 Good morning. This is joint justice oversight committee. And today we're joined by the other representatives, Senators from various committees because of the subject matter is health, prison health, as well as competency evaluation. And we have what was handed out last week or last time we met, which is the committee work for the 2023 interim. And Senate Representative Edmunds will pass this around. We also have a letter from the Commissioner of Corrections from Representative Edmunds' committee regarding some of those on that in regional correctional facility. Sorry. So I'm Dick Sears. I chair the Senate Administrative Committee. I'm going to set the appropriations committee and chair this committee and others to introduce themselves. I'm going to represent them. I chair the House Corrections and Institutions Committee, and I'm also vice chair of this committee. Senator Kezier on Hinstale. I chair economic development and we will be having a housing hearing on August 15th. Just so folks know, obviously, usually central to recidivism issues or struggles that people are facing that are compounded with the flooding. And I apologize in advance, but I look at my phone, my three-month old, he's in the pro temp's office right now. So that is hopefully going to go great. And it's also a public service announcement in case anybody needs help. Good morning, Senator Bob North, Franklin County to include L Word in the County of Graendile. I sit on Senator Senator Judiciary along with Senate Doug Offs, just to see everybody. Good morning, Representative Tres Wood. I'm chair of the House Human Services Committee, and I serve the communities of Bolton, Beals, Gore, Huntington, and Waterbury. Good morning, I'm in Renner. I represent Chittenden North, which is Milton, Westford, Essex, the rural part of Essex, and Fairfax, which is in Franklin County. I am a clerk of the Agriculture Committee, as well as a clerk of Institutions and Senate. Hi, everybody. I am Martin Marakulik. I am a senator from Chittenden Central, Burlington, Winooski, a little bit of Colchester, and part of Essex. I am clerk of Health and Welfare and Vice-Chair of Senate Education. Good morning, Senator Dave Weeks, representing Welk County. I believe I'm here because I'm a Vice-Chair of Health and Welfare. I also sit on Education Committee. Papa McFlawn. I'm the Vice-Chair of Health Care Committee. I represent Barry Tom and Pat Williams. I'm Martin LaLone, representative from South Burlington. I'm the Chair of House Judiciary Committee. I'm a Trevor Swirl representing Underhill and Jericho. I'm on House Appropriations, and I also chair the Legislative Committee on Administrative Rules. Good morning, Ginny Lyons. I chair Senate Health and Welfare, and I sit on Justice Oversight Committee. So it's really a pleasure to be here in the conversation today. I think it's exceedingly important. There are a lot of things going on here. I've been talking recently with Medicaid about their work with folks who may be transitioning out of the Department of Directions. We also have online representative Goldman. I think she does it. Yeah, I'm here. Leslie Goldman, representing Wind of the Three, Rocky Hamwest, Minster and Brookline on the House Health Care Committee. Thank you. And we also have Katie Delaney, who's called the committee assistant, but she really runs the committees. And Ben Novigalski, who's our ABLE Legislative Council, does a terrific job for us on this committee. So with that, I'm going to start. The first topic is health care in Vermont prison. And we have Leslie Goldman, who's a spokesperson for the non-just Justice Coalition. Join us at the table. Okay. Meg McCartney is going to introduce us. We're going to be fitting up and down and up and down. Okay, well. It's a trip. All right. Okay. Whatever. Okay, good morning. It's nice to have met everybody, although I don't remember who you are. My name is... Well, our name tags most... There you go. Okay. That helps. Thank you. My name is Meg McCartney, and I'm from Marlboro, Vermont, and we live in County. And I'm a member of Vermont criminal justice group. No, I'm not. I'm from Vermont Justice, I used to be. We're a group of health careists working for changing Vermont's legal system. And we have ties with incarcerated and formerly incarcerated people. We have loved ones in Vermont prisons that range in age from 21 to 71. I myself have been living with incarceration for 12 years. Most of us have been involved with, are still involved with other justice organizations, such as Ally's Line, Vermont Cure, Vermont is for criminal justice reform, which I was once a member of many years ago. We're currently focused on health care due to the April death of David Mitchell. We wanted to shine the light, not just on the steps, but on the experience of people inside our prisons, people with no agency over their health care. We felt that if Vermonters and our legislators knew what people were experienced, they would demand change. Members of this group are in a unique position of having a direct line to be incarcerated. We gathered over a dozen stories of inadequate health care from people in and out of prisons that were eventually sent to the legislators on the Joint Justice Committee. And we hope to people, affected people, will be testifying today. One will be not on Zoom, but will be on the computer screen. And the other one we hope will make it in person. What we collected the stories by sending out an email blast to people that read our blog, and also reaching out to people that aren't a Facebook group. And we got 12 stories that we eventually sent out to the committee, more payment after the fact, but we started with the 12 that we sent to you all. And our takeaways were a comprehensive lack of mental health services, lack of skill and resources among health care workers in prison, barriers to preventing action to address urgent medical needs. I will add a simple one barrier that I believe happens. And that is that both staff people in the prisons and medical staff in the prisons, I believe, because I was trained to be a volunteer in the prisons, they are trained to doubt. They are trained to be skeptical when people are asking for help. And the reason is I believe that sometimes people exaggerate their needs and they just want attention or whatever. But I think that that is a serious issue when it comes to people that are really suffering medical problem. And I think that we've seen that several times in our prisons. And changes to protocols when people come incarcerated, they'll come into the prisons with a certain set of medical needs. And the medical team in the prison will tell them we're not doing that, we're doing something different. And that often causes some serious problems for that person. Deaths soon after release, in addition to those incarceration to the lack of care in prison, one of the stories we collected was from a woman's friend. The woman was in Chittenden and had been complaining about rectal issues for a long time. And they told her she just had hemorrhoids and gave her aspirin. And when she was finally released, she was told that she had terminal colon cancer. I may be getting the details of that story incorrect, but that's the gist of it. Do you see structure, culture and structure make it difficult for people to get the care they need and have their grievances addressed? And I think I talked a little bit about that when I talked about the barriers preventing action. And we listened to this committee's last meeting and know that several of you had questions. So we are going to try to address those questions this morning. Okay. The first one that I am going to address is the question of nutrition. Did you identify yourself as a writer? Yeah, do I need to come up or can I speak? Well, are you testifying? Yeah, I will be speaking to you. Okay, well, are you? I did identify myself at the beginning. Is that who you're asking? I think you introduce yourself at the beginning. Yes, I did. Yes. I'm asking if somebody else speaks, they need to identify themselves for the record. That's what I was. Okay. So my name is Jonathan Elwa. I'm Elegan Browbro. And yeah, I'll be speaking to this point about, you know, older and sicker, which is a line that you all heard when it's from the DOC we're testifying to this committee last month. It's a line that the public has heard quite a few times throughout the spring is there's been a focus on health care. And I think it's really, really important to talk about because it kind of illuminates some of the dynamics around these issues. So this line is used to explain away preventable deaths and make them seem inevitable because these people are so old and so sick. And it really obscures the role that DOC plays and the sentencing policies play in creating this older and sicker population. So the first, neither two sides fit first with the sicker side. The fact is that prison makes people sicker. And this is not some sort of like radical conjecture. This is from the DOC zone data from the print studies that have been conducted in Springfield on that Southern state. We see that both incarcerated people and folks who work in corrections in that facility are reporting these outcomes due to their time at Southern state working and living there. And these numbers, just to be clear, the phrasing of the question is since started working corrections, I've developed the following. Many people are given boxes to check or since entering prison, I've developed the following. So this is not the percentage of folks who come into prison experiencing these conditions. It's the percentage of folks who develop these conditions during their time in prison. And so the numbers are really striking. You know, over two thirds developing anxiety or depression, over half developing PTSD, also physical ailments like obesity or high blood pressure are very common. And that's for incarcerated population. For the correction staff, over half developing anxiety, over 40% developing depression PTSD. These are really serious numbers that make it clear people don't just come into prison sicker, they get sicker in prison. And the other side is this aspect of the older population. So that has a lot to do with our sentencing, because it's not that older people are committing more crimes, or that the majority of folks coming into prison are older than they used to be. Those numbers are actually pretty stable in terms of the ages of people who are becoming incarcerated. These are older folks who have been there for decades, you know, the crimes that they were convicted of happened decades ago. For the most part, these are people who are, you know, pro-social who want to return to their communities, and who clearly also need the resources that are in their communities, not in prisons, to keep them healthy. And so the other side of this is also if people truly are so old and sick, they really don't seem to present the kind of threat, you know, of someone who were told needs to be, you know, kept in prison to protect the community. So yeah, I appreciate you all listening to that point, because it's kind of a window to, yeah, explore these dynamics. And now we're on to the questions. Now we're on to the questions. So I took the question about nutrition, and I did a little bit of research, and I found out that the Farm and Institute New England with the Vermont Law School had done a study on prison nutrition all over New England. And they found that the prison meals cost $1.23 on average. That's about less than the half the cost of a school meal. I haven't been able to get the specific data from DOC. I could ask them because I wanted to know what the average cost specifically for Vermont was, and maybe somebody at DOC can help with that information at some point. The sample meals appear to be varied, but a closer look shows that they are weighted heavily towards processed carbs and sugars and breads and a little bit light on protein, vegetables, and fruit. And it also gives the impression that the portions are measured, but some portions are not measured. Sometimes they're a little heavier handed with pasta, for instance, and a little bit light on the meat or a slice of cantaloupe. The vegetables are often overcooked and unappealing. People often report that they're hungry after meals, and according to the print survey, again, over 50 percent say they don't get enough to eat, nearly 70 percent say the quality of food does not support a healthy lifestyle. It's impossible for the menu to tell how much the food is over processed. The AMA website says the concerns of over processed foods, ultra processed foods, is an increased risk of type two diabetes, cardiovascular disease, and dementia. And if we look at the commissary, we will see that the commissary is really loaded with ultra processed food. In fact, if you look at the cereals that are offered, there are three cereals and they're all almost like a child's cereal. They're very sweet and sugary. And there is a beverage that is served every day on the menu and that is loaded with preservatives and sweeteners and some sweeteners that have kind of, if you background to them. And the package itself says not for daily consumption and they receive it at every dinner. There's no nutritional value if you look at the ingredients in this beverage. So suicide it's going to be taken by. Good morning. I'm Jennifer Canfield and I live in Burlington. So I wanted to answer your questions that you all had last time about suicide protocols in the DOC. So I'm going to give you my personal experience. So my son is incarcerated and I wanted to just kind of get you to think about what we all have heard about the thing to do if you know someone is suicidal, right? We've been told find someone you trust to talk. And so I'm my son's trusted person. We talk every day multiple times. Sometimes he's 21. He went in when he was 19. He went through a really difficult time and he does go up and down. But he was talking on the phone and he said, mom, I feel so depressed and scared. I feel like I want to kill myself. So those are his words. I'm up the phone immediately was taken to the whole. So the whole is solitary confinement. And so right now, I fully understand the DOC's responsibility to keep people alive. Like I'm not disputing if that's a responsibility that we have to take seriously. But for him to be taken to the whole and then move to what we call a suicide cell, you're stripped of your clothing. So he was wearing a paper smock. And it was like a Friday afternoon. And