 morning. This is the meeting of the House Appropriations Committee in conjunction with the House Healthcare Committee. We welcome healthcare to this joint presentation from the Department of Mental Health. We very much appreciate you all being with us together. I think we have about an hour for the presentation. What we normally like to do is to give our presenters a chance to try to get through portions of their presentation and try to bulk up questions at appropriate stopping points. So if that's okay with everybody, we'll try to manage it that way. And Representative Lipper, before I turn it over to the commissioner and let her introduce her team, do you have remarks that you would like to make? Just that it's good to see committee members again. And I would just remind committee members that there will be a brief period, I think 15 minutes of maximum for us to identify issues that we might want or need to hear more about, not just for us, but for both committees. And that we're not, it's not an intention that during the testimony this morning that we engage in any type of debate or try to resolve issues, but we're trying to identify if there are issues and what they may be. Thank you, Rep Lippert. And one other thing that we've discovered in our conversations with department leaders throughout this morning is that the presentation that we're receiving, we knew was being built off of the governor's original, original recommendation for the fiscal year. What we have come to realize is we may not see highlighted some of the changes that he was proposing in it originally, they may still be on the table. And so, commissioner, if you're not highlighting in your presentation, some of those original changes, could you also note those? And we're trying to figure out a way to generally summarize that, but I just wanted to give you a heads up to that. And I think I've covered it, Rep Toll, in terms of the things that we normally like to touch on before turning it over to the commissioner. Thank you, Mary. Thank you for starting. I thought I was going to be not distracted, but I did get the phone call of a daughter leaving for college. So I was a couple minutes late and I apologize, but it's been a long morning, an emotional morning, I should say. So it's very good to see everyone here today, commissioner. Thank you. And it's wonderful to have the committee of jurisdiction with us. It's going to expedite our work and, and, you know, this team approach, I think is exactly what we need to do in light of what is before us now in the very condensed timeframe. I just did want to make aware to the other committee members that have joined us that next week on Thursday and Friday, we will be holding public hearings on the budget Thursday, the 27th at five o'clock and Friday at one o'clock. And so Teresa will send out links to all members. Notices have already gone out and, and you already may be aware of it, but I wanted to invite everyone to those public hearings. The following week, we will start making our, we would like to hear recommendations from the committees of jurisdiction as we work together with you on either the first or the second. It would be a very aggressive timeline to vote the budget out on the fourth out of committee. If it doesn't happen on the fourth, it would have to be voted out on the next Tuesday, because Monday is Labor Day. So regardless if it's voted out the fourth or the eighth, we would need recommendations back the first or second. And these can be a very informal memo. We just need the highlights getting across to us. We don't need to cite statute or sections of the budget, just the areas of concern. Even if we voted out the eighth, the day we vote out is the date we just proofread and vote. And so all of our work would likely be done on Friday the fourth either way. So it's a, it's a compressed timeline. It's, it will be tight, but I'm confident we can do it with this team approach. And so I think we should just jump right in now to the commissioners, the commissioners presentation. Thank you, Sarah. Nice to see you. Great. Yeah, thank you. It's great to see everyone. I hope that everyone is doing well. For the record, Sarah Squirrel, Commissioner of the Department of Mental Health. I am joined here by a few other members of the DMH team, Deputy Commissioner Morning Fox, Finance Manager Shannon Thompson, and our Director of Quality and Accountability, Alison Crumpf. And also would just note that Sarah Clark from the Agency of Human Services Fiscal Office is also joining us today. So I will be walking us through the detailed amended budget talking points. That is what is being shared on the screen right now. I will also, per the request of the chair, reflect back on any changes from the original governor's FY21 recommended budget and can certainly dig into any questions that folks might have regarding that. I did pull that up and prepare to speak to it as well. So again, I want to thank both committees for your time today and continue to support to ensure that we have a strong mental health system of care in Vermont. So I'm going to go ahead and get started. Referencing these detailed talking points is probably easiest for folks. And then you can, of course, they align with the ups and downs spreadsheet that you've also received. So the first area that I will focus on are some savings that we've been able to achieve related to our internal service funds. The first one is a savings of a gross savings of $33,000. I would also note that we also put the general fund equivalent here so that committee members can see that. So that is the 3,207 number as well. So essentially the workers comp, we have a 5% reduction for our workers compensation costs for DMH. Moving down, we also have a 5% reduction for fee for space, insurance, IT, ADS, Agency of Digital Services expenses, as well as HR. As we were looking at the FY21 budget amendment, given the current fiscal climate, we were obviously looking for any efficiencies that we could find within central office at DMH and also within our facilities. So at the PCH and MTCR, we are proposing operating reductions focused on some equipment that we no longer need. Getting rid of one of the vans at MTCR that we feel that we no longer need, as well as a 10% reduction to travel expenses and conference expenses. That also continues down with additional savings to our central office operating budget. Again, looking at a reduction to travel expenses and conferences for central office. And given that we're operating in more of a remote environment, this is a very achievable savings for us. And we'll still allow folks to access the kind of professional development that we want them to. I'll just keep on going. The next point is related to the 12 new level one beds at the Bartleboro retreat. In FY20, the legislature did appropriate funds for the 12 new level one beds to open in the fourth quarter of FY20, which we were delayed from there as well. COVID obviously impacting the state in mid March. Obviously the construction of the beds at the Bartleboro retreat had to come to a halt for safety purposes. The construction of those beds has resumed. The anticipated opening of the 12 new level one beds is now January 1 2021 of the Department of Mental Health and BGS and the retreat working close collaboration to monitor the ongoing construction. It is back on track. It is moving very smoothly. So this essentially reflects the reduction to our budget because of the delayed start of the opening of the 12 level one beds, which is a gross total of $2.5 million. The next area is related to suicide prevention. So in the FY21 governor's recommended