 So, first let me start by saying this is the House Health Care Committee. This is Tuesday, March 9th. It's about 145. And we are hearing testimony today about the replacement of the secure residential facility currently in the middle sec currently in middle sex Vermont. We have a number of witnesses and I'm going to request that when witnesses are not testifying if they would go off video. It's easier for me to monitor the screen and then have you come on video when you are testifying and I see we have a number of witnesses with us that will help me. And I think it's, it works for, it works for everyone, I hope. Let me start by saying we are going to be hearing first from the Commissioner from Commissioner Squirrel and Deputy Commissioner Morning Fox who are going to do a presentation about the Department of Mental Health's current proposal for the replacement of the secure residential facility. We then have, to my knowledge, we have five additional witnesses, actually a bigger part I think we have actually six additional witnesses scheduled today. We've received many letters with varying points of view about this facility and what should happen or not happen. And as a result, we have also scheduled additional testimony for this committee on Wednesday afternoon after the floor. So you will at some point, if not today, you will at some point see a list of some additional witnesses who will be invited to comment as well. We recognize that this is a, this, this replacing this facility has many issues involved in it and it has a point of some, indeed some controversy. So we are listening carefully both to witnesses but also to written testimony that's shared with us and we're receiving emails and letters and they will be entered into our record and shared with the full committee. So, oh, one other, one other announcement for our committee is that we, I'm asking our committee to convene tomorrow morning at 8.30. I hope that works for everyone, apologies for the short notice, but given the potential list of witnesses for tomorrow morning and their availability, the times when they're available, I'm asking our committee to convene at 8.30 tomorrow morning and I'll ask Colleen to help us remind ourselves of that as well. So I think with that, I'm, I would like us to proceed with hearing from the commissioner and deputy commissioner. My anticipation is that we will, we will take some period of time to hear this presentation to entertain some questions. This is not a time for other witnesses to ask questions, this is a time for the committee. We will then proceed to hear from our witnesses and we've asked them to each take 10 to 15 minutes at the most so that we get to hear from each witness. And I believe that, hopefully that will work sufficiently. The initial presentation by the department, however, will be a longer presentation than we anticipate that, but we do need to allow for. So I'm going to look to monitor the time we're taking and we'll, we'll manage it. So with that, welcome commissioner, deputy commissioner, and I'm going to, I think you have a presentation to share as well. Is that right? But I'm going to turn it over to you, commissioner squirrel, and you can take it from here and work with Colleen if there's a screen to be shared. Great. Thank you, chair Lippert for the record Sarah squirrel commissioner of the department of mental health. Great to see you all this afternoon. I am joined by deputy commissioner morning box. We also have Dr. Allison Richards, who is joining us, our medical director from Vermont psychiatric care hospital, Dr. Janice LaValle, LaValle and Dr. Janice or Kevin Huck Schorn, who will be joining us. They are national thought and content experts that have supported the department really support the six core strategies. So we'll be hearing from them also, I'm going to go ahead and share my screen just so I can walk through the presentation. And then when we get to the Q&A portion for the chair, I'll try to pull that down so everyone can see each other. I know that can be challenging when we do the screen share. So let me see if I can get this right. While we're getting the screen share going, I'm saying I will see if we can take a break in the Mrs. We will full afternoon. We'll see if we can take at least a stretch break, if not a longer break. OK, can folks do folks see the presentation? Yes, it's in full screen. Excellent. OK, well, I will go ahead and get started and just jump right in. There were two documents that were shared with the committee. One is an overview of the proposed recovery residence. We will not be using that for our presentation today. It is designed to be a reference document for you all as legislators for the public to kind of go back and review what we are proposing in terms of the future recovery residence. And then in addition to that, we have our slide deck of the presentation that we've provided as well. So a few areas that I'll be hoping to cover just a little bit of the history of the current middle sex therapeutic community residence, talk about system of care needs, capacity analysis and costs of care in the system. The future recovery residence and what we envision sharing of clinical perspectives from Dr. Richards, Deputy Commissioner Morningbox will be walking through very briefly some high level design ideas related to the future recovery residence. And then we'll be hearing briefly from Dr. LaBelle and Dr. Huck Schorn and talking a little bit about next steps. So in terms of the history of the current residence, I know that many members of this committee have visited the residence and certainly, you know, just to kind of back up and say that, you know, broadly as a state right now, as we continue to grapple with the impacts of the pandemic, having a strong, stable mental health system of care is absolutely critical. So going back in time a bit when Hurricane Irene changed our mental health system of care, we moved to a decentralized system of care for Vermont State Hospital level of care created a system of which we have level one beds across the state. That was actually when the current middle sex therapeutic residence was created. It was identified even at that time that individuals that were ready to step down required a secure setting in order to be safe and to continue on their recovery. So that was when the current middle sex therapeutic community residence was created. It was built using FEMA funds. It was intended to be temporary and again, intended to support those individuals who were no longer in need of impatient level of care, but who still required intensive services in a secure setting. Just in terms of, you know, there are some additional legal components related to individuals, admissions to the program. Individuals are under an involuntary legal status under the care and custody of the Commissioner of Mental Health. There also is an order of non hospitalization indicating by the court that this individual requires this level of care in a secure setting. So just wanted to note that as well. This is just a quick review for those who have not seen the current recovery residence in middle sex. It is a temporary facility. It is clear, you know, from the photos that it was designed to be temporary. It has outlived its lifespan and it needs to be replaced. There are many site issues that some folks who have visited have certainly observed not having a permanent foundation, which leads to a whole host of moisture issues, repair issues, etc. In terms of the current operations, it is licensed as a therapeutic community residence. It's about six thousand square feet. The current funding is global commitment funding with some private pay. And the budget is approximately two point nine million dollars in operating costs. And we have about twenty five or twenty eight full time staff at the current program. I want to talk a little bit about the system of care. And I think in order for us to provide the best care possible for remonters, that really does require us to have a continuum increasing our step down capacity in the system has been identified as a critical need. I think a permanent secure program will continue and does continue to be a continued need for those individuals who still require twenty four seven treatment and support. I think the replacement and expansion of the current middle sex therapeutic community residence is an essential and smart solution in terms of addressing some of the systemic challenges that we face across the state. And certainly as we reflect on, you know, some of the proxies that we use to evaluate how we're doing as a system of care, long wait times in emergency rooms are certainly in symptomatic of what we call inadequate flow in the system, which is our ability to really, you know, manage individuals with minimal delays as they transition through levels of care. And for those individuals who might no longer require hospitalization, but continued have continued treatment needs, really need to have a safe, stable, secure, stepped out environment to go