it was a holiday weekend. So he did not get any attention from mental health staff. I know they do checks every 15 minutes, but that's a guard. It's not anybody's thing. He wasn't allowed to call me. He wasn't allowed to have a book, nothing to write with it. I finally was able to get him a journal. I think on Monday I called and I just said, please can someone bring him a journal so he can write. So you know, it's really embarrassing to have your clothes taken away from you. I understand that that's for safety so that you're not going to try to do anything with your clothing or your bed. But he sat for five days until somebody got back to work all day and could talk with him. At that time, it wasn't even a psychiatrist that he spoke with. It was a nurse or someone from the medical staff that was just checking in with them. And of course, at that point he's going to say, I'm fine. I'm fine. I'm not going to do anything. And my takeaway from that was what person is going to want to talk about how they were really feeling if they know what the consequences are if they say those words. That's our current standard in the DOC for someone who's feeling suicidal. We've got to put them over here and take their stuff away. And that feels like punishment. So I think we could be doing better with that. I think there needs to be a way for people to feel like they can trust the system that they can really talk about how they're feeling if they're at that place in their life. I'm going to move to the next question for mental health treatment. And you all asked, what is mental health care and prison actually entail? My son came into prison after having a full year right when the pandemic started of psychotic breaks. And we were not able to get him the care he needed because people were locked down. We couldn't get to providers. Telehealth was at best, you know, what can we really do with telehealth if you're a 19 year old who's having psychotic breaks for the first time? So he ended up in jail. Of course there's more to the story, but my feeling is that his mental health was a big reason that he ended up there and it was during the pandemic. He did not get any kind of full diagnosis when he came in. So we just don't have the setup to do that. I know they do an intake and I know they ask a lot of questions, but it's not a full psychiatric diagnosis. And so you have a young person, 19 is a critical age for things like schizophrenia and bipolar to start. You have a young person coming in with these symptoms. Why are we not having a fully trained psychiatrist do an intake and get a diagnosis? He ended up on some meds. I think some of them are helpful, but I've spoken with psychiatrists about what he's on and they feel like that's probably not exactly what he needs and he doesn't have a diagnosis. So I think we could be doing better with that. There's no counseling. There's no group therapy. There's no kind of what we would in the community want to have for mental health treatment if we ourselves are experiencing some of these things. He ends up spending a lot of time on his tablet because that feels like the safest place for him. But I don't feel like that's going to get the treatment he needs when he gets out. So my feeling about mental health is if we really want our communities to be safer, this is the place to start because if we can do good diagnosing, we can do good treatment plans, we can carry that over to the community. So they're going to have that continuity when they get out. Our communities are going to be safer. So that was what I thought about suicide and mental health. And I think we're going to have Sam talk about sickness. My name is Timothy Burgess. I'm a member of the Vermont Justice Coalition. I'm also the state director for Vermont. And in addition to all of that good stuff, I have been incarcerated and I am a person who works with people who are incarcerated currently. So in terms of turnaround time on six slips, I'll go from my own experience and sort of give you an update on what I'm hearing from people who are currently incarcerated. So my own experience, and this is over five or 10 years ago, was that six slip turnaround time was approximately five to seven business days. Now, if you flip and hurt your arm, and I'm not even going to talk about breaking your arm, I'm talking about just hurting yourself, you start on Monday, let's say, and you don't and you say, I really just need time on and that doesn't happen till Friday or the following Monday. Generally, those issues, a small issue can go away in that time. And then you're called to medical and they assume that you were just making it up to get out of whatever. That was my experience. Having a heart condition, having a pacemaker, which I got after my incarceration, but certainly happened during the blood pressure and the heart condition developed strongly during my incarceration. The issues I dealt with were the issues of if I got dizzy or started sweating or had heart chest pains. There was a reaction as if you'll be, go to your cell taking that. Those things may have improved since I've been there, but that's not what I'm hearing from people who are currently incarcerated. The people I'm hearing from or currently incarcerated are saying that those turn times are still within three to seven days, which is two days. I'll give the credit there. And it's a problem. It's a real problem. If you have a headache and you need a Tylenol, as I said earlier, by the time you see medical or by the time they prescribe the, this was my experience, by the time they prescribed Tylenol, well, you don't need it anymore. And now you're on a course, by the way, they continue that track while you order Tylenol in April and in June, you're still getting Tylenol at every medical call. So that, that tends to be a problem that I experienced and that people who are currently incarcerated are experiencing. But those are my stories. And if I can answer any questions, feel free to ask. Thank you. Good morning, everyone. Thank you for having us. I'm Leslie Thorson and I have been a high school based registered nurse for 45 years. I also did a very small stint in the Windsor work farm where I did 35 years ago. I did get to witness some compassion in healthcare there. I would like to talk about the healthcare prison versus in the community. And I'm going to do that under the umbrella of sciatica. I'm going to use that as an example. So in the community, let's say an individual wakes up with searing nerve pain going down their leg, they can call their medical provider and they can get an appointment. So you have a closed loop form of communication. You've got your appointment. You can go to your medicine cabinet and take an ibuprofen. When you are in prison, you are going to be filling out your six lip and you're going to be waiting. You're going to be waiting for a response. You're going to be waiting to find out if your six lip made it to medical. So you have an open-ended question, am I going to get care? And you cannot go to your medicine cabinet and take an ibuprofen. So when an individual arrives in the community with their healthcare provider, they're going to get a hands-on assessment. Their concerns are going to be addressed. And they most likely will receive the conservative evidence-based treatment for sciatica, which is going to be ibuprofen or another NSAID and REST. When an individual, oh, but most importantly, you're going to get a follow-up appointment. So in six weeks or four to six weeks, if it has not resolved, you already have an appointment for going back to your doctor. And if you need to call for a question or you have your condition worsens, you can make a phone call. In prison, when you're finally seen in medical, it's most likely going to be telehealth. You're not going to have a hands-on assessment. You're going to have a telehealth assessment. And you're probably going to get that first conservative evidence-based treatment of the ibuprofen, REST, and AIDS. You're going to be instructed that if you need to come back for this issue, you know how to fill out a six-lip. So you're not going to have your guaranteed follow-up appointment. So six weeks go by. The individual goes back to their community provider, and they still have sciatica. What is going to happen then is an MRI is going to be ordered. They're going because sciatica is not a disease. It's a symptom. So why are you still having this symptom after the conservative treatment? So you and MRI will be ordered. And based on that result, you might be referred to a back clinic or to a specialist. If you go put your six-lip in and you get back to medical when you're incarcerated with your same sciatica pain, you are going to get that same conservative treatment. You're going to get the ibuprofen renewed. And this is exactly where the evidence-based standard of the community care and prison care diverged. The health care model in prison does not reflect a community health care model. I feel that intentionally not ordering an MRI or a follow-up study for an individual suffering with sciatica is a form of willful negligence. I also feel that pursuing a willfully negligent health care model for a profit needs to change. And when conditions are not treated, they get worse, as we have seen. Next one, John. So this is John Thelwell. Again, this next slide is going to be presented by Will Hunter. I'm unmuted now. So can you hear me? Okay. My name is Will Hunter, and I would have liked to have been there this morning with you. I'm in Springfield, Vermont, where I run a housing program where I have the number of people who have been recently incarcerated. And the reason I'm not there with you this morning is that yesterday I was confronted with the release of two people, one of whom I had bad things notice was going to get released, and he was released homeless as he was maxing out. He wanted to borrow some money from me to pick up his meds. And because he has a chronic alcohol problem, which is why he walked up, I told him that I would pick up the meds for him at the pharmacy. When I got to the pharmacy, I was told that there was a prior authorization that was required, and that they had no idea who needed to do what to have that happen. I presented him with that information, and he decided that he would like to go to New Hampshire and relocate there. And I loaned him some money so he could get a ride to New Hampshire. The other fellow who I did know was going to be getting out, I had attempted, because he has a long history of mental problems, and I've housed him before, I attempted to talk with the mental health providers in the prison ahead of time to find out what medication he was on and make sure that he would have it when he got out. Even though he was willing to sign or release the medical people apparently were not willing to talk with me. And so yesterday when he got out, I picked him up to provision, and we went down to the pharmacy. He had a slip in his packet of materials indicating that his psychiatric medication was being called in last Friday. When we got to the pharmacy, there was no record that anything had been called in for him. By this time it was 4.30, I tried to call the jail, and when you call the jail, you have an option to talk to the mental health and get the numbers. He mutated. We lost him. This is the world of computers. I'm excited to announce everybody I think of to see whether anything could be done. I didn't get any response from anybody official, but I did contact Jen Canfield who you heard from a few minutes ago, and she gave me the name of Annie Rand-Lissano. I'm not sure I'm pronouncing that right, but I sent her a copy of the email that I had sent, and first thing this thing, I got an email from her saying that she had instructed the truth be dealt with promptly this morning, and I called Rite Aid a little bit before this meeting began and found that yes, now there is a prescription there, and in a couple of hours, probably after we finish with this hour-long segment, I'll be able to go pick it up. I'm using these two examples because they are absolutely typical of what I experience almost always with people that come out of prison. Many of them are prescribed Suboxone, but they have no way of getting Suboxone when they get into the community. I have gone through making phone calls and sometimes being lucky enough to get a really cooperative Medicaid worker who gets the Medicaid in place, but I'm trying to provide housing, and I'm trying to provide some support, but it shouldn't depend on me being able to know how to navigate the system for people who have mental, physical, financial problems to get the medication that some professionals have determined to need. The fellow, the alcoholic who's now gone to New Hampshire, a couple of times I got calls while he was incarcerated asking if I could transport him to Valley Vista because apparently the Department of Corrections couldn't get him there. One of the times I did it, I wasted an afternoon, he never was ready, and then by the time he was ready found out there wasn't a bed for him. The next time that he was ready and I got him in the car, we had to stop to get his medications to go there, and once again when we got to the pharmacy nothing had been called in and more time went on. So these, I could give you many, many more examples, but I think you get the drift. If we're concerned about making sure that there is a seamless transition from incarceration to the community and that people continue to get the help they need, we need to do a lot better and I think we can. Thank you, Will. Nice to hear from you again. Thank you, Dick. I think Jonathan. No, Will again, and I know we have more to share, so I'll try to keep the meeting quickly. Are we into the gap or are we still in the healthcare versus concerns about wealth? Yeah, so just quickly before we hear from some folks who have a very recent experience or current experience in incarcerated, it's important, yeah, to note this transition. There are kind of two aspects of the move to well path. So first being clear that historically over the last decade or more as different for profit companies have come in and out of providing healthcare in Vermont prisons, not a lot has changed. Most of the staff stays the same. Many of the protocols and policies stayed the same or very, very similar. So it's likely that not much will change, but it's also fair to be skeptical that things could get worse because well path, as you see here, does have an extensive list of scandals