budget, there was $575,000 for suicide prevention. The Department of Mental Health is going to utilize CRF and carry forward funds for suicide prevention efforts. The Joint Fiscal Committee did approve a $500,000 allocation CRF funds for suicide prevention efforts going forward. As many on this committee are aware, we did apply for a SAMHSA emergency suicide prevention grant. We were not awarded that grant. So per Act 136 section nine, we do have the allotment of the CRF funds, as well as the department will utilize carry forward funds from the previous fiscal year to ensure that programming can continue through all of FY21, given that the CRF funds, as we know now will need to be expended by December of 2020. I did want to talk a little bit about what we're targeting some of our suicide prevention efforts on. It's quite exciting. We've been able to actually lean in and develop some areas that we had hoping to do. Our first strategy, of course, is continuing to expand the zero suicide model in Vermont. We also want to continue to expand the national suicide prevention lifeline. I would also just note for the committee's edification that the federal government has approved a three digit number for the suicide prevention lifeline, which will really increase expedited access to emergency care and resources related to the suicide prevention lifeline. We are also articulating funds to develop targeted suicide prevention resources that are culturally informed to reach identified at risk populations, really leaning into some work related to the LGBTQ population. We've actually already started some really exciting work without right Vermont, who is helping us with some training broadly across the mental health system. We want to continue that focusing on racial minorities, older Vermonters, and domestic violence victims. So some of those funds will be utilized to develop specific materials and outreach to those groups. We're also very excited to be looking at expanding mental health first aid. We've done a tremendous job in Vermont with mental health first aid, and we want to expand the teen program mental health first aid as a component that is focused on teens and public schools. So we'll be utilizing some of that funding to focus on that as well. And then of course, we want to continue to focus on older Vermonters, who we know are very vulnerable. We're already experiencing isolation prior to COVID. So now more than ever, we need to ensure that we are doing targeted outreach and suicide prevention work. That work will be done in collaboration with the Department of Aging and Independent Living. I would also just note for the committee, one other opportunity that we are excited about is that we did apply for a five year grant with VDH through the CDC. It's a comprehensive suicide prevention grant. We should know again within the next couple of weeks, if we are successful recipients of that grant, if we do receive that five year grant, it would be an incredible opportunity for Vermont to really invest in some sustainable long term infrastructure related to suicide prevention. So certainly I will keep both committees apprised of any information that we receive related to that CDC grant. Thank you, Sarah. Can we stop here for a minute? I have a representative Lanford and members of the House Healthcare Committee, if you have questions, just raise your virtual hand and we'll try to stop in between testimony. Diane? So, oh, thank you. Thank you, Madam Chair. I was just on the suicide prevention. We heard from the, I don't know if it was the Agency of Agriculture, but during some of the CRF conversations that there was, there was an increase in suicide among farmers because of the pressure in that sector of industry. I was just wondering if that was included in one of your at risk populations? It's a great question. It isn't specifically articulated here. I've had some meetings with folks from agriculture to see how the Department of Mental Health can continue to assist in support of farmers in the state. When we look at our statewide averages related to suicide, we look at five year averages. We did have a slight uptick in the April period. Things have stabilized and we are currently below the five year average overall. But certainly we want to continue to partner with the Agency of Agriculture. And if there are any of these opportunities that we've articulated here, that we could also leverage to support those groups. That's something that we're actively working on. Thank you, Diane. Thank you, Sarah. Of course. Let's continue if I don't see other questions at this time. Okay, so the next section really highlights one time CRF expenditures and that therefore being being able to leverage those CRF funds does result in overall savings. So this represents expenditures related to COVID 19 at the Vermont Psychiatric Care Hospital and the Middlesex Therapeutic Community Residence, as well as we're able to attribute some of the costs of our medical director who works on the Health Operations Center. So essentially the department will utilize CRF funds for these COVID related expenditures. And therefore that offsets the need for global commitment dollars, federal dollars and general fund thus resulting in the savings that you see reflected here. I would also just note overall the overall dollar need for these expenditures is $1.9 million. We already had $1.3 million coronavirus relief fund carry forward that we're going to utilize, leaving the total CRF need of $559,000. I'll talk a little bit about what some of these expenses were. The first one is related to overtime pay at VPCH and MTCR for 12 hours shifts. When COVID hit the state and impacted the state, obviously that I had a significant impact on our staffing for good reasons, for reasons that staff needed to be out for their own personal reasons, safety reasons, etc. So to manage the shortage, we did implement 12 hour shifts at our facilities, which really, it's actually an industry standard in general, but it really allowed us to maximize staffing the way that we were able to negotiate that with the VSEA is that there is some overtime that is built into that. So that is through November 7, 2020. So that's a big chunk of what these expenditures are. We also had the premium pay for face to face work for individuals who are employed at VPCH and MTCR. And then we do rely on travel nurses for our work at VPCH and MTCR. As you can imagine, as COVID was really impacting the health care systems across the country, the demand for travel nurses went up significantly and therefore the cost went up. So we are using some of the CRF funds to cover the increased cost to pay for those travel nurses. But that is that is the summary of the section and those one time CRF expenditures, which are resulting in some savings due to our ability to utilize that funding source. Thank you, Sarah. I'm looking for questions and I don't see any at this time. So I think we can continue. We'll probably have more questions at the end. Of course. So the next area this reflects our work to stand up a COVID positive capacity within the system of care, working with the Wyndham Center and Springfield Hospital. I would just note that this is primarily FEMA dollars. Almost all of it is FEMA dollars with a little bit of coronavirus relief funds. As these committees are aware, the need for capacity for COVID positive patients became a significant priority. We had convened all of our inpatient providers and hospital providers across the state. This is the recommendation of that network of providers. This facility has been able to provide capacity for individuals who are COVID