcare quality of service and better outcomes we really need to look at it holistically and this is just a great opportunity to do so and our commitment to that is clear we were working a legislator making sure that mental health was part of the work of the Green Managing Care Board even saying review our budgets, it's important. We're part of that healthcare expenditures and we want to look at that in a holistic way and we see this as a really opportune time the all-care model and new value-based models of payment enable us to look at how we finance healthcare in a whole new way and so we're working with the department the health agency, human services, department of aging, independent living around how do we pay for services and really focus on outcomes and flexibly meeting people's needs and integrating that into healthcare so this is, I feel like this is like a real turning point and we can really move forward with it so this is an exciting time even though yes, we also are dealing with some crises. The other reason I think it's really important is just how prevalent mental health conditions are and Melissa mentioned some of it but one in five adults at any one year have a mental health condition half of us will over our lifetimes and I think it's one in 12 have a substance use disorder so that's pretty prevalent but it's even more prevalent in our Medicaid population we look at public resources we're putting a lot of public resources into Medicaid so one in four Medicaid beneficiaries have a mental health condition and one in 10 have a substance use disorder and if you look at the highest spending in Medicaid the top 5% you will also see that 50% of them have a mental health condition and 18 to 20% have a substance use disorder so more of a reason where we really need to focus on this population. Additionally, the co-occurring nature of mental health and other health conditions is very significant and when you have a mental health condition on top of another health condition you are more likely to have higher expenditures and kind of a record journey and the comorbidity is just so important. So back to the mental health crisis I think we're all very aware of the issues with our emergency rooms and inpatient backup and as a native they're working really hard to look towards solutions, to work with the hospitals, to help people flow back out to develop that social fabric, housing resources, a care coordination, integrate services for people and I don't want to spend too much time on it because I think the other panelists will both do a great deal on that but another issue again that we don't think about too much is that people with serious mental illness tend to die 15 to 30 years younger than other people and I think that's a very critical issue we need to look at and you might assume that must be suicide and overdose and accidents, things related to the mental health condition but that's not actually true. They're dying from the same things or most people are dying from comorbidity with that cardiovascular disease, diabetes, stroke and things like that so we really need to look at that together. There's also clinical bias when someone with a mental health condition presents a clinical need very often the response and really this is coming from the New York Times and is well it doesn't matter that much that person's really already ill or you know what's the point they're just not giving the person the same level of attention and then there's diagnostic over shadowing when the person with a mental health condition presents or personally some use disorder presents a health care need again the thought is oh that's just their mental illness of course they have headaches or they're just you know it's other things going on and not giving people the level of medical attention they need so we really need to look at those medical issues. Kind of looking at the panel's name of addictions I think we're very aware of the opioid crisis it's tremendous, it's growing we're working very hard as a state to provide treatment and support and one of the serious problems but though is that a lot of people who have addictions aren't getting treatment up to 90% so even though we're providing so much and we've expanded so much there's so much more to do and I think we often overlook alcohol addiction many many Vermonters suffer from alcohol addiction 37,000 Vermonters and what's even more striking to me is that we have 2016 there are 293 deaths from alcohol addiction compared to about 100 in opioid addiction the deaths from alcohol addiction are related more to chronic conditions so it's not like an overdose it's not in your face but we're having as many deaths as much suffering that affects families so I think we really need to spend more time focusing on alcohol than we currently do suicide is also a common issue that we really is growing and deserves and continues to deserve attention there is more being done there's a zero suicide program that's being developed in the number of agencies with leadership from the Department of Health and I'll go faster because of the five minutes I also just want to point out several underserved populations because I think it's important to do that children of parents with opioid addiction are really having a tough time not only do the children need support the families need support sometimes that's the grandparents sometimes it's the child care center but we really need to be able to work with those families more elders have a very high rate of suicide a very high rate of alcohol abuse loneliness it's very hard to serve that population many of them are homebound can't get out so I think we could do more there LGBTQ youth have very high rates of depression and suicide and as much as we think we do a lot we really need more resources in our communities to serve that population New Americans are another group that it's a struggle try to develop resources the Howard Center has done a great deal of work but there's not a lot of specialized resources clinicians who know the population speak the languages who understand the cultures families in need of in-home support care coordination this is an interesting one if you have Medicaid you can get a full range of supports to address some of the issues that Melissa mentioned if you have private insurance it's much harder to access that full range of in-home supports that you need to address mental health and addiction issues and going back to early childhood and families the more we can do for that for those folks and schools are asking for supports and we just have limited resources I do want to say we need to look at the underlying issues stigma is really very high it creates feelings of shame inferiority, failure, brokenness and people that are afraid to access treatment and I think that's one of the reasons that so many people with some use disorders and mental health are not getting treatment it's not just the funding it's also their own feelings about it and the way they're treated by society and our culture around that the other part is that we really don't have parity we have moved strongly in that direction but as long as we continue to cap funding in Medicaid and under reimbursed the services we are never gonna really have full parity and that also really prevents access designated agencies really would like to do more we get limited because our reimbursement rates are too low to attract clinicians and staff we also are just capped we know so it's