 Okay, good morning. It is April 6, and this is Senate Health and Welfare Committee. Thank you all for being here. Welcome to people who are out on YouTube. And just as a heads up for people who are looking in, we have a number of bills that have come to us from the house. And I know that there is interest in providing testimony on those bills. So if you have an interest in testifying, it would be very helpful for you to contact Nellie Marvel, our committee assistant. You can find her email address on the webpage and just let her know that you're interested in testifying and which bill it is, and perhaps which section of the bill you're interested in testifying if there is a specific section or two that you're interested in. That will help us as we go forward. The other area to let us know, and I know people are not hesitant about doing that, but our concerns regarding budgeting that we'll be talking about a little bit over the next several days. If you have an interest in testifying on policy elements that are in the budget that came to us from the house. I think that's H 439 am I right or wrong on that. On H 439. Please let Nellie know that as well. So we can coordinate it isn't easy for us not being in the state house to coordinate all the requests that we get and I know a number of you make requests of your individual senators or people you know, so be helpful to send it into Nellie that so that's all that was an announcement. Good morning committee. So it is 11 o'clock we, we accomplished about, maybe a half, not quite of what we would, we were going to do, but we've invited Commissioner squirrel and others in today to talk about some mental health issues and Commissioner squirrel welcome. Nice to see you all. It's good to see you. I'm going to pull up my agenda which just disappeared. All right. So, so that we our conversation this morning was more about H 46 that we have in committee and will be inviting and other areas of interest that will be inviting you in to talk about another day but today. We thank you for thank you all for being here to talk about the middle sex facility and the plans for that. And if you, if you could and I see maybe everyone should introduce themselves from your, from your shop that would be great from your area. Why don't we have you introduce your folks and then we'll hear your testimony on the middle sex residential recovery facility. Okay, great. Well, good morning for the record Sarah squirrel Commissioner of the Department of Mental Health, joined here by a few other members of the DMH team, as well as two national content experts who have been assisting the department on this overall project and other practice improvement efforts across the state. I will have Deputy Commissioner morning Fox introduced himself, then Allison Richards, then Dr LaBelle, and Dr Huxhorn. Good morning. Yeah, good morning everyone thank you all for being here. I feel like we're all sitting around in the committee room and we're, we have an opportunity to have a robust discussion. We look forward to hearing what you have to say about the secure residential mental health facility. Thank you for having us and for the record, Morning Fox Deputy Commissioner Department of Mental Health. Who's next. I think it's me hi I'm Allison Richards Dr Richard from the medical director at the Vermont psychiatric care hospital. Okay. Kevin. My name is Dr Kevin Huxhorn. I'm a national consultant on the use of EIP's and also on the implementation of trauma informed care I'm currently director of evidence based practices for a international provider, and prior to that I was a commissioner and Delaware and then I ran the National Technical Assistance Center for state mental health programming for SAMHSA and national for about 10 years. Thank you. And Dr LaBelle. Good morning, Senator Lyons and everyone thank you for the pleasure and opportunity to be here today. I'm Dr Janice LaBelle I'm a board certified psychologist working in a neighboring state, and have a day job and a public mental health agency as the director of systems and also been working nationally and internationally unrestrained and seclusion prevention, implementing trauma informed care, and really affecting functional service systems changes to promote recovery based treatment so it's a pleasure to be here with you today. Thank you. Well thank you all thank you all for taking the time to be with us we greatly appreciate it. And we are good listeners today and with but we will have I'm sure we'll have questions as we go through. And as we hear about middle sex so. Commissioner squirrel I'll turn it all over to you and you can lead us through. Thank you. I'm going to go ahead and share my screen to walk us through the PowerPoint. We also sent a supplemental document which is an overview of the future DMH recovery residents so I would invite you all to take a look at that as well. Okay, can everyone see that. So Commissioner. I think you have to decide how much you want to be interrupted or not during this. What are our usual process is if they're questions of understanding, as you go through them we asked those questions. We'll try not to get into too much discussion until after you've finished. I think that's a great approach. Senator lions, we have a lot of content to share with you. And certainly can pause, you know throughout the presentation for some questions but certainly want to make sure we hear from Dr Richards and Dr labelle and Dr huck shorn as well so we'll just want to make sure we manage our time well. So I'm going to go ahead and get started. Some of the areas that we're hoping to cover with the committee today are just an overall history of the therapeutic community residents the current middle sex. Looking at system of care needs capacity analysis and costs of care, talking about the future recovery residents and what we're hoping to accomplish by expanding and improving that. Dr Richards will share some clinical perspectives. Deputy Commissioner morning box will walk through kind of a high level overview of the current design of the future recovery residents. And then we will hear from Dr labelle and Dr huck shorn as national content experts on the project. So I want to start with just a reminder about the history of the middle sex therapeutic community residents. Currently is located in the town of middle sex, pretty much right on route to many of the committee members may have had the opportunity to tour the facility. As it currently is and just as a reminder. This facility was put into place post hurricane Irene as part of act 79. So when hurricane Irene impacted the state. Quickly to a decentralized level one state hospital system of care. It was also articulated in act 79 and act 79 explicitly called for the creation of a secure recovery residents facility. It was designed using FEMA money to FEMA trailers that were put