positive. And we really wanted to ensure that any individual who is presenting in an ED, even if they were COVID positive, could have access to timely care. So we've been working very closely with the Wyndham Center. This funding represents our, you know, cost to contract with them to maintain that capacity. We also were able to utilize the FEMA dollars to upgrade the Wyndham facility. The Wyndham Center is a 10 dead inpatient facility. And typically and historically, they have really admitted or focused their care on voluntary patients. So in order to ensure that they could safely and therapeutically care for higher acuity patients, we did need to make some upgrades to the facility, which we also utilized the funding for. It's been an incredible partnership, and it has been critical for those individuals who are presenting in an emergency department, who are COVID positive to get them timely access to care. This is funded through the end of December. We will obviously as a state, as a system, we're continuing to evaluate the impact of COVID will continue to evaluate the need for this capacity to have COVID positive capacity. You know, as we continue to move towards recovery, we want to make sure that we continue to be proactive. And at the point where we as systems partners determine that we no longer need a COVID positive unit, you know, the Wyndham Center unit can just revert back to a traditional inpatient unit. And then we've obviously upgraded the facility as well, you know, which is an asset for the mental health system of care. Thank you. Are there any questions on the Wyndham Center Springfield Representative Donahue? Thank you. I was just wondering what the current censuses of that unit. They currently do not we do not have any COVID positive patients right now. Thank you. Did you have a follow up or does that satisfy your question? So does that mean there are no patients in that facility? That's correct. Thank you. Representative Lippert is is that facility fully staffed at this time? Yes, so they've been able to maintain their staffing. That's part of the capacity payment that we provide to them because obviously we want to ensure that they have adequate staffing. While some of the upgrades to the facility have been made, they actually utilize their staffing to support individuals who are COVID positive in they have a two bed ED unit that they were utilizing in the short term. So those Wyndham Center staff have been kind of at the ready to provide care and treatment. And again, we'll continue to evaluate this need and continue to evaluate how long we want to ensure that we have this COVID positive capacity. Could I ask the number of staff that are that are in this unit? That is a great question. I don't know that I have the staffing grid numbers off the top of my head, but we could certainly get that to the committee as a follow up representative poll if that's OK with you. If there are no individuals being served at that time and the staff are there, do they have other duties that they're assigned? Yes, my understanding and I guess I would I would have to defer to the CEO of Springfield Hospital that they are utilizing those staff, you know, in other capacities as needed. And again, you know, it's been really fascinating to watch the trends in our inpatient mental health system, you know, things add and flow very quickly. And, you know, we had a period of time, you know, just, you know, about a month and a half ago where we saw a significant uptick in individuals presenting in EDs. We saw a little bit of an uptick in COVID positive patients. Now things have the pendulum has swung back again to where we only have three to four individuals waiting in an ED on a daily basis. So I think Springfield is doing the best they can to maintain adequate staffing. And I'm sure they're trying to utilize those staff as efficiently as possible in other areas. Thank you. And representative Lippert, I jumped in there. Did you have a follow up? No, I was asked. I was interested similarly. And actually, I'd be interested. Have we do you know what the total census or census the number of patients who were COVID positive, who needed to access a facility? Has it has it proven to be a needed facility knowing that we needed to anticipate it, but has it actually shown us to be needed? Yes, we have had two COVID positive patients. And, you know, this is this is the challenge. You know, we need to have the capacity because if we don't have it, you know, it is it is, from my perspective, not okay for an individual to wait in an ED for a long period of time. If we don't have the capacity, we're going to have to, you know, continue to evaluate that. I think having this capacity has allowed us to preserve and maintain a great infection control with some of our larger facilities such as VPCH and the Brattleboro Retreat. So again, it's something that we're going to have to continue to monitor as we go forward to see if, you know, we need to continue to have this capacity. Did we need it on a smaller scale? How best do we manage infection control? How do we carve out that capacity separately if it needs to be smaller? Those are all things that we're continuing to evaluate. Thank you. Representative Christensen. Yes, the facility has been upgraded and when when we hope COVID will pass, what will that facility be used for? Is that earmarked for that or did those upgraded facilities go back to Springfield Hospital for their use? Oh, it's it's a great question. And I think, you know, the upgrades have really significantly, I don't know if any of you have toured the Windham Center. It's a lovely 10 bed unit. It was older. It did not have all of the updated safety and therapeutic, you know, physical attributes that we would like to see, which is why we actually, at a point in time, the Department of Mental Health was not sending involuntary patients to the Windham Center because we didn't feel it had adequate physical capacity to keep individuals safe. So with the improvements that have been made to the facility post COVID or whenever we determine that having this COVID unit is no longer necessary, we've increased the capacity of the Windham Center to accept and treat higher acuity patients in a safer and more therapeutic environment. Representative Christensen, did you have a follow up? I'm going to move to Representative Donahue. Thank you. And I think this probably is a question to raise now, but to get the response maybe too much in detail right now. But I noticed that you include in the potential patients for the unit, those who are refusing COVID-19 testing in the ED. But my understanding is also that, of course, all inpatients are required to be tested in the ED prior to admission. And we all know that there is a delay in time for getting results. So I would be interested in knowing the amount of those delays and how long people are staying in the ED and whether or not they could be transferred to make use of this rather than staying in the ED without reports how that impacts our ED delays as a whole. Again, not for now. Yeah, it's a great question, Representative Donahue, and I appreciate it very much. We're happy to follow up. We did put expedited testing protocols in place by working with UVM and with VDH so that psychiatric patients were prioritized. We even put into place an expedited career service to ensure that the COVID testing did not add to wait times. I and I think that has gone actually fairly smoothly. I do think the individuals who are refusing COVID testing, which is not to be unexpected for someone who might be presenting in an ED. That is where we have experienced longer than desirable