 Good morning. This is the house health care committee and we are Honestly, it's February 4th. Is it I think yeah, and Yes, two days post our massive Groundhog Day celebrations, so we are that's how I can tell it what day it is Okay, Bill Today we are going to focus the entire day actually on the important issues of the mental health system in Vermont and we have scheduled time this morning to Have a great deal of time with the commissioner of The Department of Mental Health and I see and the deputy commissioner and there may be other staff that they have brought with them which I'll have them introduce and then Later in the morning, we'll be hearing also from Julie Tesla from the Care partners, which represent which are the Community mental health developmental disabilities substance use disorder providers in our communities who contract with the Department of Mental Health and This afternoon, we're going to be hearing from some other stakeholders so Welcome commissioner And deputy commissioner and others are glad to have you with us I think we have done our introductions to most of you, but not all of you, but we'll I think we'll proceed as if we have and We have we have between now and probably late morning For not very late morning, but late morning. We have a good chunk of time because this is a really important issue for this committee It's an important issue for Vermonters. It's important, but we have just so people Who are tuning in and may not follow us regularly understand that As the health care committee, we also have been given jurisdiction specifically of mental health care Which we consider an essential part of health care broadly And we have a particular Interest in understanding it more fully And then as we approach the budget process, which we will not focus on primarily today But we will be inviting commissioner squirrel back to meet with us I believe on again on tuesday Just pull up a chair and stay for a while, you know So, uh, but we'll be focusing on budget issues, but the conversation and information today will help lay the background for Particularly for newer members and for those of us who've been on the committee for a while We're going to get some updates and other information. So with that, I'm going to turn it over to commissioner squirrel and Ask you to help guide us through Information and some questions that were forwarded to you earlier by our Committee So good morning and thank you Good morning, everyone. Uh, wonderful to see you all for the record. My name is sarah squirrel and the commissioner of the department of mental health I'm also joined by other members of our leadership team at the department of mental health To provide an overview Related to many of the urgent and important topics in our system of care So i'll just pause for a minute and let the other folks from the dmh team introduce themselves great Good morning. Uh, morning fox deputy commissioner for the department of mental health Welcome Thank you. Good morning. I'm shannon thompson the financial director for the department of mental health Welcome shannon Good morning. I'm allison cromf. I'm the director of quality and accountability for the department of mental health Yeah, welcome. Glad to have you all with us Great. Thank you everyone. Um, so if it serves the chair and vice chair and ranking I will share my screen and walk folks through our presentation. So I will start doing that now Can everyone see that? Yes, we can Notting heads wonderful. Great. Um Well, I will jump in Certainly this week is an important week. Um in vermont for mental health. Monday was mental health advocacy day Um a little bit different given our virtual environment. Um, but nonetheless powerful Um, certainly a great way to kick off this week. Um and to present this overview To this committee. I think now more than ever as the pandemic stretches on The significance and importance of ensuring that we have a comprehensive system of care for vermonters To access mental health care in a timely way Is so important and we have to ensure that when our friends family members ourselves loved ones children Need access to mental health care that they can access it in a timely way and then it's high quality So I will um move through. Uh, I guess we'll just pause for questions as we go. Um Representative leopard, but I will take my cues from you on that And if there's an obvious if there's obvious break points to Pause and take questions. Maybe that's what last committee members to hold questions until that There are there. Yeah, I see that there's probably some obvious Points to stop and take questions. Does that work? Yeah So you can see there's an outline of the presentation here We wanted to be responsive to the request from the committee To we'll do a broad overview of the mental health system of care We'll dive deeper into inpatient capacity planning for our dmh recovery residents suicide prevention efforts vision 2030 implementation Some review of legislative reports and some high level recommendations And we'll wrap it up with some initiatives and opportunities So we could pause after each of these sections To take questions Which might be low That sounds good and perhaps along the way depending as we go along We'll just take a complete break for you and the committee So that we all get a stretch break and uh, because sitting on Sitting in front of zoom and remember our computers non-stop is Not good for our mental health Sounds good to me. Thank you. Um, so first just to start obviously Related to the mission of uh, the department of mental health We do take our role in responsibility very very seriously And our broad mission is to promote and improve the mental health of vermoners And when we think about our vision broadly, you know, we really envision a system of care And an understanding philosophy Way of approaching our broader health systems and health care That mental health is really a cornerstone of health And we really believe that there is no health without mental health And certainly, you know, we have a vision of vermoners having access to an effective system Promotion prevention early intervention treatment and recovery And to support individuals To live work learn and fully participate in their communities You also see here a visual of vision 2030. This is something that we are Very proud of as a department in the system of care We will be talking in more detail about vision 2030 and our efforts to advance that work in terms of achieving a holistic and integrated health system So i'm going to just walk through some overview points. There are many seasoned committee members Who have a great understanding of the mental health system of care But i want to make sure that all committee members have a good sense of the system and the components So certainly the department of mental health, as i mentioned, we have significant statutory responsibilities Two vermoners to provide comprehensive mental health services and care A lot of that work we facilitate with collaborative partnerships With other non-profit partners across the state That includes our designated agencies specialized service agencies and designated hospitals Certainly we see our work as one of collaboration I often say that, you know, sometimes we think about our best way to serve the system of care Is to optimize our partner. I really think we have to optimize the relationships between the parts to get the outcomes that we're after So we really do value this collaboration with our community partners The designated agencies and specialized service agencies we contract with them To provide services on behalf of the state that we are federally mandated to provide There's a significant designation oversight and authority that we take very seriously But we're grateful to have such a strong network of designated agencies and specialized service agencies Providing community-based care to vermoners We also work with seven designated hospitals Who provide inpatient care to vermoners? We operate two facilities. So the Vermont psychiatric care hospital located in berlin Which is a 25 bed hospital, which is designated as level one And then our middle sex therapeutic community care residents Was it to is a seven bed physically secure residential Located in middle sex and we'll talk a little bit more later in the presentation Related to our efforts to replace that facility with a new state of the art trauma informed facility In terms of staff at the department, we have just over 300 staff About 250 of them Work at our facilities so working at the Vermont psychiatric care hospital or working at middle sex We have 61 staff at central office. We are a small but mighty team and We have several units within dmh. They kind of align with other units in the agency of human services administrative support business office and legal services our quality research and statistics teams clinical care management team policy and planning Child adolescent and family team and our adult mental health services team As I noted, we really value partnership and collaboration. So we have some notable collaborations here that we've listed and also Vermont Has incredible community partners and advocacy partners that we also work closely with and support Inclusive of the Vermont federation for families the Vermont psychiatric survivors national alliance on mental illness nami Pathways and many many others including peer advocacy organizations Again, I mentioned this in our and some of my introductory remarks when we think about a public health Spectrum and a continuum of care as I noted promotion prevention early intervention treatment and recovery This is just another visual Going into a little more detail on our designated providers So you can see the 10 designated community mental health agencies listed here Some you may be familiar with those that are located in your own communities across the state The seven designated hospitals That we work with to provide inpatient care Inclusive of the bridleboro retreat central vermont medical center Rutland regional medical center The university of vermont medical center vermont psychiatric care hospital The va medical center and the winem center And the two specialized service agencies that I mentioned Pathways vermont and nfi This is a very colorful Visual of the designated community mental health agencies across the state This is really just to give you a sense of how our da's are kind of oriented across the state They each have catchment areas Which are geographical areas that they're Responsible to provide an array of community based services to so this just gives you a visual sense of the different designated agencies across the state I would also just note that the two on the bottom here Northeast family services nfi and pathways vermont as specialized service agencies Actually provide services across the entire state of vermont. So I just wanted to note that specifically for the committee This is a visual overview To give you a sense of the adult system of care And you can see that we go from some of the most intensive services and supports that we offer across the state Down to our community mental health agencies and systems So starting at the top you can get a sense of that. These are our inpatient facilities across the state We have three level one inpatient hospitals or units if you will When hurricane Irene Essentially closed the vermont state hospital We created a decentralized inpatient system for level one Level one is also codified in statute There is clinical definitions related to level one and how an individual Might be admitted into a level one unit There's also specific language in terms of how we fund level one So level one is codified that the department of mental health has to pay reasonable actual costs to those hospitals providing those services So essentially what that means for the Brattleboro Retreat, which has a 14 bed level one unit For Rutland Regional Medical Center, which has a six bed level one unit There's a cost settlement process that we go through To ensure that we are covering the full costs of care For those individuals From a capacity standpoint as well. I'll be talking a little bit more about we have additional level one capacity That will be coming online with 12 new level one beds at the Brattleboro Retreat Would you be willing to very briefly actually help define what level one what what does level one mean? I think it doesn't have meaning for anyone who's not thoroughly Grounded in this system Yeah, there's other levels and how does this compare, you know, but what does level one meet for the Yeah, I can I can start it off and then I think deputy commissioner morning fox could probably add more to that It's a great question So really when we think about clinical and safety needs for an individual That the department of mental health our care management team Utilized is to determine if someone meets level one criteria So certainly individuals who are presenting with the highest level of acuity Whose current clinical presentation indicates that they do to their mental health Experiences and challenges would be a danger potentially to themself or others And I will pause there and let deputy commissioner morning box speak more to that And and maybe in the court Fox if you if you could clarify, you know Is there a correlation between those? Vermonters patients who would have been previously at the Vermont state hospital versus general hospitals? Or is that not necessarily a fair equivalency? I I think That's that's relatively fair. Uh, I think that's that's kind of how it's Developed and grown to at this point That I think most folks will consider when they hear when you're working within the mental health system level one Are those folks that would have in the past traditionally been Vermont state hospital? patients It actually originally began I believe Partly connected to billing practices As we were decentralizing Or maybe not But Yeah, I'm afraid well, but This this is part of the challenge for us here is that I think representative don if you actually may have Originated the term in another committee at another point in time So it's a bit of a setup to ask anybody to explain it other than her. Sorry. Sorry fox and sorry commissioner No, no worries, but but the the the general construct is you know, how it's how it's operating now Are those folks who have Kind of the more complex or higher level needs We're generally looking at Need for additional services that might be traditionally provided on a general psychiatric unit And so it it could include Meeting one-on-one staffing or you know closer monitoring of that sort additional psychiatry support Things of that nature and so it's it's really for those individuals that Really kind of need a bit more support than what you might find in a general psychiatric unit But and so I think I'll just ask you a couple more questions just because I think that's important to understand for members This is not the equivalent of involuntary status No, uh, you're exactly right. Most people Uh, the the great percentage of people who are uh on a level one unit are involuntary But not always, uh, there there are people and there are exceptions when a a voluntary patient can require similar Uh, those higher level, uh kind of care needs But there's a large overlap then Okay I'm just going to since I brought it up I'm going to ask representative donahue if you would like to make any comment without taking us down too far into the history Or well, I think the flip side of your question Representative lipper is of course the vast majority of inpatient admissions are voluntarily folks voluntarily seeking care Yes, then there's a subset who are involuntary Because they're deemed a threat to self or others and are not accepting care and it's only a subset then of