together. It was designed to be temporary and 10 years have passed and we have still not moved forward with a permanent secure recovery residents. During that time I would also note that was act 79 that actually allowed us and provided the funding to build up our community system of care from a residential standpoint. So we created our network of intensive recovery residential facilities, many of our crisis programs and other community programs across the state. And so, certainly, the current facility has outlived its lifespan and needs to be replaced. This is also critical in terms of our system of care. We do require having stepped down transitional opportunities for individuals in the system who might not need hospital level of care anymore, but do still have intensive needs that can be provided in a secure setting. Also just to note that for those individuals who are receiving Karen treatment at the middle sex therapeutic community residents. They are on an involuntary legal status under the care and custody of the commissioner of mental health, and they also have an additional order of non hospitalization, indicating by the court that this individual does require a secure setting. So just wanted to make sure that we were well steeped in the history of the current middle sex. For those of you who have not seen the current residents. These are some photos of where it currently is very clear that it has outlived its lifespan. It was designed to be temporary. So the site itself has challenges in terms of poor drainage, it's challenging to maintain our partners at BGS have done a tremendous job. It doesn't have a permanent foundation so you can imagine being in Vermont that creates a whole host of issues for the facility itself. I think it's really important that we focus on the system of care needs and certainly now more than ever as we know with the pandemic that having a strong stable continuum of mental health services and treatment is absolutely critical. We provide the best care to Vermonters we also need a robust continuum of step down residential level of care, increasing our step down capacity in the system has been identified as a critical need. We have presented to this committee historically on our analysis of residential bed needs, where we see gaps in the system. And this is certainly an area and as a key component for those individuals who require 24 seven care and treatment. The development of the current middle sex therapeutic community residents, and is it's expansion is a really critical and smart solution for us as a system, as we try to really essentially improve flow in the system, which is our ability to manage individuals as they move through different stages of care and treatment. I think that long wait times in our emergency departments are indicative of not having that flow in the system, meaning that folks are not moving through the system, as we would like them to. I would also note that this secure recovery residents serves a very particular cohort of individuals who are currently served in our level one beds, and occupy a significant number of bed days. For example, in 2019 of the five residents who are referred to the middle sex therapeutic community residents. They had an average length of stay of 300 days in our hospital beds. So, if someone is occupying that hospital bed for that longer period of time. It is taking away the opportunity for an individual who might be waiting in an emergency department to access that bed so expanding this critical transitional step down capacity will help us alleviate and improve that flow in the system. And certainly, of course, fundamentally we want any individual who is ready to step down to a lower level of care to be able to do that on a timely basis. I also think it's important to note what we also value at the Department of Mental Health and certainly clearly articulated in our vision 2030 is this balance and need for ensuring we have a strong and robust community mental health system of care. We've long been a leader in this regard. This slide here really indicates the rate of community service utilization for Vermont, compared to the rest of the United States, and you can see that Vermont is consistently has a higher rate of utilization of services than the US in general. Also, when you look at our utilization of higher levels of care such as inpatient. We are, we have lower rates of utilization of inpatient care, thus indicating that our continued commitment to ensuring that we have a strong community based system of care is a focus of the Department of Mental Health it's a focus of our community and something that we are continuing to be committed to. I also think this slide, you know really indicates that in terms of where our budgeted dollars going in terms of community based care and inpatient care. So what this chart here illustrates is the funding for mental health services across the state of Vermont sits in both the Department of Mental Health and diva so diva as our Medicaid payer also pays for many of the community mental health and inpatient services. So what this slide illustrates is that in 2019, our total spend on mental health care, both community based and inpatient was about $315 million. 77% of that was used to support community based programs 244 million and 23% of that was utilized to support our inpatient system. So again, I think the slide really articulates for months continued commitment to ensure that our community based programs and services are a top priority for the state. This committee also might be aware that Mental Health America recently put out a report in which Vermont was ranked number one in terms of access to mental health care so another indication. We always have more to do we certainly are never going to pat ourselves on the back and say, our work is done, but certainly I think demonstrates again Vermont's commitment to ensuring we have a strong continuum of care. We also want to note, and again, we're happy to come back to the committee as a follow up to do a deeper dive on this. We're also really well positioned as a state right now there's a lot of federal dollars flowing into the Department of Mental Health, all of which are intended to support our community mental health systems. I just wanted to note as we're looking at investing in these critical residences and facilities, we're also poised right now to really invest these federal dollars in our community mental health system. And so this just articulates the current tranches of funding that are coming into the Department of Mental Health that we have the ability to utilize over the next, you know, 123 years. There's a lot more detail on this. We did a recent presentation with house health care, where we really go through and detail some of these federal funding opportunities but I thought it was important that the committee have some sense