wait times. So certainly something that we're thinking about in terms of how we continue to utilize the Wyndham Center. But you know, we're happy to follow up with with more detail on that as well. Thank you because my my understanding is that the policy itself discriminates against people who are there voluntarily in terms of the expedited protocols. So it only it is only required for involuntary patients and others may be waiting longer. So again, we can wait on that. Thank you. Thank you, Anne. And Representative Cordes. Thank you. I would just like to add that the University of Vermont Medical Center latest policy about testing is that at least for most of the units that I'm familiar with, we no longer require testing prior to admission. So we do we do test everyone, but it doesn't preclude their admission onto our units. Thank you. Thank you for that information. Sarah, did you want to respond or that really wasn't a question? It was. Yeah, our current understanding is that all inpatient units, including UVM, are requiring COVID testing. So based on the representatives comments, we'll follow up on that just because that is certainly the protocol that we've been following. And that's the guidance that's come out from VDH related to inpatient psychiatric units. So we'll be sure to follow up. I guess I'll just clarify. It means it doesn't stop the admission onto the unit when before we couldn't admit them onto our unit until we had COVID results. And now that's not the case. So I think we're still. Yep. No, I didn't mean to cut you off. Could you please finish? Oh, that that was it. Thanks. Thank you, Sarah. I think we have three small pieces left and then we can go into before we move into a broader discussion. If there's a couple of pieces from the January proposal regarding residential youth, I believe, and funds to the Brattleboro Retreat. And I don't know if you're prepared to talk about the the earlier proposals that would still be on the table. Sure, I'm happy to do that. Perfect. OK, thank you. So let's just finish up this. And then those would be a couple of the pieces. And I don't know if there's more that you would like to comment on that we're part of the governor's January proposal. Sure. Yeah, I'll get through these small pieces. There was one area I wanted to highlight and then I'll circle back to the original 21 budget recommend. So related to the three additional areas, next one is fairly straightforward, using Sierra funding for laptops, for telework use for some of our staff who shifted, obviously, to telework and are continuing to telework during covid and the next two areas are good news for the department and for our budget in terms of cares, revenue that the Rott psychiatric care hospital received. So on July 14th, we were notified by the Department of Health and Human Services that we would be receiving one point nine million dollars as part of CARES Act funding. This is payment because we are at acute care hospital and considered a specialty of rural provider. So good news for us to have an additional one point nine million dollars that is a grant to support overall operational costs, which obviously supports our budget as well. And then earlier in the year in April, we received additional CARES revenue that was focused on Medicare and they must have had some formula behind the scenes that they utilized. It was an automatic payment to us related to Medicare patients. And that was one hundred and six thousand dollars. Thank you. We like that good news for the general fund. Thank you, Sarah. It is good news. So I did go ahead. Oh, well, if you had something else and I wanted to move to the other initiatives that are still part of the governor's proposal from January, when when you're finished with this piece. Yeah, one thing that I did want to recommend that I am sure either of the committees might comment on is mobile response. So in the FY 21, governors recommend there was originally one time funding to pilot mobile response in one region in our state. You will notice that that is not part of our current FY 21 recommended. I just wanted to talk a little bit about that. Mobile response remains significant and important initiative that we feel strongly will continue to provide more proactive supports in the home and in the community. And right now our community mental health system continues to grapple with the impact of COVID and we're trying to really stabilize that system as it currently stands. So from an implementation standpoint, I think it would be wise for us right now to continue to stabilize and support our community mental health partners who are still struggling with the same kind of staffing issues, trying to provide care in a different way and look to move forward potentially with a pilot of mobile response in the future. Rutland mental health was the identified pilot region for this if folks will recall. That was a data driven decision because the Rutland area had the highest ED utilization rate for children and youth in conversations with leadership from Rutland mental health. They are actually moving forward with some very exciting initiatives related to their emergency services. They're actually moving their emergency services team to a more central location in the community in Rutland. They've received a mobile response van as one of our other grants that we provided to them that we received from COVID and they're really trying to shore up kind of a foundation for a mobile response model that I think we can build upon as we go forward. Certainly in speaking with leadership from Rutland, as we move into the January time period, we'll continue to evaluate is that the right time to assess and implement mobile response. So I just wanted to note that it is also one of the priorities and part of an action area in our 10 year plan. I also think as the Mental Health Integration Council starts to meet in October, this will be another priority policy area that the Mental Health Integration Council can also focus on as well. But I wanted to make sure that I kind of explained to the committees what our thinking was related to mobile response. Still an urgent priority, but we want to make sure it's the right implementation time for that pilot. So that is. Thank you, sir. Of course. So I can question from Representative Jessup. Thank you. Commissioner, in middle sex, the facility there was used by DCF for a while. And I'm assuming that it's now reverted to use again by Department of Mental Health for the same purposes. And is that capacity? Is that correct? Yes. So the middle sex therapeutic community residents when we were trying to manage staffing shortages at VPCH and MTCR, we did move the individuals from MTCR to one of the units at VPCH. During that time period, the middle sex facility was open. DCF was obviously grappling with some challenges related to Woodside. They occupied that facility for a short period of time. The facility is now we opened. Folks are also aware we had some water quality issues that we had to address. So we have a new water filtration system that has been installed. All the water quality results have been very positive. So the water filtration system is doing its job. And we are anticipating to move the residents from middle sex, from VPCH back to the middle sex location in the next three to four weeks is the current plan. And is there anything you care to comment now about what might be the future cooperative efforts with the central Vermont Medical Center? Representative Jessup, are you referring to the previous plans around expanding inpatient capacity? Yes. Yes. Well, as we all know, the planning related to additional 