both our reimbursement rates and the amount of services funding available to provide the supports in the case of private clinicians many of them will not accept the rates of Medicaid insurance and so people don't have a lot of choices about where to go so those underlying issues I would like to see addressed but there's a lot of work to do but we're also optimistic that we can do this working together the Green Medical Care Board the Agency of Human Services the department private clinicians and providers and designated agencies we can make some really important progress so we're excited to be part of that and to work with you all I was wondering Mr. Mullen if I could go after some of the others to tailor my presentation to not go over the same things sure thank you sir I appreciate that you might get more concise presentation I guess that would make me an X we've got the board for this opportunity just to talk about some quite important issues that affects so many Vermonters when I think about this I often think about the words of wisdom of a mentor and teacher of mind in medical school and residency at the University of Vermont this is Jim Hodgeak who's a child psychiatrist and Jim would often say that there is no health without mental health and so I think that we are finally at a point where we're beginning to discuss these issues as front and center and central to the health of every Vermonter and our communities and our economy I think it's incredibly important and I think taking a holistic and integrative approach to addressing these issues is critically important as an example as an economic driver the number one cause of a lost productivity in industry is mental health approximately 625 billion with a B, billion dollars per year is lost in industry because people are depressed they're present there's this phenomenon called present he isn't meaning you're so depressed you're at your desk you're not doing anything you're not producing anything you're not contributing and so I think within industry there's opportunities to address this in terms of promoting health and wellness among our employee population I think at other extremes there are obviously incredibly ill individuals who require very high levels of intense care there are individuals in our departments of corrections the department of corrections is currently the single most largest provider went to health services nationwide we often incarcerate people because of mental illness so there are legal solutions there are primary care solutions there are well established models that allow for addressing many of these challenges and so really I think the biggest barrier to succeeding in these endeavors is really about access access to high quality care access to timely care access to affordable care and so as I think our panelists already have identified there are multiple levels of analysis that we can begin to look at primary prevention is obviously incredibly important substance use disorder so working with schools working with pediatric practices in terms of preventing the onset of substance use disorders if you can delay the first use of alcohol and other drugs beyond the age of 15 the rate of substance use disorders among young people decreases by nearly 50% and so these are important public health opportunities for us other opportunities about access there are very well established evidence-based and supported practice models that until recently we currently had no economic model to support so there's a collaborative care model of primary care psychiatry that uses extremely vitally and rare expert opinions not to treat patients individually but instead to treat panels of patients so for instance an hour of psychiatric expertise can be shared with a primary care provider they can run 15 or 20 cases and really enhance the primary care providers ability to effectively treat individuals in their practice whereas that same hour can only be used to treat one individual directly by that psychiatrist and so there are well established models strongly supported by evidence but currently with our reimbursement structures as they are there is no way to pay for that care unless the primary care practice sets that as a vital priority and decides to integrate that into their own financial models thankfully CMS has recently developed some billing mechanisms and CPT codes that are beginning to support those practices again strong evidence-based to support vitally important ground-breaking innovative approaches to providing care expanding access and our economic system or funding systems have to catch up in order to help support that and so I think if we step back a moment and we look at some of the challenges many of the challenges are our funding stream or funding mechanisms have not caught up to the science we have the medical science to say that we can really move the needle on many of these initiatives we need to get legislative support for pushing these things forward we need to get some of our reimbursement mechanisms to push these some of these models forward most of my work is at the Browler Burger Retreat where we every day treat the sickest psychiatric legal patients in the state and we have a vitally important role in that and we are faced with challenges day in and day out and the challenges that we often face are again with access getting really highly skilled psychiatrists to work in our hospital getting patients the care that they need both in our system of care and beyond trying to work with our hospital partners throughout the state in terms of developing solutions to get psychiatric care in the emergency departments where individuals too often find themselves stuck, ill, in distress stressing the local systems of care out waiting for a bed not having access so some of the things that we've been working on is how do we use telehealth solutions telemedicine solutions to address many of those critical issues so with the retreat we've developed a program in which we have been using telemedicine our inpatient service and it's been highly effective we've succeeded in recruiting four full-time five full-time psychiatrists to provide telepsychiatry in our hospital and health system we're working on partnering with emergency departments throughout the state to allow telemedicine to be implemented in emergency departments so we can get psychiatric care to patients where they are, when they need it as opposed to somebody waiting four, five, six, 10, 20 days in an emergency department without seeing the psychiatrist when they're in the midst of a psychiatric crisis we can do better we have the opportunity we have the technology I think we just need to use Vermont innovation and Vermont creativity and flexibility to get the services where they need in the time that they need to get there so I think this is a great opportunity for all of us to share ideas to think about solutions to identify barriers to implementing meaningful and effective change because this is too critically important issue to just to be left on its own so thank you for the time thanks Rick Barnett, the psychologist and addictions counselor and I'm also the legislative chair for the Vermont Psychological Association past president but I represent really myself as a community provider in Lamoille County I was just listening to people talk about the suicide issue in Vermont and Lamoille County has five times the suicide rate as Grand Isle County so we see suicide rates 30% for 5% higher in the