those who are Most at risk and require additional staffing And it was after we identified that as being a need for extra support that then evolved into the Billing criteria for meeting that threshold to that's why I was saying well, no it didn't start as a billing Billing piece evolved from it, but I think it's been well characterized. Yeah, I think that's so I think we're we're on the same page here I just wanted to make sure there wasn't some sense that maybe that we were not Thank you. Thank you I think that let that terminology is one that I think often is assembling block for people in understanding the system of care But thank you Just to add one brief thing the the reason you know, why do you have level one without two or three the intent when I Pointed was that there would be a two and three for those other categories at level two are involuntary, but who can be Placed at a regular inpatient unit and level three are voluntary patients those never caught on But that's why it's quote level one Okay, and I do want to just make clear too that Individuals if someone you know has one hospitalization and then at another point in time another point in their life Requires hospitalization again. It doesn't mean that they're always needing level one services So I don't I want to make sure that the committee understands that individuals That may require level one treatment services this go around if there is another Need for hospitalization that doesn't necessarily mean that they're going to need that same level of care again thank you Great question representative leopard. Thank you. Fox and representative donahue So the next I guess tear here that we've identified Within this pyramid if you will Trying to provide a visual depiction of some of the capacity in our mental health system of care on the adult side Is the secure residential which I just noted we will go into more detail on the secure residential Why it exists what the needs are some of the specific legal parameters around that in terms of individuals who are admitted But is a seven bed facility Located currently in middle sex And it is does serve primarily as a step down From the level one beds that we were just talking about about 90 for five percent. I think of individuals who are currently residing At the middle sex therapeutic community residents have stepped down from level one We also have an array of intensive residential programs across the state the acronym for that is irr We're trying to not use acronyms today. Um, and really just say and spell out exactly what we're talking about these intensive recovery residential programs And residences are located across the state They are operated primarily by our designated community mental health agencies And we really see them as a statewide resource So that's just something important to think about when we think about the scale of vermont Geography where these are located across the state And we utilize them as a statewide resource Of course, we always want individuals to access Care and treatment as close to their home as possible But the irrs we do See as a statewide resource We also have a peer run Residential program, which is the satiria house that pathways operates as well Which is another part of our system Then we have crisis supports and response. Um, so a comprehensive system of services and supports For adults who might be experiencing a mental health crisis We have mental health crisis beds across the state again operated By our designated community mental health agencies For a total of 12 of those With 38 beds and we'll be talking a little bit more about capacity and the impact of covet on the capacity Of some of those crisis beds across the system Then of course, we have our community mental health system of care And specifically Another level of support in the system are group homes So group homes For individuals who might need longer term care and support in our residential setting We have 19 homes across the state Again, primarily operated By our designated community mental health agencies and specialized service agencies They're a big part of the system of care The department of mental health also did If you're looking for some additional reading An analysis of residential bed needs across the state Which gives a very comprehensive overview of kind of current state and where some gaps are Group homes were clearly identified when we think about flow in the system as an area that we need to continue to look at For potential expansion To support reminders across the state So i'm going to shift to the children's mental health system of care This visual Really gives you a sense of that continuum of care when we think about promotion and prevention Early intervention and then more intensive services and supports that children youth and families may need I think that this visual depicts Kind of our philosophy and fundamental values when we think about Child youth and family mental health, which is that the children youth and family are at the center of our care I would also note that of course whenever we are working with a child or youth That family system Is so integrated into the work even though we might be coming in to support a child or youth because of their individual needs We all know that there's probably complex interlocking factors within that family system And we're typically working very closely with the adults and those child and youth slides as well We have many promotion and prevention activities across the state that we're currently working on And I think this also Does resonate with our vision around an integrated and holistic system of care in terms of trying to integrate More work with pediatricians offices. Where are we seeing children youth and families? And how do we move more of our services and supports upstream? I think we would all would recognize that the earlier that we can intervene the better the outcomes Children are setting long-term health trajectories in their earliest years We know the impact of trauma. We know the impact of adverse childhood experiences So the more that we can intervene in those earliest years The better the outcomes in the long term Then we do move into I guess more of the intensive intervention or mental health supports that we offer I would highlight here our school-based mental health services across the state Vermont has always been a leader And is a model that is held up by other states in terms of our expansive school-based mental health programs It really demonstrates a collaboration between mental health and education, which is critical Essentially what this looks like is that our designated community mental health agencies Provide school-based mental health services directly in public schools Or working I think in over 70 percent of schools across the state Providing those school-based mental health services And again, there's kind of a pyramid related to intensity of supports There's very intensive one-on-one services that are offered in public schools As well as school-based clinicians that work with a broader caseload of individuals And then of course we do have alternative schools across the state as well Which provide an alternative educational setting that has more mental health Supports in it for children and youth where the public school setting may not meet All of their social emotional behavioral needs And then kind of up the spectrum a little bit more We're looking at more intensive services for children and youth Including our residential services, which we'll talk a little bit more about Impatient services. So all of our impatient Services are located at the Brattleboro retreat So that includes beds for children as well as beds for adolescents We do have crisis services, of course for children and youth as well and crisis beds across the state So there are we did want to bring some data into this conversation as well I would just say that this is not the comprehensive art results based accountability overview We do have a much more robust Set of slides that we'll be providing as part of our budget testimony But I did want to you know start to put some numbers To the system of care needs Representative Lipper I thought representative Houghton may have had her hand up She did and I'm using my judgment to uh Put her in the queue but to let your Okay, your presentation continue Sounds good. So I think what this slide really illustrates Is just and when we think about longitudinal data, this is a a good spans of longitudinal data going back to 1986 to 2018 In terms of the increased need and demand for children's mental health services Again, we know that there's a lot of factors at play here that impact child and youth mental health Whether it's poverty parental mental health challenges substance use trauma We're also very good at identifying Mental health challenges In children and youth which is a good thing because that's exactly what we want to be doing But vermont does have some of the the highest rates in the nation of identification of children and youth with serious emotional disturbance Which is a terrible name by the way Not strengths-based but that unfortunately is the language that is used So again, I don't want to dive too deep into too much data But I do think it's important because it does start to tell the picture About vermont and our system of care and need So we have residential capacity across the state for children and youth Who might need to access residential care and support? They could be accessing that from the community based on need or they could be accessing Residential programming as a step down from inpatient There is a lot of collaboration at the community level Related to when a child or youth is deemed to need residential level of care So there's an intensive process that happens And thoughtful process that happens in collaboration with many partners as well as the family, of course What this data trend shows at a high level? Is that for the Department of Mental Health? Particularly we are seeing an increase in residential bed days As well as children and youth who are accessing residential care I think that does speak to Some of the increased acuity that we are seeing in children and youth across the state We're also seeing very complex cases So complex cases highly acute presentations Possibly children and youth that also have or experiencing developmental disabilities as well complex medical profiles So again, we do continue to see Higher acuity and we have seen an uptick In the past year of children requiring residential care So that is a good place to pause Great and yes, let's pause there I must say I have a number of questions, but let's turn to other members first Well, actually I'm going to one broad question. I'm going to I'm going to suggestion just this is really helpful If you if you if we were looking at the the slides that show The designated agencies and specialized service agencies way back at the beginning and Um There that I think that that's maybe a One place um, you you list the number of full time The number of employees that work for the department and the inpatient units I think it would add perspective For people who again for unfamiliar if there was a full time equivalent staffing for all of the designated agencies Uh, which I think would astound people And I think if there is a ballpark figure, I have something in my head, but I don't know that it's close to accurate I think The reality is that most of the services in the state of vermont are provided Through the contracts with the community partners Rather than through the department staff It sounds like sounds like the department has a lot of staff when you say 300 some but that includes your inpatient The the facilities that you're responsible for as I remember But the number for the staff in the community is in the thousands as I recall Yeah, that's exactly right representative leper and that is such a good point. Um, and you'll see I think the impact of that is not as clear with when you don't if you don't know the system That so just just if there is such a number It'd be great to share at some point and I mean, I know there is a number Yeah, it is in the thousands. You're absolutely right And I know that julie tesler will be testament testifying shortly and she can probably give you a more exact number But yes, you're correct And you'll see when we do our budget presentation Over 70 percent of our budget goes to the community mental health agencies providing services That is where the bulk of the services are happening And it is certainly a number that is in the thousands and I would just say that for the facilities Those only reflect the staff Who are at the vermont psychiatric care hospital and middle sex? So also does not include all of the staff that are working in the inpatient units at the designated hospitals Right. So it's just as I was listening. I was thinking that's Some perspective for people So I'm going to turn first. I think lori was in in the queue and then we'll turn to Represented pierce and represent burrows and then represent pierce Thank you. I just have a couple of questions on the children's slides Um, I just want to clarify so the slide where I think it showed 10 000 youth being served That includes the youth that are being served by the designee agencies in the schools, correct Okay, so the trend line that was going up in terms of the amount of One yeah, yes. Thank you. Yes. I will double check allison is on with us our director of quality and accountability But I believe that this number is representative of the children who are served in public schools as well Is that correct? It is inclusive of that number. Thank you. It is all of that funding through the success beyond six Mechanism or is there funding and you don't have to go into it? You know, we can that can be later discussion, but is there funding separate from that that flows through the schools uh So this is not representative of all of only success beyond six from a monetary flow perspective So we have children's services Which is part of the case rate in dmh's budget Which I think off the top of my head is probably 26 percent of our overall budget And then success beyond six is separate from that It is not included in the case rate. That is still a fee for service model And I believe that's about 25 percent of our overall budget So they are They are separate. Yes. Okay. Thank you Representative burrows Thank you, and excuse me. I apologize for not being able to turn my camera on but it's everything is really garbled when I when I do so we understand Uh commissioner on this slide right here. I'm glad you have this one up I was wondering what accounts for that spike in the year 2010 if you if you know Oh, that is a great question. Um Um, I'm trying to think if there were any significant policy pieces or otherwise We certainly attribute We have seen some dips that we have attributed to the da is bringing on their new e h rs But ellison, do you have any e h r please translate Oh electronic health records. Thank you. Um, so you'll see in our slide set next week when we Go through kind of individuals currently serve for the da's You'll have seen a little bit of dip in children's services last year, which we attribute to the implementation of the new electronic health records But going back to 2010 ellison, do you have any insight into that? Yeah, I think this is one of those cases Where it looks like a peak simply because when in actuality it's kind of some normal ups and downs And so you'll see some other places on this chart where it did increase just as much It just so happened the next year to decrease just as much And so we've looked at it. There really isn't any major indication of what that may be except for some kind of cyclical You know a few hundred kids who are there coming in each