to. And that essentially does free up those beds for individuals who might be waiting in EDs and would benefit from one of our inpatient beds. The other thing I would just note and I'll hone in on this again when we talk about the data to support the need for expanded capacity is that the individuals who are coming to the current therapeutic residence are primarily coming from our level one beds that they do represent high and long lengths of stay in our inpatient beds. I think in 2019, the five individuals who were admitted to the secure recovery residence on average had a length of stay of 300 days in the hospital. So you can see how our ability to discharge these individuals to a lower level of care has a significant impact on inpatient bed availability for others. And just for comparison, the typical length of stay in an inpatient unit is about seven days or less. A little bit on the current middle sex data is that 95 percent of referrals to the secure residence are from level one units across the state. We have served 53 individuals since its opening. The average length of stay is between eight and 10 months. Sixty five percent of the residents have stepped down to less restrictive settings or independent housing. And just the graph on the bottom just shows the occupancy rate over the past few years, indicating very high occupancy rates in general in terms of demand for this. And again, that it has been very successful in creating this transitional step down so that individuals can then move successfully to different levels of support in the community. We have seen this slide before. This is really just meant to demonstrate and illustrate to visually the step down capacity that we're talking about. And when we think about the continuum of care strength across the continuum of care, it is critical that we have strength in all areas. So this really gives you the sense of, you know, how we see that continuum of care from our level one inpatient units to our general inpatient units to the secure residential programming, the specialized enhanced funding that we have that supports many of the iPad programs, the Pierce House across the state, our array of intensive recovery residences, our mental health crisis beds, group homes, transitional staffed housing and individuals who have shelter plus care vouchers. So they have independent living with services that might be attached. And of course, there may be those individuals who are living in independent housing but might simply be accessing outpatient services as well. So again, just to give you a sense of that continuum when we think about the system of care and beds. You know, one of the questions that has come up a lot in terms of, you know, the current secure recovery residents and what DMH is proposing is clarity on the level of care attributes and how do we differentiate between hospital level of care and the secure step down that we currently have. And I think that's a good question and it's an important one for the department to clarify. So when we think about inpatient level of care, we're providing care and treatment to someone who is in an acute phase of a psychiatric crisis. They're requiring immediate assessment and stabilization. They are at risk of harm to themselves or others due to dysregulation due to the mental health challenges that they might be experiencing. There may be court ordered non-emergency medications and the provision of emergency and voluntary procedures. When we think about the secure step down capacity, we think about that as step down level of care and again, really designed for individuals who are subacute, meaning that they no longer need hospital level of care. They've received that assessment and stabilization. They are ready to step down, but they might not be ready to step down right directly into the community and other levels of care and require this additional transitional step down support. And what this additional programming provides through the current recovery residence and will be expanded and enhanced with the new recovery residence because of the improvements in the environment of care is a safe and secure environment, individual and group therapy that could be readily accessed, skill building really to help individuals improve their own capacity to manage their symptoms and social skills. Building those daily living skills, whether that's cooking and food preparation, cleaning and house care, dental and physical hygiene and then supported in community engagement is another one of the key tenants and attributes of the step down level of care in terms of, you know, preparing to go to the grocery store, meaning with care providers in the community and opportunities to practice social engagement and skills in the community. It really is designed to help presidents to develop and implement those skills that will help them integrate back into their lives and back into the community through this transitional step down support. The next slide again, this is a good question that's been posed by committee members, members of the public, other interested parties in terms of, you know, as we looked at that step down capacity continuum, how the cost of care then correlates to the different step down or different continuum of cares and levels of care in the system. So we've tried to articulate there in terms of approximate daily operating costs for the different levels of care. So you can see at the top of this chart, we have level one intensive inpatient care, the Vermont psychiatric care hospital, the level one beds at the Brattleboro retreat, as well as the level one beds at Rutland Regional Medical Center, which range from about $1,800 a day up to $2,600 a day. Our non level one inpatient units, which the average per diem rate paid to these hospitals is just over $1,700 a day. The current secure residential, which has an operating budget of $3.1 million dollars at about $1,200 a day. And then the proposed secure residential, which would increase capacity. The current estimated operating cost is about $9.1 million dollars. Just under $1,600 a day. We are going to be talking about some changes in terms of some of the attributes of the programming. And that will likely decrease those operating costs. But we have kept it as is for now, but we will have some information to share shortly that will likely influence that daily rate a bit, if you will. The average cost per day for our intensive recovery residences, our community based recovery residents, the Satiria House specifically, and then intensive supported housing, which is really looking at the daily operating costs of the iPad programs. And I see Representative Donahue has a question. You don't identify the level one's beds at the retreat that are coming online. Is there a rate known for them yet, or is that just expected to be the same rate? Because you list 14, but there's actually going to be 26 total, correct? Yes, that's correct. So this was the last cost settled rate. So I would anticipate Representative Donahue that the rate will be close to that, but it may go up a little bit, just given inflationary costs of care, probably more reliance on locum docs and travel nurses at this time due to COVID. But I think it will be close to that, but probably slightly higher. And just to note, given that we are focused today on our proposal for the new secure residential, that of that $9.1 million in operating costs, we do utilize Medicaid funds to support that. So if we were using that $9.1 million number, for example, as I mentioned, I do anticipate that will change and go down. We would need an additional $2.7 million of general fund to support that. And again, that may shift, but just because we are able to utilize the Medicaid funds, just to note that the general fund need for that would be about $2.7 million. So I wanna spend some time talking about the future recovery residents, what we are proposing for the committee. We propose to replace the current secure middle sex therapeutic residents with a 16 bed facility that would continue to be physically secure, that would provide the highest quality of care possible, ensuring the safety of residents in an environment of care that is recovery oriented and promotes rejoining and rebuilding a life in the community. It is designed and will continue to be designed for individuals who are subacute and who are ready to discharge from inpatient hospitals, but do have higher treatment needs, may have risk factors that might impact public safety and their safety, and may actually exceed the capacity of community providers. So when we think about this transitional step or this transitional step down programming and why it is so essential is that we do have a cohort of individuals that have very high acuity needs in the state of Vermont that cannot be immediately served by our community programs given some of the safety risks that they may present. This is a specialized population. As I said, that cannot be immediately accommodated in other settings. And I feel a deep sense of