and criticism. You can read the quotations there. I won't do that so we can keep rolling. But it's also important to note that this isn't just some sort of skepticism, like this is already happening. So I heard from incarcerated people last week, they shared with me a memo that was shared with them from DOC, which acknowledged that on July 23rd at Northwest State in St. Albans, quote, an estimated 15 incarcerated individuals received Tylenol with codeine instead of your scheduled subutex. So these are folks who are part of the medication assisted treatment program or in recovery from opioid addiction who were relapsed because they got the wrong medication. So these are really significant issues. And this is not just one or two, you know, cups that got mixed up with 15 people. And it's also just an estimated 15. We're not sure. So it's hugely concerning. And it's also important to note that in terms of the remedies that are available to people in these positions, again, quoting from the memo, it said that if they have any issues to quote, reach out to medical by completing a sick call slip with your concerns. So again, we've heard, you know, from from multiple people about the issues with the sick call system and how it takes lots of time to address the issues that they're ever addressed. And so this is just one example of how things have changed and potentially not the better. We will pass. And I'm going to hand it over to the community to share about your experience. Thank you very much for having us here. And I will try to not be super bomb. I had to write mine down because if I don't, I just go and go. I'm here today as a directly impacted form an incarcerated person on the rock fraction system. And I'm Tiffany Harrington and I was under supervision of DOC for 15 years for my first and only criminal charge. And I work with Free Harbor Monk for the National Council for incarcerated and formerly incarcerated women and girls. I could talk for hours and tell you countless restoration examples of the negative impact of corrections that's had on me and my friends and family. Today, however, I want to briefly discuss the reality of proven culture, how different it is from what the general public is allowed to believe. And frankly, how extremely dangerous and detrimental it is to a vulnerable group of people who are oftentimes caught up in a cycle of poverty, crime, and substance abuse because they can't see any other option to stay up slow or get ahead other than to commit crimes for survival. Our society needs alternatives to incarceration that actually disrupts underlying problems, ultimately correcting something versus breaking our communities down. DOC estimates that it costs about $100,000 per year to keep a female and me at housed. When someone has medical issues and is at high risk for a number of physical or mental health conditions, I'm sure that number is high rockage and is quite a bit more than that. All of my pregnancies have been high risk. I've given birth to five sons, two of which, while I was housed in the Vermont correction facility. I had three aclampsia in all of them. My three-year-old son was born via C-section while I was maxing out my 15-year supervision sentence inside the prison. Despite being incarcerated simply for not being able to afford a residence by myself with no familial or financial support for anyone, that they deemed approved or good enough. Truly, it would have been a highly incredibly admin teachers, less of a hassle and significantly more cost-effective to keep me in the community under an alternate supervisor to program than address not only my needs, but the needs of my soon-to-be-born child. Despite being hungry, incredibly uncomfortable, and unsupported by outside means, I did my best to keep my head up and stay positive. When I approached medical staff with various valid concerns, they generally ignored me or just told me to drink some water, which was their catch-all solution. Drink some water and rest. Countless ailments kind of went, they went largely untreated, but I always believed in choosing a positive mindset, so I did. I worked at job and facility, airing for dollars a day. I stayed active. I went outside and walked, trying to keep my health as good as I could. And when I was released, I got admitted to the one home, which was awesome. But anyway, I want to talk about what happened with my C-section. I'll skip that part. I had a C-section in November 1, 2019. While I was in the hospital, I did begin showing signs that physically something was really wrong. Usually my blood pressure is pretty low and steady, but it was bouncing all over the place and it was extremely high. Very, very scary. With my medical history of preeclampsia, the doctors and nursing staff were becoming really concerned. However, DOC and CRCS required the CO to be at the hospital with me at all times. I remember one male officer wouldn't even leave the room while a doctor examined my, you know, lady area. It was really humiliating and the doctor even told him, please stand outside the room next to the door. She can't even walk. They just had a very painful major surgery. When it came time for my discharge from UVM Medical Center, the nurses were really scared to get me back to the facility for fear of my health and safety, because they had seen a lot of people go back and not receive the care they were supposed to get. The hospital staff called CRCS medical staff and gave them very, very clear instruction to keep out all these medications and to check my blood pressure at least three times a day, approximately every four hours, as my blood pressure was indicative of a problem. I was really struggling being separated from my newborn and they promised the hospital that they would allow me to order. Literally, as soon as I returned to the facility, the medical staff chose to ignore the medical instruction. Day after day, I felt worse and worse. I put in sick cough slips after sick cough slips and I felt something at every medication like my past. I kept getting blown off. There wasn't anyone available to check in with me psychologically either and all I thought about was ending my life. My friends on the unit could see that I could barely stand up and we're putting medical slips on my behalf as well. This is about two weeks after I'd given birth and I had to have my blood pressure checked. Two weeks. This is like having your blood pressure checked with a simple non-invasive procedure which not only takes less than a minute but requires little to no training to perform. Finally, my friend on the unit called her friend who was working for the ACLU, who then called the president and put in some medical staff to come take my blood pressure right away. It was so high I wasn't even allowed to walk back to the unit or even get off the exam table. It was that bad. They called the ambulance immediately. My ambulance arrived, loaded me into the back and started on my V and literally on the ride to the hospital, I lost consciousness and started having seizure activity. Apparently they thought I was starting to have a stroke. Upon arrival, I was immediately admitted and my head felt like it was going to pop right off. I had postpartumeclampsia which is a really dangerous and often fatal condition and I had to stay in the hospital for close to two weeks to get under control. I had resulting damage to my brain and organs as well. I almost died with the medical staff at CRCS who was to ignore strict medical orders from the hospital. There are so many stories like this that I would actually tell you. Oftentimes it's systemic inadequacy and flaws that create the condition for inhumane treatment. When this kind of egregious behavior and mistreatment becomes commonplace and individuals in power position engage in it, it reinforces the idea that these folks are less than. Their lives, dreams and families are not valued and their existence is worthless. The lack of medical, dental, psychological, psychiatric and substance abuse disorder treatment leaves individuals in much worse states, if not dead, when they're in the prison. For your heart for mind, I have a beginning for alternative corrective action instead of jailed in prison. Please feel free to look us up online or enjoy us at any of our events or anything like that. But basically it's literally a medical negligence and it's something that happens very, very frequently there. So I just, you know, want to reiterate that that's, you know, a really scary thing. Talk to you later. Thank you. Thank you. So now we're going to share the screen again to listen to someone who is unable to be here today because they're currently incarcerated in Newport. Okay, we could not get that wide video from an individual who's presently incarcerated with a very serious diabetic condition and I'm going to talk, what I'm going to be talking about now is changes we hope to see and I will talk a little bit about that mindful of the time. Anyway, what we would like to see for better healthcare and prison is independent medical oversight by a Vermont non department of corrections provider on a weekly basis. We feel like, you know, outside eyes looking at the six lips are they being appropriately cared for or not. So we would like to see independent medical oversight by a non DOC medical provider. I know when a lot of these six lips are grieved, they go through a process of people are not medical. The people that are in place employed by the state of Vermont, a medical person is not reviewing the grievances. And in fact, when the grievances get to the defender general's office, that's an office for the lawyers. Well intentioned, but not medically trained. We would like to see maintain the continuity of care provided for a community provider, which we already spoke about if someone is on a certain medication, keep them on that medication. It works for them. The community provider knows them. We would really like to see evidence based practice of care equivalent to Vermont Medicaid. If you would look at Medicaid as the minimally adequate health care in our state, why are incarcerated folks not receiving the Medicaid standard of care? And for an example, Medicaid pays for an insulin pump for certain high risk diabetics who have a difficult time controlling their diabetes, oftentimes juvenile onset diabetes, not an older and life diabetes where if you exercise and lose weight and take an oral hypoglycemic, your blood sugars will come under control. But people who have really bouncing around blood sugars, it damages their bodies severely. Medicaid does pay for an insulin pump. So prison healthcare in Vermont denies the community level of care with the insulin level of the insulin pump. And it's actively contributing to the debilitated complications of uncontrolled blood sugars in a detained individual who we did have on the screen. Blindness amputations at kidney failure are to name a few. I believe this is negligence. Negligence with resulting harm is called medical malpractice. All in the name of private equity corporate for profit less than minimally adequate health care in our state. So that is changes we'd like to see continuing the community level care and at least providing Medicaid level treatment, which would be the MRI in my situation, the sciatica. So that's the changes we hope to see. I'm sorry we had these technical difficulties, but I'll send you a link to the video so you're able to watch it afterwards. And yeah, so thank you Leslie for laying out some really concrete ways and some important practices to improve health care in prison. I think in terms of changes we hope to see it is important also to be frank about the limits to that change. And I can clear about this system is truly like unable to keep people healthy to even put people alive. And we need to concentrate on getting people out of it. And so there are a variety of ways that this can be done. Firstly detainees as of the population report this morning 509 of the 1,353 people who are incarcerated in Vermont are being detained. So these are folks who are being held just to be really clear about that being held before they've even been convicted of the crime that they're being held for. So, you know, keeping people in the community before they're convicted of crimes is an important one. And then also thinking about sentencing reform for people who have been convicted of crimes. First there's good time legislation that was passed for everyone and then that was rescinded for people with more serious or violent felonies a couple of years ago. And this is an important one to think about because this is also like exactly the older population that we talked about earlier. And so when we think about good time for all, second look legislation, ending life for that parole, the vast majority of the folks who would be held by these are folks who are 50, 60, 70, even 80 years old and who have these health conditions that they need more care than the prison can provide. So to ensure their safety, it's really important to let them out. And then finally, just thinking about, yeah, some future decisions that some of you all will be making in your committees and you all will be voting on at some point about what the state will do for potentially replacing CRCF. And again, just being clear, not just about the recent past, but about decades of history, where in 2003, Jim Quigley died at Northwest State Correctional Facility. We were promised in the wake of that an overhaul of the grievance system, which then was reviewed by state auditor last year. And I hope you all have seen that report if not incended to where you said that the grievance system within DOC was so flawed, that it was difficult to even conduct a system wide audit where they had to only focus on localized cases. And then when Kenneth Johnson died in Newport in 2019, we were promised a culture shift, we were promised practices and policies that would avert this kind of tragedy in cases where urgent medical care was needed. And we see almost exactly the same kind of situation in the case of David Mitchell and the care that he was denied. And so truly, this is not some kind of rhetorical question. This is an honest question that I'm interested in talking with you all about in the future. At what point do we say that this system can no longer reform itself, that giving it more money, that giving it more resources, more power is not going to contribute to better outcomes when we've tried this again and again. Same things. So, yeah, it's really important to be