25 inpatient beds was put on hold during COVID as the UVM Health Network was managing the impact. My assumption would be that at some point that work will resume, that planning will resume. But I have not had those conversations with leadership at Central Vermont Medical Center yet. Thank you. Of course. Thank you, Kimberly. There were a couple other changes in January. Do you want to highlight those, Sarah, and then we'll open up for questions? Sure. I am diving back into the original FY21 budget submission. I guess I will focus on, you know, maybe what would feel most significant and certainly can dig into some of the smaller pieces as well based on the committee's interest. But certainly children's residential is an area that is a consistent budget pressure for us. We certainly continue to see an increase in acuity in the clinical needs for children and youth related to residential care. It's increased challenges related to, you know, mental health challenges, difficulty managing behaviors. Anyone who has spent time with the youth risk behavior survey data, you know, we're clearly seeing significant trends in depression, anxiety, suicidal ideation. So overall, we continue to see an increased demand for residential services. We also have a core team here between DMH Dale and DCF that really focuses on residential care. We produce quarterly reports that look at children and youth who are placed in state, children and youth who are placed out of state. Obviously, our goal is to reduce the need for residential care. But the past few years, we still continue to see this as a potential, you know, pressure on our budget and just a continued need in general. I would also add that part of our children's residential cost is and Shannon, please correct me if I'm wrong, is that the Howard Center, which is the Jarrett House, which is a crisis stabilization bed, also falls under this bucket of funding. So certainly that's a critical program where we need to maintain capacity. So that's an additional cost that is represented as part of this residential. What we refer to as PNMI funding bucket. The other two that I will note, these were BAA items, but I'm sure that that was feels like quite a long time ago, you know, did want to know that we had some increases related to level one costs. So our level one bed capacity at the Brattleboro retreat, as well as Rutland Regional Medical Center. As many are aware, act 79 requires reasonable, actual reimbursement of costs for level one hospitals. We have a cost settlement process that we go through to ensure that their costs are covered. That is reconciled. So we had an estimated gross increase on level one costs as well. Thank you. Yes, and the other two, the other one that I would note was just folks will recall that we did put into place rate increases for the Brattleboro retreat. DMH is responsible to ensure the payment of inpatient care for folks who are eligible for CRT services. So this was a BAA item, but those inpatient rate increases were also reflected in the original FY21 governor recommend. So those for the chair, those were the ones that jumped out at me as areas from the FY21 budget, the original budget that I wanted to highlight for the committees. Thank you, Sarah. Are there any either appropriations or house health care committee members that they would like to ask the commissioner or the CFO at this time? Representative Lippert. Yes. So help me out if I'm not understanding where we are in this process. Is there, so what we've just reviewed is the ups and downs from the budget, but we haven't reviewed all of the underlying budget. Am I correct with that? The existing budget, these are any new initiatives would be in the governor's proposal that created ups and downs, but the programs that haven't been highlighted would be remain as existing. So I guess I wanna just ask a question because I don't have that underlying budget in my mind fully. Is that underlying budget include any increases for the designated agencies or the related agencies in terms of funding for staffing, et cetera? It does not currently include any increases to the designated agencies for staffing. There are some tertiary increases in terms of like the increased funding for P&MI, which like for example, the Howard Center has some of those programs, but there are no additional increases. So essentially, so I mean, I think that's important for us to understand in terms of the work that we had done over a period of years to try to recognize that we can't sustain the community mental health system by level funding it. That's a statement, Bill. It's a statement and a question in terms of do we anticipate reductions in the capacity of the community system based on our not being able to provide any additional funding? Sarah, would you like to comment? Sure, yeah, I'd be happy to. Well, certainly we value our community mental health partners and the incredible work that they do on a daily basis. As the committees are aware, we worked very hard when COVID hit to ensure that we stabilized them because essentially when COVID impacted Vermont, services couldn't be provided in the same way that they were before. So because we had already implemented payment reform within DMH that provided us with a lot of flexibility so we could continue those prospective payments who are designated community mental health agencies so that even if their volume of service was different, the amount of people that they're providing services to was different, they were still receiving the same amount of funding. I think the impact of COVID has certainly impacted the capacity of our system and I think across our continuum of care, we continue to focus on trying to rebuild that to have more community based services that keeps everyone safe. The only other point that I would add is certainly AHS is in the lead on the healthcare stabilization package. So prior to that, we had actually myself and Commissioner Hutt had worked very hard to ensure that we had additional funding for designated agencies and SSAs for hazard pay. You'll recall, I think they received about $7 million in additional funding for that and there was the additional relief, coronavirus relief that they could apply for and now that the healthcare stabilization package is out, the designated agencies and specialized service agencies are also applying for any lost revenue or COVID impact during that time period. So I do feel like right now, we are absolutely prioritizing our community mental health agencies and ensuring that they have adequate funding to be able to rebuild and continue to do their work. If I may, just a quick follow up. Can you remind me, because I honestly don't remember, in terms of the payment reform with the designated agencies, is there a true up at some point in time in terms of any type of recognition that they either didn't have the same capacity or is there any kind of true up or is it the payment reform provided to them regardless of the ups and downs in actual patient numbers? Yeah, so it's a great question and certainly as we look at payment reform, alternative payment models, of course we need to continue to monitor volume of services, quality of services, et cetera. During COVID, we also have a lot of flexibility so that we're not penalizing agencies because their numbers are going down or shifting. So yes, there's accountability. During this COVID period, we have a lot of flexibility from CMS to continue to support the agencies given that their volume and how they're providing services is different. Okay, so they don't need to anticipate during this period a, I don't know, clob-X, not the right term but