responsibility as the commissioner of mental health to ensure that for those individuals who are ready to step down from level one beds that we have the appropriate transitional programming for them to keep them safe and to keep the community safe. I think we are also thinking about trying to enhance equitable access to appropriate timely and high quality care and treatment. We certainly want that equitable access even for individuals that have some of the highest needs across the state of Vermont. And we certainly do not want individuals who are ready to step down who cannot be served successfully at the community level and may have community placements that do not work and then results in those individuals ending back up in our emergency departments and being re-hospitalized. As I mentioned, expanding this level of care for the sub-acute population still addressing their need for stabilization and active treatment will really help support those individuals in terms of their recovery. The other piece I would just note is that the program is capable of serving individuals with forensic needs and increased risk. Individuals who have forensic needs who might come through the criminal justice system, they are a part of the population that we are required to provide care for. We know that many individuals come into the mental health system due to interactions with the criminal justice system. It is certainly our responsibility to provide appropriate care and treatment to those individuals as well to ensure that their safety needs can be met, community safety needs can be met, but they can work on those daily living skills that they need and then successfully transition to the community. I was down here, you have a question? Thank you. I'm sorry, it's when the screen is up, it's hard to see the side screen also. Didn't realize my hand was still up. And as I noted, again, just sharing what we're thinking about in terms of the future recovery residents, it does serve individuals with the highest acuity in the state who are ready to discharge. As I mentioned, 95% of those referrals come from level one units. So we do feel strongly that replacing the current residents, expanding its capacity, will have a significant and material impact in terms of improving flow in the system. As I mentioned, given the high acuity of these individuals, they are occupying inpatient bed days at a much higher proportion. As I stated the data earlier, in terms of length of stays in hospitals of up to 300 days. So I think that our proposal from our perspective is the right thing for the system of care and for Vermonters without this capacity in the system and without the expanded capacity in the system, I think we would be doing a real disservice to those individuals who are ready to step down, need this additional transitional support in a safe and secure setting so that they can continue on their journey to recovery. We also value collaboration and partnership as a department and those are really key tenants of advancing what I would call urgent and important capacity in our system of care. And we have certainly demonstrated our capacity and investment and commitment to listening to stakeholders across the state. I think was evidenced by the approach that we took to creating our 10-year vision, where we spent almost a year fanning out across the community listening to Vermonters to really inform that work. And our commitment to that is no different now. We understand that there have been significant concerns raised to the department regarding the proposed use of seclusion and restraint at the recovery residence. And I think what I can say is that we've heard you. We have heard your feedback, we have taken it into consideration and which is why we are no longer proposing the use of seclusion and restraint at the expanded program. What we really want to do is to ensure that this expanded capacity can serve to support this group of individuals who deserve step down capacity in our system of care. We wanna work with our community providers, hospitals, stakeholders and advocacy partners to think about the programming, to really boost peer support and positions in a meaningful way in the expanded program to continue to work collaboratively with DRVT, NAMI, Vermont Psychiatric Survivors, Legal Aid and other advocacy partners to ensure that that community voice is integrated into the design, to look at evidence-based assessments to evaluate the level of care that is needed for individuals and to create admissions criteria that reflect that other community placements might not be available for these individuals and hence why this transitional level of support is so needed. Commissioner, I'm gonna step in here because I think what you just stated is a very significant alteration of the proposal that has been put forward initially by the department and I don't want it to get lost in, if I'm understanding correctly and I don't wanna misunderstand and I don't want others to misunderstand but I think I heard what you said was that the department is no longer proposing to include the use of seclusion and restraint at the proposed replacement facility. Did I understand that correctly? That is correct. Okay, well again, I think that's a significant alteration of the initial proposal and one which needs to be fully heard and understood. I'm interrupting this because I think that's a notable change. I want to hear, I see Representative Peterson has his hand up. I want to hold most questions if we can. So later, I wanna be able to hear the full presentation by the commissioner and I frankly interrupted because I don't want that to get lost in the process. So Representative Peterson, we'll give back to you. Thank you, Chair Lippert. And we also wanna thank all of our partners across the system who have provided input. It is our job as leaders of the Department of Mental Health to take all input into consideration as we think about these critical programs for Vermonters. So I do wanna thank everyone for their input around that and really welcome everyone and invite continued conversation about the continued design of the program. I'm gonna go through a couple additional slides, maybe one more just related to data supporting the expanded capacity. I think it's important that the department really be able to articulate why we need the expanded capacity in addition to replacing the current seven-dead facility. As I noted, we have had good outcomes as a result of this program, serving individuals who are ready to step down and transition to the community. I certainly think we all recognize that the impact of the pandemic on escalating mental health needs is something we also need to take into consideration when we talk about the increase in mental health needs over the next couple of years, if not longer as we go forward and the demand for high intensity services in our state is certainly not decreasing. We continue to see 95 to 100% occupancy in our level one beds. And then of course that direct correlation between this cohort of individuals who have acute needs who are also occupying higher bed days in the system and by creating and expanding this transitional level of care, we essentially really unlock some areas of the system and create more access to those inpatient beds. Also just to note, the improved environment of care of the new design does enhance program treatment capacity. So going from two trailers that we put together with FEMA funding to an environment of care with additional space, I think also will really expand our capacity to support individuals. Certainly the occupancy rate of the current residents indicates high need for this level of care in the system. Our analysis of residential bed needs found that, based on that point in time data that inpatient facilities to indicate that at any given time there are at least seven to 10 individuals who would benefit from the step down level of care. Certainly taking into consideration Vermont's 10 year vision to decrease inpatient bed capacity, which is something we have articulated, as we think about improving and expanding integration of mental health and healthcare, community supports over the long term as we decrease our reliance on inpatient care, having these secure programs, therapeutic programs will be even more critical to us as a state. And of course we need to have the long range view of being aware that the Centers for Medicaid and Medicare services are requiring us as a state to really think about, at least from a fiscal standpoint, the phase down of IMDs. So we are looking at our need to phase down from our IMDs and our inpatient care. And again, we wanna be thoughtful about the investments that we are making now, knowing that that is something we as a state and a system are going to be grapple with. And I think I guess finally, I'll wrap up and then turn it over to, I believe Dr. Richards, you know, as a commissioner who at any given time has over 300 individuals under my care and custody, I do feel a deep sense of responsibility to ensure that