frank about that. And I hope this isn't ongoing conversation with you all about how we can invest just to ensure the health of people who are incarcerated, but the health and safety of all of us moving forward. So we have a couple of recommendations and also questions for which Leslie is going to take. Oh, we're not going to ask questions. So you can state your questions, but I don't expect them to answer them directly at the time. That's fine. That's fine. I'm going to be just- He will provide a commentary. I'm just actually going to go talk about recommendations for WellPath. And I looked around on the website and I saw that the job requirements for all of the WellPath health care providers, RNs, LPNs, PAs, nurse practitioners, MDs, the only recommendation they need besides their license is CPR. And I really don't feel like CPR is adequate. There is a next level up called ACLS, Advanced Cardiac Life Support. It's not that difficult to attain. I think anyone who's working in a prison should have ACLS because the emergency services response is slow going through the saliports and whatever else you have to do to get there. So I think a lot of the jobs I saw posted also were listed one-year experience, which is not that much experience, especially in an emergency. So we recommend ACLS for their staff. We recommend increasing staffing in the medical department so that six slips can be answered timely and people can feel heard and treated. We recommend following the care person was providing the community. We've mentioned that a number of times. I also feel that nursing needs to have the basic skill to start an IV in an emergency. If you're waiting for the ambulance to arrive by the time they get there, it might be too hard to get an IV. You want to get an IV right when a person goes down. And I also feel very strongly about what goes on in the infirmary. I don't know what kind of equipment they have in the infirmary, but if someone does not have ACLS, they don't know how to read a cardiac monitor. So if you have someone in an infirmary on a cardiac monitor and you don't know how to read that rhythm, what's the point? If you can't recognize that the person has an irregular rhythm or whatever is going on with them, what is going on at infirmary? I haven't been in the infirmary. I'd love to take a tour, but individuals are being held in infirmary instead of being sent to the emergency room and the people in that infirmary should know how to be critical care providers. That's it for me. This is our last round of musical chairs. We have the questions that we have. So first, for well path, we're curious what menu of services are available, what's the approach to preventive care, which mental health treatment is available, and what range of options, what kind of therapy do they provide, and what forms, and what are the theories, what are the foundations behind this therapy, what are people trained in? And then also really important, especially thinking about the oversight role that you all play, how is treatment documented and what barriers exist to being able to understand the treatment people are getting, and how can we remove those barriers as much as possible to understand more of what's going on? And then also some questions for the commissioner, which hopefully I think you might already be prepared to answer in your powerpoint. But yeah, we're curious where at the last meeting you mentioned more than 300 emergency department visits, and we would love to see these records reviewed by a medical professional, and that these could be a really important window to research and to understand where the care is lacking and where we can improve care so that it truly can save lives. So understanding the diagnoses in these cases, what was the outcome, and yeah, we hope to be able to collaborate on that soon, because yeah, it is so crucial. So yeah, with that, thank you all for hearing us, for inviting us to speak, and for having this really, really important conversation. Thank you. There may be questions from the committee of various people, but I wanted to just give you two points. Don't disagree on the Z to continue to lower prison populations, but I will point out that since 2008, our prison population has been reduced by over a thousand people. That in and of itself is a major accomplishment that I don't think any other state, when you look at the cap, their numbers has achieved. On through a variety of efforts, everybody at this table was involved in some way and somehow. As a member of the advisory board of the Justice Center, I had an opportunity to compare our director with other states. Justice Center for the Council of State Governments runs the justice reinvestment programs around the country. Today we have about 1386 prisoners. That was actually yesterday. Of those, as you pointed out, there were state detainees were 265, federal detainees were 73, and we can do better than 265 that I don't disagree with. Of the population in state, there was 1137 males, 123 females. Only 126 people out of state. When we started, there were over 750 people out of state. To look at that, since 2008 is a major accomplishment. Remains number four in the nation in the lowest per capita incarceration rate. Doesn't mean we're doing great. Doesn't mean that everything is fine and I understand that from the perspective of family members and others. But I think it's important to note that we have a lot to do. But as you reduce your prison population, and this is missed by a lot of folks, you have a much more difficult population, more violent, more mental health problems, more people who are have other issues who should not be in prison. They should be in the mental health system or they should be in the Dale system. But the institutional last resort becomes the prison. And that I think we have to keep in mind and that is something that all of us need to look at. You all who are advocates and those of us who represent you, because inappropriate prisons have a place quite frankly in my view, just my view. For those that are so dangerous that we need protection, or some who need protection from themselves. But on by and large, I think that's the population we should be looking at and the detainees. Is it necessary to detain everyone? We did a look at prison in Senate Judiciary. We did a very high level look at life without prison. There were 16 people in that category. Listening to the families of their victims, they were all murderers. It was something that was really difficult for my committee, some of the most emotional testimony I've ever heard. I will say that we continue to look at ways to improve. I don't know much about well path. I do know that years ago we had the state employees who were the healthcare providers. Maybe that's something that we should be looking at again. I did look at well path before this meeting and find out they have a $1.26 billion in revenue. That's quite a bit of money. In Massachusetts, the Department of Justice investigated them on the mental health issues and times that they may have violated the constitutional protections against cruel and unusual punishments for those mental health issues. I don't know what the outcome of that was. I hope that we will, as a committee, will look at well path than what some of the alternatives may be. I know we don't sign contracts in the legislature, approve what the administration does or don't approve it, but I think we ought to be looking at alternatives. That's just my personal opinion and there may be others. So with that, I'll take two questions from the committee of any of the witnesses. I thank you all for the presentation. It was well done and clear. I'm sorry the video didn't work, but that often happens with technology. Any questions? Thank you all very much. I don't know if that commissioner or are you prepared to... When you're ready, sir. I think, Jonathan, I think you're related to people that we know. But I don't know if you're related to the L Wells in Bennington. A ways back. A ways back. Yeah, a few generations. I know them well. Anyhow, commissioner. Can I just make one comment? Yes, please. Yeah, I'll just make a comment. I just want to thank you all for being so clear and having looked at information and data and brought us some of your perspective and your recommendations. Senator Sears and I have been working on healthcare now for many years. Added up together. It's really a lot in the prison system and we share a lot of the concerns that you have. But we also understand that there are federal requirements and other requirements that preclude some of the things that would make a very robust healthcare system. So we'll continue to work and listen to you. I appreciate what you've brought to us. Also, looking forward to the commissioner's discussion and what road path can cannot provide. Yeah, sure. I just want to say that since there's so much stigma around sharing your story, being incarcerated or having a loved one who's incarcerated, it was extremely brave to share what you did. It's so important that we hear directly from people with lived experience, but it's also really hard. And with a three-month-old and having gone through a C-section, you know, I really, really feel for you and what you went through. And I'm so sorry that happened to you. So I just want to appreciate what you all shared and hope that we can hear more from people with lived experience and that hopefully this was a positive exchange so that people feel like they can come forward and share. Commissioner. Good morning. My name is Nick Dimmel. I'm the commissioner of Vermont Department of Corrections. I appreciate the opportunity to be here with you all today. I think that's a good place to start, maybe, is just to pause and reflect on some of the experiences that we just heard about, the stories as poignant and painful and acutely salient to us as they are. And especially for those of us who are working to reform and improve the system, we can't capture enough of those stories, perspectives, experiences, because they're really instructive to us charting our path to a better place. I agree with the senator that it's extraordinarily courageous to come don't take this the wrong way, but you can be a bit intimidating to come here and tell a story that is really personal and intimate. And I think Vermont benefits from more of that in these forums. I think certainly my administration in the department that I run benefits from that. And we're working to seek other ways to bring that into the process, but including folks with lived experience in these forums, I think is critical. And so I appreciate the leadership of this committee in making sure that there was space for that, but also for the folks who joined us, either with their personal experience with a loved one, a family member, a friend. I also think it's important to start by highlighting first and foremost that the department takes this work extraordinarily seriously and personally. We have staff on a daily basis who are working to improve the system, that's a big picture, and improve the daily life of the individuals are serving at a very local level within our facilities around the state. And this is as at least Senate Judiciary Committee and House Corrections knows the health and wellness of our population is one of our four priorities, the four areas that we really are focusing on and working to improve. And I'm happy to share some of that work with you today. But I wanted to underscore how important this is to us and then that we take it very seriously. I also think since I briefly mentioned staff, it's important to highlight that our staff live this experience on a daily basis as well. The trauma, the desperation that can occur is vicariously transmitted to the people who are living in the units are working in the units and helping the folks that that we're serving on a daily basis. And as you know, the Defender General and I have a very nice relationship, we talk a lot about this. One of the things he recently flagged to me was almost always the first person to provide care is not a medical provider, but a correctional officer. And that I don't want to step on those and testify for him, but that often that care is quite compassionate. It happens very quickly. And so I think it's important to highlight the role that the correctional officer, those public servants play in the health process. We don't always talk about that because in Vermont, health is provided by an outside private institution. But the role the correctional staff is critical to this. And so I think they deserve a great deal of thanks and appreciation for the service that they're putting in a daily basis. But I think particularly as it relates to taking care of the human beings that we're charged with. So from there, we can go forward into the deck. I want to provide some context and discuss the path that we're taking to help improve our healthcare system. I know it was casted as as blame and I can appreciate that perspective. But I do think talking about and openly transparently discussing the complexities of health in our system is important. And so I think we turn to this often to help not cast blame but to illuminate the real change in the healthcare landscape that the true the condition that our population is in right now because it has changed dramatically since the pandemic. And we met with a couple family members this morning and I shared it's in part because of the pandemic and in part, you know, a second order third order effect of the pandemic. So not necessarily because people got COVID, but because the healthcare landscape changed in that time period. And so we need to understand this if we're going to be able to start impacting these these outcomes. And so that's why we continue to bring up the demographics. We continue to express that our population is significantly sicker than it was five years ago. Because if we don't recognize that and really appreciate that change, we cannot design a health system that's going to be responsive to that. And so we see that the population as the senator pointed out has decreased dramatically. I think a large part of that is justice reinvestment, particularly justice reinvestment to it's a lot of the reform work that this committee and your home committees have done to include bail reform to include sentencing reform work. It also is in part because of the pandemic. I mean, that was a watershed moment for our system where we really did finally push out populations that probably didn't deserve