year Um, we it doesn't line up with when we transitioned EMRs in that year, but we are expecting to see um in 2019 I'm a little bit of a dip because of that EMR transition Thank you Representative Peterson Yes, thank you Commissioner since you have this slide up. I I've got a couple things I wanted to ask about but Um of all the things I've seen in my Month of being a legislator This is the the the scariest and most troubling thing I've seen When you consider That probably from 2008 on Our numbers of children have dropped. I'm guessing at that date But our our numbers are going down in kids and our and our And our kids with problems are going up Um, this is probably beyond your purview here, but I Am actually horrified by this slide that that we are increasing That much in the needs of kids to have mental services I I mental health services Pardon me mental health services mental health services. Um Anyway, that's just a comment that I mean is that we could spend three days here just talking nothing about that um I the other question I had her in the beginning When Irene hit and you had to Take take all of the level one patients and move them around What did that do to um Your budget for security things like I assume some of those folks need to be secured or watched or So that that function had to go to several different places I'm in the ruttland region. I I thought you said there was six beds in ruttland And so those places cordoned off that they have to build a separate thing and And would you prefer to have them back in one facility so they could be better served? Wow, all great questions representative Peterson. Um going to your first comments just briefly with the slide on children Um, I think you make a really good point. It came up yesterday in our testimony as demographic shift and we see Declining populations that may change as we go forward You know with the influx of individuals wanting to live and raise a family in vermont And then we still see this increase And I think we have been consistently seeing increased need if you talk to the folks from department for children and families Um department of aging and independent living just across the board. We see more need I would also say That we're also very good At identifying children and youth who have complex social and emotional needs and that's a good thing So while this number continues to climb the fact that we're identifying them or wrapping them up with services Really bodes well for them and their families and their future So I just wanted to note that The only other little piece I would note is that Vermont was recently named number one In access to mental health care And part of that is because of the Incredible access to health care That we provide to children. So again I also think that we also just do a really good job of providing services to children and youth Which is also a good thing Do you get parental need a parental uh permission to serve these kids? Yes Yeah, you know, okay And um to your next question related to The decentralized system, you know, I would say and I would refer to others Who were here and experienced that crisis That having a decentralized system that is integrated more broadly in our health care system is the direction that we do want to go In terms of inpatient care That's a best practice model. That's something that representative donahue has been an incredible leader on in the state of vermont and from a security standpoint Those individual units within those inpatient facilities, whether it's at the retreat at retland or vpch You know, they're all designed to have the appropriate security safety environment of care components To ensure that we can meet individuals needs to keep them safe and to keep them happy Okay, thank you. You're welcome Thank you representative black and then I'm going to suggest that we continue with the presentation So I mean some of the questions that will emerge again as we touch on other parts of the System, I'm sure but represent black Simple question. I'm just wondering what the capacity was at the vermont state hospital before iran How many beds were there at that time? Believe it was 54 Is that correct? correct And then we we now have 45 level one beds representative black and then we have 12 new level one beds coming online at the retreat And deputy commissioner morning fox always speaks eloquently To some of the reasons and for that delta between the 54 and the 45 Thank you when When tropical storm iran came through There were 54 patients at the vermont state hospital of those 54 There was a cohort of folks half dozen or so maybe a little more of folks who Did not require hospital level of care per se but due to safety needs and and clinical issues had traditionally had been unable to be discharged from the state hospital and and so When when the first 45 beds kind of decentralized system was was put together it was also in mind that Of the 54 not all 54 necessarily needed hospital level of care and that also helped in In 2012 which I'll speak about in a little bit but in 2012 an x 79 was passed Which helped create the middle sex therapy community residents or the secure residential And so that residents was in Part part of its intention was for some of those individuals who no longer were acquired hospital level of care but because of their particular clinical needs and and such Had had not been able to be placed in the in the community And so the middle sex facility was developed as that residents and as well as working on transitioning those those folks Back into the community Thank you so much. Thank you at some point. I'm aware of our time and we got a lot to cover still It might be interesting I think it would be interesting to just have a historical perspective on what the Vermont state hospital number of beds were I think most people are not aware that it was in the hundreds high hundreds But that's that that Some point we can delve into that Let's continue Yeah, a thousand. Yeah that thousand plus well over here Right. It's like and and and anybody I think it's important for people to understand that when we look at what we're doing today versus where we've been Let's continue with the that's and here we are we're talking about inpatient capacity. Uh, and uh Let's continue and that's hold our questions until the next time for a break And then because we do have a lot of ground to cover here still so Great. Um, so this next section captures a lot. Um, but it's all very important information and current trends So we'll talk about in inpatient capacity broadly. We'll talk specifically about the impact of coveted on our inpatient capacity residential capacity across the state crisis bed capacity And wanting to brief the committee on our planning For the new secure residential facility. So those are the pieces that we're going to cover in this section This is really simply an orientation slide. I recognize that it's probably hard to see all of the detail We can follow up and send this as a pdf That you can essentially zoom in and expand It's really just intended. This was part of our analysis of residential bed needs to give you a sense visually Of where our residential crisis bed and inpatient capacity is geographically located across the state This encompasses both child and youth Capacity as well as adult. So a lot of information here You can clearly see where we have areas where we have a lot of resources You start to see areas where we might have more disparate resources And also keeping in mind that some of our capacity across the state We do see as statewide Not just regionally based, but I do think this is a helpful visual So you can really get a sense of our capacity across the system of care So this is a chart that we include every year in our budget testimony I think it does It's a good starting point to kind of tell the story about our Our crisis beds intensive recovery residential beds secure residential and inpatient beds across the state So on the very far side of this graph, you'll kind of see pre Irene and where we were in terms of total number of beds Post Irene and then some of the gradual increases that have occurred across the state in specific areas And then way over to the right What you will see is our visual depiction of the decreased capacity that we are currently seeing Across the state due to the impacts of covid So we have seen and albeit this is not permanently decreased capacity But in the moment it does represent the availability of capacity Both for our inpatient beds our crisis beds And some of our residential beds across the state I'm going to use this next slide Just as another grounding point for us What this really shows and this is a lot of detail and I apologize. There's more acronyms on this Than probably there should be but what we wanted to do was really show you the capacity of The beds that we have in our inpatient system The current number of closed beds and current capacity And I'm just going to back up a little bit to talk a little bit about what happened When covid hit the state of vermont So certainly back in march and april When covid first hit It had a significant and immediate impact on workforce. That was probably one of the first areas That really became challenging for us As you can imagine Vermonters in general Possibly couldn't work due to their own health care concerns due to their you know needing to stay home and take care of their children Staff being anxious about covid-19 and exposure And then there was a period of time where I think that financially it may have made more sense to collect an employment versus coming into work So that had an impact kind of chilling effect Capacity in the system because without workforce you don't have capacity We also simultaneous to that We also saw a significant reduction in demand So between I would say march and may of last year we saw a real drop off in terms of demand particularly for inpatient And you know the first email I read every morning when I wake up Is how many individuals and who is waiting in our emergency departments across the state? During this period of time there were days where we had no one waiting We have never experienced that in the history of the department of mental health. So that just illustrates to you the impact on demand And again, that was not necessarily good news to us. If anything it was worrisome In terms of individuals, maybe not accessing the kind of care that they might have needed at the time there's a couple of I guess Ways that we might think about why that happened, which would probably be a question of some of the committee members Certainly at that time we would Hypothesize that individuals didn't want to go to emergency departments because they were fearful We also didn't have the individuals out in communities as much So people were quarantining Not in public as much maybe not coming to the attention of some of our community agencies and supports We were experiencing less face-to-face time with providers And at the same time we've also The agency of human services stood up significant amounts of housing for individuals Which we also think that those efforts around housing so many verminers Also had an impact on demand for inpatient Um Then in june and august, you know as vermont was kind of moving into more of a recovery period if we can remember that There was a period in time where we were seeing Covid cases decreasing. We were restarting folks are more out in the community We saw an immediate uptick in demand for inpatient services Um that somewhat made up for that lull and dip that we saw So we have more demand across the system of care And what you can see from this is we're also experiencing decreased capacity And that of course is very worrisome to the department Particularly when one of our priorities is timely access to care I would say currently We have continued to see maybe a little bit of a leveling off from the peak that we saw Over the summer, but still steady demand for inpatient That overlaid against decreased capacity Is something we're monitoring very closely because we worry a lot and one of our Proxies for how we're doing as a system are wait times in emergency departments So we'll talk a little bit about that data as well We actually have a report that we've submitted to you That gives more detail on wait times over the past year I would say that Currently we are seeing an increase In wait times due to some of the decreased capacity that we're seeing across the state So with that all said what this slide is really meant to illustrate Is what is the maximum capacity that we have across these units? How many beds do we currently have closed and what is our current capacity? So when you see br that's the brattle borough retreat and their units Brattle borough retreat is our largest provider of inpatient services in the state When covid hit and folks are also aware Simultaneous to the pandemic the brattle borough retreat was also and has been continuing to experience Some challenging fiscal Times as well. So covid hit And that certainly had impact for the retreat They did have to take one of their units fully offline, which was their tyler one unit So when you see t1 enclosed beds that unit remains completely offline I don't want to get dive too deep, but just so there's some awareness tyler one Was their detox co-occurring unit And they've worked very hard to try to consolidate their staffing to the best of their ability To prioritize high acuity to prioritize and voluntary patients But you can start to see the decreased capacity across the state And even for our other partners There were the staffing impacts as well as infection control So many of our inpatient units had to create quarantine units at the vermont psychiatric care hospital We have I believe it's d unit that we have to kind of hold for potential quarantine space So you see that reflected in the four beds who are closed That are closed UVM and some of our other inpatient hospital partners Also, there are some rooms that are double occupancy that had to be reduced to single occupancy So just to give you a sense of what the system was having to recalibrate to And we still have work to do We really need To ensure that our capacity comes back online Because we know that there is going to be continued to be increased need so again, this is just to give you kind of a visual of Our bed availability what's currently closed in current capacity And then at the very bottom We did aggregate together all of our statewide adult crisis beds So currently we have over 75 of those open, which is a good thing But there were certainly times where that number was a little bit lower as well Okay, sorry, that was a lot of information on that slide But I think it's really important that the committee understands the impacts of covet on capacity across the state This is a similar slide, but it's more focused on child's crisis and inpatient capacity across the state Again, this is point in time data We do have A bed board at the state That is can be accessible by anyone Where we kind of track availability of beds and capacity across the state So you can see at the Brattleboro retreat for their child's unit and their adolescent unit They do have some beds closed due to staffing shortages NFI north and NFI south are two of our hospital diversion programs Um, they have been able to ramp back up capacity even though they've had some challenging moments in times over the past several months Um, and the howard crisis stabilization program Is back up to 100 capacity. Um, so again I just want to acknowledge the incredible work of all of our partners across the state Um to grapple with the impacts of covet the stress of the workforce challenges infection control And really our network of community partners have just been phenomenal In working with the