we have adequate step down care for all individuals who require it. Even those individuals who have increased acuity in order to serve those individuals, they also deserve equitable access to quality care so that they can access those treatment services, recovery services, and then transition to the community. And if we don't provide services to those individuals, then the question we need to ask ourselves is, who will? So I will pause there. And I believe I am going to turn it over to Dr. Richards, who will share a bit of her clinical perspective. Hello, can you see me and hear me okay? Yes, yes. Thank you. So I just wanted to say thank you, Commissioner Squirrel and thank you, committee for the opportunity to speak. My name is Allison Richards, and I'm the medical director at the Vermont Psychiatric Care Hospital. And I wanted to talk to you a little bit about having the privilege to work with this group of individuals that the commissioner is talking about that have high complex mental health needs. I appreciate the attention that this project is getting, and I have an important perspective to share with you. I also just wanted to share a little bit about where some of this comes from. I have my own story in the mental health system, having a father who had mental illness and psychiatric hospitalization, a son with neurological and psychiatric illness that has resulted in hospitalizations and restraints, and then my own mental health story. And all of these things have led me to where I am today and the compassion that I feel in the work that I do every day. I've been working as a physician and psychiatrist in Vermont since 2007, and I came here to Vermont in all honesty to be part of a different experience and training in psychiatry, where the focus was on therapy and helping shift the culture of care, which has been happening at the old state hospital and more so at Vermont psychiatric care hospital, where we continue to make changes for the people who struggle in their lives and our hospital lives. I have worked at the current middle sex residents where when I was there, we did open dialogue style rounds just to give you a sense of kind of care provided with every resident. Residents would go out fishing, cooking, eating the eight meals together. And it was an opportunity for people to recover, to go out into the community and get on with their lives. And I don't want it to be perceived as a prison or anything like that. It was actually a nice community, but it's in much need of an improved facility and also capacity. I do evaluations for the Department of Correctional for the Department of Mental Health and Department of Correction, but it's quite a striking difference and that's part of what some of these individuals needing this type of residence. I can speak to that, I would say. So I'm asking just not to lose sight of the people that truly need this level of care that's critical to their path in recovery. So I want to tell you a little bit about some of the people that I have worked with and gotten to know over the years that this group of individuals that have been impacted by not having the expanded capacity and access to the programming that the new recovery residents are supposed to have and is being proposed. In some sense, I'll say they're voiceless individuals. They're not here to tell you their stories themselves. I will do my best to tell you it as I have known them, but certainly they aren't here and I think there are two different sides, but I'm going to try to offer you a little bit of what I have known. So when you are trying to recover, I guess I would say it is very difficult when you are living in the current facility, the two FEMA trailers, they're attached, they're intended to be used for a short period of time and now they're going on their eighth year of operation. It lacks the amenities, space and design that these individuals deserve when they're moving on into their lives. They all want kind of a private, I think everyone that I've worked with has always wanted a private space, their own bathroom, like their own space to call their own and then the opportunity to work, which is also something that recovery residents has supported jobs and moving on in life. So not only would we need that, but the new facility would allow people to open their windows and breathe air and have the space so that they can move on in their lives. And again, they're not here to speak to themselves. So here's something that we can all agree on. Life is challenging and difficult, especially when you have a mental illness and the people that I'm talking about and the difficult experiences that they have been through that put themselves and others at risk of harm. Sometimes their families are at risk of harm and the people that they love and are closest to are impacted. They deserve a place to receive care and to be able to work towards their recovery. And despite these difficult experiences, however dangerous their people, they have families and they deserve a place to be, not to be left behind. I don't, I just want to reiterate that, but these are people that wouldn't have any other option at this current point. I agree that there should be more apartments in the community, the community needs more resources, but this is, again, a group that can't be served at that level. So I'm gonna tell you a little bit about some of the individuals. I'm trying to give you three people. They're kind of more than three people because they're anonymous and I've given them names. Just so that you understand the complexities of these individuals. So Greg is a 40-year-old man with a history of numerous psychiatric hospitalizations. He's lived at various group living settings. His lengths of stay at the group living situations vary from days to weeks to months because the transitions often result in re-hospitalization. The hospitalization history includes meeting non-emergency and voluntary medications. These people stop medications in the community and then at several of the intensive recovery residences where he's either eloped or assaulted other people, he's kind of been seen as someone that they can no longer safely serve. He stabilizes when he's in the hospital on medications, but then there aren't any other agencies, DAs or peer-run programs or second spring intensive residential that feel that they can safely meet his needs due to ongoing violence. And this is a situation where the new expanded facility with a new environment of care could, I think with the right programming that the commissioner's talking about, this gentleman Greg could be referred to that program. Another example is Randy. He's 45, he's been charged with murder. He's been found incompetent to stand trial due to mental illness and he's refused medication and is not on medication because he wasn't symptomatic in the hospital and not that the court thought he needed medication and so the order was denied. But he does remain delusional, he's not treated and due to public safety concerns and this history of alleged extreme violence of murder, no community providers feel that they can serve him in the community. But this is someone that could be referred to this new facility and safely help to reintegrate and adjust for life and free up the bed. In the last his question, she's 38. She's a woman who have a long history of inpatient hospitalization, including court ordered non-emergency and voluntary medications. The medications don't always seem to help and she doesn't respond. She remains psychotic at baseline and she has just regulated moments that are erratic. She'll destroy property, she assaults other people and she remains psychotic and these are like every four to six weeks and other than these, she's okay behaviorally. They're just these little blips that put other people at risk and due to these episodes where she struggled, the community providers also feel that they can't guarantee the safety of the other residents in those programs and so she would be someone that a facility like the new recovery residents could tolerate a bad day with the additional space in the environment of care. I think that's the proposal is with Kevin Huxhorn and Janice is working on tolerate letting people work through that distress. But just wanted to thank you for your time and thank you for listening to this need. I am proud to be working in Vermont and part of a changing system of care for the individuals, families and networks. And I truly believe Vermont is a leader in progressive and compassionate care and the work in the community will continue to evolve and I appreciate that and I value the peer perspective and the collaboration with the peers. The need for these individuals that I just described to you, again, it's different. They can't be met in the community for all the reasons that you've heard about today and I don't want them to be left behind in our system of care. Thank you for your time, committee and thanks commissioner for asking me to speak. Thank you, Dr. Richards. I'm gonna go back to screen