state of Vermont than nationally and this is a very serious issue that the thing that stands out from many of the meetings that we've all been to regarding the all-parent model and healthcare reform is the focus I think that Pat Jones delivered a couple of years ago and it's a primary importance and that is the three areas that the Green Mountain Care Board wants to focus on and is legislatively directed to is to increase access to primary care to reduce deaths to suicide and drug overdose which in and of itself is confusing because it's hard to distinguish between the two sometimes and reduce the prevalence and morbidity of chronic disease all of those areas primary care, drug abuse and suicide as well as chronic disease put mental health and behavioral health front and center when it comes to any discussion every meeting I've been to which is many whether it's a steering committee for the SIM grant or a blueprint meeting or a vital meeting or any of these meetings mental health comes up consistently consistently and it doesn't matter if it's a mental health focused discussion or just general health care discussion whether it's a surgery or hospital financing mental health comes up regularly so this is the fourth time I've presented to the Green Mountain Care Board on mental health and it's the delight to do so every time and hopefully we will continue to make progress and I believe we have made progress so far I have a lot of different areas that I would want to focus on but to keep it as concise as possible some people have mentioned already Jero said college Jero geriatrics as well as the population of teenagers or younger population so we can think about the population of 18 to 65 and what their mental health or behavioral health needs might be but if we really want to look at reducing costs and improving quality of care we really want to look on the prevention side of things and getting kids access to quality care or resources even if it's not formal mental health care but resources on the front end and then having worked for five years full time in nursing homes and having Jero psychology services and assistance with medication decisions even as a psychologist I know that the mental health services in nursing homes is a much, much needed resource and one of the problems I think is in the all-payer model as I remember reviewing the term sheet before we signed the agreement was that LADC's licensed alcohol and drug counselors were included as a eligible provider under the all-payer waiver model now previously under Medicare LADC's are not eligible providers so I was delighted to see that LADC's were included on that term sheet I'm not actually sure if they are in the current model as it exists but one thing that did not get included was master's level psychologist and licensed clinical mental health counselors were not included as a waived provider group this is a huge group of providers who can do a great deal of quality care but are currently excluded from being reimbursed by Medicare for mental health services and that's a huge issue and it's a huge ask that I bring to the table every time I have the opportunity to present the other thing regarding addiction because it is something I'm obsessed with near and dear to my heart personally and professionally is as much progress as the up and spoke model has achieved in getting people access to medication if you look at the Department of Health report that came out about a year ago despite the glowing reviews it seemed to present it clearly indicated that mental health services the quality of the physical environment and some of the hubs as well as the quality of the mental health services regardless of whether it was a hub or a spoke was not good it was poorly rated by most people family members, patients and there's a high level of burnout whether it's counselors or primary care providers who are getting more and more trained to address the complex nature of addiction so if we were going to invest time and energy and money into improving the hub and spoke model or addiction treatment model it would not only be to really enhance our efforts around mental health but also I believe I think, what did Melissa say a little while ago I forgot what it was lost my trade of thought there but to really reduce the emphasis on medication only and to broaden that to peer recovery peer support which we have a great Vermont recovery network peer recovery supports psychosocial services not as a requirement because I think some people would get I have a barrier to access to like buprenorphine or methadone if they are absolutely required to have mental health services I don't think that's a good idea I have plenty of patients who have been on buprenorphine for five years and the fact that they're required to come see me for mental health services seems like a joke because they're fine and they don't need to you know it's like it's written into the rules I guess they have to have to be seen like once a month or something but it's still a really really important piece of the whole addiction oh I know what it was was Julie was talking about alcohol I mean that's the whole thing that gets lost in the hub and spoke thing is this poly drug use, alcohol use people are still dying in very very high numbers because their mental health isn't being addressed and there seems to be permissiveness around continued alcohol use, cannabis use, benzone use we're doing a good job in trying to address it but it's something that I think is could be addressed in a more focused way to reduce the death rate and finally I think I've got a couple minutes left I want to make a mention of two other things one is again to the scope of practice issue I believe we have a robust workforce there are 800 there are 800 practitioners in part time or full time private practice in the state of Vermont we are not talking about necessarily the most severe and persistent mentally ill people the people that utilize hospital based services for crisis care but there's a huge network of providers out there ready willing and able to treat a vast number of Vermonters who are not necessarily a crisis but post-crisis and the linkage between hospital systems medical homes hub and spoke between them and the independent practitioner community is weak as frankly that's something I've been interrupting for a long time and there are great opportunities to provide better linkages in collaboration with all these providers out there assuming that some of us are willing to do that not everybody, you know, a lot of you aren't independent practice because they want to be an independent practice but whether it's the all payer model or partnering with one care there are great opportunities there I know Otter Creek has started to do that scope of practice again there's great providers out there we live in a silo based world you do this, I do that and I think that competency based care is a much better model one thing that I've been advocating for is prescriptive authority for appropriately trained psychologists nurse practitioners prescribe a ton of psychiatric medications physician assistants do private care docs prescribe a lot of psych meds we've got great psychiatrists in the state but there is a shortage there we're bringing telehealth into the state more which is great but there is a growing population of psychologists who are qualified to prescribe which I would advocate for any chance I get and finally with regards to technology I