essentially a true up where they will get a bill for services not rendered. No. Okay, that's helpful to understand. Thank you. Thank you, Bill. We have a question from Representative Donahue and then Yakovoni. Anne? Thank you. I think the comparison between what the original budget proposal had been in terms of ups or downs and the current is probably something we'll need to get a better understanding and maybe more of a side-by-side. But specifically in terms of suicide prevention, my recollection is that there were some initiatives in the original budget proposal for increases in that area and then separately there was the COVID grant supplemental initiatives that if the grant didn't come through, we were going to seek to replace with CFR. I think it would be helpful for us to understand which things were part of the original proposal, which were the supplemental initiatives and which have ended up now in the budget proposal as CFR funding, but are, is no longer resources being proposed as part of the regular budget. It's a great question, Representative Donahue. So our original overall funding proposal for our suicide prevention efforts was the $575,000. That included expanding zero suicide, continuing to expand the Vermont National Suicide Prevention Lifeline, as well as expanding programs and supports for older Vermonters. Because we are able to leverage CRF funds and potentially utilize our carry forward funds to continue this work, we were actually able to add initiatives that we felt were urgent and important given the impact of COVID. So the additional items that we are now able to implement is the targeted suicide prevention resources that I mentioned, really focusing on at-risk groups, culturally informed resources and outreach. I mentioned the LGBTQ community, racial minorities and domestic violence victims. We were also able to add the expansion to the mental health first aid training to focus on the teens. We are very concerned about our young Vermonters expanding mental health first aid, 14s is a kind of a national policy recommendation. So we're also using funding to advance that as well. Thank you. Just, I think it'll be helpful, not today, but soon to get a side by side of what would have been if we received what we hoped for because clearly it's half or less of what the funding would have been if we had both the original budget proposal and the COVID grant that was supposed to be replaced by CFR funding if we didn't get the grant, which we didn't get. So not looking for a response right now which will be a higher level as you just gave but we need to see what actually got dropped out that we were hoping for. Of course. And then we again, as I mentioned, the five year CDC grant would just be an incredible opportunity for us as a state. So we'll certainly keep the committee apprised of that as well, but we can put together that side by side representative Donahue and get it out to the committees to reflect on. Thank you. Thank you. We have representative Yacoboni and then Fagan and Lamper. Thank you, sir. Could you speak to your understanding or give us a status report on the success beyond six services that typically are provided by our designated agencies? Do you have the expectation that those services will continue as they have previously in a remote learning environment in our schools? Thank you. Yes, thank you, representative Yacoboni. I appreciate the question very much. So just to kind of back up for this committee to understand success beyond six was actually created in 1992. It's a fiscal and policy mechanism that allows our local education agencies, our LEAs, to contract for the designated agencies for mental health services for children. And what's unique about it is that we utilize local education dollars to essentially draw down Department of Mental Health Medicaid. So it's a really effective fiscal mechanism because essentially it allows local schools to provide match dollars at 60 cents on the dollar. That's not totally accurate, but to draw down the DMH Medicaid. So it's just been an incredible program. I actually ran school-based mental health services for over a decade and certainly can speak to the power of that work and how much it supports children, youth, and families. When COVID hit, we, of course, the Department of Mental Health wanted to ensure that school-based mental health services would continue. We know that for many children and youth, school is their most nourishing environment where they access some of their most trusted and safe relationships. So we at the Department of Mental Health immediately put into place an emergency case rate for school-based mental health wanting to maintain the capacity of the DA system and wanting to ensure that those funds could continue to flow. What we did not anticipate was that the flexibility that we have under our mental health Medicaid is not shared by the flexibility of the Agency of Education funding. So it created this immediate tension point by which we were trying to provide funding for capacity. The provision of services looking very different and the local LEAs found themselves in a position of really only being able to or being willing to pay kind of as a fee-for-service model. So just continuing to pay for the direct care. So it created a little bit of a kerfuffle, if you will. So we immediately and have been working in good faith with the Agency of Education with our local LEAs and special education directors to try to problem solve around this because we at the Department of Mental Health are very committed to ensuring that this program remains intact, that we continue to do outreach to children, youth, and families. We know that remote learning has created even more anxiety for our youngest firm honors. So we really wanna ensure that we can continue to do that. So the current work that we're doing right now, we have a group of individuals from the Agency of Education, DMH, local LEAs, and the DAs that meet regularly. I think there have been five meetings so far. We have six action areas that we're trying to address to really shore this up. In the short term, it's my understanding that currently the local LEAs and the DAs are looking at short-term contracts, kind of 30 to 90 days to try to get through this first kind of reopening of schools, which is a hybrid model to try to create some flexibility. So if services need to look different or provided differently, the LEAs still feel like they can use special ed dollars to do that. Part of that is also directly related to how contracts are written to ensure that they kind of, I guess, articulate the scope of services and how they might be delivered differently. The documentation on the IEPs for the children and youth is also critical because that is what directly ties back to the local education agency's ability to get funding from the Agency of Education. So many of those IEPs don't necessarily reflect how services might be provided differently. They might be provided remotely. So there's a lot of kind of technical work behind the scenes that needs to happen to ensure our respective funding sources align and that this work can continue. So that work is underway. We have a separate PowerPoint that kind of summarizes that work to date. That would be helpful for the committee. I'm happy to share that myself and Secretary Smith also met with Secretary French yesterday and Deputy Secretary Boucher. So it is on everyone's radar to find a solution and a path forward. And I think we've made a significant amount of progress over the past month, but we still have some work to do. The other thing I would just note is that part of the healthcare