state to ensure that we can keep as much of our capacity open as possible Okay, so that was a bit on capacity I want to shift now to talk a little bit about the future dmh recovery residents This rendering is not the current middle sex therapeutic community residents For anyone who has visited it They would know that it is Two trailers that have been Strategically put together with a fence around it That was put into place post hurricane Irene So i'll just give a little bit of background on the current middle sex therapeutic community residents And then we're excited to share a little bit more about where we're headed in terms of the future dmh recovery residents um But essentially, um, this is also related to hurricane Irene that part of Our recovery efforts around hurricane Irene Were to establish the middle sex therapeutic community residents. I believe it was probably 2012 if I have that correctly is that right fox 2012? Yeah Can I just interrupt a second? Are we going to come back to be able to talk about uh, we've talked about inpatient capacity and And what the current availability is And when waiting is that is that coming up later or is this the time to ask those questions No, if you'd like to pause representative lipper before we jump into Um, the middle sex therapeutic community residents I think that would be just fine. But they're all kind of part of the same section here, but we can And we're trying to cover a lot But there's a key question that has been raised and a number of settings with myself and some others Which is the dichotomy between uh Well, I'll just put it out there. Uh spectrum youth and family services has Raised concerns that they have referred children to the hospital in uh to the uvm mc And who they felt were highly suicidal And to have children to have them be First deemed not sufficiently At at risk to require inpatient Hospitalization But simultaneously told that and in any case, we don't have any beds. There are no beds for children available in the state Uh, and simultaneously, I think some of us have been told that there are un Occupied beds at the brow of our retreat and so They've they've so i'm raising this publicly because they've raised it publicly and said so which is it, uh, we're told there are no beds And other and I have represented to them that we've been told that there are beds at the brow of retreat that go unoccupied So and and and was part of some of those same conversations. So maybe you could Yeah, I I think when we uh a little bit of the follow-up that When they talk about children their population Mark, but the spectrum was actually saying a lot of this is You know potential 18 19 year olds. They're not Children in terms of the adult their transition age youth Um and including um, you know including some level one And I keep I keep forgetting that piece. So thank you representative for clarifying that that may be part of what the conflict is Yeah, so thank you representative lipper. I do appreciate that There's probably a couple pieces at play there and we would certainly at the department welcome Any conversation with spectrum about concerns that they may have Yeah, I have not heard directly from them Myself I'm looking at deputy commissioner morning box. So we would welcome them to outreach to us To have a collaborative conversation about how we can improve access Um, so yes, they're certainly at the community level. Um, there is a process by which Um, a child or youth is deemed to meet hospital level of care Um, so that process takes place. There are screeners who are trained. They work with the community mental health agencies to do that um And certainly sometimes there are different perceptions On whether a child or youth meets that threshold, but that is a clinical decision that is made In terms of the capacity piece, I would say Very honestly in transparency that capacity is tight You know, because of some of the workforce needs and trying to staff those units I am aware that there has been some bad availability So I guess I just want to make sure that we understand what the demand is What the barriers are and to work, of course in partnership with a retreat if there is Needs that aren't being met particularly for children and youth So perhaps we could have a Let me flag this as a conversation. I think is important to have and we'll have it at another time But I think and perhaps to engage with community partners who are expressing this concern to some of us as legislators So yes, we we we would welcome that conversation Because it's been raised on a number of occasions now Okay, thank you Of course Let's continue. I think that I've Yep Okay So back to the current middle sex Therapeutic community residents. I was giving a little bit of an overview in terms of the the history components of it Which it was actually created through act 79 as I was thinking it through in 2012 It was designed As a step down facility for those who no longer needed in patient level of care Perhaps getting to some of commissioner fox's comments earlier And it was built using FEMA funds And it was built Under the understanding that it would be a temporary facility Anyone who has visited the facility can clearly see that it has outlived its lifespan And needs to be replaced And we also have a recommendation that in In addition to replacing the current middle sex therapeutic community residents that we actually expand the capacity Of that residential program to provide more care for vermoners So I want to just give the committee a little bit of a sense of where we are in terms of the process I think that was one of the questions that was asked of the department in preparation for this A little bit on the timeline and the work to date So this is a capital Project on behalf of the state of vermont So in the last capital bill process We were provided with a capital bill allocation of 4.5 million dollars to begin the work To really identify a site For the future Secure recovery residents So that was work that we undertook with our partners at the at bgs to find an appropriate site For the current residents that was an extensive process That did take into consideration several key factors And we were happy to be able to identify An ideal site from our perspective Which is the Formerly known as woodside site and facility located in essyx as the future home of The new recovery residents There is also a whole lot of Implications related to imd requirements institutes of mental disease again Really Uncomfortable language for me, but that is how it's referred to And what we've been trying to do is of course Just to talk a little bit about that there are Guidelines around what federal funding Can and can't be used for imd's The current middle sex therapeutic community residents is not considered an imd Which is a good thing because it allows us to continue to utilize federal funding For the facility, but we do have to be very thoughtful about where the future physically secure recovery residents is located And so the essyx site really ticks a lot of those boxes In addition to it being state-owned land that really allows us to advance the project On an expedited timeline, which certainly there is a sense of urgency for us So now that we have the site selected that's been agreed upon on behalf of the legislature as well We will not be utilizing the current woodside facility. That is a correctional facility It would be absolutely inappropriate For any kind of therapeutic care as we go forward. So we would essentially be demolishing that building And building anew We have been working on schematic design Related to the building. So what you see here is just a current rendering of what the exterior of the future recovery residents Could look like There's a lot of work that still needs to be done and of course Stakeholder input has also been a critical part of that process and will continue to be as we go forward The committee members i'm just going to say that This is a place where our committee Works collaboratively Or actually the lead is the institutions committee because it's a capital project because it's a state-owned project And our committee is asked for input to their work and I Yeah, I'm just Thinking that given all that we have to cover. I don't want to be careful not to Get too deep into this project right now I think maybe we should move quickly through this or even go past some of this to other key pieces Yes, happy to do so So again the next slides really just underscore Basically what I've already stated some of the history here in terms of The residents itself What we're trying to accomplish in terms of a true system of care as I mentioned 95 of the referrals to our current secure residential are from level one units So when we think about flow in the system It's not just about impact more inpatient capacity It's ensuring that we can actually transition those individuals to lower levels of care appropriately in the community So expansion of this facility will really help us Accomplish that and we of course want individuals to step down as quickly as possible who no longer require hospitalization Again, this is just to give some high-level renderings of the direction that we're going in terms of The design, you know really being intended to promote recovery For residents So again, we'll just breeze through these this gets into some of the clinical models that we'll be looking at And then just the guiding principles to a trauma-informed approach And we can come back and do a deeper dive into that project, but I know it was a request It was but it's my judgment that we that was good to fast forward there. So thank you Okay, um another area. Oh Uh, I think we might be due for a five minute break Let's take a five minute stretch Go off screen so committee members, please go off mute or mute yourself go off video take a fight We're going to do a five minute stretch Let's continue and we're going to turn our attention with the commissioner and staff To the important area of suicide issues suicide prevention and addressing prevention issues efforts. Thank you Great. Yeah, thank you representative leper And I am actually going to turn it over to our director of quality and accountability Alice and Croft to walk us through this section Good morning everyone again for the record Alice and Croft director of quality and accountability I also as part of my role as a department Have been the lead for suicide prevention efforts My background is as a crisis clinician and it's something near and dear to my heart We wanted to start off by letting you know What's happening in suicide prevention both within dmh and at ahs in general And so you may be aware last year There was a bill going through that had some suicide prevention And initiatives within it and so when we had the opportunity for covid relief funds What we did was we looked at that bill and what it was trying to do and and essentially Tried to fill that with as many things as we thought would Approach the issue of suicide prevention that's specific to covid Relief and so what we know with the pandemic Is that it is increasing risk factors and some of those risk factors are economic depression isolation Altogether stress, I know if you're a parent trying to work and Teach your children it's extraordinarily stressful And then we have our older remontor population who is already at higher risk Who are now both Have increased stressors due to the concern for physical Issues with covid but also being really unable to connect in ways that they might have been able to before So those were all things we were thinking about when covid relief suicide preventions came as an option And so I wanted to talk about we'll show you some data In the next few slides about how things have looked historically and how they're looking right now But before that I wanted to give you a sense of what we've done thus far So we did take the covid relief funds 500 000 were provided And one of the first things we did was we said we know what works and what works the zero suicide So we did apply a great deal of that funding to the zero suicide initiative And if you've heard that term a few times and it still feels a little bit vague and intangible to you I'll give you an example of what the funds were actually used for So zero suicide is a public health approach And it has pieces of everything of the entire spectrum that you would need to prevent suicide So that includes building awareness and communities of how to talk to your neighbor your child your sister It also includes making sure that if someone is identified as having suicidality that there are trained folks Who they can go to through a warm handoff that's not just you know, here's a bunch of phone numbers That know how to address suicide suicidality suicidal ideation directly Used to be that we really tried to approach it by Addressing depression and those two things are not exactly the same thing So we've worked really hard to make sure that if it is identified that the da system in particular has trained staff Who can address suicidality in an evidence-based way? So this particular funding We knew that folks might not necessarily be able to get to the doors of designated agencies So we put out mini grant opportunities for primary care offices To partner with their mental health agency networks and create a pathway to care So that if someone came to the primary care office That the folks in that primary care office knew how to identify suicidality were asking about it And then had a plan with their local mental health agencies of who they would call and how they would create a warm handoff So we had 17 primary care practices participate in this mini grant opportunity And paired with five different regions of the designated agencies And it is something that they did a whole lot of work prior to december 30th, which was the initial COVID relief funding deadline We've also put money forward and from general fund to continue that work through to july So those folks are still meeting and we've created a really great partnership And we've leveraged the blueprint for health to assist us because we also know It's not necessarily just everybody needs immediate professional help We want to through a therapist or ongoing lengthy therapy We want to make sure that if some folks feel more comfortable in their primary care office We have there are people embedded in those practices who can't help and provide brief treatment And so we're making sure that all of those options are available And really pushing the message that Um, certainly some suicide suicidality requires inpatient level of care But not all and we think folks can be successfully treated in the community if we have people who are able To ask the right questions and know how to handle those situations So that's specifically what we accomplished and are still working towards for expanding zero suicide using COVID relief The second piece there is expanding the suicide prevention lifeline We're going to talk a little bit about that in the next slide because that's the 1 800 273 talk number you might have heard about it's the national suicide prevention hotline However, it is intended to be answered in state And the goal with that is to make sure if remontra calls that number That it's not just a conversation and that it ends that the person who answers the phone actually knows What are your resources in state? pooping you talk to And everything from getting them economic supports. Um, it's not just about therapy And so we have worked to increase our ability to answer those calls in state Our ncss up in franklin county has become a lifeline certified center So they were already answering those calls pre covid we used covid relief money to expand their hours So they were able to expand into evening and weekend hours answering the phone