of this today. So, just as an addendum to that it will be very helpful to have you come in and give us a deeper dive into some of the thinking that's going on around this money. And again, you know, just to underscore that these are funds that have to be deployed into the community. So that is where they will be utilized to strengthen or embolster our community systems. And so yes, and I won't ask the question now but when you come in it would be extremely helpful to know what the guardrails are and the guidelines are because once we start investing in the community then the question of operational continued operational expenses becomes an issue for us so we'll look forward to that discussion. Thank you. Okay, so going back to just the system of care bed continuum I think this slide is really important just to understand the continuum. So you can see in the top left here. This is one of our highest level, most restrictive level of care which is our level one inpatient beds. So these are individuals who have been deemed to meet hospital level of care, they're experiencing an acute psychiatric crisis, and in addition to needing inpatient care. They've also been identified as having increased acuity and needs, whereas they are deemed level one. So they require additional clinical supports in order to meet their psychiatric needs. We have currently have 45 beds level one beds that's the B Vermont psychiatric care hospital, the Brattleboro retreat and Rutland Regional Medical Center. These are our general inpatient hospital beds. So again we have 156 beds across the state. Again individuals who meet hospital level of care, but have not been deemed level one received care and treatment and these settings. Then we have our step down secure recovery residents so the current middle six program that we are proposing to replace and expand. We have specialized and enhanced funding. So these are individuals who are being served in the community, who also have acute needs, who have specialized funding that's attached to them to create individualized community programs. This is inclusive of some of the my pad programs that kind of pair supported housing with on site services and supports. We have a network of intensive recovery residences across the state. Again, residential level of care. They are staff secure, not physically secure. So a slightly different level of care for individuals where that is appropriate and clinically indicated. We have our mental health crisis beds across the state. And also our group homes which are operated by our designated agencies. And we have trans transitional staffed housing. Some of those programs who are offered, you know, through partners like pathways, and then independent living with services that are attached as well. And just to give you a sense of the continuum of care. Certainly we want to ensure that for any individual, they're able to access the level of care that is most appropriate for them in the least restrictive setting. I won't go through this in too much detail but I do think it's important for committee members just to understand what level one means. And I think that's important because in the last two years, 100% of our referrals to the secure recovery residents middle sex have been from our level one beds. So these are individuals who do have enhanced acuity. They have additional clinical needs, meaning that there are additional resources that are needed to support them safely, even in a hospital setting. So this is just a level one criteria so you can get a sense of what we're kind of looking at clinically. And then that was also codified by act 79, and has an additional fiscal piece attached to it that we need to pay reasonable actual costs for that care. But most importantly, it does just articulate that these are Vermonters with the highest levels of acuity across the state. We need to step down from those level one beds. It is absolutely critical that we have a secure setting with a respectful environment of care, so that those individuals can also continue on their path to recovery. Also wanted to articulate the difference between inpatient level of care, and a secure step down level of care. So inpatient level of care is really as I noted, you know, for an individual who is an acute phase of psychiatric crisis. Our inpatient beds are really designed for assessment and stabilization, what medications might be needed. These are individuals certainly who may be a danger to themselves or others, because of what they are experiencing during that psychiatric crisis. These are individuals of court ordered non emergency medications, and emergency and voluntary procedures, a secure step down level of care, which is middle sex is very different than an inpatient unit. It is designed for a sub acute population. So again, these are individuals who no longer need to be in the hospital, but they do need a safe and secure environment in order to step down to. There's also a much broader array of clinical and therapeutic programming that they have available to them. It's a longer length of stay anywhere from eight to 12 months. There's enhanced access to individual and group therapy. A lot of focus on skill building and social skills what we refer to as daily living skills, you know cooking food preparation access to a kitchen cleaning house care. As well as supported community engagement. So at the secure recovery residents in middle sex individuals are able to go out in the community with their care providers to, you know, maybe meet with, they might be working on transitioning to maybe a supported community. So it's an opportunity for them to have some time in the community to practice social engagement and those skills, so that when they are ready to transition to the community. They have those skills in place and are successful. So just wanted to articulate, there are significant differences between hospital level of care, and a step down residential program. It's important to this kind of this slide really overlays with that step down continuum. So the highest level of care is also the most expensive. So this really articulates our level one most intensive level of care across to be PCH, the retreat and Rutland Regional Medical Center, the column on the far right is the cost per day. You can see Vermont Psychiatric Care Hospital Rutland and the Brattleburg retreat anywhere from 1800 to $2,600 a day are non level one inpatient units are just under $1,800 a day. The current middle sex secure recovery residents are operating budget is around $3 million. It's about $1,200 a day. We did put some estimates in here in terms of the new secure recovery residents. Expanding that capacity, inclusive of additional staffing, our initial estimates were just over $9 million that comes in at about $1,500 a day. We have made some significant changes and some of the programming pieces. So