think we are not investing enough not necessarily vital for the good work that they do but in very practical ways not just traditional telehealth like online therapy 45 minute, 30 minute consult kind of thing but leveraging the amazing world of technology whether it's a virtual reality augmented reality text based options like our suicide text opportunity for people but this is an area I believe especially when it comes to teens if we're gonna help people there's a report that came out of the well-being trust showing that teens consume all of their healthcare information and frankly treatment 75, 80% of it online online so if we're gonna invest in mental health, care, quality getting people access this is an area I think to focus on so that's my shtick I was sticking to thank you Hi I'm Devin Green with the Hospital Association and I just wanted to thank the Green Mountain Care Board for having us here today and talking about continuing to talk about the mental health crisis we really appreciate the partnership that the Green Mountain Care Board has done with the increasing inpatient capacity in Central Vermont the agreement that they came to earlier this year with the University of Vermont Health Network we think that that was a really good example of collaboration with the Green Mountain Care Board we also appreciate what the legislature has done for expanding inpatient capacity at the Brattleboro Retreat and we just wanna make sure that and I know I'm preaching to the choir here so this is more for the outside world we don't want people to throw out their hands and say all right we expanded inpatient capacity we're done, the crisis is solved we wanna keep pushing forward we know that the crisis is not solved and we need to do things at every part of the continuum of care so we really wanna advocate for that going forward I've spent a lot of time on various groups and the groups I've spent time on there's been some common themes that have come out of those groups in the discussion and some of them we talked about today but we've heard about need for more coordination of care and I think we're getting to a better place with that as Julie was saying I think organizations are working together a bit more I think there's a lot of room for improvement with the private practices and I'm certainly welcome anything that we could do there there's always talk about geriatric psychiatric support and juvenile psychiatric support and as well as housing and loneliness I'm really struck by how often I hear about loneliness and I think it's something to shine a little bit more light on I've heard of other hospitals where their hospital volunteers sort of just sitting at their desks greeting people as they come in if they have down times they will call folks and they were using this mainly for elderly folks who use care as a social outlet but there are little things we can do like calling folks, checking in, seeing how they're doing and it doesn't have to be done by a medical professional necessarily or take a whole lot of time and expense so I think it's really great that I've heard other people talk about loneliness here as well another common theme has been data collection so one thing that we realized last year was that there's a ton of great data at the Department of Mental Health on involuntary folks and no data on people who are voluntary so we saw this as a big problem we started collecting data at our designated hospitals that have inpatient units and we have just about a year's worth of data at this point and we are almost ready to share it I get very hesitant about it because it is still imperfect but how it's been collected it's sort of hand collected into spreadsheets we're still working on, we have enough we still have this number where it's more people who are not discharged than beds available so we know that there's something wrong there we're still sort of reconciling and matching it up but one of the things that we found initially is that there's no necessarily anything that has jumped out at us as an issue we've been collecting data on folks who are involuntary versus voluntary people who are receiving CRT or who are CRT status people who are designated as level one and sort of other populations and when we try to break the populations down we find that the longest saved populations are the people who are currently not discharged so we've broken it down by discharge versus not discharged and we found that about 6% of the patients who are currently not discharged make up 28% of the total bed days in the system we had looked at this data back in February and it was an even more dramatic number where it was essentially 5% of the patients who are not discharged from make up almost half of the bed days in the system so we've since learned that a couple of people were discharged and that has skewed the data a lot but there's, you know, when we look at those not discharged people it looks like about half are involuntary half are voluntary there's no real trends coming out from there which I think may get to Marisa's point of how some people just really need more individualized look and I think there are a lot of great programs going on that are doing exactly that I think hospitals and the designated agencies are doing some really interesting pilot projects that have come out with a lot of effective results and VPQHC had a great presentation on this a month or two ago where they highlighted that Washington County Mental Health was, you know, talking about a pilot project where they were coordinating care and really doing individualized care and working in teams and providing wraparound services I know in Northwestern they've also partnered with their DA to do a really great program that focused on high ED utilizers and working with them and really wrapping around services and providing an individualized plan for them and I know Northeastern with Paul Bankston he's been partnering with agencies to coordinate care even further so I do think that that approach provides great results and then finally, as Rick was saying I do think that we should look at the idea of further use of technology VPQHC highlighted brow-brow retreat doing a pilot project called the tele-friend tele-health system where some patients are sent home with essentially like an iPad and they just check in every day and there was a really small sample size study done in either New Hampshire or Massachusetts but they had fantastic results of I think reducing readmissions by 80% so brow-brow retreat is focusing on that pilot project right now and if that has good results it'd be great to expand that a bit more so I think going forward we should continue with data collection I know we're working with other organizations including the DAs to put that data all together a little bit more and provide a more complete picture of the system and just also keep looking at these pilot projects see where there are areas of opportunity for easy and helpful easy and not easy fixes to the system such as maybe phoning people who are lonely versus coordinating a lot of care for individuals and I think that's all I have. Hi, I wanted to thank the Green Mountain Care Board for not only focusing on mental health results for mothers who deserve access to care but also applauding that customer initiative that you're working on in the beginning. We also thank you guys for working on the association benefit plans to try to prevent the weakening of benefits which I understand you're