to be there. They were in for low level offenses or short interrupts. All of that appears to be working. I think that those reform efforts are working and we're seeing a major decrease in the total population. And so Senator Sears was right to highlight what we are left with is just over 1300 folks, close to 1400 folks. And they end up being the most complex individuals and cases that we have to deal with. And so they deserve a different response that is more enveloping and holistic. We highlight often that 90% of our prison population is on medication. There's a variety of different medications. Many people are on multiple medications at the same time. Nearly 60% of our population is on opioid use treatment medication. So more than one and two individuals are on just opioid use treatment medication. And we know that substance use issues stem far longer than just opioid. So we know folks have normal dependency issues and other things. We have 1000 out of the 1300, I think it's around 1450 folks today who have a chronic illness. And we also know, you know, we have this data about the individuals. We also know, and I'll be very candid that the prison environment is not the most therapeutic environment. We talk about that often. Most often we're talking about that as relates to mental health, but that applies to physical health treatment as well. And somebody highlighted in the presentation that we had over 300 ER visits last year, 354, which means that nearly once a day, an individual is leaving a Vermont prison to go to an emergency room. I'll share with you that I'm skipping ahead, Isaac will get mad at me for not using the slides in order, but I'll tell you today, Vermont has two incarcerated individuals in Connecticut because there are no hospital beds available in Vermont. And one of those individuals has been there since before the 4th of July. So this is not simply Vermont. This is not simply a Vermont prison problem. It's also a community problem and healthcare problem. When we turn to seek assistance, often that assistance isn't there. ICU beds are not available. Surgery awards are not available. Nursing home facilities, which we spent a lot of time talking about this year and house corrections are not available. And so we have Vermont correctional staff sitting We brokered a deal very graciously with the state of Connecticut to help us cover the second individual. But these are the outcomes that we're dealing with for folks who need a high level of care. And it's something we are working hard to try to address, but the challenges continue to compound and in different and unique ways that Vermont had not experienced in the past. I mean, it was very rare for an incarcerated individual to leave the state of Vermont for healthcare prior to the pandemic. And now that's becoming a regular occurrence, whether it's Albany, Boston, Connecticut. Some of the challenges we've started to talk about. As this committee knows, we suffer from significant staffing challenges. I'll talk a little about the progress that we've made on that front. But it means that our field staff who typically are curation pro officers or community corrections officers are covering hospital coverage in our hospitals when individuals leave the facilities or are on standby 24 hours a day waiting for the call to have to go to a hospital because we don't have enough security staff in our facilities to cover that historically facility related duty. We have in the last three months have had individuals in New York, New Hampshire, Massachusetts and Connecticut being served by other hospitals because our own state hospital system is also feeling overburdened by the volume of community members needing healthcare. I think painfully for me, we have individuals who but for a nursing home or a care facility in the community placement are instead sitting with us. If a bed were available, they would be there today and they're not one or two folks. I mean, I think we're talking close to 30 individuals. We have worked to address that problem but as the folks particularly probably on the health committees know, those systems are also over taxed not by us but by the broader community system. To make that very acute for you all, what that has resulted in is folks who are living out their final days in a Vermont prison on hospice care provided by our healthcare provider with correction staff sitting there to help them through that process and then ultimately dying in prison because there was no other place for them to go. Where that gets even more painful is if the individual maxes out of their sentence at that time, our hands are tied and we have to release them but there's nowhere to take them and so as Representative Emmons knows, that often means we take them to the Springfield Emergency Department at Springfield Hospital because at least there we know there are medical professionals who can help them with that last phase of life. I mentioned briefly the ability of acute care beds across the state is a serious problem. Routinely, those beds are not available when we call and need them so that's for folks who require hospital level of care which is not provided in the Vermont Correctional System but when we turn to the hospitals often it's very challenging and that's not to cast any aspersion on the hospital system. They're suffering right along with the rest of the systems of care in that there's not staff available. When there are staff available they can't properly facilitate the placement in a facility. It really challenged in the state of Vermont right now. The staffing issue crosscuts all disciplines in healthcare. I won't speak for our well-passed colleagues or previously our vital core colleagues but staffing those positions is very challenging. I think if you asked our University of Vermont Medical Center colleagues they would tell you the same thing. So finding well-trained qualified individuals to take those roles is a huge gap across the state and then going back to the complex populations I mean there is not a day that I have been the commissioner where we've not had individuals who have a myriad of challenges either disabilities, significant mental health issues, who fit in categories that as Senator Sears said would probably be better served somewhere else but that somewhere else doesn't exist or there's no space available. Good just to be understanding the availability of care providers in terms of psychiatric care, psychologists even professional level mental health workers. Well-passed provide that or district department have to provide that? That would be covered under the healthcare contract. So well-passed would provide mental health care practitioners a slew of different qualifications. Given what level is can we get some not perhaps not this meeting but the next one specific information about the mental health care for offenders both in the community as well as in the facilities. We would like to provide that service in the community but we would well but we do I know we send people to the local mental health center who live you know who require mental health treatment probably go and that can be a condition of their probation or their parole. That's true. So I'd like to better understand what we're doing in terms of mental health that substance abuse etc that's do you want to make sure I've said it right? Well it seems to me this is a this is a very broad question simply because there's so much change that's happening right now within mental health programs and systems. So it would be helpful to have you reach out to the commissioner commissioner halls perhaps and to others and to look at what expansions are taking place whether it's through telemedicine telehealth or through clinical access local whether there are mobile facilities and for me I'm very interested in what the contract is is going to say or says already very much like CDEC and understand what what capacity is there for mental health as well as for other things. Maybe you can send a copy of the contract to Ben. I'd be happy to do that. That'd be great to clarify for folks who require psychiatric inpatient level of care that is traditionally provided by the VPCH through the department of mental health. But there are no feds there. But it's challenging to find beds there yes. That's right. But we'd be happy to provide that and also be able to do that. The river view we have there's so many things that are happening that I don't really know. The changes are actually demonstrating reduced pressure on the system and whether that's happening coming. But you can't have one part of the system working independently from everything else. Yes. Commissioner when you were talking about the use of out of state healthcare facilities because our hospitals lack capacity. Is it your impression that they lack capacity in general? They lack capacity for the patients that you were trying to bring to them? I think it's certainly true to say that they lack capacity in general. I know that the hospitals and the agency can serve since the age track that availability on a daily basis and that is routinely over subscribed. Representative Edmonds and Representative Norris. I just want to clarify when you mentioned about going to the state hospital when that situation occurs it's only to stabilize the person. That's right. And once they're stabilized they do come back to DOC for further mental health care. So I want to make that clear they don't stay at the state hospital. And that's similar if I may that's similar to physical health conditions that require an ICU type setting when they stabilize their return to our system. Yes. I just wanted because a lot of folks haven't been involved. The other thing too we worked on this I believe it was pre-pandemic. If there is an MOU between the Department of Corrections and the Department of Mental Health in terms of the mental health care of someone when they're incarcerated. I would like to see that MOU. Okay. Then I'll have to get his email sheet fired up. Or Peggy Delaney. Yes Commissioner in an earlier slide you had mentioned there's approximately working under incarcerated individuals within the state but you want to say that approximately a thousand of those individuals suffer from chronic illnesses. My concern is that seems like an awful high number and it seems like you're running more of a hospital setting the Department of Corrections here. What is the definition of chronic illnesses. That's something that DOC sets towards a medical definition of chronic illness. Some medical definition medical theory we can provide that to you. I think you're right to highlight we look like a prison but we are in fact a hospital system a nursing system. We're also school for a while we're in business building things but it's to say that we're a microcosm we just happen to serve the folks that that often have run out of other options in the agency human services. We highlight often that the federal crisis really ends up in one of three places. Homeless in an emergency department or in a prison and oftentimes the population we're serving is cycling through all three and I think that's because other systems of care are also failing and the folks are not breaking out of these cycles. It is a high number. I think it highlights that while Vermont as a state is also getting older and there have been indications particularly post-pandemic that the state is getting sicker we're seeing that very acutely in the correctional system. That that's challenging and I think we are trying to get at what are the underlying causes of that. But you know we run a very interesting system in Vermont. We're a unified system so we have everybody who's in any type of detention or incarcerated setting in the state. There's all the five other states in the country that do that. Every other state has a county jail system and then a state prison system and they're bifurcated. The issue there is particularly related to the 80s which the senator pointed out is well over 400 today. They can be with us for three hours. They could be with us for three years with the court backlog. It's very difficult to manage that population and then separate from that way of folks who are sentenced in or with us for a long period of time. But if you go back to the math a thousand out of 1,300 means at least some of the detainees are also suffering from chronic illnesses. What we've found in conversations with BDH and the Department of Health and some of our hospitals is the Vermont prison system is essentially a second site for healthcare. Many folks first access healthcare at the prison. They did not have access to community healthcare and so folks are presenting very sick. I mean the substance use issues are only exacerbating that as we see folks come in, go through very severe detox or withdrawals and it's difficult to separate out what is the substance use issue that can be treated, what is a physical health care issue that can be treated and where those things overlap. So yeah where prisons used to be places for detention they've really become a full suite of services and and certainly I think we all agree that that continues to need improvement and we need to provide those services better but we don't often get to decide who we get in our system. So we're presented with folks that are very challenging. We're trying to meet those needs and really strive into that. Thank you. Commissioner you were quick to say that someone's no longer your responsibility I think in relation to mental health when they're in the community but you also said that 90% of people in the prisons are on some kind of medication. Though I didn't know if it was a surprise to you to hear that people might be struggling to get their first prescription refill right when they leave if that's the responsibility of well path you know others on committees of jurisdiction may know more about the transition and how I mean how obviously cleared of a link to recidivism and death that can be you know people can't get continued care right when they leave. So I'd love for you to speak to that and I would be curious about nutrition improvements. I mean I think when we've seen those in our schools you know we've seen that I always say you know meals are like the 40 million we spend to get a billion dollars worth of value out of the rest of someone's life you know I mean it's a small cost actually to really improve health and well-being for a population. So I didn't know if you had metrics where you're trying to improve nutrition as well. Excellent