stabilization relief fund, the designated agencies can apply for lost revenue related to Success Beyond Six as well, just to also provide them some relief. So that's a, well, probably wasn't a quick summary, but that's a summary of where Success Beyond Six currently stands. Yes, Sarah. I appreciate that. If I could just a quick follow-up. Are you confident that the LEAs are getting the guidance and direction they need to be able to make this work? I think they are getting the guidance. I think the agency of education has been working very hard to provide guidance. The interpretation of that guidance is also unique to that supervised reunion. So you have special ed folks, you have legal folks from supervisory unions that are interpreting the guidance differently. So I think that has also been something that we've been trying to clarify is how to help the local LEAs interpret that guidance accurately and more consistently across the state. Okay, I'll be following on this. Thank you. Of course. Thank you, Dave. I think from here, we went to Representative Fagan and I did get Representative Cooper who can't put her hand up. We have Lampere and Representative Lippert. And we have about 10 minutes left of this discussion. Peter, you're up, please. Thank you. Thank you, Sarah, for coming in. You've answered a lot of my questions regarding the healthcare stabilization coronavirus relief fund of 275 million we passed in relation to DAs and the SSAs. Are they accessing it for more than just success beyond six? And can we get information as to what they are accessing it for, please? Yeah, that's a really good question. As other healthcare providers, there are several areas that they can apply for that are eligible, whether it's revenue losses or additional expenses, costs, and PTE, et cetera. I don't believe that we have, for the previous tranche of funding that wasn't necessarily specific information that we shared, the current process and is still underway. So certainly I could take it back to AHS in terms of if and how that information might be communicated. And I can see Sarah Clark just unmuted herself. So she might have a thought there as well. In keeping with what I always state, if this has got to be reinvented, if somebody's got to invent the wheel to be able to get us this information, please tell me and I'll back away from my question. I was just going to say that the agency actually just submitted an update report to the legislature on the status of this program. So you'll be able to find a bit more information there. As Sarah, Commissioner Squirrel indicated, the first round of applications just closed on the 15th and so we're kind of in the process of evaluating and preparing to issue grant awards. So there'll be a lot more information available to you in the next three to four weeks. Thank you, I did scan the report and that was part of the reason why I'm asking the question, so thank you. Thank you, Peter. Representative Lamfer. Thank you. So one of the joys that we have is to be able to sit in a place where we hear all of the different budgets and as you present, talking about the mental health issues and some of the supports around that and I'm not always familiar with everything, but a couple of days ago when the agency of education was in and they presented their proposal for reductions, their 3% reduction in grants, one of them that they indicated is that they reduced the outright Vermont grant by $40,000. And I'm not sure how that impacts the mental health support that would kind of tag up with what the Department of Mental Health is working on. I don't know if you can speak to that at all and I know like the relationship between AOE and highlighted it just now, but that just came to mind that that reduction is in their proposal and I don't know what it means for you. Yeah, I wasn't, thank you, Representative Lamfer. I wasn't even aware that there was funding going from AOE to outright Vermont. We, as I mentioned, we're actually using some of our mental health block grant funds to provide funding to outright Vermont, to do some of the training that I mentioned for our community mental health agencies across the state. They are also going to be a key partner and we'll receive some funding from the suicide prevention work that we want to do. So it's actually, it's a partner that the Department of Mental Health is actually looking to utilize more. So I can only speak to the current funding that DMH is currently utilizing to support their work and their expertise, but that is definitely something that we are working to advance and increase at this time. Diane, you're muted. Were you finished? Sorry, I just said thank you. Of course, you're welcome. Representative Hooper. Thank you. You can tell that House of Props has all been sitting here together since most of my questions have been covered. I was going to ask about outright the DAs and the success beyond six, but I wanted to dwell on the DA issue. So the other questions have been asked but I am concerned about rating the ability of the designated agencies to continue their services if they do not see an increase in funding in the coming year. I have heard from my designated agency that they are not going to be able to offer any staff increase, pay increases. So they're level funding their pay. This is at a time when I think there's some on the order of about 30% below the rates that the state is able to pay and significantly below what privates pay. So I'm worried about our first line of defense. I understand that notwithstanding the fabulous work that everybody has done around homelessness, we have an increase in homelessness in central Vermont. I'm guessing that's true elsewhere because families become more fragile because of income issues. And so I think we need to be increasing our capacity to provide services, not level funding. And I'm wondering if you would comment on that please. Yes, so certainly the capacity of our community mental health system is critical as we look across the system of care. I think we are all still continuing to get our arms around the impact of COVID. I think we are benefiting right now from the additional coronavirus relief funds that we are able to leverage. Again, we are using all of the flexibility within our case rate and payment reform to support the designated agencies. So while their provision of services has changed significantly in some areas that has had the decrease, which we understand, we have continued to maintain full funding for them and to create that flexibility on the back end as well. I do think the success beyond six is unique because it's outside of the case rate. It's still a fee for service model and it's clear how problematic that is, which is why I guess I would also add in addition to the comments I made earlier, we are still committed to coming up with a case rate for success beyond six, which will help and will kind of continue, I think, to create that flexibility and sustainability. So I think across our system of care, we'll have to continue to look at the needs of all of our providers across the state and then balance that against, where is Vermont economically in terms of our recovery? I appreciate that. And you stated that we've been able to maintain full funding for the DAs and I just want to highlight again that that means level funding for them and a time when there is huge competition for their services, let alone the stress of it. And I think this is where we need to be making the investments, the upstream investments are so much more, they're all important, but the more we can do there, the less expensive it is. So I hope the healthcare committee