that will actually adjust our staffing grids down a little bit. So we're still revising that number. But just to give you a sense again of the continuum of costs, our intensive recovery residential programs, our community based programs such as the area house and that intensive supported housing. Again, just to give you a sense of the costs. The only thing I would also note to keep in mind, particularly for the new secure recovery residents is that we are able to utilize Medicaid funds for that. So we talk about a $9 million operating budget, just to use it as an example. We're talking about a general fund need of, you know, closer to $4 million. We also have monies that, you know, obviously are already currently budgeted for the current middle sex. So the general fund need for ongoing operating costs, we estimate between two and a half and $2.7 million. But I just think it's important to remember that these are Medicaid funded programs as well. The data is really important in terms of how we make these decisions, how we look at system of care capacity. As I mentioned, 100% of the referrals to the secure recovery residents are coming from our level one beds. We've served 53 individuals since it's opening, the average length of stay is about eight to 10 months. Just over 60% of the residents have stepped down to less restrictive settings or independent housing, and then our occupancy rates at the current middle sex do run pretty close to 100% all the time. Which is why we have those cohorts of individuals who are waiting in those level one beds, because our current seven bed program is pretty much at capacity all the time. So the future recovery residents which we are proposing is to replace the current middle sex with a state of the art trauma informed and responsive facility to expand the capacity from seven beds to 16 beds. To address current need and unmet need. So when we talk about that demand when we talk about any given time, you know, eight to 10 individuals in level one beds who could step down who cannot because we don't have this capacity is critical in terms of the data that we're looking at. And it's also really critical that we can provide a high quality of care that we can ensure the safety of residents and these individuals also deserve a path to recovery to step down from those more restrictive settings, so that they can reintegrate back into the community. So these are individuals who are subacute, they are ready to step down. They do have increased treatment needs. And those treatment needs, you know, can potentially pose a risk to public safety. These are individuals who at given times may have exceeded the capacity of other community programs. These are individuals where when I talked about that continuum of care for some individuals, you can step down from an inpatient hospital bed, right to supportive housing in the community, right to a staff secure recovery recovery residents. For some individuals, that's just not the case, and our providers also know when to tell the Department of Mental Health when someone is exceeding their capacity. So these are also individuals who are community mental health partners are saying to us, we cannot admit this individual, this individual is beyond our capacity. And again, therefore, we feel a deep sense of responsibility to ensure that those individuals also have a safe environment in which they can transition to. And that really facilitates, you know, success for them in the long term, they might need the step down secure setting while they can work on those skills, and then can take that next step to an even less restrictive setting in the community. And again, we really think about this from an equity standpoint that these are individuals who also deserve and require equity and access to high quality care and treatment. And again, I don't need to reiterate just the level of need in terms of referrals coming from our level one beds, replacing the current recovery residents and expanding its capacity we think we'll have a material and significant impact on flow in the system. When we talked about those individuals and the number of bed days that they are occupying our ability to move those individuals step down into this transitional level of care is critical. And again, it's the right thing to do for Vermonters, it would certainly be doing them a disservice to not have access to this level of care in the system. And also noting that collaboration and partnership are really key tenants to this work from the department's perspective. That is why we made the decision to not utilize emergency and voluntary procedures at this program. We had stakeholder input. And it's very clear that the stakeholder input was to not utilize emergency and voluntary procedures at this residence, and we listened, and we took that into account, and we made that change. We will continue to engage with our peer and advocacy partners. We're really looking forward to having robust peer services and supports in this program as we move forward. So again, that's just something that we really value as a department, and we'll continue to work with stakeholders around those areas. And again, I'll just wrap up with a little bit of a snapshot of the data again. Just in terms of our success rate or our ability to transition individuals from middle sex to lower levels of care and the community. We certainly know that the impact of the pandemic on escalating mental health needs, the demand for high intensity services is not going to decrease in the short term, which is why this capacity is so critical. We talked about the long length of stays of this individual of this cohort of individuals in our level on beds. The improved environment of care in and of itself is going to be a significant advance forward from the current location. And again, we're averaging really high occupancy rates at the current program. And I noted our analysis of residential bed needs report that we did that indicated that at any given time. We have anywhere from seven to 10 individuals who could transition to the level of care, but are unable to because we don't have the capacity. Also, as we look more long term vision 2030 that the Department of Mental Health put forward really articulates a decreased reliance on inpatient capacity over the next decade. If we are to achieve that vision, we absolutely need to ensure that we have an adequate step down system of care in place that can meet a variety of clinical needs for individuals. Also members of this committee might be aware that the Center for Medicaid Services CMS is requiring the state of Vermont to look at the phase down of our IMDs with our Institutes of Mental Disease, any inpatient facility that's over 16 beds. So again, in order to for Vermont to achieve that having this secure step down capacity will be absolutely critical over the next decade. So