questions. I think the nutrition question if I can take them in the reverse order might be better if we came back to present to you our nutrition system. It's it's related but distinct from the health system and I think that'd be helpful to discuss. Last time I talked about present nutrition was Nutriloquy. So if I might demur on that question but promise to bring back a presentation on that I think that could be helpful for this group. The other question I think is a really salient one. It's not surprising to me the story about prescriptions in the community and a lot I mean there is some degree of trying to connect folks out to the community. I think the biggest hitch here is nearly all there very many of our population are would be Medicaid eligible in the community but in the United States incarcerated individuals are not eligible for Medicaid under federal law. There is an effort afoot to expand Medicaid eligibility 30 days prior to release from a correctional system that would those folks wouldn't go on Medicaid and Medicaid start paying for their healthcare for those 30 days but what it would allow us to do is connect them with providers in the community all we could help get them enrolled in Medicaid and then when they left our facilities and went to the community they would already have Medicaid insurance and ideally connections to primary care providers who could support their medical needs in the community. That cannot happen under the current framework and so what happens is individuals get right up to their release date and I think you know I don't know the specifics of some of the cases we talked about today but but I think well-path and previously vital core made an effort to try to get them prescriptions so that they connect on the outside but as soon as they leave the doors that's where our legal involvement with that process ends and we're no longer their medical provider but they then have to go out and connect with Medicaid. I don't know if you've ever tried to fill out a government form but they're not always the most simple process to go through and often we're talking about fights with complex needs and that may exacerbate their ability to successfully speak that. So we're kind of pushing people out the door without the kind of parachute they need and I think we've talked to the federal delegation about that I know the Vermont federal delegation supports that legislation we're hopeful it's also something that President Biden's administration is working very hard on is trying to expand Medicaid eligibility in a carceral setting. I have a agenda problem. We have the public Canadian program that was scheduled for 1130 and I'm sure a lot of people are waiting so we could ask you to finish up with health system improvements and then maybe go to the next slides at the next meeting. Sure, absolutely. System alternatives. There's a lot of questions about healthcare to come back with any. So I think the big takeaway here is we recognized coming out of the pandemic that the health landscape had changed dramatically I think most acutely in the mental health side of the house but also in physical health and that required us to revisit our contract structure and try to address these needs and so we did that we put the contract out for bid. Vermont received two bidders for health services in the state. We selected the most competitive bidder based on a variety of criteria and that was well pat. They starved in our system on July 1st and so they're new and I think we're all getting our legs under us but we're cautiously optimistic that this will help us to move this whole system forward. I think some of the important things that we wanted to highlight were really ensuring that their vendor was able to provide robust mental health services. That's going to include telehealth services and I think that's really important because there's a shortage of mental health providers in the state of Vermont. We can significantly more care if we can expand into telehealth not as a replacement but to add to the amount of services that are provided and we also talked significantly with WellPath about connecting their work to our values and making sure that they can deliver the Vermont community standard of care and that's our goal as we move forward with the new vendor. I will say it's highlighted on the bottom of the slide. That came at a cost. I mean health care prices are skyrocketing that's driven I think largely by staff but not only by staffing costs and so Vermont saw a 10 million dollar annual increase in the cost of health services in our correctional system. I know Senator you asked that I not go to the next slide but I want to preview just one thing we have tried to estimate what it would cost for Vermont to take over its health care system and run it as a state system and that cost we estimate to be between 80 and 100 million dollars a year. We're at 33 annually right now. Is that the exact same system or would it be an improved system? That would be to create a system where we could provide basically the care that's outlined in the contract right now. That adds substantially to the costs. I think there's also a question about whether the state could adequately recruit and provide the level of service to the scale that we need to. I think this is one of the issues where Vermont runs into a problem that we can't create economies of scale due to our size particularly as it relates to health systems and things like this but that is an option we've considered is how do we bring it in house and could we do that and I think it's difficult to see a path forward on that. The other would be to turn to one of our health care systems in the state of Vermont and seek their administering a health program. There's not been a lot of appetite for that but I also think they would experience the same types of challenges that an outside vendor provides. And then the third option is finding a separate entity to do it but as I said we put the contract out for bid this year and only received two bidders and chose what we believe is the better of the two proposals. Can you get us the estimate how you got to the point where we can break down those costs for you? I know that we're running out of time but a couple of things that were said that I want to make sure taking care of them doesn't wait for the next meeting. The first one and if I was wrong in hearing what you said you talked about acute care and calling the hospitals to see if they had a better available. That goes along with another statement that was made by one of these people here talking about medicine keep coming the medicine kept coming and they didn't need it. Are you aware of that? Well I'm not aware of that specific case. I will say all of the decision making about treatment is done by the medicine providers not by the department of corrections and that's important because they're trained medical professionals making those medical decisions. Yeah okay I understand what you're saying. My question is that you're looking for that to see if that is happening and put a stop to it. The other thing about calling ahead to me if a person is in need of care right away like they mentioned people with heart you can't call the hospital say hey you need to take the person there. Sure yes I would let you look into that to make sure that's not happening. Yeah maybe I can clarify in the instances where we seek out an acute care or a higher level of need bed those individuals require that level of care but it's not emergent. If an individual needs emergent care they're taken by ambulance and as I mentioned we did that 354 times last year. Okay the definition of acute is a word. Yeah that would be the decision. So acute would be oh goodness if we have an individual who has a chronic condition that's worsening that requires hospital level care perhaps surgery something of that nature but if I don't get that one minute that won't exacerbate that but we do need to get them there usually within a 24-hour time frame versus you've fallen and broken your leg or you're having a stroke that would require that would be an emergent need and you'd be transported by ambulance. Usually the acute care folks are also taken by ambulance but but it's not as time sensitive necessarily if it were we would take them. Thank you. Thank you. And David Thompson's here from Well Path. He's on Zoom. I wonder if we can reschedule for the next meeting David if I may. Understood. I know we've run long on time. I appreciate your being here and listening to the testimony and I'm glad you didn't fly out from Nashville. Thank you and we look forward to hearing from you at our next meeting in September. Thank you Commissioner and thank you. The next issue is one that going on as long as I've been in the setup which is a long time time. It's the public inebriate program. I'm going to start with Kelly Docherty who's the Deputy Commissioner of the Department of Health at Starley Woods. She's on Zoom. Good morning. We understand there were two closures of public inebriate programs. One in Franklin County and one in the Memorial County. And there aren't many around the state. I wondered what the status of the public inebriate program is and that impact on DOC or Department of Corrections. Yep. I'll start just for the record. My name is Kelly Docherty. I'm Deputy Commissioner at the Department of Health. Thanks for having me this morning. So yes you are a correct Senator that two of our funded programs for public inebriate services in Franklin County and in Lamoyle County opted to close starting July 1st of this year. So starting with FY24. So those programs collectively well separate them out. In FY23 so the year ending June 30th the St. Alvin's program screened a total of 2225 people in their PIP program. So not everyone who is screened ends up either in a PIP bed or at corrections or at a hospital. Sometimes they're screened, found not to be incapacitated and can be released to a responsible adult family member or friend. Of those 225 in St. Alvin's during FY23, 57 of those or 25% were diverted to DOC with the remaining 110 remaining in the PIP program. I'm sorry is there a question? No. Okay in Lamoyle County we actually only have data from them for the first two quarters of of FY23. If I annualize those data there would have been 92 individuals screened with 12 actually 24 being diverted to DOC which is also about 25% of the population and the remaining 52 staying in the PIP. So I know it's early we're only in the second week of August. I've been referred to my colleagues at DOC to see what impact they're seeing so far from that. You know but I can say I mean I think it's likely that there will be an impact although I will say just statewide we have seen a pretty dramatic decrease in the number of people presenting at public inebriate programs over the last several years and for FY23 we don't have all of the data in yet but it looks like we're on track to have screened less than 1000 individuals statewide compared to almost 1200 in FY22 and 1421. So the numbers have been decreasing across the state. Thank you. Any questions for Kelly? Kelly I appreciate it. Are you going to stay on? Because our next witness is Al Cormier the Chief Operational Department Correction. Yep I'm happy to stay on. I have a question. Oh you have a question for Kelly. Can you clarify when you say 225 people or 1000 folks statewide is that unique individuals or is that some folks are coming through the system constantly? Yeah I think it is not unduplicated. I will confirm that but I'm almost certain that that's not unduplicated. So it could be individuals presenting multiple times. It could be individuals presenting multiple times. Yes. What's the impact on DOC? Do you have any sense? Yes thank you. Good morning. Al Cormier Chief of Operations for the Department of Corrections. Yeah so we expect to see an increase based on the numbers that the Deputy Commissioner Doherty just presented. We have seen a decrease statewide over the last 10 years which is the concern for us and we work with VDH and DSU on this topic and we'll continue to do so. The challenge for us is these people they come to our system but they don't appear in our system. They're a ghost. They're not charged with a crime. They don't get entered into our offender management system. We have just coming off the healthcare discussion we have very limited ability to provide healthcare to this population because they're not in our system. So that requires a call to an ambulance should there be health concerns with somebody coming in? We're seeing an increase in inebriated folks that we don't know what the cause of that inebriation is. That causes concern for our staff. 