doing. I am speaking on behalf of the Vermont Psychiatric Association, I collect a lot of thoughts from colleagues this is not a data-driven presentation I will leave out the things that my colleagues up here have talked about in general or unless I'm reinforcing them. So, we all know about suicide we all know that there's been a huge need for psychiatric nursing home beds for years I've had horror stories from my colleagues about where does the senior go when he or she has a severe mental illness when a nursing home won't take them. Emergency and other services and Julie you can correct me if I'm wrong for developmental disabilities have often been short-changed and need more resources. That's been a problem for a long time according to some of my experts. More outpatient psychiatrists when I first came to Burlington in 1983 there were scads about patient psychiatrists in the phone book. Clearly our workforce has collapsed over the last 30 years we can thank payment models and manage care for that. Another thing that we've needed has been that I've noticed in my practices that when I have a patient with dissociative disorder or severe trauma I've had to send them out of state. We don't have an inpatient unit that has handled that well in my experience. Many young people my colleagues have said who would be good psychiatrists are becoming PAs because they can't afford medical school. We had extensive dialogue about that earlier in the summer about loans and repayment and so on and we happily support efforts in that direction. I won't go into detail about the fallout from two few psychiatrists. There are some nightmare scenarios the Vermont School for Girls which takes extremely ill individuals. Right now has somebody who they can't discharge because they can't find an outpatient psychiatrist. And this is somebody who's been there for four years with multiple psychiatric diagnoses. Some of us don't know how we're gonna retire because we don't know who's gonna take care of our folks. I may have to start planning that now if I've been retiring five years who knows. And there's certainly lack of enforcement of the parody laws which I've heard from my colleagues as well, disparities in pay, disparities in re-certification or prior authorization processes that are a real hassle, insurers refusing to cover drug screens in substance abuse but covering them for medical things, that sort of thing. Repeating a medical pre-cert when somebody's already on the medication and a simple one such as Lerazepam which Medicare requires and I know we may not be able to do anything about that but it's abjectly stupid for me to call in and have the main question be did the doctor reassess the risks? Duh. You know, it's just, it's rigged stupidity. One of my colleagues as the final example was told by a Medicare drug planner that she couldn't prescribe new dextub for Pseudomulmar affect. She was actually involved with clinical trials. There's a lot of stuff out there that really frustrates those of us in practice and makes it very hard to try to do what you know your patients need. We have talked about how many families aren't able to provide environments that support good brain development and I couldn't strongly enough support all of the efforts into prevention, you know, working with kids, working with whole families and I know that my colleague, Dr. Attu had said something as well which I reiterated partly in my handout or mostly in my handout. There's a dismal number of private practice. Child psychiatrist and part of that is reimbursement. There is so much work involved for all psychiatrists but particularly on the adult, on the child and on the geriatric end of the spectrum with collateral sources of information and care coordination. There's a lot of it in general site but it's worse in those two areas and you don't get paid for that. And I know a psychiatrist who's child certified would be a brilliant child psychiatrist who's not practicing child because he or she can't get paid to do all of that collateral information gathering that is required. And I won't go through the rest of Dr. Attu's suggestions. The current structure of mental health practice and financing needless to say isn't supporting all of us in private practice whether we're psychiatrists or other clinicians. And the current system also doesn't fund us to do what our patients need. And I will go over what are two other things. There are a lot of hurdles from pharmacy benefit managers and so on that are really stressful for patients as well as wasting the time of pharmacists and psychiatrists. If the board can do anything about regulating that within Vermont I know you may not have control over Medicare although you can try but if we could regulate any company that's working in Vermont and Medicaid that would be very helpful. Many years ago we had a once you've done a pre-cert for a psychotropic in Medicaid I think you had it for lifetime as long as the patient was on it. I'm not sure where that went but it seems to have gone away. Let's reinstate it. It would save a lot of wasted time. So obviously you're hearing assessing the needs statewide and building capacity and we appreciate that as much as you have the power to do in working with the legislature. I've mentioned a couple of those needs. Investing in prevention is enormously important. Multimodal care as we've talked about it's not all about psychopharmacology. I would lovingly differ with my psychologist colleague about that. Oftentimes that's not gonna be the solution is getting families involved in multimodal care. That's well documented. Rebuilding and this is where my suggestions come in are recommendations rebuilding the psychiatric mental health primary care workforce particularly in outpatient practice which is my area of expertise. Obviously the residency stipends and helping with payments for medical and graduate school would help. Obviously raising reimbursement would help. Please consider using your rate setting power to get payers to shift the healthcare dollar, a higher percentage of the healthcare dollar progressively year upon year for about five years to primary care and mental health. The Rode, have you heard the study that Alan Ramsey, the studies that Alan Ramsey talked about Rode Island and so on? Rode Island saved 18% just by making the shift without even doing single payer, okay? Just shifting to primary care. We are not focusing on the things that are gonna save us the money. If you also fund mental health it saves a lot of money because as Julie and others have pointed out the lifetime costs and suffering in medical issues and social issues related to mental health are enormous. So if we do the investment, we can help Vermont meet internally out here and save money. I would recommend that include mental health and primary care and to the extent that we need to substance abuse as well. I don't have data for that, you all have that because that's not my area of expertise. So please use your rate setting power to push that priority and that will help to pay disparity. Please help with the parity issue. As you mentioned Mr. Mullen, thank you so much and support those essential and innovative and I'm almost done, ways of caring. If we could be paid for those collateral contacts and I don't care whether I paid a reasonable salary or by the hour which would probably work for me in my tiny practice. I can't be undercapable because it's just I've got to work. But if we were paid reasonably