I'm going to pause there I'm going to turn it over to Dr Richards. We think it's important also that the committee really understands who these individuals are. Dr Richards has worked with many of these individuals who have transitioned to middle sex so I'm going to turn it over to Dr Richards to provide some clinical perspective. Thanks Commissioner Squirrel and Senator Lyons and the committee for the opportunity to speak today. As the commissioner said I have been working in Vermont since 2007 with many of these individuals. I'm a board certified child not a lesson psychiatrist and adult psychiatrist and if there's two things I could share with you. I want to highlight sort of the progressive mental health system that Vermont feels very strongly in for Vermonters. And that ties into the equity that the commissioners talking about for these individuals these Vermonters that really need a place to step down out of the hospital and to be able to reintegrate into the community. And I want to be able to try to share some of their stories with you. I think the perspective is very important. So, I'll tell you a little bit about so I work at a level one VPCH is a level one facility and we do have a lot of high complex needs individuals that come here. And again they all have done something that has resulted in them being hospitalized involuntarily, at least at the level one facility and then the goal is really to kind of be progressive and then work towards a step down. I have also worked at middle sex and over three, four years been psychiatrists there and so I've seen both sides of this system of care. And so Gretchen is an individual. These are all fictitious but they're made up of people that I've worked with. They're not here to tell you their story but I oftentimes I'll share a little bit of the passion is that I want people to be able to move on with their lives when they're here it's it's hospitalization if anyone's ever been hospitalized it's just not ever really a fun place to be when you don't have access to all of the things in the world. You're kind of following the medical system of care and so I really feel passionate about getting people down to the next level of care. So Gretchen Gretchen's 38 year old woman she's had a history of long hospitalizations and inpatient stays, including times where she's had court ordered non emergency and voluntary medications. And her response to medications. Sometimes they just, they can help with symptoms they can help with aggression, but they don't always treat the psychosis or the delusions. Sometimes those just don't go away so she remains psychotic at baseline and has some delusional beliefs that just don't change. And during her hospitalization she has these moments where she's dysregulated, she'll destroy property, she will assault other people patients or staff, and these occur every at a frequency of every four to six weeks. And other than these episodes. She's, she remains psychotic but she's behaviorally stable and doesn't require this level the highest level of care. And due to this ongoing episodic nature where she destroys things assaults people, the other community providers at the lower levels of the system of care, they don't feel that they can guarantee the safety of the staff or the other residents. So they, Gretchen isn't able to discharge. She stays in the hospital because there isn't this other level where she can go. Randy is a 45 year old man. So this is another individual that doesn't have access necessarily to the to be able to step down from the hospital. He's been charged with murder and has been found incompetent to stand trial due to his mental illness. He used medications and due to his stable presentation in the hospital court ordered non emergency involuntary medications have been denied by the courts, which is unusual but it has happened before. So he remains delusional. He's psychologically not treated the circumstances under which he was charged with murder kind of remain the same risk from a provider's perspective that that hasn't been treated. So he remains a risk, and due to public safety concerns and the history of extreme violence, the community providers and these other facilities that aren't locked or secured, don't feel that they can safely treat him when he isn't treated. And so we can't really treat him in the hospital there isn't any other place for him to go other than a recovery residents like middle sex, and, and I'll do the next one. And one more example is Greg, he's a 40 year old man who's had a history of numerous psychiatric hospitalizations as well as placements that we could say, every other level down the continuum so he's been at all of the other group homes, the other residents my pad and his links of stay at these group living situations have range from days to months. And what happens for Greg is he just destabilizes and ends up back in the hospital again. And when he's in the hospital he needs non emergency and voluntary medications, because he oftentimes will stop his medications in the community. And when he's been at the other residences he's either eloped or assaulted other people. And so again, the community is saying they don't feel that they can safely meet his needs due to the elopements the assaults. And so he's back in the hospital again stabilizing and the other agencies all say like we really don't, we can't meet the need of Greg, due to the ongoing risk of violence and the challenge really is, you know, Greg. Well, he comes in and he deserves also as a remontor to be able to step down out of the hospital. And as the commissioner described the program, you know, anywhere up to 12 months four months, 12 months to be able to have that stable time in with a consistent team of providers, also going you know cooking meals with staff and working at Middlesex we had a very holistic approach to meeting with the residents of the program on their terms, cooking together we shared meals together. Community outings were important if it's fishing or grocery shopping to learn those life skills and the socialization and how to manage the times when you would go out to other facilities and just kind of not do well. It's a building place and then a place where he can move on from there. And I, I just, I feel very passionately about this and the need for the new facility, and especially given the condition of the current facility and then an expanded capacity so that we can have people in these level one beds just as long only as short as a time as they're needed. So I really appreciate you letting me speak. I have anything at this point. Thank you. This is I think very enriching for us. Appreciate. No, thank you. Thank you Alison. So Deputy Commissioner morning box will do a quick overview of just some of the current design renderings so you can get a sense of the environment of care that we're creating. And