for folks calling the lifeline We also were able to bring on board another agency. We want to we're moving towards 24 7 coverage in remont of the lifeline So northeast kingdom Was able to be on board of using some of these funds and they're continuing to work towards certification as a lifeline member The third piece is targeted resources for at-risk groups One of the things we do understand is if you stand up what I might describe as you know some vanilla medical model Approaches it's not going to be welcoming to all people So one thing we we're becoming more aware of when we still have work to do is making sure that these All of these initiatives are accessible and are speaking the language of folks Literally and figuratively across remont So we've been working The center for health and learning is building some educational modules for all of us including providers Including people who would answer the lifeline just about We're working with our Refugee populations in the health equity group to make sure that we have language options for folks who may not be english speaking We're also working without right remont to make sure that The way that we're marketing these and and the folks who answer the phone are welcoming and accessible To the lgbtq plus community and know the resources that would also be welcoming to those folks if they need a referral Additionally looking at the bipod community and we making sure we have a referral list that have folks who are people of color so that We are making sure our resources are really diverse and comprehensive for everyone And then the other pieces to that in terms of targeted resources for risk groups We know we have increased Suicidality amongst older remonters We know we have increased suicidality amongst veterans and individuals with disabilities So we are working with the disability community va and Dale to look into how we can make sure we're reaching those populations in particular We always have an eye on youth Through this process We are concerned about some of the increased suicidality that has been shown in the youth risk behavior survey As well as I'll be showing you some data that shows an increase in suicide deaths for youth We have applied youth mental health first aid And one thing I do want to note and we've received some feedback over the last few years of concern about mental health first aid as a model That it may be pathologizing To medical model So I did want to note this new model that has been employed this past year has been updated It is specific to teens and youth and it is about having more peer-to-peer Interaction peer-to-peer support We're also highlighting that at some point you may need to reach a trusted adult and you shouldn't be handling that on your own But it is something that we're keeping an eye on to see how this new model is received So that we can keep keep our eye on I think that Some of the criticism is you know treating folks as if if you have a friend who might have a need all of a sudden You're pathologizing them and identifying them with a diagnosis and someone who needs treatment We're really trying to make sure we normalize the fact that youth No matter who you are it is extraordinarily normal to have these thoughts at some time in your life And we don't want that to be the message we want it to be the message that There's lots of different ways to get help And so again, we'll be evaluating this new model with an eye for that going forward Then the fifth piece that we utilized CRF funds for is expanding our elder care clinician program This was a big concern right off the bat like we talked about with older brahmanters being isolated There is a specific program where we have clinicians going out to the homes of vulnerable Older brahmanters who might have mental health conditions And this funding was used to make sure that the folks who are going and going at times might be virtual But money was spent on making sure we could help older brahmanters know how to connect virtually Provide PPE if someone did need to actually go into the home As well as making sure the people going to those homes really understood how to assess for suicidality The other piece I wanted to note about cold relief funds We did provide pathways for monta $200,000 to Work towards a 24 seven operation of the warm line And we do see that as a very important suicide prevention effort The folks who man that line Answer a lot of calls from people who are experiencing suicidality and we believe that pure model works very well So $200,000 went to that as well as an additional $60,000 from the SAMHSA emergency funding That we hope to maintain through july 1st to be supporting that effort The other piece I wanted to note so that was cold relief funds. That was sort of what can we do? fast That we that we think could hopefully really prevent a spike in suicides, which we were concerned about with when covid began I also wanted to highlight that at the same time we were awarded in partnership with the department of health a 3.8 million dollar cdc grant and this Was just such an incredible opportunity because it allowed us to play a little bit less reactive whack-a-mole and a little bit more How do we take all the things we're you know piecing together right now and build them in a sustainable way? And so for this grant the grant does sit in the department of health We are we were able to squeeze a 0.5 half-time communications person That's going to be focused on how do we reach folks who might be at risk for suicide in a way that we haven't been able to before And it is really looking at a public health approach to suicides So we're building infrastructure and I would say the best way to describe that is it's less about just How do we make sure mental health providers know how to treat suicidality? instead, how do we make sure vermont knows how to Talk about address report on Have the data that we need and make sure that anyone is having a touch point with someone who might be struggling Would know how to address it in a moment So i'm going to speak a little bit more about the cdc grant from the next slide I want to note that we're calling it vermont addressing suicide together So when you hear more reporting on this in the coming years, it will be referred to as vast And right now we are in the beginning stages of identifying partnerships With the goal of creating a much more coordinated statewide prevention effort We've had lots of great work happening in pockets all over vermont We're really looking to build a team that can work together and has an eye on everything that's going on Another piece to this is using data to identify vulnerable populations and serve them better And I would highlight one of the problems we have with that Sometimes we don't have the data we need to know if certain populations are more vulnerable For example, we don't have any data that can tell us if someone who died by suicide did identify as lgbtq Therefore we can't track if it is disproportionately affecting the lgbtq community We have a similar issue with the abenaki population. They are not recognized federally as a native american tribe and therefore We aren't able to see that in our data. However anecdotally we're aware of higher clusters in that population So those are some of the things we're going to be working towards and that's where the department of health Is going to be very helpful. That's their wheelhouse They work with the foreigners office on gathering this information and putting practices into place so that we can get the information we need Another major focus is going to be on health equity If you look at any of the youth risk behavior surveys or adult risk behavior surveys, we know That um underrepresented populations are disproportionately affected And therefore we've got a lot of work to do on how to reach them how to include them in all of the processes from how we message to How we treat and I think One of our jobs right now is figuring out who needs to be at that table from the beginning to inform all those processes It would highlight That the goal for this entire grant and one of the performance measures we're actually beholden to Is to decrease suicide deaths in Vermont by 10 percent And decrease suicide morbidity by 10 percent the morbidity piece means attempts And suicidal ideation we look at that through visits to the emergency rooms and crisis visits And what we know Is the morbidity issue folks who are extremely distressed feeling hopeless suicidal And attempting Are more predominantly female and also fit some of the rest of the data we have on health equity Disproportionately people of color lgbtq disabilities And so we have a lot of work to do there However, when it comes to suicide deaths in vermont We have another target population that we really need to focus on and it's white males in rural vermont The vast majority even this year it's 82 percent or male And is this is a national issue nationally more white males in rural communities are dying by suicide Vermont is even higher than that in terms of the proportion who are actually Dying by suicide Versus attempting so one of the big pieces of work we have to do is how do we reach that population effectively? um We're feeling most who are dying by suicide are not in care and did not have an identified mental health issue So the last pieces here are we have a lot of work to do to expand recovery and peer support groups And we have some great partners with that With pathways and with nami and we're working to expand so that if someone is lost from suicide Right away. We need to wrap those families We need to wrap those communities and we want to make sure that people know where to go and that there are peer driven supports for that work So we are looking to develop that over the next few years with these key partners Another major issue that I think the committee should be aware of because it's going to be an interesting development nationally and in vermont That 1800 line I talked about is shifting to a three-digit number in 2022 So instead of being called the 1800 273 talk line to reach the national suicide prevention lifeline It'll simply be 988 and with that transition Comes a lot of pieces to be worked out in terms of how do we make sure that we are Effectively messaging to folks. When would you call 911? When would you call 988? and if you call 988 Are we do we have the infrastructure the staffing and everything that we need to make sure that those calls Are answered 24 7 ideally in state and have good referral options? both peer and treatment across the board And so again wanted to highlight the expectation is these calls will be answered in state And we are working towards this aim with having ncss currently answering the phone And nkhs is about halfway through their certification process and we're hoping they'll be up and going by may of this year to answer those calls And current status as we're putting together a 988 planning coalition An invitation will be going out in about the next week With a broad group of stakeholders and we do need to include state police and our dispatch folks It will impact Right now one of the goals for this is We want to divert people from the emergency room if the emergency room is not appropriate and if you call 911 Right now it's hard to divert that if you call 988 and you're able to someone's able to talk and you can meet their needs That diversion could happen. So we want to make sure we're doing that in a safe way So we're partnering with the state police with mommy Um with the federation With pathways and then looking also with our groups that are representing Underrepresented populations such as the refugee mental health work group And through that we we are using a small planning grant that we are all awarded from February 1st To september 30th this year that will help support the hours it will take to meet with all of these stakeholders And and do this important but difficult work Thank you, allison before we move into the data slides, which I'll defer to the chair in terms of How deep we want to go on the data? I just want to acknowledge You know the impact of loss for family members for communities And just you know our empathy and understanding of what that means for families to lose a loved one To suicide and certainly it has been our priority and the priority of the governor to make sure that family voice Is a part of this work. It's a big part of the suicide coalition That really drives a lot of this work and energy and effort The governor held a round table last year of which, you know Parents and family members, you know really were in the driver's seat in terms of what are the needs? What are the gaps? What was missed? So I just want to underscore that as being just a fundamental value to our work And certainly an area that you know, we all take very very seriously and and understand the ripple effects for communities And the devastating impact on families so I I'm unfortunately because of the way I'm organized here I don't have access to your slide deck right in front of me to see where we're headed in terms of More information around suicide prevention, but I I see that there are a number of committee members who are Eager to ask some questions, and I'm wondering if we might just field some of those questions first Again, I'm aware of the time that we have I should say that I've spoken with julie tesler To see if we can have her testimony Continue at another time as well, but we're we're a lot of we're trying to cover a lot of territory here this morning More than is probably Have been realistic, but this is an important issue But without getting We could set aside a you know others we can set aside additional time for this at a later time But let's field some questions. I know representative black had her Hand up to get in the queue then represent page And represent donahue and represent golden. I think our representative chin is also kind of in line So there's a lot of this is let me just say this is an issue that has touched many members of our committee in our personal lives And our professional lives and so this resonates in many many ways So let's let me go turn first to represent black then represent page I actually would like to get through a couple of the subsequent slides Because I do have questions on a few of those so I'll defer to anyone else who'd like to ask a question I wasn't quite sure. Yep. Okay, represent page. Then that's let's let's try to yeah represent page um I just want to recognize it must be extremely difficult to build this infrastructure and uh and and to start That's basically from scratch But one item I do want to bring up and and maybe it's been raised with you before the term vast The acronym and I'm not being flip here But you know the vermont There is another vast association the snowmobilers is something like that and You know, I know you've put time and effort into building this this program and you've got your name all set And the acronym that you really should maybe reconsider using that acronym So that's just my thought. Thank you Thank you for your comment. I was unaware. I appreciate that. Thank you representative right Uh, represent Donna here I'll just say that that struck me immediately as well. It's an extremely well known acronym around many parts of the state I just also I just wanted to foot the bookmark something not for now But when we address the budget next year I was concerned to say to hear that the pathway is warm line Funding was prioritized through july 1st. So I'm looking forward to hearing Where it fits into next year's budget proposal, but not today Thank you representative goldman Thank you so much representative lippard and for your presentation Um, I of course am disturbed as we all are about hearing these data about 82 percent of white men um 