share and I'm gonna turn it over to deputy commissioner Morningfax just trying to keep things moving just to do a very high level walkthrough of some of the preliminary design so that committee members can get a sense of the residents that we're talking about. So I will share my screen again. Can folks see that? Yes. Okay, excellent. And deputy commissioner Morningfax, I will advance the slides as you direct. Don't worry, sounds good. Thank you commissioner for the record. Morningfax deputy commissioner for the Department of Mental Health. So what you see in front of you is actually the artist rendition rendering of the front entry way of the new recovery residents. This is based off of the architectural work and design team that we had. And we really want to kind of present, it's a residence and people who would be coming to live there or coming to visit there, that is the entrance to it. Not through a back door, not through some other type of entrance, but through a front porch, a Vermont covered front porch. And so all the parking and such like that, commissioning go to the next screen is behind the building. Again, trying to create the sense of a residence. And so you see at the very bottom there where it says drop off, that's the area that we were just looking at is the front of the building, the area in the back. There is a gymnasium that remains from the current site where Woodside is that and the Woodside building will be demolished and the new building footprint is what would be built. The outside yard has walking paths, places to gather, different things where we have the capacity to have meals outside, have groups outside, or just have the need or the request for space and things of that sort. And so you have all of that and then the staff parking, things of that sort would be around back as well as their entrances. We can go to the next one. So what you see here is one angle of one of the multi-purpose rooms. There are a couple of rooms that were designed in this residence that resemble kind of large gathering spaces that can be used kind of as a living room model or just places to gather, places to have community meetings or if there's no actual programming going on in that space, it's just a lounge space, whether it be for television or other things or just to have some space. But as you'll see, it has a wall of windows and you'll see throughout some of these images, the extensive use of lots of windows to bring in as much natural light and the outdoor into the indoors. There's a lot of research that's been coming out in recent years of the impact of having natural light in environments. As you can imagine, the current MTCR in its two FEMA trailers does not really have tremendous light being brought in and that really has an impact on people's natural circadian rhythms and being able to have good sleep and impacts on depression, anxiety, et cetera. We can go to the next slide. And so this is also that same room actually and it goes out the other side. There's a circular window there that actually the nurses station is on the other side so folks can be in there and there's still a line of sight so that people can look for a nurse if they need something or nursing can look in, things of that sort. And the doorway actually exits out into the dining area. Go to the next slide. And this is one of the other living room spaces in the residence. This is actually probably one of the first rooms that folks might encounter when they come into the building. It's after you come into the entryway, it's on your right. Again, trying to create living room style, comfortable furnishings, comfortable color tones, things of that sort. But also for any of the committee members who have had a chance to visit Middlesex, we're looking at these rooms. This room or the last room take up the entire space of what we have currently in the trailers. And so really trying to increase that space and bring in as much of the outdoors into the indoors. Okay, we'll go to the next. This is the dining and kitchen area. They're seating for 16 in the dining area but there's also separate spaces over by the counter in the kitchen. This is a kitchen that's fully accessible for the residents to cook on their own, to have groups, skill building exercises, things of that sort. It also has a commercial kitchen that's in the back where we will have staff that will prepare all the meals, except for maybe those times where the residents have decided that they're going to prepare their own meals or something of that sort or we may even have joint cooking exercises and such like that around holidays or special occasions, things of that sort. The door on your right that you see at the end of the dining area actually leads into a greenhouse space. That's again, I know for myself, having my hands in the soil is a very grounding experience. There's actually a lot of research that supports that. And so bringing in a greenhouse type place for residents to work on their own gardening and then that accesses out into the yard where there's raised beds and other things of that sort so that the residents can raise their own flowers, vegetables, et cetera, for cooking and for the residents. Okay, we'll go to the next one. And this is just a picture outside of one of the rooms. This is in one of the main hallways, but throughout the residents, there will be these little kind of areas of seat cushions and such like that so that there's places where people can have seating and just kind of get away or just take a time out and such. And so it's not just that if you need a time out or a space to get away that it's really relegated to your room, there are other places throughout the residents that folks can go or even gather to have a small conversation either to meet with a peer counselor or social worker or just a couple of residents on their own, okay? And this is the rendering of one of the bedrooms. Each bedroom has their own bathroom, private bath and you have desk and seating bed and then kind of the window bench seating as well and storage areas. There's a large kind of amour place and it's done with the thoughts of again, trying to bring in the natural lights and things of that sort, but also keeping an eye to ligature points and things of that sort as well in trying to develop and make sure that we have a safe and environment as possible for folks. So, and then finally just that it's, we can't stress enough that the work here, we're really looking at trying to bring in as much trauma informed kind of thinking and work throughout this. And one of the big parts of this is peer support. And so we're looking at having as part of the treatment team, peer counselors that are actually employed and working at the residents as well as significant collaboration with other peer organizations like from on psychiatric survivors and not only having folks that may come in as peer representatives to advocate and support residents but also to help collaborate with us in programming, come in to do programming, things of that sort. So it's a really important piece and we just didn't wanna lose sight of that and wanted to just bring that to the forefront here. Great, thank you, Fox. Can folks hear me or am I muted? Oh, you're good. Excellent. So I'm gonna stop screen sharing for a moment and I'm going to invite Dr. Kevin Huxhorn and Dr. Janice Lebel to share a little bit from their perspective. As I mentioned, their really excellent national content experts have been consulting with the department for years in terms of our overall implementation as a state of six core strategies. And we've also brought them in to help support us around the design of this programming and this project overall. So I will pause and I think I will turn it over to Dr. Huxhorn to start. Good afternoon, everyone. It's an honor to be invited to participate in this very important committee meeting. My name's Kevin Huxhorn. I'm a psychiatric nurse by training. I've been in the field for about 41 years as Commissioner Squirrel says I've been lucky enough to be working with the Vermont system of care since about 2005 when I was the director of the National Technical Assistance Center for State Mental Health Programming in Washington, DC. I did that for about 10 years, went on to become the Commissioner of Mental Health and Substance Abuse in Delaware for six years where I was challenged to implement a US DOJ settlement agreement based on Olmstead and the Americans with Disabilities Act. US DOJ had found that Delaware was too invested in inpatient services and had too many beds and not enough community services. So I wanna start out by saying that I'm a real proponent of the American with Disabilities Act and the right for people to live in the community with disabilities and with supports that surround them and was lucky enough to be able to implement that system of care in Delaware and reduce a number of our inpatient state hospital by about a hundred beds as well as bring up to scale a number of community programs. That said, in my experience working