then we'll also get a sense of what some of the outside yard areas are so Deputy Commissioner Fox, I'll turn it over to you. Thank you. So what you see here in front of you this, the, and the following half dozen or so slides will show some artists renderings based on the, the architectural drawings and schematic drawings that we've been working with architect firms and the folks from BGS to put together. And this includes input from various stakeholders that we've received over the past probably two years now. As far as information regarding the, the look of the, of the residents as well as kind of the conceptual design and other areas internally. One of the big pieces that we want to make sure that it looked like a residence, a large residence but a residence nonetheless, and not a kind of brick cinder block kind of institutional feel. There's a lot of growing research around how living in a place that is more comfortable residential feel has a dramatic impact on on one's mental health. So what you see here, again, artist rendering of what the front of the residence would look like with kind of your classic Vermont porch as the main entryway. And that's where residents would would come and go from and new, new people being admitted would come through the front door. It's a residence it's a home people come through the front door not through a Sally port in the back like at, maybe at a hospital or something of that sort. And so, you know, there's a place for, you know, drop off and pick up, as well as, you know, you'll, again, just trying to make it have that feel of a residence. Okay. So you can see this is a site design of the entire kind of area. The down at the bottom where you see the words drop off. That's really what we were just looking at the image was looking at that area that that's the front of the, of the residents. It's, it's a little tough to tell in this image where the fencing is for the yard, but it's basically in the back, you can see where it says raised garden and gazebo to the left of that the. Oh, there it is even better. Thank you. I forgot we had that slide. So the areas that the commissioner is showing now you have one, one area of a yard here and one area of the yard on the other side. We have 1,600 square feet in one and just over 4,000 square feet and the other, giving us a total of just shy of 11,000 square feet in those yards, but up against the other building, which is the existing gymnasium that we will be building on site, which will provide other space for activities, both in in good weather as well as an inclement and our long winters, so that people can still have kind of that outdoor activity and exercise in a in a safe temperature controlled environment. There will be a lot of places for people to sit to congregate to have meals outside or have groups outside one on one conversations, there will be walking paths raised garden beds, things of that sort. So there's, there's really quite a lot of space to be provided with easy access from multiple locations with from within the the residents. This is just an example of one of the larger rooms, gathering rooms in the residence. This is what we're referring to as a multi purpose room. It can be used for anything, everything from watching elections to sporting events to having groups and group process. As well as, you know, even smaller things where maybe just two or three folks are using at a time maybe to have a separate meal in a quieter place or something else. But you'll notice in this and in other pictures, lots of large windows that that are functional that are able to be opened to have fresh air come in, getting in a lot of natural sunlight and similar with the, the kind of natural softer tone colors. Going back to research and best practices and design of residential placements for folks with in recovery from from mental health services is the the access to bringing the outside in that having that natural sense really supports one's mental health and has a significant impact on their progress during their recovery as well. And this is actually the the same room but just from a different angle, but just what I wanted to point out in this image is, you'll see the round window on the left is actually faces where the nursing area is in the residence, so that it allows nursing to be able to see through through that window for some sight line visibility. The doors that go into the room as you'll see at the end are also glass or plexiglass but that you can see through as well so there's numerous lines of site but also again to help with keeping it a bright and airy type space. And if go out that you come into not okay. We go into one of the other rooms a living room area, which is right near the entrance actually that is set up kind of as a pseudo library space, but also provides separate spacing again the large windows, the windows in the in the hallways. Again, so even if it's a smaller space, having all the windows gives it a much more expansive feel to it, the sense of space, but also it allows for good viewing for the staff. One of the reasons we're designing the residence is also be mindful of the cost of staff and not wanting to have extra staff needed because of lines of site issues and concerns around that. And so really we're intentional about helping to create the ability to see into various areas for the staff as they're working there as well. So the main gathering areas central hubs of the of the home. Like in many homes the kitchen dining areas they is kind of a central gathering area. This will have the capacity to have the 16 residents eating together tables can be separated so that they're not as together folks can sit at the breakfast nook as well. Kind of a smaller conversation or getting away from some of the hubbub. What you also see on the left side there is the, the residence kitchen, and it's a fully functioning kitchen that they will be able to use on their own with staff to develop skills. The main goal is to help folks develop those skills that they can move on from this residence to more independent living and some of that work is learning those skills to live independently. Part of which is building grocery budgets going shopping and then putting meals together. There is a commercial kitchen that is in the back of the building will have staff that provide meals three times three times a day all meals and snacks for the residents so this is in addition to their own meals and such like that. You'll see in various places within the hallways. Again, separate small little congregating places where an individual can sit by themselves and or sit with maybe one or two other individuals so that they can have either some quiet space. It's outside of their room, maybe wanting to be out in the milieu but not necessarily in a large multipurpose room or living room area, but then having these types of sitting