for collateral contact, for getting that information, for collaborating with therapists, schools, parents, other clinicians that would be amazingly effective. It would make us so much more useful. It would be great if we could pay for phone work with patients, particularly emergency calls. We get a lot of, I can't imagine the number of hours I've spent for no head with my patients on the phone. You don't even want to think about it. I could have made twice as much money. Pay for psychiatrist, this is one of the ideas that came up and was well documented. I think Dr. McGee, telephone consultation with primary care. We've wanted to do that for years and haven't figured out a way to get it funded except in the pediatric area there's been some funding. Please help us think about ways to push the payers to do that because it makes us more effective. Most of us love working with our primary care colleagues, I certainly do. So that kind of either telephone or face-to-face, one case after another, without having to see the patient, could be very useful. But of course, we're gonna have to be careful because there are some patients where primary care may think they know what's going on and there's actually some other psychiatric stuff that they're not picking on. So it requires judgment. And finally, one of my colleagues suggested possibly tying payment to access in the alternative payment models and paying new urgent evaluations and consults hype so that they are, the number of consults that got taken would increase and the number of days to a new patient about would be tied to payment. Those are the ideas that last part is really our most important ideas and we really thank you for holding this together. So thank you all very much for that insight into your work you're doing in representing the mental health areas that you work in. What we are going to do now is we're a little bit ahead of schedule actually. Are we gonna use that phone now? I was gonna ask, do you guys wanna ask some questions or do you want to open it up to them? I think that would be great. Sure, so we can open it up in the next 10 minutes. Is that okay Christina? Will it be okay for some questions for the panelists? I think it's for all of us first. I don't know what's in the mic. Right next to it. But I really appreciate what you both said. And I really like when Erin and I agree with much of what you said. I like the whole idea of looking at people as people in populations as people and actually good. I have a very specific prevention related question though. How many of you have heard of wellness recovery action clients? So how much do you know about how much there is? Yeah, I believe there are trainings and VA's. It's been like starting was it 20 years ago or even more. So it's funny, I looked at the website just last week because I was telling Mark Redman at Spectrum House about her wondering whether we could have those for specifically adolescents because there's actually wraps that are specific to specific populations now. All right. I'm just curious if you then have the designated agencies as a whole have like a percentage understanding of who uses them and what are the strategies we're implementing because just listening around to different people in agencies, it puzzles me why it's more people and I know there are different wellness recovery clients with different populations, but it puzzles me that the percentage of people who have developed those with care equity savings or the percentage is pretty low and it could be really cool if we could get it up around 100% because I strongly believe prevention is really worth that. We're thinking about beds and all of that sort of thing. That's gonna be a never ending challenge unless we get to the determinants. My colleagues here from the designated agencies have no more about the level of the community than we have right now. I couldn't even remember. Yeah, I couldn't either, I mean. We can get that information, but I just don't know about the top of my head. Would mean that we really accelerate that strategy. It's not a strategy that's reimbursed, but. We're used to that. Yeah. It should be, but it's fine. It's a great recommendation. Yes. Yeah, I have two similar related points that I'd like to raise. First of all, Rick's idea of disassociating having different offerings go on with only prescribers involved and I don't agree with it. As a primary care internist, I was running behind almost every day the work with mostly complicated geriatric patients, a lot of medical problems, and I had not had time to really do what it takes from looking to the mental health of the people who were receiving buprenorphine. It's a highly different drug. I couldn't, there was diversion going on and I just didn't have time. I agree with you 100%. I was not, I don't know if I was misunderstood. I think leading that, and I also want to say that I work with Springfield now and on the inpatient service and I think it's not a good idea to not require the prisoners who are receiving buprenorphine to have counseling going on, too. And they're allowed to opt out of it if they don't feel like going and often they don't feel like going. You have to remember a lot of people in prisons have a disproportionate amount of mental health, homoridity, personality disorders and other issues. And I think it's really important to make sure they're getting linked in to substance counselors and other mental health personnel and not just have to start going on without that because I think you can get a lot more people addicted. Buprenorphine is a highly addictive drug. Keep that in mind. It's not a panacea. It's a highly addictive, modified narcotic. I think we should be really careful. I agree. I don't want to be misquoted. I did not suggest that people should not do mental health counseling. I was suggesting that the requirement at a certain stage of recovery process can become a barrier. That's what I meant. Okay, Sam. And I just wanted to respond if I may. And I'm sorry, what is your name? Marvin Malek. Nice to meet you, Dr. Malek. So there, as I understand the suboxone prescribing, it's the requirement of the prescribers only to have access to a referral. It's not actually required as part of that treatment, but as someone who is actively involved in providing suboxone treatment, I think it's an important aspect of that recovery. But I think this is where we can get, we can look at innovative treatment models that allow for a very robust treatment environment but do so recognizing that access to skilled clinicians is a real challenge. And so I think for Rick to see an individual for one hour per month as a requirement may not be the best utilization of his expertise. However, one of the models that we've explored is a group approach to suboxone treatment in which you have the prescribing clinician part of that therapeutic encounter along with another mental health clinician and LADC, licensed social worker, LMHC, et cetera. And so what I've found, having done that work for several years now, is that even people in very, very stable recovery, they still have something to benefit from that clinical encounter. They support each other and appear support mechanism. They have access to a medical professional to say, hey, tell me about this aspect of my suboxone treatment. Can you tell me about this other aspect of my primary care needs? So, and as part of that process, we're doing ongoing screenings for mental health needs. We can make referrals