10 years ago the majority of that was alcohol. Now we don't know what these individuals are presenting with in the state when they arrive at our facility. So we continue to tree. We continue to monitor. We take care of this. Right now the impact has not been great but we do expect to see an increase. Part of the challenge with the Boyle County and with also coming out of Burlington is as you recall two years ago we diverted from Chittenden facility. There used to be men and women in the facility. From best practice we diverted all men out of that so we don't believe that there should be men coming into the women's facility. Those are all going to northwest now. So that takes up additional time for law enforcement. That takes up additional time for the transports to occur. And I only see that increasing on the law enforcement side. The other challenge for us is around releases. When they are zeros or have served their 24 hours they're released again. They're not in our custody any longer. That presents a challenge. When they're picked up in Chittenden County or LeMoyle County and they're in Franklin County how do they get back? That's presenting a problem and I believe what kind of weather we will be thinking about that. But we're seeing the challenges. These are challenges to the earlier point, Senator. We've been talking about this for a long time and it's an issue that we are concerned about. So it's kind of a guessing game at this point with our other programs going to close or others going to open. That's really the question as to what that impact may be for us. Thank you all. Are there questions for our representative? I'm going to make you a Senator. No, I don't want to be a Senator. Stay where I am. Now can you share with us where these folks housed when they're coming into a facility and they're there basically until the next morning or they've slept it off? Yeah, so yeah that's a great question. In our facilities we have our intake and bucking area. Most of those folks will reside in the bucking area overnight. They may go into a single cell depending on the need and depending on the numbers. I know this is part of our request in our Northwest expansion because we have started seeing that increase in the numbers up there. We currently have a limited number of beds at Northwest in the bucking area. So on a weekend, which is when historically we see the greatest increase of incapacitated population, it's overcrowded and we see those issues. But they do not go into general population. They stay in the bucking area because as I had stated earlier, they technically don't belong to us. Yes, this is probably a question for the deputy commissioner. But quickly, what is the reason for the closure of these facilities? Is it a staffing issue? Is it a financial issue? It's down upon that place. Yeah, it's both. So the programs are having a very difficult time finding a staff. So oftentimes the workforce situation in the social service arena and other places is definitely impacting these programs. So there's a staffing issue. Also, their funding has stayed relatively stable over the last number of years. But we all know that costs go up year over year. One of the challenges that we've heard with staffing is that these are 24 seven programs. So staff have to be available 24 hours a day, seven days a week. And it's difficult to staff that, especially when the staff that are on call are being paid at an on call rate, rather than actual working wages, you know, they would be working wages if they actually have an intake. So that's a challenge as well as the unpredictability of the utilization of those beds. So it's difficult to know if there are surges and then there are times when beds are empty. So it's just, you know, it's kind of an unpredictable system. But workforce is definitely a big part of the issue. Thank you, Anna. I've been trying to get a hold of the Howard Center and I have some correspondence with them. I guess what I'm interested in is I'm from Franklin County. I'm interested in the actual costs that are incurred within Franklin County. Is that something that we can get hold of as a committee? Yeah, sure. I mean, their actual costs for running the program. Yes. Yep, yep. Staffing shortages quite possibly. Say that again. And the staffing shortages quite possibly. Thank you. It's underlined. Oh, I'm going to answer a question at the end. Okay. Going back to the contract question. Okay. Well, that's going to be my question. Al, any further? Commissioner, did you have anything? Why don't we go right to Mr. Robert Bick, the Executive Director of the Howard Center. Bob, been a long time since I've seen you. It has, Senator, and as you accurately stated, you've been dealing with this issue for a very long time. So I'm not sure what the committee was hoping to hear. I can tell you that I appreciated the Deputy Commissioner talking about the numbers. It's really interesting because if you go back 10 to 12 years, our Public Anibriot program in Burlington, the F1 program alone would screen 22 to 2400 people a year. And this past year, that number is down to just under 200 people. And so there are a number. I'm sorry. No, go ahead. Okay. Yeah, I'm sorry. I'm out of state and I'm using my phone to make this connection. As folks have said, staffing is a huge issue in the Franklin County program. We had to rely heavily on existing staff who work in other parts of the agency to take on call shifts. We were trying to run, I think somewhere between 13 and 15 different people to try to cover the shifts that would be necessary. And as the Deputy Commissioner pointed out, that's an on-call program. So you never know when there's going to be a demand for the services. The Act 1 program, I'm going to mention that again, because that was a fully staffed 24-hour day program, a 24-hour day program where we actually had staff in the program, we actually allowed clients to walk in as well as folks that are brought by the police department. But during COVID, what we really saw was law enforcement, both because of staff shortages in their department and perhaps because of a desire to minimize contact with individuals substantially cut back on the number of folks they were bringing to the program. And when the shift was made to move men to Franklin County for law enforcement in Chittenden County, it became an extra stop to come to our program to determine whether we were going to be able to house the person or we needed to send them to Department of Corrections. It became, I think you might hear from them, more efficient to just go to the West Correctional Center. I think in terms of thinking about strategy going forward, I think we need more screeners than the current statute permits. I think mobile crisis staffs across the agencies, across the state, could be in a position to do screening. I think there's some question about whether it might make sense to think about state police to be able to do screenings, outreach and crisis staff. There are a number of outreach programs now around the state, are those trained to also do the screenings. But frankly, the program has been grievously underfunded for many, many years. And part of the challenge, obviously, I get it. The legislature needs to balance multiple priorities. But this has been a program that has the opportunity to intervene with individuals at a moment when they are perhaps open to understanding what brought them into contact with the program and created door into treatment and recovery. So while the economics were not huge in the St. Albans area right now because of staffing in the Burlington area, which is the high volume public inebriate program in the state, we're at a point where we're only able to do limited screenings. We're not able to house people at all. And that's a program that has been losing somewhere between a quarter and a third of a million dollars a year for the last four or five years. So from an economic perspective, if we were able to get the staff, our organization is going to be in a need to make a hard choice about whether we can actually sustain that kind of a loss. Question from Bob. Bob, thank you very much. Appreciate it. Next one is Michael Dr. Hartman from LaMoyle County Mental Health Services. Thank you, Senator. Let me just correct the version that you have there. I'm a master's in social work and I'm the executive director at LaMoyle. They attempted to elevate me, but I'll decline. So maybe I'll make the lieutenant a captain. I think I would really echo both what the deputy commissioner spoke to and what Robert Beck spoke to in terms of the numbers going down. That is a phenomena that started with COVID. And that is a mixture, I think, of the public availability of drinking in bars and outside other kind of pieces that went away during the early part of COVID. And the numbers have been going up slowly. And considering that we don't really see a huge decrease in the use of alcohol, I wouldn't see any reason why the numbers wouldn't return back to where they were. Truthfully, I would see some reason why they might even go up from where they were. But I think we similarly to the Howard Center ran into the same problem that our funding was actually cut by 50% back in about 2018. And we immediately went into a loss with that. And we did get some of that cut back. But basically, for the last four years, we've lost about $100,000 a year. Very much for what Bob states where we do have to pay under our contract with the union, we have to pay people a on call rate. It's not an hourly rate the same as what they would make. So it's the lowest we could pay. But that by itself is just about $10,000 short of the entire contract to cover that for the whole year. So costs for people actually working and getting the higher pay when they're working costs for the building, et cetera, cause that that loss. And there hasn't been an increase in the program in the 10 years that I've been here overseeing it. So, you know, compared that to 20 to 30% increases and other kinds of programming. And again, I don't think this is a fault of anybody not interested in blame, just interested that I think as Bob said, we lose a real opportunity when we can't have contact with these folks, we've at different times tried to do some outreach to people who show up frequently. We've tried to do some follow up work in the community with the police to make visits afterwards for situations where these have been the folks who were involved in public inebriate. And they had limited success, but they had more success than what we're doing now. We have continued to be part of the response for the police about when they do pick up a person for public inebriation. But that's that's as far as we can go with it at this time. And I think that the concern that I have greatly is that we went, we have a pretty strong community network here of healthcare and mental health and substance use providers. And we tried for months before July 1st to see if we could find an alternative to this for the community to still have the service. And there really isn't any other capacity in the community for it. So at this point, the majority of folks are now going to custody because there isn't an alternative where they have any supervision, unless there's so much in medical need that they might meet the criteria for staying in the emergency room. And I think that's probably covers it. Thank you. Other questions? I really appreciate the testimony from both you and Bob and in terms of I don't remember making a 50% not funding for that. It wasn't this year, but I know it was it was a decision to spread the wealth, so to speak. So the half that we lost went to Northeast Kingdom to try to start a similar program up there. Now I understand. I remember Senator Starr. We can blame Senator Starr for that. All right. Thank you. If I could just make a comment. I mean, this is really troubling for me, particularly hearing the testimony from the commissioner corrections earlier just half an hour ago in terms of our community systems are starting to fail. And then it puts more pressure on DOC. DOC is always the default. And nobody sees DOC because it's behind closed doors. And that's always concerned me. And this is putting more pressure on DOC, where people are going to get lost in the system that needs support services. And it's not given to them. And the other piece that plays into this is the DOC budget is funded directly through our general fund. And our DOC budget at this point is 180 million. This is going to put more pressure on DOC's budget. And it's going to put more pressure on their staff because they have no linkage to the folks who are coming in on the public and neighborhood situation. And there could be some real legal consequences if something happens in that 12 hour or 24 hour time that they're in a booking that that's a concern that I really have in this. I mean, we've been dealing with this for 20 years. I didn't even know it was a program until I got elected. Found out we were failing in 1983. Thank you. I just want to echo Representative Ammons. I share your concern and VDA and DOC. We had been meeting regularly up till the COVID pandemic to really start to think through how we could best sort of limit the number of diversions that go to DOC. And, you know, we're continuing to have conversations and we're committed to working together, moving forward to try to make this as palatable of a situation as we can. So just want to reassure you that we're working in collaboration with our DOC partners on this and that we share your concerns. Our next, thank you, Deputy Commissioner. Our next witness is Jason Weatherby, Lieutenant for the St. Albans Police Department. Jason, thank you for joining us this morning. And I know Senator, you probably spoke with Senator Norris about this. Yeah, thank you. I'm going to pass on the promotional opportunity as well. So yeah, I concur. We can concur with a lot of the things that are being said here today. One of the big issues for us is there's talk about us doing our own potential screenings. You know, by statute, we're not allowed to do that. It has to be done by a substance crisis team or a substance abuse counselor or a medical professional. In that case, we'd be looking at bringing individuals to the emergency department. I don't think it's a new fact for everyone that the medical fields and the emergency departments are already generally overwhelmed and understaffed themselves. The way this whole process is kind of going down and or went down kind of left us last to know about the individuals holding the bag to figure out what to do with folks. So there was a community conversation that took place yesterday with hopes of figuring out what we can do with some of these folks when we do encounter them. There's multiple agencies in Franklin County that utilize this system. Obviously we're sure staffed ourselves much like most other law enforcement. So running a two to three person shift and sending someone to another county for a PIP program is not really practical and or safe. So I guess the long and short of it is we're trying to work obviously with our local partners here with Department of Corrections and the hospital staff. But August 31st is close and we just don't want that door to shut and it to be forgotten at the end of the day. Can I just so I fully understand you confront an obviously inebriated person and what do you do then after August 1st? That's a great question. We utilize the same things that we try to do currently. We try to figure out if there's someone that is able to take care of them, a family member that is willing and able to take care of that individual. Secondly, it looks like we're probably going to end up statutorily at the hospital in the ER looking to have them screened by a medical professional to in fact deem that they are incapacitated. They generally and we'll speak for them won't have the ability potentially to house them in the case we'd be delivering them to the to the correctional center. Currently in a correctional facility they're there about 24 hours and then they're released and they may have no way to get back to wherever they came from or whatever. That's not a great system either so. Well, they're being introduced into the correctional facility for being incapacitated and as opposed to a criminal charge. Right. I