82 percent are white men Yeah, 82 percent of suicides are white men. Let me get that right. Um, sorry Um, and many of us have been touched by personally as you said myself included um, there is a legislation coming forward about a 48 hour gun waiting period And I'm wondering if the department has any thoughts about that in terms of in Reducing this statistic I can certainly speak to what we've Testified on this before and then I'll defer to commissioner squirrel in terms of in terms of, you know, official department positions We were a part of the testimony when this issue came up in the past And we have testified around the importance of means restriction and so From our perspective means restriction across any type of means so firearm Um, when we meet with folks who has a crisis clinician myself It's one of the first questions we ask and it's the most important Because it is the difference between an attempt with survival and most 92 percent of folks who attempt do not go on to die by suicide It really is a lot about means and access to means and type of means that ends That can really make be the deciding factor of if being a death versus an attempt So I would just highlight that thus far and the work that we've done will really We are not um, we don't change policy We have taken some focus on what we can do and one of the things we've really pushed this year is counseling on access to lethal means And that is about having those conversations And one of the things that if you look at research um as it turns out Many provide um primary care providers are not comfortable or will identify themselves as not being comfortable having those conversations with patients Because many are not gun owners themselves And so we're doing a lot of education around let's just take the politics aside How do you have a conversation with someone who does own a weapon and is going through a mental health crisis and can we Make sure that we have a plan for who can hold on to that weapon during this time And so that's been our focus um this year is how I would answer that and then I invite of course commissioner squirrel Yeah, I think allison um you have captured it in terms of you know the department's previous position and how it all relates and is another aspect of our suicide prevention efforts Um specific to the waiting period. I think we'll have to circle back to the committee Once we have an opportunity to review the current bill But could share more um specific to representative goldman's question Thank you Thank you. Uh, so let's Uh, let's take a look at The rest of this continue through the presentation Again being trying all of us to be aware of The time as well as the material that we want to try to cover Yes, I think these next few slides will only take a few moments Knowing that representative black wants to raise some questions following the review of these slides We'll come back to her separate um So what you're looking at here is an illustration over time of the rate of suicide deaths in vermont We have had a concerning increase in this rate over the past 10 years And over the past five to six years we've hovered around 30 higher than the national average for suicide rates in vermont We've also been increasing at a higher rate than other states We were encouraged to see a dip in 2019 after three consecutive years of increases However The overall trend is increasing and it is something that is deeply concerning and One of the reasons for our full commitment to increasing and expanding the efforts going on in vermont The next slide will drill down into this a little bit So one of the things I want to note that what you just looked at is official published data that the vermont department of health Gets through the national violent death registry This is what we're looking at is something we've put in place in partnership with vdh As more of an informal. So I just want to highlight that these are not final This is not final data and it could look different once 2020 is fully wrapped up However, it was really important to us when covid hit that we keep a pulse on this Month by month. So this is a monthly report that the department of health has generated that looks at How we're trending this year in terms of suicide deaths in comparison to the three-year average We are You know, certainly encouraged that some of the stressors folks are going through this year did not appear to cause a spike in suicide deaths thus far However, obviously These numbers are too high And we are working towards the philosophy of the department is zero But we are watching this month by month And wanted to highlight that as of november the year to date We were at 105 losses in vermont due to suicide versus 106 as the three-year average We so we are expecting By the end of 2020 that it is pretty close to average this year And certainly I would just note This has been a theme for us at the department of mental health We are expecting some of the peaks for the mental health crisis To follow some of the peaks from the health crisis And so I think there was sort of a stunned reaction from folks for a few months that We saw stymie access to care and folks not seeking services And that's um, that's going away. And so we're really keeping a close eye on 2021 as well And the next slide just digs into this that exact data You just looked at but breaking it out by age and gender And you will see what I was speaking to earlier that there's significantly more males lost by suicide every year and this year was no exception in 2020 and we had more older vermonters And younger vermonters who are disproportionately affected As well as males I know representative black may have had a question But those are the data slides that we have for you today regarding this issue Great. Thank you representative black and then representative chena Um, so first of all, I was just wondering what was the total number of suicides in 2019 I have been unable to find that data anywhere and here you just have the rate dropping to 15.3 Yes, and that's a good question. They haven't published it yet. It usually comes out. Um Sorry That's okay I can circle back with you on that because we certainly were looking to provide the latest data as well and it comes out and officially from the department of health and I think they were working on it this week Um, so I just want to make sure that I have the official number for you, which is It comes to formally That was another thing is that the department of the vermont department of health hasn't actually updated their I guess you call them their total metrics around suicides since 2017 I think that was the last year that they did in depth with You know Attempts hospitalizations and I'm wondering when that data will be updated as well I know that They're a group um that normally does that work to get pulled for covid And so we've been in talks lately about how we can make sure that both are being prioritized Um, so I think that is why there was a delay Again, I we have a partner over at the department of health who I would know to ask and could get some further information for you Okay, um, you know, obviously We do know that um white males um Have the highest rates of suicide um And we know why vermont has a higher than Normal rate of white males with suicide because we know that gun ownership correlates directly with Um suicides So I mean, that's why we know that we're higher um I'm wondering You made mention of um Physicians and Not having comfortable conversation around um reducing access to lethal means Um, I just I just would like to point out that I actually have a bit of an issue with that phrase because I think that phrase is designed specifically to make an uncomfortable Uh conversation more comfortable because when we're talking about Access to lethal means we're really talking mainly about firearms. Not that there aren't other methods um And I'm sorry. I had one other question Oh, I know um, so in 2019 in june of 2019 vpr updated their gunshots project um, and there is a Mention in that june article um from you specifically that The department of mental health was working on additional programs um to address specifically suicide and gunshots deaths in the state and i'm wondering What has happened with that and what programs have you been working on in the last year and a half on that? And when can we see something? That's an excellent question representative black We are um, we have a list of folks that we are looking to um Connect with so as part of our I need to think of a new name to call it now that I understand that Fast has a different application Part of our cdc grant is is to reboot that work. We did have some successful partnerships with gunshot products Gunshots in the past and I will be frank some of those partnerships fell apart as some of the Policies were being pushed forward and and people feeling like there was a time where they couldn't work with us on this anymore And we want to fix that and we do have we've been working with folks who already have connections with them to bring us back into the fray So they will be on our committee for the cdc grant It's just a question of whom And that's the piece we're working on right now is is who specifically can raise their hand to say you will join us with this I have a few contacts who have expressed Absolute interest in this and I think I'm feeling really optimistic We want to be back in in gun shops with promotion of how do you identify someone who's come in to purchase a weapon? And if we want you to be able to feel comfortable asking questions about the intense without Applying judgment or anything like that But those are important questions to ask and I have enough stories that I have heard or those questions were not asked Um, and in looking back gun shop owners wished that they had And we want to provide them those tools and I think they want those tools it's really getting some of the you know if speak frankly the politics out of the way And we're committed to that and I would like to make a commitment to show you some of that effort As they join our committee And if you'd be interested in knowing who that those contexts might be I would be able to provide a list in the coming months I actually would because I um, I haven't really been able to find very much information on the gun shops project I mean, I know it exists, but frankly other than having printed material hanging Randomly around gun shops. I'm not quite sure What exactly it entails Okay, well, let's come let's this is this is very important and let's come back to it in In addition edit when there's more opportunity as well Is that I don't not wanting to in any way cut you off Representing black, but I just want to Further time with the committee. No, I was done. Okay, great represent Gina Yeah, I have some questions just about the numbers that we're hearing that most um of the people who died by suicide were white males and I'm just curious The relation of that number to the general population and what the disparity exactly is for example If I believe it said 86 percent were white males But 46 percent of I'm just saying that if that's the wrong number I'm just using it because I'm not looking at the slides So forgive me if I got that wrong because I saw some heads shaking So I'm not I'm not trying to claim. I know what the number is I'm just trying to make a point about the context of the number. Okay, so if Hypothetically the number was 86 percent of the deaths were white males But 46 percent of the population were white males that shows a huge disparity You know, so I'm curious in relation to what the general population is What the number is if we can get some more info or that over time Another example would be like when looking at the suicide rate for black indigenous or people of color if the overall deaths by suicide Is 10 for BIPOC But BIPOC make up only 2 of the population. That's a huge disparity Even though they're only 10 of the 100 percent if they're only 1 of the population That's a huge disparity. So what I'd be curious to see is just some more comparison Of the numbers in the showing the context and showing the disparity To help us as we make decisions So that would be just down the road. It would be helpful And then I'm also curious about other factors for the white males because lumping all white all white males into one group May not be fair Like how many of those white males are lgbtq and how many do you would you even know? Because how many people who are closeted kill themselves? Like there's a lot. So just putting that out there having lived through that myself and uh and What's the socioeconomic piece? Like what is the socioeconomic situation for those white males? Are they predominantly White males in poverty or are they predominantly wealthy white males who lost their money when the hedge funds got, you know Taken down, you know, like what is you know, we're looking at that piece, you know Not making wanting to make assumptions about who that is but just seeing if we can get more info About like the sort of what social determinants might be influencing the suicides. Um, I'm also curious I'll just two more things. I'm curious about what the the impact of the pandemic has been on the numbers in 2020 And I'm also curious about the intersection of overdose deaths and suicides because There is sort of a A venn diagram where they intersect where sometimes people will intentionally overdose Um, or they'll engage in risky drug use Pushing the limit knowing they might die and they might be suicidal So even though it wasn't a planned suicide attempt that It was there was a suicidal behavior connected with the overdose and so I'm just putting that out there because when we look at that That group of white males I actually think there's a lot of factors involved and I didn't see that in the slides And I'm hoping over time we can learn more. Um, because I think knowing those Um, knowing those factors can help us help people better So I don't know if you have any more info based on that But it's sort of a question for the future or a request for the future if you don't have it now. Thank you And I'm going to just I'm going to suggest that there's a lot of questions you've raised there rightly So, uh, I would add veterans to that list Uh for white males Clearly high risk group There's a lot to uh, there's a lot more to come back to on this and I'll just restrain myself around lgbtq Youth and adults it's it's incredibly painful for those of us within the lgbtq community Who are acutely aware of the incredibly high level Of suicidal ideation From many people who are not Visible in any way the rest of the population thinks it was had nothing to do with anything and we know From our personal experiences That many many lgbtq Individuals go unidentified because of the pressures even today to not reveal sexual orientation or um Or trans issues that not just sexual orientation We trans trans people are at high risk very high risk as well So there's a lot here and as I said, uh, this has touched many members of our committee in very personal and profound ways And so as you can see And rightly so there's a great deal of interest and a great deal of expertise actually Well expertise and and uh available Support for thinking this through I I would take all of these questions in the in the direction of how can we do better? How can we do more? How can we be successful? Uh, so let's let's I'm going to suggest that we move on at this point Uh, but that this be uh an invitation for all of us to find ways to do more collaboration on behalf of All the people that we all know and love Thank you representative leper Thank you allison for for taking the Taking the lead and and I guess I want to be really clear. I don't see this as any of this is directed Uh I mean we all know there's a