alcoves where they can have some some quiet space or maybe one on one time with another resident, a peer, a peer counselor, their case worker, things of that sort. And this is a rendering of one of the bedrooms. Each each bedroom has its own own bathroom. So there's no shared bathrooms no having to walk down a hallway to go to go to the restroom or anything of that sort. We also were intentional in not wanting to place in the residence, your typical twin bed type thing. Most of us as adults don't sleep in twin beds. They're relatively small and narrow unless unless you're as small as I am. And most people do not fit comfortably on a twin bed. And so we made sure that all the beds are full size and all the building cabinetry for people's own personal belongings. And the idea here really is that, you know, for the next foreseeable future several months, you know, several weeks to months to up to maybe a year. And so that they have the ability to decorate it as as they would like, and really to make it their their own as as they see fit. But again, windows to the outside that are openable and operable by the resident and things of that sort. So, and everything is designed with also kind of the psychiatric perspective in mind and the literature proof, literature resistant materials and designs as well. And then finally just want to touch base on the fact that we really are trying to imbue trauma informed approach throughout, not only the design of the of the residents, but also in the operation of the residents treatment plans and the designs of that sort are highly important to have the resident be involved and have their voice that it's residents centered and resident led, and how their treatment will evolve, how their recovery there will be involved that they really have a sense of being empowered to to say, Here's what I want my treatment hires what how I want my recovery to look like. So we really envision that the residents would really take an active and leadership role in the design and direction of their treatment plans, as well as having peer advocates to be there to support them to help them to learn how to have that active voice and to advocate for their own needs, as well as having peer counselors as part of the treatment team to really help support them and support their recovery through this process. Thank you, Fox. And now we want to thought it was important to hear from Dr. Kevin Huck shorn and Dr. Janice LaBelle. They've been critical partners for us in the state, in terms of implementing six core strategies to to reduce seclusion and restraint. And they've been critical and advising us on this project so I'll turn it over to Dr. Shawn and Dr. LaBelle. Thank you commissioner. This is Dr Kevin Huck shorn again and thank you honorable legislators and the rest of the state staff for giving us a few minutes just to weigh in. Both myself and my colleague have worked with the state of Vermont, probably since about 2005 ourselves in in helping to reduce the use of the IPs and implement trauma informed care so it's an honor to be back. I first want to just congratulate the state of Vermont. You guys really should be very proud that your system of behavioral health care. I have worked in probably all but three or four states over the last 20 years, and you really have demonstrated your incredible commitment to evidence based trauma informed practices throughout your entire system of care. Your access to care is excellent. And you have really partnered with your very powerful advocacy groups and have relationships that may be strained at times but that's normal with advocacy and state staff and trying to meet everybody's needs. So, I guess I just want to make a couple comments. The first is that all states have a top priority if not the highest priority to meet the needs and services required by people with serious complex mental health disorders and this is the group of people were talking about today. I personally am very strong believer in the Americans with Disabilities Act and the Olmsted decision and have helped a number of states implement those principles which basically say people can live in communities and should be able to do these in their own apartments in their own homes with a natural social support system. However, what we're talking about here in terms of the middle sex facility are the small group of people that all states grapple with and struggle with. These are folks who may or may not and certainly may not right now but are very similar or meet the criteria that Dr. Richards talked about these are your fire setters your people with sometimes inappropriate sexual behaviors, serious felonies people that have patterns and habits of self harming people that have very difficult very poor self care skills, who in the old days probably would have gone into a nursing home right now not controlled substance use disorders and people like Gretchen that are treatment resistant no matter what we know and try we still haven't figured out that remedy. These are the people that in the old days were forgotten. These are people that were forgotten in state hospitals and either live there for decades or the rest of their lives. And even though, yes, some of them could be cared for in the community, the cost of care would be over your level one expense costs it would be probably close to a million dollars a year for one individual and that's just not efficient, or good use of dollars nowadays. So, basically, while this group of folks are very small. They also have very specific needs that we now know 2021 how to treat and what we're talking about here is psychiatric rehabilitation. It was identified through a lot of research and studies over the last 20 years that a lot of folks who have these conflicts mental illnesses can indeed eventually live in the community, but the way they can do that is if they get the type of services that take longer and are different and the type of services you get a level one or crisis stabilization beds. Those are skills as the commissioner had noted in the PowerPoint that include managing your own recovery plan writing your own wrap plan which is an evidence based practice shopping money management cooking, taking transportation public transportation, how to use electronics, how to do basic housekeeping. These and most important are the socialization issues that people need to learn by living with other people before they try and live on their own. Those are skills that are critical and having and currently working with the US DOJ on another project. One of the one of the emerging concerns is the loneliness experienced by people who haven't built up those socialization skills and get put into apartments all by themselves who then have no one. And we need to do a lot more work on that. So last, I think that the debate here in Vermont, if you would be so, if you would