in most all of the states in the country, there's always a set or unusually a small group of people with these complex disorders that really need these kinds of services that are being discussed today in terms of a step down secure residential system. Because without that, they end up staying in a more restrictive, more unnatural system which is usually our inpatient level one beds as you turn them in Vermont. It is, I have to give you kudos for looking at both the needs of this group of people that are currently sitting in your level one beds and really trying to expand the options for these folks so they can get out of those beds, open up those beds for other people that need them who are often sitting in emergency rooms or just not getting level services they need while being able to provide an opportunity to this group of young people in many cases or middle-aged people with disabilities to get the kind of rehabilitation services based on evidence-based practices that we know now work and to move them back out into the community. And I think having sat in a number of meetings on this issue and really hearing the very valid concerns of the advocacy folks, I have to just say that it's not either or a state has the responsibility as you all know to try and provide for the most vulnerable people. And these are some of your most vulnerable people and they deserve to be served in a best practice type of system that's recovery-oriented, trauma-informed and helps them learn to manage the challenges that are keeping them from being successful as adults in their community. That said, Vermont is very similar to most other states in terms of the need to continue to grow and support our community service systems with diversion programs and act teams and peer support inpatient and outpatient services that include bridging services from higher levels to lower levels of care, independent living, single-site housing and vocational services. And I think for Maxwell and its way, you guys really, I mean, I remember back in 1998 we were looking at improving systems of care in Florida and I was sent to Vermont and to Oregon back in 1998 as models of best practices. So I think we all find ourselves struggling with our individual state needs. And again, I just have to say that I think the planning that's gone into this program has been robust and thorough. I think that the discussion about the need to use EIPs has been robust and thorough and I give kudos to the department to agree to negotiate the need for those. And I can only say that my colleague, Dr. Robelle and I are in support of this process, how it's been going so far. I think I'm not sure if my colleague is still on the phone. We are also working with another program in Vermont and so we're kind of taking turns doing that work today and she may have dropped off to help out on that other project. If not, Janice, please speak up and otherwise I'll turn it back over to the commissioner. So there she is. Thank you, Dr. Hochshorn. And thank you Chairman Lippert and commissioners Squirrel and thank you to the House Health Care Committee. It's a pleasure. It's an honor to share my perspective and I will say quite succinctly what Dr. Hochshorn said, I absolutely echo. My perspective is slightly different in that I've been working in public mental health in a neighboring state for the last 36 years and I oversee facility based care and working on transformation within our state system. I can just absolutely affirm what Dr. Hochshorn has said that the elements that are in this proposal are absolutely consistent with state of the art, evidence-based practice and what every state system should have in place to be able to address some of the critical challenges that every state and it's happening in my own state right next door. We have a serious problem with emergency department boarding which is creating a clog in the system and backlog throughout hospital-based care and the flow through the system creates its own problems when it's impeded because we don't have an adequate continuum of care. So what I think is being proposed here is absolutely consistent with state of the art practice and what's essential to be able to get the system and keep it functioning well. I would however say that commissioners Squirrel and her team have gone further than what they've recommended because it's not just a really solid evidence-based trauma informed approach. This model is trauma responsive. It's one thing to be trauma informed that's taking the information but there's a responsibility owed to the information and that's what's present in this model and not just in its design but how the design has been informed by the consumers, by the person served, by the advocates and respected. And that's what I see in this is that the model, the process all connotes tremendous respect and value for the service, the service users and the advocacy community itself. So I think what you've got before you is a very solid proposal that is trauma responsive state of the art and associated with strong positive sustained outcomes. So what you will find that people will be able to receive the service and not come back into higher level of care. So I thank you for this opportunity to be able to share this perspective. I apologize for having to drop off quickly to attend to another meeting, but I thank you again. I was muted. Thank you, Dr. LaBelle. Thank you, Dr. Huck Schorn. Really appreciate your thinking and sharing your perspectives and also the great perspectives that you've afforded to the department as we continue to evolve and improve our proposal. As I said, I feel a deep sense of responsibility to provide for care for these individuals and to also be responsive to the feedback that we've received from the community. So I'll just wanted to share a little bit in terms of next steps and then we can open it up for questions if it serves the chair. Do have a slide related to the timeline. I won't put it back up but you can view that on your own. Well, maybe I will share it just briefly just so folks can see. Okay. Do folks see the full screen? We do. Excellent. So this is the current project schedule and timeline and just a little bit related to the capital bill and that process in and of itself just for the committee to be aware the Department of Mental Health or I should say BGS, Building Grounds and Services already received an initial tranche of funds of $4.5 million to start the process to replace the current recovery residents. Those funds have been utilized for the design development that we've talked about some of the site selection pieces, et cetera. And then our current capital bill request is for the balance of that which I think is just over $11 million. So I just wanted to share that just as a point of reference. And this is the current construction timeline. You can see where we have come in terms of some of the design work that we have done. And then when you look out ahead given the sense of urgency and replacing the existing facility if we are able to advance this and move it forward then we would be ready for occupancy at the end of December, 2022. So I just wanted to note that I'm also wanting to note that the department is greatly looking forward to continuing to work with our advocacy partners, DRBT, NAMI, Legal Aid, Vermont Psychiatric Survivors and others. And certainly I think we are poised to significantly advance our mental health system of care in the right direction and to provide equitable access of care to those who need it and really require the step down capacity. And so with that, I think we will pause and we will open it up for questions. Great. Thank you, commissioner and others. We're going to take some questions right now in order to be respectful for other witnesses. We're going to have to come back to further questions at another time I'm afraid because I think there are a lot of questions. I certainly have some and others do I know but let's start by, I think Representative Peterson had a question and I think Representative Burroughs and then Representative Black. Yes. We're going to be focused in our questions if we can. Absolutely. Thank you, Representative Lippert. Commissioner Squirrel, thank you very much for your presentation. The only thing I was wondering about and one of the slides you showed the new facility and the existing facility, new facility annual operating cost was 9.1 million. The existing was 3.1 million. They also mentioned 2.9 million operating costs, staff of 28. So it's around 3 million to operate. You're going from seven beds to 16. I'm wondering why the operating cost is so much more. Why was it, are you adding other things and does that make it more? I just curious. Yeah, no, it's a great question. I think a number of us have. It's a great question. Thank you. And as I noted, those initial operating estimates were based on our previous proposal. Essentially we'd be looking at going from, I think it's 28 staff to possibly 70 staff. So a significant increase in staffing. I think we had currently