lot more for us to understand and a lot more for us to be successful So thank you. I agree. Thank you all Okay, so uh representative leper. I will um continue and we do Uh, you know, this is the the strength of our vermont legislature As you said representative leper. We have a wealth of um thoughtfulness expertise And we really do see this as a collaborative effort So I think there's lots of follow-up to be done and we really appreciate The committee's great questions around this So we'll follow up formally and we might actually want to schedule some additional testimony That can focus. We'll find a way. Yeah, of course Okay, so I'm going to move us forward. Um Good, could I ask could I ask you could give me a sense of the remind me of the number of modules that we're about to try to cover I apologize. It's hard for me to juggle on my devices all of the But it was very well laid out at the very beginning and uh and I think Yeah, uh, so we have um vision 2030 uh wanted to orient the committee to the existing work that's happened Wherever headed next And then we have just an orientation to legislative reports some very high level comments on those reports That can be as short as it needs to be And then just some high level initiatives and opportunities that we're looking at so kind of three Three topic areas Okay So I would like to suggest that we Aim to get through those three topic areas in the next 20 to 25 minutes Given that that's a challenge But that so that we can give uh julie tesler at least the opportunity to begin to describe And talk about the community-based system of Of mental health care and I would think that I know that representative donahue may Uh, she's articulated a number of reports, but I'm going to suggest that that section we come back to Okay Uh, yes, that's certainly um make sense to me. Um, if it works for um, you representative leper That's going to be my best judgment at this point in time trying to move this train forward Great. Just just naming them will help Just without discussing them will help the committee frame the reference. Thank you. Thank you. I think that's a good good point Okay, um, so I want to make sure that the committee um Is oriented to visioned 2030 I also want to thank uh vice chair, uh, donahue for her Incredible leadership in this arena Really pushing the department to think about where are we going as a system of care? And helping us articulate kind of the the value and impetus behind this Which is really moving us towards an integrated and holistic health care system So I just want to thank representative donahue for her leadership and support on this um So vision 2030 really what we wanted to do was step back and take a comprehensive look at where are we going as a system of care Um, because you know, if we don't know what our end state is then we don't know what our first steps are And we have a lot of work to do Um to truly achieve a holistic and integrated system of care Uh, we also wanted to ensure that this work Um really was representative of the voice of vermoners So we had a very very extensive listening tour That we took place in that we facilitated I think it was maybe the year before last now In terms of executing this Where we fanned out across the state We set many community tables where we had diverse perspectives Individuals of lived experience here's direct care workers Our health care providers and partners Really coming to the table expressing You know, what has worked in the system of care and how do we build on those strengths? And then of course, where are the gaps now? What could we do better? Here was my experience and this would have made it better because it's the delta between that that can really motivate us And move us towards change We then took all the high level themes Needs that were articulated through the listening tour And then we brought that to a think tank And that think tank was again, it's a representative design process So we bring the diverse voices of many perspectives together I do believe that the diversity of our perspectives is truly our greatest strength We look at moving something like vision 2030 forward That think tank did some very intensive work over several months To arrive at and deliver vision 2030, which is what you see here Unfortunately with the impact of covid It did have us have to unfortunately hit the pause button a little bit On some of the next implementation steps related to vision 2030 But the department's commitment to this And excitement in getting back to the work of implementing vision 2030 Is a top priority for us as a department And I want to thank everyone who has already contributed a significant amount of their time and energy to achieving that So again, this really is just I guess underscoring what I just stated in terms of how do we have an actionable plan To achieve an integrated and holistic system of care The stakeholder engagement and involvement was absolutely critical for us And how do we weave this together into actionable strategies? So we have a vision. We also have a plan and we have strategic short-term mid-term and long-term action steps to help us These are the eight action areas I was going to go into them in a little bit more depth But I think that might just be too much detail for right now We will probably follow up with the committee just to make sure that each committee member has seen the full report I would invite you all to review it and read it There may be opportunities for dmh to come back and do a deeper dive into these areas But these are the eight action areas that were synthesized essentially By the think tank of areas that we really needed to focus on Including broadly, you know, promoting health and wellness Influencing social contributors to help eliminating stigma and discrimination Expanding access to community-based care Enhancing intervention and discharge planning Expanding peer services across the state Ensuring service delivery as person led and working on work Development and payment parity What I will also say is that the department is really using this as a guide for how we Evaluate and target deployment of resources So to give an example of that, we have a mental health block grant fund Of which we have a you know fairly typical annual allotment that we get from the federal government We also receive sometimes Somewhat haphazard and sporadic increases We use these action areas to guide and use in terms of our decision making hierarchy Where we're prioritizing resources and targeting resources So this truly is a plan that we are utilizing to inform decision making at the department as well One of the key next steps that I wanted to highlight And again want to thank representative Donahue for her leadership around this Is creating and Implementing the mental health integration council So there was legislative language that was introduced and passed last year To ensure that we move forward The integration of our systems together I'm trying to be careful about not just saying that we need to kind of fit mental health within health care But probably that we really think about a holistic system of health care This integration council is going to be critical to get us there We need our health care partners at the table side by side with this with us when we think about integration The integration council I think provides the kind of structure and governance that we need to advance that work forward We were this is just the actual some of the statutory language itself I'm sorry, I think we can just keep moving through the language Yes, of course I didn't know I was off of you No problem Just trying to move us along Yes, the only thing I would just note there Is that we did delay the implementation of the council Obviously the engagement of health care providers is critical and everyone is still really in full pandemic response So I want to thank the chair and vice chair of the committee We will be starting that council Up in mid july so I won't go through all of the legislative charges here But certainly you get a sense of the spirit and intent of what we're trying to accomplish in terms of full integration Okay, so the next Area that i'm going to move on from vision 2030 again. There's a lot there I can go through this very very quickly. Um, I know that the committee is Interested in what are the impacts of covet right now on the system of care and on vermoner So I just want to highlight a few things very briefly There's a lot of follow-up to be done here and a lot of work that's happening I just want to note that when we talked about our residential system of care our crisis beds our inpatient system You know a lot of the requirements around social distancing and quarantine have been very very challenging to implement Many of our facilities and residential programs were not designed To have quarantine space or to facilitate social distancing So again, that has just been something I you know really accolades to our System of care partners who have worked on that But certainly that has been a challenge and just the nature of an individual Who might be stepping down into a residential bed? And being isolated in your room would certainly not be what we would be thinking about in terms of you know therapeutic steps towards recovery. So just acknowledging that that continues to be a challenge Certainly with the deployment of vaccines across the state as we move towards recovery That is an area we know will continue to improve I did want to make a note related to the mental health needs of children and youth particularly as we've pivoted to a more remote deployment of educational services Um, we know that many many particularly at risk youth There is a risk to not being in school. There is a risk to not being able to access comprehensive mental health services and supports There is a risk to not being able to access, you know nourishing relationships with your teachers and your guidance counselor And other school-based mental health folks. So we do remain very concerned about the impacts of remote learning um on the mental health of Children and youth across the state and as has already been mentioned even before covid We were seeing significant concerning data related to particularly with adolescents increased depression and anxiety And so this is just an area that we're continuing to focus on and working very closely with the agency of education Also, just our school-based mental health programs across the state have done An absolutely incredible job of continuing to provide services through telehealth Through community-based services to try to continue to ensure that those children and youth are still getting their needs met Obviously, there's access gaps in the system that we worry about now in terms of decreased capacity that we already talked about You know co-occurring is also something that we need to focus our attention on We certainly know that and we are seeing an increase particularly in individuals who are presenting an inpatient With very complex co-occurring issues Including substance use Again, there's a lot of work that's happening in partnership with adap But I think that's an area we have to consider continue to focus on Overall wellness and well-being. We know vermoners are reporting the impacts of covid on their mental health We know that there's You know not having trouble sleeping increased alcohol consumption general stressors Which is why we've stood up covid support vermont in partnership with vermont care partners as a resource But certainly something we're worried about and then workforce We were already experiencing workforce challenges pre covid Certainly the impact of covid has really Exacerbated some of those challenges again. This is an area that's been really articulated in vision 2030 But we cannot take our foot off the gas in terms of continuing to think and problem solve around strengthening our workforce across the system of care And I would just note that you know, we've had some advances to you know The ability for us to pivot the telehealth I think does bode opportunity down the road in terms of expansion and access to services But I would also just say that telehealth doesn't work for everyone. It will not meet everyone's needs So while telehealth will allow us to advance access in certain areas I just want to recognize That for many individuals telehealth might not be something they're comfortable with might not have access to broadband services And so there still are a lot of limitations there that I just want to know Yeah, and we're we are actually focusing have been focusing on time on telehealth issues. So thank you I'm going to skip this slide in the interest of time. This is federal funding and grants related to our children's system of care But I will move through this I do want to just note some of the current federal funding that we have We have our FEMA crisis counseling grant, which is the funding we've used to stand up covid support vermont We have our emergency SAMHSA grant that allison referenced That was a two million dollar grant that we split with aid app. We did just find out we have an additional 2.8 million dollars So we'll be looking to continue to expand emergency services and peer services, which is where those funds have been targeted We already went into detail on the comprehensive suicide prevention grant We do anticipate some continued increases to our mental health block grant Additional increases to suicide prevention efforts and possibly increases for project aware These are the slate of reports That the department of mental health is required to provide to the legislature every year I'll just do a high level overview of what those reports are We can certainly provide more follow-up testimony in terms of some of the recommendations And what is the data telling us? Act 79 is one of our larger reports It does really describe the use of services capacity individual experiences of care Person and recovery evaluated performance metrics of the mental health system as compared to national standards I would encourage anyone again to take a look at the report that we recently submitted I think this recent report articulates some of the complexities of shifts in our system in terms of capacity and other impacts And it tells the story a little bit behind some of the anomalies that we've seen this year And how does or doesn't that inform and influence how we move forward? The next report is act 114 This is an important report. This is a real important piece of accountability Around the utilization of involuntary medication for individuals across the state I can say at a very high level that the report does not indicate any significant change in terms of the data around court ordered applications for involuntary medication And actually we saw by moving to virtual hearings There's a whole very complex legal system that we have in place for individuals who are involuntarily receiving care under the care and custody of the commissioner And actually we saw Easier engagement in some areas by moving to virtual Court proceedings. So that's somewhat highlighted in the report again I would encourage folks to take a look at that. It is a short report. So it's easy to digest Act 140. I would just note There's a significant provision of funding that was provided to the Brattleburg Retreat in an effort to stabilize them that also came with more accountability related to quality metrics So there is a report that we will be providing on February 15th that articulates specific areas related to patient quality of care We've been working very closely with Vermont Psychiatric Survivors and Disability Rights for Survivors and Disability Rights on that report So you should see that coming soon And then Act 200 Is data on inpatient access To inpatient units Emergency wait times, etc. So