can maybe drill into this a little bit more and see if we need to shift how we're making those investments. And I don't know if we can do it in this budget, but going forward, thank you. Thank you, Representative Hooper. Thank you, Mary. Representative Lippert. I wanted to just clarify, in terms of one of the ongoing very difficult issues is the wait times in our emergency departments and hospitals for psychiatric care, inpatient psychiatric care. And if I understand from what you've said that with the movement of, so what my question is two-fold one, if there's the movement of patients from PCMH back to the Millsex facility, will that increase capacity at PCMH for additional admissions? And secondly, so that's one issue. I'm trying to see where the capacity is and where it can increase. And in terms of the Brattleboro Retreat, the 12 additional beds, is the January 1st, 2021 deadline a deadline for completion of construction? Or is that a January 1 deadline where admissions can begin at the Brattleboro Retreat for those 12 additional beds because staffing will be in place, et cetera? So I'll start with the first question, Representative Lippert, which is just generally capacity across our inpatient system of care. When COVID initially hit, we had a little bit of an eerie silence, if you will, in terms of just a general decrease in individuals presenting in EDs. Obviously, our inpatient system was also grappling with staffing shortages, double occupancy rooms, having to shift to single occupancy rooms overnight for infection control purposes. So slowly over time, we have been rebuilding our inpatient capacity. I would let the committee know that across the system, we're running at anywhere between, you know, 60 and 90% capacity across our inpatient units. And I guess where the higher capacity is is within our level one beds when we've been able to maintain a fairly high level of capacity there. As I mentioned before, we did see a little bit, we started to see an uptick in individuals presenting in the EDs for a brief period. And now again, that has tapered off again. So we are continuing to keep our eye on it. The Department of Mental Health looks at wait time data very in depth. So I am waiting for our data and statistics team to get us the current data on wait time so we can really see and analyze where we are trending and what the impact of COVID had on those eight times. I just don't have that data yet. In terms of the overall retreat, it is my understanding that the construction will be completed by January one, that the retreat will of course be working on staffing and hiring prior to that. So the goal would be as close to January one that admissions can begin as soon as possible. Obviously there are many variables and factors there that the retreat will have to grapple with in terms of just, you know, ongoing staffing shortages across the state. But the intent is that that capacity, maybe not that full capacity, a full 12-bed unit will come online January 1st. Part of the action plan for sustainability related to the retreat as well is also continuing to monitor and ensure that those 12 level one beds are on time and on schedule. So that is certainly something that we are keeping a close eye on. Thank you. Bill, did you have a follow-up or? No, it's just a concern that those deadlines keep moving. And so what we intended for additional capacity hasn't been able to materialize. Some have been understandably because of COVID, but I think we need to keep an eye on that very closely because if those 12 beds don't materialize, we really haven't increased capacity. Thank you, Bill. We have a final question from Representative Donahue and then I need a couple of minutes to tie up some loose ends and make sure that we're all on the same page going forward. So, Ann, your final question. Just a brief, again, request for follow-up information, not right now, but I think it would be helpful for us to have a bed capacity comparison locations. And because we did, we did as part of the sustainability plan for the retreat close a unit. So we have lost a certain number of beds while we're also opening some. So I think having a clear picture of how many beds prior and after at each of our hospitals would be a useful background. Yes, of course. We can provide that. Thank you, Ann, and thank you, Sarah. So as we move through these budgets and make our conclusions, and Sarah, first I wanna tell you, your presentation was excellent. It was well presented, easy to follow. So thank you very much. Of course. Your presentation. But as we work through these and come to conclusion, we have to remember these are only showing the delta, reflecting the delta from the governor's proposal in January. So if there are proposals that have not been changed or they have not been delayed or anything that's happening to them, they're still on the table for consideration in that proposal. And so we are really faced with reviewing two documents at the same time, going back to the January document and then taking this new restated document and determining what's in, what's out, what's delayed and what's still in place. And it's going to be tremendously difficult to do it. So we have to understand the budget is not presented to us in one document. It's presented to us in the document from January and then this restated document. And so I would ask my members when you're working with your agencies and departments to get a good handle on what has changed and what's still on the table that we need to consider that's impacting the budget. And Sarah, it is working on helping us to identify some of these areas, but not just within AHS but across the board, we're only seeing the changes. And so we really have to have in front of us the proposal from January and then sort through all the changes ourselves because we're only seeing the Delta, we're not seeing what's still in place, which were the original proposals of the administration. So it's quite a task that we have ahead of us, but I'm sure that the administration will be helpful in helping us identify what proposals are still a priority to them. And just a quick example, one that we would not see because there wasn't a change, the community high school of Vermont, there's a change that the funding would come from the Ed Fund. So that isn't in any of our presentation materials, that's something that's in the January materials that we would have to go through and pick up and see that that change is still in the proposal before us, even though we haven't seen it since January and February. So I wanna thank you. Kitty, can I just add one thing to that as well? Cause when I'm looking at the January proposal or at least in the crosswalks, they also indicate nicely in places where it's like budget adjustment, BAA. So when I'm looking at that, I'm making an assumption which may be bad that all of those BAA, because it hadn't passed when they presented this to us originally back in January, that some of those may be different, maybe we don't know. Don't make any assumptions we'll have. Right. I'm going to the fiscal office will also help us with that. So it's a much larger task than a regular budget before us because it's coming in pieces. So thank you all, Sarah and your team for being here. Bill, Mary Hooper has this budget and she'll be working directly with you. And as you take any additional testimony, if she could come in and sit and listen, that would be really helpful. And the recommendations on this budget, if we could get them by the first or second, I know it's a very aggressive timeline, but I didn't set the timeline, the calendar is setting the timeline for us.