as necessary and appropriate within the context. And it's a 90 minute schedule group that we have up to 10 individuals participating and so it becomes an incredibly efficient use of scarce clinical resources. It, I think, adheres to the integrity, the intended integrity of that particular treatment model and I think it really results in really excellent outcomes at a relatively low cost. And so I think there's different ways that we can work within that system to share ideas about novel and innovative approaches to ensure our patients get the need that they want in a rational and sensible fashion. Okay, Sam. Another point, the other point I wanted to make is that at Vermont Psychiatric Care Hospital where I worked for a year and a half, there's highly, it's an extremely expensive place to run, highly trained staff and the patients are spending tremendous amounts of time not being treated, violent or a threat to the staff with the injury rate of assault on the staff is very high and at the same time, the majority of the patients have some version of pheromonesic schizophrenia and they all don't want to be treated because they're paranoid. And so they, the legal structure of how things are going legally is that they get lawyers and they all don't want to be treated and they're not being treated month after month after month after month and they're taken up a bed that could be given to somebody who actually wants to be treated or who's already been legally adjudicated or through the legal system rather than going through all these legal delays. What a waste of staff expertise, it was painful to work there, it's the most inefficient system. I think maybe I'll go base proposal for a pheromonesic unit where the people are still in the phase of refusing to be treated that they wouldn't be tying on beds at VPC agents, it's just so inefficient. So it is we're operating within the laws that we have in the state and we don't have a mandate to restore competency, so there's many things that contribute to and I would say that in the last year and a half under new leadership at the hospital things have begun to shift and I would invite you to talk with folks and hear more about what's happening there now. I think there was some work a year or two, a few years ago, Courtney von Rommel was on trial to shorten that time that people had to be in before you could go for involuntary medication. There were some legal changes but we're still talking about a criminal justice system involvement if you're talking about people that have potential charges but are not going through the court system because of competency, that involves a lot of civil liberties and rights that need to also be considered. The question is, as we appreciate it's the best place for mental needs to not be cared for, for me of a crisis in the case of mental health. I can maybe comment, we deal with this particular situation with the Brouwer retreat on an ongoing basis as of yesterday, I think we had 32 involuntary patients. So essentially an equivalent or sometimes higher senses of individuals in the care and custody of the Department of Mental Health. And as a clinician and as an administrator it's something that I struggle with because it is, it's frustrating to care for patients and to watch them suffer greatly from a very serious and untreated illness. It's frustrating to watch our staff really wanting to help them get better but because of the nature of the illness it often impairs their ability to recognize that they're ill and to accept appropriate treatment. And I think as Melissa was pointing out for a subset of those patients, these forensically referred patients, they have some criminal justice involvement prior to their admission. They have a serious psychiatric illness and if they lack competency or not seen at the time of their criminal offense there is no legal mechanism to allow for a restoration of competence for them to potentially be held accountable and not accountable for their criminal behavior. And so what that then does is that even if we pursue treatment through the courts and they get treated to a point of recovery if it's a very serious criminal offense then it becomes a legal issue. There are no mechanisms for resolving that criminal matter and there are small subset of individuals in that system of care who then kind of gets stuck and clogged in that system. I think a larger proportion are the folks that don't have criminal justice involvement. They're just very ill and as a result of their illness they're not safe in the community and getting them treated I think is an important issue. So whatever mechanisms that can be done legislatively to streamline that, I spent a lot of my time training physicians from elsewhere who practiced in different states and I spent a lot of time talking about the idiosyncrasies of the Vermont's mental health legal system and they will often say oh boy we can treat somebody in three days if we have two psychiatrists agree that they need treatment and so there's this huge spectrum Vermont is at very one far end of that spectrum in terms of the proactive approach to treating psychiatric crises and gravely ill individuals. That being said that's one issue about access. I think there's another important issue about access to high level acute psychiatric bed capacity and that's really on the other hand when somebody has been successfully treated they're at a stage of sufficient recovery and then that transition back to the community. They may lack the resources or they may have destroyed and squandered all their resources as a result of behavior associated with their illness for instance they may be homeless, they may have lost their jobs and been estranged from loved ones and their natural support systems in their community and working with the designated agencies to try to find those resources can be really challenging because they are really at a limit in terms of what their capacity to take on new individuals and so when we talk about a broader approach to increasing capacity that's an important aspect to be considered is what about the step down sub-acute level of care from hospital closer to community integration maybe not independent living. The designated agencies do a wonderful job with the limited resources they have to one divert hospitalization through their crisis beds and oftentimes they're incredibly collaborative in terms of helping us get individuals out of the hospital closer to their home communities reintegrated back into their community-based outpatient care providers but I think if we're thinking about how to utilize resources effectively and in a smart way, a targeted way enhancing the sub-acute capacity for transitional treatment out of hospital and closer to the communities I think that has a tremendous potential in terms of freeing up additional bed capacity at the highest and most acute level of care. Okay, Sam. Okay, I have to not necessarily closely related question but I think they're important and related to the panel discussion. He asks this in a different venue but what are you doing to preclude the potential and very real overuse of psychotropic meds particularly anti-psychotic meds which as you know contribute to earlier than otherwise, mortality particularly if it's comorbid with dementia but so that's number one and two under the social determinants of health how are you dealing with employment implications related to mental health and substance abuse for example, the