proposed at about 41 new staff. So that is the primary growth, I think, in the operating costs given the shift that we have made in terms of not contemplating the use of seclusion and restraint at this program that does decrease our needs for on-call doctors, other staffing needs, which will decrease the staffing grids. So we do anticipate that the overall operating costs will be reduced. I just don't have those numbers for you today. I need to go back with my team. We need to work with our partners to kind of recalibrate what those staffing needs will be. And then to come back to you with a revised number, which I anticipate will be lower. And then again, the general fund portion of that is less than the overall operating cost because we can utilize Medicaid. So just wanted to note that as well. Okay, and the cost of the project was 11 million. Is that what I heard? The total construction cost is actually 16 million, but we have already received $4.5 million in a previous capital bill allocation. The operating costs would be a part of our FY23 budget ask. Thank you. You're welcome. I'll just note for further point in time, we will be very interested to know where that additional operating cost funding will come from since there's nothing in the budget currently and it must come from somewhere. So you can answer that at a different time. Representative Burroughs. Thank you very much. One short question, which is, what are the stars? What are the stars represent on your timeline? Am I still sharing my screen? No. Okay, the stars on the timeline, I believe indicate things that have been completed. So the design development estimate, the construction document, demo site mobilization. So I think I might have to follow up with BGS to get clarity on that, because now that I look at that, I'm not sure. So I apologize. I don't know, Deputy Commissioner Morning Fox, do you have more insight into the stars? Unfortunately, I don't. Okay, but my other question is, what alternatives did you explore before moving ahead with this plan? Alternatives to serve this population? Yep. Thank you. Yeah, of course. So I think that what we have seen and what we have experienced, and again, I think this was a decision that was made back when post-Hurricane Irene, when Act 79 was put into place, there was a significant investment in the community at that time. I think that's where we established a lot of our network of intensive recovery residences, also identified that there was still a continued need for this sub-acute population who required a secure setting. So I think the need for this setting was established at that time. And what we have continued to see is increasing demand and acuity. We continue to see this cohort of individuals who is occupying longer lengths of stay in our inpatient beds. We continue to see an experience that, based on I think some of the vignettes that Dr. Richards shared, that these individuals do present with complex safety needs in the community as well. And so we really do wanna make sure that we can continue to serve them. And I think that the current use of the seven-bed facility has been a real example of that success that we have had that capacity to step down individuals to and they have then been able to transition to the community. And so continuing to expand that and build on that success feels very critical in addition to recognizing and experiencing some of the limitations of those community supports pending these individuals' needs. So I guess what I'm asking is, did you look at what you could do by scrapping the whole thing and starting over with a different kind of program or did you just decide to move forward with filling the need that you knew was already there and going with what you know? Yeah, I think we certainly evaluated, was this program actually meeting the needs of the individuals that it was designed to serve? And I think our assessment from that was yes. If the current middle sex program was not meeting those needs, then I think we absolutely would have pivoted to something else or thought about a different kind of program. And certainly have evaluated that having this critical capacity in a secure setting for individuals with these high acuity needs continues to be an essential component of our system of care. So a 65% success rate is, I don't know, is that a very good outcome or is it ideal or I really, I don't know so I'm just asking you. It's a good question. And I think given the acuity of the individuals that we're talking about, I think some of the vignettes that Dr. Richard Sears shared, hopefully gave you a sense of some of the needs of these individuals that a 65% step down right to the community certainly feels like a success to me. And Deputy Commissioner Morning Fox, I know that you were trying to say something as well. I would just add that during the past several years while we've had the middle sex residents in trying to support some of the individuals as Dr. Richards kind of described in getting out of the hospital and not having beds necessarily available at middle sex to transition to so as to not have people left in hospitals because that's one thing we all agree on that from a state we've been a leader in trying to de-institutionalize and not warehouse individuals in hospitals who do not need to be there. And so some of the work that we've done is to try to create some individualized plans for folks. Part of that is what has created some of the my pads as discussed, the part of the issue with the my pads is that it takes anywhere from eight to 18 months to get that set up in that the designated agency has to find the actual residents and get it prepared, find the staffing, get them prepared and then eventually transition those folks from hospital to a my pad like place. And so we've looked at other models like that and my pad does work for many individuals. But again, every time we're trying to set that up for each individual, it can take up to a year, year and a half to actually get that set up. And when we set up individual plans for just a single individual, we're looking at, again, similar startup timeframes to finding the place and the staffing but also when you're talking about an economy of scale of one, it becomes a pretty cost prohibitive in that sense as well. So we have looked at some other models and have done some of those other things in order to get people out of the hospital. I think that's partly why we landed kind of in this direction as well. Thank you, Representative. We're gonna take a few more questions and then we're gonna take a break and then we're going to hear from our other witnesses. I'm going to also just note that I think there are going to be many questions that don't get the chance to be asked today. And so we're gonna need to find a time for the commissioner and deputy commissioner to return perhaps with others, but to really, there needs to be a time when we can ask all the questions we have in order to not feel like we're not getting that opportunity. But it's a balance trying to find the respect for other witnesses to be heard as well. So we're gonna take Representative Black, Representative Donahue, Representative Page and I will go to hold on my questions. We're lucky. You may have answered a little bit of this in your last answer. I'm really wondering what percentage of residents in middle sex currently end up going back to a level one bed? And if there's kind of a revolving door between the level one beds and a step down facility and if you think that this new facility addresses some of that, I don't know if that's a problem. I'm asking if it is a problem. Yeah, it's a great question. And I would just add that, creating this step down capacity, improving the environment of care will all have great benefits for the current residents and for new residents, particularly given the acuity that we are providing that step down care for. I would also say that it's really important and that we acknowledge and have good systems in place to identify when someone might require hospital level of care as part of their treatment and recovery. Certainly what we're proposing to do is create an environment of care that mediates against that to the best of our ability because we've created a trauma-informed setting. We've got the right staffing, the right programmatic components, the right trauma response, trauma-informed response. But someone may require re-hospitalization to stabilize and assess. So certainly when we talk about the individuals that we have successfully transitioned to the community, there are also individuals that have had to be re-hospitalized just as there are, across all of our intensive recovery residences, group homes, certainly, that is something that does happen for individuals. So I do think our proposal will hopefully mediate against that, that's part of the intention. And that by having this step-down level of care that's appropriate for them, we mediate against as well to Deputy Commissioner Mourning-Fox's point where our care management team works 24-7 