give me that opportunity to say the debate should not be between community services versus inpatient residential services that debate should be about how to create an even better system of care than the one that you all have are leading the way on in the country. And how to do that and part of that is going to be plugging this whole this gap for these people that really need these services and who waited for some time and who your state staff have done so much work to prepare the road going forward for them. So I'll step down and turn it over to my colleague but thank you for the pleasure of talking to you today. I'm Dr. Huck Schorn and thank you Senator Lyons and fellow committee members. This is Dr. Janice LaBelle. And it's very hard to follow such eloquent speakers and I'm sure you've got questions. And at the risk of being redundant, I'll just sum it up I say as a neighbor working in state government. Please believe me when I tell you that Vermont has enjoyed such a reputation outside of your state that you may not be as well aware of as those who are not Vermont residents are about how impressive your service system is and that doesn't just happen. That happens because of stellar leaders and you've just heard them today. So I just want to underscore a few points that we in public mental health are all preparing for the pandemic related tsunami of mental health need that is headed our way. And we have to have a system of care that flows. And it can only flow unless you've got good link pins like this recovery residents in place to be able to help move people through the system and not just move them through but as Dr. Huck Schorn and others identify having them prepared to live in the community because ultimately that's the litmus test of the power of the work that's being done. Not how well they do in residence not how well they do in a hospital they should do well there they're getting all the bells and whistles and props. But the test of our work is how they succeed once they leave and every ingredient that's needed to be successful is embedded in the design that's before you today. It's consistent with evidence fakes practice trauma informed trauma responsive care is much more efficient and effective and cost beneficial when it's properly implemented and this design delivers that to you by the physical plant. The views of nature which are absolutely calming and underscored by evidence the skills oriented approach. So what you have something before you is prudent. It's pragmatic. It's reasonable and it's necessary. So I thank you for these few minutes and I will stop and pause here because I'm sure you've got wonderful questions. Thank you again. Listen, I can't thank you all enough. This is this is exceptional and extremely helpful to inform us as to where the current thinking is and I guess we do have a lot of questions but unfortunately we're at a real hard stop. So what I'm going to suggest is a commissioner when we schedule you in that we have some time for questions and discussion in this on this as well as some of the other issues that we were going to talk about, you know, including adolescent mental health needs as a result of the pandemic and those are those are ongoing issues for us and then the funding. As we do see Dr. LaBella is happy to hear you mention not well not happy about it at all but the the tsunami that's going to be coming at us. So I think that's an exceptional health tsunami related to the pandemic so but I mean I will I do have questions just the very broadest at the broadest level. I think it will be important for the committee to understand the places where emergency and voluntary treatment is utilized and then where it is not utilized I know that's been an ongoing question and discussion. So just to help us understand where you're thinking on that and and that you have made some decisions as a result of talking with folks so it would be I'd be happy to hear about that. And then the other area is in the area programming obviously what's going on in this new in this new facility is is going to be critically important for the improvement and the recovery for the folks who are there. And I know we've had the programming discussion in the past but what the thinking is there because that's where our committee really can support the work, the good work that's going on. And then also workforce and how how we're going to have sufficient workforce to carry out the work that's here I mean you talked about peer support but it's broader than that and greater than that. And then, as I'm very acutely aware of the need for some some some spacing for people when they are when they work in these environments needing some time, their own time downtime so how that's being evaluated from a workforce perspective. So, those are some of the, I think those are some of the questions we might want to explore going forward, but I cannot tell you enough how how very I was going to say happy but how pleased but how informative all of this has been, and the, the giant leaps forward from where we might have been last year at this time. So, thank you. Thank you all. Committee any final thoughts. Dr. Huck shorn you had your hand up for you going to comment. Okay, that's good. Just goodbye. I know we're we're over time a little bit. Dr. Dr hearty, Dr. Hardy, Senator Hardy. Well, first of all, thank you all testimony explanation of this project. This is in our capital budget right now and review by our institutions can be. I just wanted to make sure that anybody who's listening from the outside this is not related to a bill we're working on specifically but related to our capital budget which is being taken care of by another committee. Obviously important that we know this information but I'll. It is in our committee what is in our committee obviously is our all of the policy decisions that are being made so when we start talking about emergency and voluntary procedures that is our committee. I understand that but the facility itself that's what I wanted to make clear it's not you know what I was going to say yes you're right but also the treatment modality and the way patients are handled informs the facility. So that has to be hand and glove. I know you get that we all we understand but. So we'll come back to this. Another day, and we'll, we'll try to stay. I have been staying in touch with our institutions committees and other committees who have been hearing the testimony and asking questions we want to, but we'll also want to put our stamp on this as well. Of course. Well thank you all for your time this afternoon now and we'll look forward to coming back, responding to some of those questions and also digging into some of those other topic areas, but I know Senator lions you were interested in having us address. Terrific. Okay. Thank you. Thank you committee. We just used up some of our early endings.