correlation of employment with increased overall health and decreased costs. That's why I'm probably using your idea as a comfortable answer. To answer your question about what are we doing to prevent the excessive use of anti-psychotic medications that increase the risk for metabolic side effects and premature death particularly in elderly individuals and those with dementia. I would say we're not doing enough frankly. At our hospital we have mechanisms in place to ensure that if anybody is using more than one anti-psychotic they have to clearly articulate a rationale for doing so. So there are I think a number of systematic solutions in place that I think have a great deal of potential so flagging, reminders, our pharmacies is always actively interacting with our medical staff particularly if we have contract physicians that are working in our hospital just to remind them of standards of care remind them of their responsibility to be thoughtful and cautious about utilization of those medications. Regular metabolic screening for adverse effects is another important area to really decrease those serious adverse side effects. Educating individuals who are using medications really providing informed consent. These medications can be potentially life-saving in many instances and so really it's a risk-benefit analysis in terms of engaging in the discussion educating our patients. I think physicians have a primary educational role in terms of giving individuals information about their healthcare choices and then assisting them in making reasonable and rational decisions about how best to care for their health. In the event of individuals who lack decision-making capacity and require court-ordered processes part of that process demands that the risks and benefits be clearly articulated as part of that legal process and so it's part of the initial application for court-ordered medications that you clearly articulate the risks, the benefits and the alternatives. Unfortunately for many individuals there are no alternatives to any psychotic medication there are no effective alternatives and so for those individuals that were really requesting the highest and most intrusive level of psychiatric care we do so with great caution and we do so with great deliberation. These are not things that any of us take lightly. We do not compromise individual autonomy and do so lightly without great pause. We've mentioned some of the legal requirements I think judicial review is an incredibly important part of that process and to be able to clearly articulate those risks, benefits and alternatives within that framework I think is an important and necessary part of that. But I think as a clinician, as a physician I think each and every one of us who prescribes any medication I think it's really incumbent upon us to be able to have those conversations to really provide, to really acquire freely given informed consent. Clearly articulate and understand what those risks, benefits and alternatives are and then have a conversation and a discussion with those in our care or other important engaged members, family members of support systems. Sam, I would just add to that I think that in the nursing homes that I worked in many years ago if you look at the rates of the use of antipsychotics 10 years ago compared to now in Vermont the rate has actually gone down dramatically so there has been significant progress in reducing the reliance on those types of psychiatric medications and all psychiatric medications. Now I would disagree a little bit with Dr. McGee only in the sense that yes, there are absolutely needs at times for psychiatric medications but there are many non-pharmacological approaches that can assist people who have severe dementia even if they're not competent to make their own decisions about healthcare, providing special environments in the nursing homes, other types of staff or community interventions that can come in, sit with people, work with whatever photos or environmental things or just physical touch in some cases. There's a lot of non-pharmacological approaches that can reduce the emphasis on psychiatric medications in nursing homes and I've seen it be quite effective so that's an area to invest more as well. Excellent point, Rick thank you and yeah I think all of us in the psychiatric association and I think I'm much more aware over the last few years of those reasons why we have to be as Marx that very, very cautious and really be on top of that prescribing. The risks are not small of a lot of things. So Designated Agencies and even working on the open dialogue model which is originated in Finland where when people are in a psychiatric crisis how do you step and provide, bring family together, their social network together and work with them verbally, socially and help them through the crisis and not turn to medications unless it's absolutely necessary and a number of our agencies have been working on that same as Steingart from the Howard Center's been training around the state. So we're really excited about that plus there's Hill House down in the southeastern part of the state which is really focusing for people of high intensive psychiatric needs who need residential support trying to provide that support with a minimal use of medication if any at all. So we've been doing a lot of work across the state trying to find ways to minimize the use of medication provide other supports. We also, our model of community mental health is about helping people be in the community and employment is a very important factor to help people get through mental health crisis to address developmental disabilities and just end the challenges of that. So we have actually very high rates of helping people get employment and that's why we need kind of a broader approach to mental health than maybe some other parts of medical care and that's Medicaid funding has been very helpful and that it funds that as you know. So we're really actually very proud of the work we're doing in employment and see it as critical to help people get through their mental health conditions and have an active life. And in the substance abuse world as well the opioid care alliance in Jitton County has done a great job of working with employers to hire people in early recovery to get them working again and really support their recovery process. So there are efforts being done in the substance abuse world that are very significant in helping people enhance their recovery efforts through employment and training. So I hate to cut folks off but I do want to stay with the agendas that we have planned and this is giving me ideas for future topics in future advisory meetings to perhaps even have a panel and open it up to the advisory. I think it sounds like you guys are enjoying this discussion but we do want to make sure that everyone can contribute in the breakout session. So I'm gonna have Marissa, you just stand and anyone interested in participating in the workforce of education you're gonna convene around Marissa. I think she's gonna be up front. Melissa Miles will be convening the group on capacity and need for beds. You're gonna stand up just so people can see who you are. And then Michelle will be convening the group on access and quality. We're gonna take the next, we point into our time a little bit, so the next 20 minutes to discuss and then we'll ask one of the participants to share out the results of your breakout session. Thank you everyone and thank you very much.