to try to move individuals to the community. And when we don't have capacity in the middle sex, for example, and then we're trying to fit capacity in the community, and sometimes we worry that maybe it's not the right fit. Are we asking the community provider to do too much? Are we really able to keep individuals safe? And then we have those failed community placements that are really not in the interest of the individual's recovery. We don't want anyone to be put at a public safety risk. So those are other factors that we take into consideration as well, when we think about this. Okay, thank you. Oh, of course. Oh, go ahead. I was just gonna add that there have been a handful of folks, I don't have the exact numbers in front of me, that have been re-hospitalized and then readmitted to middle sex. That does happen. By and far, that's not the norm, but I think we've served 53 individuals but have had maybe over 60 admissions to the facility. So there are some folks who have been re-hospitalized after a period of stability, and then have returned. And there's some variations to that kind of occurrence. But so it does happen. I do wanna be clear that that does happen and such. And I think as the commissioner said, our goal here is to try to help through the environment of care and the staffing and the treatment modalities that we can actually put into place in this new residence that really aren't able to be done functionally well in two trailers will have an impact on that. I think our outcomes will, and kind of devil's in the details, the outcomes will tell us how much of an impact. I think the research kind of supports that it will have a significant impact, but I think we'll have to see how that plays out yet. Representative Donahue and the representative Page and then we're gonna take a break. I'm just gonna put about three questions out there that we can come back to, but we probably don't know them offhand anyway. So first of all, I didn't see on the timeline where the certificate of need process with the Green Out and Care Board fit in and how that affects the planned timeline. Secondly, it would be good to follow up more on that discharge data, what happens to the 30% who, what happens with them, but also the long-term tracking of people who leave the hospital, as you said, six months or a year may be back. How does that compare in terms of long-term trajectory? But the third one is, I think two weeks ago when you were here, I had asked for data on the forensic breakdown. So I would really appreciate getting that. I think that's really actually critically important because of other moving pieces and the Senate and so forth that could change lengths of stay and so forth, understanding what for involuntary patients and level one and the current secure residents, what the percentage of the care time, the bed days are forensic status patients. Yes, thank you for that. Yeah, thank you, Representative Donahue. All great questions. The COM process we have put in our application or notification of intent to apply. And certainly there's an opportunity for other stakeholders and partners to weigh in on that process. We can follow up. We did start to look at the discharge data or looking at the other 30 plus percent, if you will, so we can follow up on that and then see what longitudinal data we have in terms of beyond that. And I thought we had pulled some of the forensic data. I'm just looking at my notes here but we may have to follow up with you on that. Yeah, I have some data here related to forensic admissions and FY 20 to FY 21, but these numbers look low to me. So I just wanna confirm before I state that so I can follow up. Right, because it's actually not the number of individuals as much as, you know, how much of the bed use and the secure residential, how many of those folks are the cohort as you call them that go to secure residential. Thank you. Of course, thank you. Let's come back to some of those questions. Representative Page. Yes, and you can answer these questions later on, but you made a pledge that Chair Lippert emphasized, you'd be putting that in writing so that perhaps see it in the future. And also, will this as mental health needs grow in our communities, this is gonna be large enough. It's a great question, Representative Page. And can I just clarify in terms of what you're requesting in terms of the pledge? Well, it's based upon what Representative Lippert called out earlier. I was just repeating what was being said and I didn't want to get lost. Yes, Representative Page, we will ensure that I guess maybe the easiest way to do that would be through the document that we shared with you that gives an overview of the program and we can state that explicitly. And in terms of your good question about capacity and data, so we did look at, you know, kind of current capacity operating at somewhat full capacity on a regular basis, looking at the, you know, bed days that these individuals occupy in terms of level one, looking at the demand that we're currently seeing for these beds, which is where we arrived at this number. Also wanting to be thoughtful and careful about staying under the threshold of what would be considered an IMD. So that, you know, is something that we're also thoughtful about as well. I think the department is confident that the current capacity that we have proposed will address current need and future need as well. And could you expand at a future basis if needed? I would have to, I mean, the site footprint, I think may limit future expansion, but that is certainly something we could look at and we're always being thoughtful about the space itself being able to be reconverted for other purposes, you know, for example, when we've talked about the 12 new level embeds at the retreat as needs, capacity shifts in the system of care, could those beds become, you know, some kind of intensive crisis beds? So those are things that we're also thinking about, but I think I'd have to consult with BGS in terms of the footprint and whether or not it could afford expansion. And one other piece just to speak on the expansion, we also would have to really take a close look at that as well. As one, if we expand beyond 16 beds, the federal government would potentially look at that as an Institute of Mental Disease or an IMD, which could mean a loss of the federal funding for the residents, so. Okay, so thank you. I am going to indulge myself, at least with one question that just jumps off the page and I just don't want it to be confused. In terms of the photos that represent, or that Deputy Commissioner Fox was showing us, this is indeed continuing to be a secure residential facility, is it not? That's correct. So will there be a secure fence around the entire facility? Yes, it will be similar, well, the fence will not be similar, but the current secure recovery residence is surrounded by a fence as well. I think you just need to not be unaware that seeing pictures of the facility itself does not suggest, leaves one wondering, but in fact, a secure facility that will be surrounded by a fence. It has one in the picture, it's just hard to see. It's hard to tell. It basically just follows the outline of the buildings. The yards are very small, so it's just contained there on the picture, that it's hard to see. I don't want to just focus on that, but I think it would be a mistake for people to be misled or misunderstand that that is a change in the design, so. No, and just to be clear, the residence itself is not surrounded by a fence, the side and rear yards have fencing. There's no fence in the front of the building and such like that, so when you approach the building, you don't have to go through a fence to get into it. That's not clear from the presentation. I have other questions as do others, but this has been very helpful. I think it's clear as well that there's been some responsiveness on the part of the department to some of the questions and concerns that have been raised by advocates and frankly legislators as well, but I think right now I'm going to suggest, hey, I got to take charge of this to make sure that the time work. So Devin Green, you are listed as our last witness today and because you have more flexibility many times than others, I'm going to ask if we're not able to get to you today that we reschedule you from the hospital association, it has no impact, there's no reflection on your testimony, but I want to make sure that we scheduled someone from our care partners because we moved them up on the list only because they had a time constraint and we'll hear from them and then Ward, is it Niall? Niall I think, we'll hear from Ward Malika and I'm Kareem. Let's come back, let's take a, let's be realistic and come back at 25 after, let's take a stretch, let's go off video, we all need a break from Zoom. Let's rest our eyes and hopefully get up and stretch and we'll start promptly at 25 after with hearing from, and I'm Kathleen and I'm sorry, the printing on my machine doesn't show your last name properly, but we'll come back.