again I would strongly suggest that DMH and VAS come in to do some follow-up on that report specifically because it does get into trends in terms of admissions Emergency department wait times, which again are really important proxies. I think for the system of care So that again is something I think that we should focus on And then there's the Act 200 IMD report which gets into The need for Vermont to phase down Our funding for the IMDs Which at this point the IMDs in Vermont are Vermont Psychiatric Care Hospital and the Brattleboro retreat And I believe One last slide This is just looking ahead in terms of some of the areas and initiatives that we're focused on many of which we touched on today The 12 new level one beds at the Brattleboro retreat the replacement of the current middle sex secure residential Mobile response for children and families. We'll get to dig into at our budget testimony continued implementation of mental health payment reform We talked about vision 2030 and just advancing a more equitable mental health system for all We also have some opportunities. I think related to expanding community supports peer respite and crisis services Is an area of priority for the department In terms of thinking about how do we really meaningfully expand Those services and supports across the state And then we of course always need to continue to turn our attention to geriatric psychiatry and needs across the state So I think That's the end Thank you for your patience and stam and I know it's a lot of information But uh, we really did want to give you a comprehensive overview of the system of care and the work that's happening Representative donna you I wanted to make note for committee members is that we did specifically Ask the commissioner not to get into two other issues that we'll want to come back to One of them we worked a lot on last year about mental health police Support issues and there's a report back on that that'll be coming And the other is the whole area of follow-up with the Brattleboro retreat. So We set those to the side for now for now So are there I saw a hand I'm looking for Representative goldman, did you I saw your hand up and then maybe down and went down and I think I'll raise my question Okay, thank you represent page Yes, I don't know whether commissioner squirrel can address this But can you talk about northeast kingdom human services? Yes. Thank you I was I made a note earlier that we really need to know and yes, and it's Current status on its rating system and I will also Mention your picture of vermont and I've mentioned this to you before Um for the dmh residential crisis designated hospitals Um, you have a blank spot in orleans and s6 in caledonia counties and I don't have to go any further you you know that There's limited resources there compared to the rest of the state But thank you very much and I look forward to hearing your comments Yes, thank you representative page. I greatly appreciate that comment and that's I think the power of the visual of that report as well Related to northeast kingdom human services, I'm very happy to provide an update as the committee is aware Based on feedback and input that the department of mental health had been receiving over the past year We did initiate an additional agency review For northeast kingdom human services. We have a designation process It's a very robust and in-depth process by which we designate the community mental health agencies Typically that's an every four year cycle We do if concerns are reaching a certain threshold have the ability to implement an additional agency review at any time Based on the level of concern that was coming to the department from community members and staff We did implement that additional agency review the result of that was Significant findings in several areas of the overall agency Met the threshold of being so concerning that we did Move nkhs into a different designation status Which is a provisional status with intent to de-designate Um, we immediately started working very closely with the leadership at northeast kingdom human services What I can say is that their board of directors was so responsive To um the concerns articulated in our additional agency review Folks are aware there has been a change in leadership at northeast kingdom human services We have been working side by side with them and their leadership team and clinical team Part of the process is that they are required to submit a corrective action plan To the department of mental health We then have 30 days to review That corrective action plan once that corrective action plan is approved that basically lays out the groundwork of next steps And then they have six months to implement it. What I can say is that northeast kingdom human services has submitted their corrective action plan We feel that it does materially address Many of the deficiencies and concerns that were noted We will be at some point in the future Officially approving that corrective action plan And then we'll be working side by side with their board and current leadership to advance it forward So I think we are on the right track and again We have a lot of confidence in how seriously they are taking this and that the agency Will get back on solid footing again There's a page is that Address your question. Yes. Yes. Thank you so much. I really do appreciate it I guess I would ask one if I if I may I would ask one other follow-up or question which is I mean one one can only assume that there were consequences for patient care In the process of the deficiencies that had come into play because otherwise They wouldn't have been deficiencies I would assume unless they were primarily financial And even that can lead to patient care deficiencies. Can you comment on? Whether there have been additional steps required to ensure To remedy any patient care deficiencies that had impact on particular Groups or individuals Yes, there were significant areas related to service delivery and patient care that was Above concerned that we took into account and moving them into this status Part of the corrective action plan Does really address The deficits and some of the areas related to patient care Allison has actually been leading that work Allison Is there anything that you would add specifically to that that might give representative look for a bit more information? Yes, I would just add The nature of those issues were not what we would call critical incidents So we weren't receiving issues of safety concerns or You know assessments that were were causing concern around the the safety and care of clients It was more along the the area of staff and community voicing We are getting to a place where we are concerned that might happen And part of that issue was having the appropriate licensed folks And the amount of folks and the support from the leadership. And so just to be clear We we didn't have critical incidents that required a specific follow-up due to safety concerns It was more about preventing that from happening. Okay. That that is really part of what I was trying to understand and Thank you Representative Peterson Yes, thank you just more of a comment and And a question here, I guess a little bit, but I want to share a commission of squirrels concern about Our school kids You know, you had a slide up and we talked a little bit about Can we take the slide down just so I can see the committee that would be helpful. Thank you. Sorry. Sorry, Art interrupt you. No, no, no problem You know about the mental well-being of our kids in school And I just want to point out and remind everyone I sent a petition around about Encouraging the governor To restart high school sports to those kids who have been practicing since december at the end of december To not have games and to and to still be practicing I think we need to give those kids hope so I just would encourage anyone that wants to any legislators to Email me and let me know if you want your name put on a petition to try to get the governor to give him some Thought about maybe reopening games like new hamps or massachusetts. That's all. Thank you Okay Thank you We have covered a lot of territory here this morning and And I think profitably so I'm going to I don't see any Hands right at the moment. I know we'll come back and we're going to have an opportunity to hear it from Commissioner squirrel around budget issues and particularly one of the areas of course that comes immediately to mind And she's referenced it but in more detail When we hear the budget it's like So how are we going to address the gaps in this system? What because we recognize there are gaps in the system for all that we're providing there are still gaps Uh, so we'll we'll we'll certainly be coming back to that at another time and deal with budget Questions about that I think it's my again My best judgment right now is that we should take a break And then during that break, I'm going to consult with julie tesler and with an lorry My thought right now my my preliminary thought is that we probably adjourn for the morning I think we may have maxed out our ability to Take in information profitably on zoom And that uh, I'm going to work with julie tesler to make sure that the she and uh care partners I believe we have actually some time that tomorrow we can schedule and I've consulted with her but during the If we if we may let's take a five minute break during which I'll do that consultant Then we'll come back and we'll clarify our next steps In the meantime, I really want to express my appreciation to commissioner squirrel and deputy commissioner fox Uh and allison in particular shannon. We didn't get a chance to chat with you But maybe that's just as well from your point of view Uh But seriously appreciate you being here and the work of the department is so crucial This this and and again to ground this in this is the health care committee And this is as we Have articulated numbers of times to our colleagues and to the public We share the point of view I think of the department of mental health That mental health is an essential component of health care It is not something that can be addressed health care cannot be successful Without addressing all of these components so I and There are other better ways to express it. I'm sure but this is this is This is important for us in thinking about the well-being of vermonters and the health care of vermonters So thank you so much for your work. It is hard work and it's an important work So let's take a five minute break If you wouldn't mind checking back in in five minutes and we'll make our plan from there Okay, thank you everyone Thank you. Thank you So, yes, we're all back. Okay. Can you hear me? I don't know why Oh, it's it's the phenomenon of all of you are on mute, which is appropriate And I I'm like feel like I'm operating in an empty box with no sounds. It's just the funniest thing So Oh, take yourselves all off mute. I'll feel the better son. Yeah, we can do we're just we've been trained to be silent at this point Like I know I know you're doing exactly what I would have asked you to do but it's just there's something odd about it You know and Representative Goldman had her hand up from before we broke So I think she has a pending question Okay Okay, uh Representative Goldman Yeah, my question was actually for the mental health team. Um, who are now off. Yeah, they Sorry, I missed that apologies But I just like to get it onto the record. Yeah, you can think about it. Sure On slide 33, they talked about the quadruple aim and vision 33 with mental health integration council It's really impressive work. Um, what I wanted to know is there parallel work going on the department of health um, how how do these two You know pieces of health integrate, you know in a larger system. So that's what I'm my I'm curious about Well, I'm going to turn to our vice chair who appears to want to comment on that The 32nd answer and we can talk a lot more later or offline Is that that was the reason the integration council was created was to say that mental health Can't work on this alone And so that I think it's like like co-chairs between dmh and vdh in terms of the council and and that that was the whole purpose Everybody's got to be together working on this. Yeah, I'd like to see more of that because the slide didn't really imply that It seemed like it was a high load. So that's a periodicity of mine Yeah, and it's just just to say give it, you know, when we're lots We really need to acknowledge the covid overlay on everything we heard today. I mean it was referenced a number of times, but even even My mind's going blank, but someone we had I think there was a reference. Oh, I think uh, representative black had asked about some of the work around gun shop issues I believe I believe I'm remembering the connection here and one of the comments was that because of covid Everyone in the department of health was frankly redeployed. I mean at some level, I mean Many I don't know if everyone but virtually everyone plus people from other departments were brought in and redeployed to just address covid And so a lot of things which otherwise would have moved forward including what made me think of it including the department of mental health convening the 10-year The integration council that representative donny who just referenced several times We've been requested and agreed to without question Deferring the beginning of the implementation of just bringing that council together because all the people involved are just dealing with covid and We said absolutely So we really do need to Take that into account as we listen to many of the everyone from the community level to the impact on workforce in the institutional at the inpatient level And and what and what you're what we're talking about right here. Yeah, I totally understand and Totally, but it's a great question because it highlights what let as the answer represent all you said the integration council was was in fact In part or in large part intended to do just what you're talking about But there's a lot more to be done and I find myself asking questions About the fact that we don't usually have the department of health come in and testify and we need to Because they're often seen as the jurisdiction of the health human services committee But we're we're a work in progress in terms of how we work collaboratively and there's more opportunities that we will create for that Thank you representative lippard. I just would like to say yeah, I'd like to see the same thing for the department of health If that's possible. Yeah, so let me say I did consult and We're we're we're going to finish up. We're finished up And I mean that in We took the amount of time that was necessary. I've spoken with julie tesler and invited her to testify tomorrow afternoon Fortunately, we have that time in our schedule So beginning at 115 we'll meet with julie tesler from care partners We will come back in the morning To address the work that we worked on yesterday and committee around audio only And representative houghton has given me some sense that we should be able to bring that to closure In the time after the floor tomorrow morning So that's the plan Apologies and julie tesler is being incredibly flexible. I appreciate her assistance and flexing flexing for us um This afternoon we have a number of witnesses. We will be backing committee Let's say 15 15 minutes after the floor whatever that Approximates we do need these breaks as well And I don't think we'll be on the floor very long, but that's Let's come back 15 minutes after the floor And Colleen will make sure we have the right link and uh With that let's let's take a breather. We need it Thank you all. This is your questions are completely We're we're great and uh, I there's a lot more questions. We want to ask still