just want to clarify when we say public inebriates in the old days it was folks that were drunk alcohol. Are we just seeing that when we say public inebriates is that just what we're talking about or is it also now including folks that have severe substance use disorders? Are you seeing both or is it mostly alcohol? No, we're seeing both. We're seeing an increase in all kinds of substance use with the folks coming through our door and that's that's one of the additional challenges for us because we don't know what they're on we're not providing drug tests to see what they're on which increases the concerns that we have with that population and the added burden on our staff for for monitoring that. And there's also an added safety measure depending on what a certain individual may be on they'd be more maybe more susceptible to acting out or acts of violence which generally isn't good for a hospital setting either. If I just to say it might be helpful it might be helpful for folks to understand what protections are offered when an individual is in the public inebriate program. So protection is from arrest question. Yeah generally if someone is being introduced into the public inebriate program it's not an arrest it's a it's for their safety or the safety of others so that they can hopefully be introduced to resources that may be available so they're not in the situation again and or a safe place to give back to a functioning level. I would just add that I think also the protection is that the person is able to be closer to home and there is the possibility that we may be able and the next day when somebody has reached a better level of sobriety we also can engage with them with the recovery center and some other resources to try to help them to some kind of care and as we were doing this about 70 percent of the folks who stayed were willing to engage in further discussion and follow up with the local preferred provider for substance use care so that was also an additional feature that has gone to the situation. Senator Norris and I'm representing one. Yeah Lieutenant Weatherby how you doing? Good thanks sir. We just explained the process as far as if the public inebriation program closes and the law enforcement picks up an individual and there's no place to bring them they must bring them to by statute to the hospital is that correct? Yes at this point that's the only location currently that we have that has one of the listed means necessary to deem them incapacitated to be brought to corrections yes. So is it my understanding that while you're there you can't leave them there they're still in your custody? Generally speaking yes they're going to be in our custody until we can essentially get them to an approved facility to take care of an individual in that capacity yes. So you could be there for undetermined amount of time then law enforcement? It could be 30 minutes it could be four or five hours potentially yes. Okay well I think bringing up if someone needs medical attention I think that'd be very beneficial I see if they go to the hospital but if they don't need medical attention I think that by bringing these individuals who are under the influence of something up into the emergency room setting kind of flies in the face of S-36 which we both passed last year as the protection of the health workers within within facilities here so I think this is a very problematic and hopefully we can come up to some type of resolution here within the committee to maintain this program or at least work with those individuals who will receive this program to come out with a positive finish on this program so thanks for being here with him. Okay thank you I just I'm trying to make sense out of the data that the deputy commissioner reported in terms of the decreasing number of people who are being screened each year and the increases that DOC is seeing so it it it seems though that it's relatively around 25 percent and 25 percent of the decreasing number is going to be a smaller number I'm just trying to figure out the connection there and then the the second question would be for Mr. Hartman about is it just a matter of dollars and cents so I mean if that if that deficit were erased would you be continuing your program so two questions yeah I thought I'd just get it in so yeah sure so the the number the actual raw numbers of the individual screened and the individuals being diverted to corrections are both going down it's just that the relative percentage of the number of people at least until the closure of these two programs recognizing that that will have an impact has remained you know relatively stable so when you look at the raw numbers they're both going down as are the relative percentages but but like I said at the start with the closure of these two programs I think we can anticipate that there will be an impact on corrections okay so I'm seeing Mr. Cormier not as had I just had understood I am to say that they were already seeing an increase and I'm I'm just trying to trying to determine if if the I'm sorry I guess you weren't you weren't live there now you are okay so yeah thank you for that question and just to clarify we expect to see an increase with the closure of the peps we we understand and we see the decrease as well in the number but with the the the PIP programs closing we anticipate that there will be an increase two corrections because there's no other no other alternative for them okay thank you the question for Mr. Hartman and maybe uh Bob Benke if he's still with us is if you had the funding would you continue the program yes from from our perspective here the answer would be yes we were asked by the community to start the program back in I think about 2011-2012 have run it pretty much with a loss every year but the losses just mushroomed in the last few years and so there was no interest in in closing the program there was interest in trying to close the gap financially and there really wasn't we tried to find some grants and some other things to do that but we really couldn't find alternative means to keep the program open and after four years of those losses really had to close it but it would take a you know we already closed ours as of July 1st so we take a little time to hire folks and fill in those positions but most of them are still around and really would be glad to come back on so it wouldn't take long to do it but we can't do it at a loss any thank you it just it seems this is just a comment it seems like counterproductive for us to now be having to send people to the most expensive place in our healthcare system the emergency room from a community-based program which is the least expensive place for them to be screened and served it makes zero sense committee we can make a recommendation for January I would ask Ledge Council to draw up a recommendation that would be based upon the testimony that that we would recommend that they do everything in that hour deal with this in budget adjustment and try to refund these two programs they being the department I help I guess I'm about also looking at the screening and the screen actually well before we did that that becomes a big issue guys of course I think if you could do that and we can throw it on that before we leave this afternoon we could send a letter to our commissioner health commissioner by nanson secretary of administration I guess maybe the two secretaries on behalf of this committee adopt whatever Bob are you still with us yes the question I guess would be if funding were available with Howard keep the program like Mike indicated we have closed the program we are open to having the conversation if the funding were adequate and sufficient I think the challenge obviously is staffing and I can't tell you how quickly it will take to try to staff up I do want to highlight that we are currently operating the ACN program in Burlington on a shoestring right now both in terms of staffing and limited screening only and so if and that that program the losses are far more substantial and so if there's going to be a conversation about trying to resurrect or sustain the existing programs because I do know that this couple of other providers across the state who are also struggling I think it's a systemic conversation that really needs to take place we're happy to be part of that conversation and and look for a solution I don't know who said it but it definitely makes a whole lot more sense to try to serve these folks in the community where they are at far less cost than it will cost to have them serve in the emergency room and corrections too we have one more witness Louis Dandorand and I hope I pronounced that correctly the director of emergency medicine Northwestern Medical Center well can you hear me okay yeah excellent yeah thank you for for having me I am the medical director in the emergency department at Northwestern Medical Center in St. Albans and the closure of PIP in our county and I have a huge impact on our department and so we've had conversations related to that I want to clarify that the PIP program has not yet closed here so the impacts are not felt yet it's closing August 31st so it has not closed yet I want to also mention that this decision to close PIP in our county was made without any input from the local stakeholders I was not involved none of our administration the hospital involved police department was not all the stakeholders that are most impacted including the local director of Howard center here in fine county apparently had no say in this decision so it was made at a level that was not you know conducive to one finding alternatives and then we're ready for this problem to solve in a matter of weeks and it's a big problem the the cost of screening these folks as it was pointed out will fall the highest cost center in our county in terms of healthcare and currently the process for screening individual for incapacitation is done oftentimes outside of the emergency department not even including you know healthcare professionals with Howard center screeners and it's been very very efficient so screeners are called the police officer will present to us directly outside of the medical center and within minutes can have a decision that yes the patient incapacitated and then make a decision of whether they go to the Howard center bed or to corrections in most most cases the individuals which would end up being housed in one of the other the corrections was used if the if the person is not cooperative and won't do a blood alcohol corrections will be used then otherwise if patients are willing they would just be able to place it to Howard center and and this program has been in place for years and it worked very efficiently and beautifully and it's being pulled back so that there's a huge gap and how we're going to manage these folks and it's going to it's basically going to come back to the highest cost center for medical care in the community I mean we'll manage it you know because we have to by statute but that's really what the result of this closure is going to be we're talking about 20 approximately 20 people a month you know not quite one a day the other issue is that on top of the screening is that those folks one need to be screened you know evaluation so once they show up on their campus and tell it to kicks in and we have to get vital signs and and do a complete medical evaluation takes time so we'll take a police officer out of service for the amount of time that takes and then that person will need to have housing so if they're on cooperative potentially going to department of corrections otherwise they'll have to over up an immersive department taking another probably eight to 12 hours of time of our staff to manage these folks so this is very costly the alternative very very costly so we're looking at budget dollars here and we're looking at the highest cost center possible to manage these folks moving forward without pip so I just want to mention these few things should have me opportunity to speak thank you any other comments I think all of you very much we'll come back to this later on in the meeting in terms of the resolution and then sure back to each meeting well problem doesn't go away just become somebody else's problem in this case probably doc and the emergency rooms which are already speaking to my own emergency room in bennington because I'm frequently visiting there with my wife it's not easy they are overworked and over why don't we get back together at 1 15 which Peggy if you could just let the witnesses for the afternoon competency evaluations now we'll get together at 1 15 all right good good afternoon since joint legislative justice oversight committee section 8 of act 28 arrest 91 doing competency examinations asked this committee to review whether we're monologued to commit competency examinations attendance under 13 bsx 48 month four in addition to psychiatrists and doctoral level psychologists trained forensic psychology to be conducted by other level mental health providers and added to this committee or two members of the senate committee on health and welfare and two members of the house committee on health care pointed by the respective chairs on before november 15 the committee shall recommend any change the dean advisable to the bsa for the senate and house committees on judiciary the senate committee on health and welfare house committee on health care and the house committee on oh what uh that is not as a short slide presentation now I thought we'd have him pick it off and see what's our last witness schedule sure thank you senator sears ben overgrossi from the office of legislative council i'll share my screen and go through the the presentation that's that's before you but really guys that senator sears said this is pretty short in sweden it's really just more of a reference point as we talk about some things we're going to have um and uh we'll go from there so fitness stand trial comes with the exams in vermont and other states so as the senators just went over the committee's charge is the chivalrous law expand to allow other doctoral professionals outside of psychiatrists and doctoral level psychologists specializing in printing psychology that was just added this past session through s91 which believes act 28 and has a sunset of july 1st of 2024 just the the uh the psychologist edition um and then the the goal of the committee is to recommend any changes a dean advisable to the governing statute if any so the bottom line who should conduct company examinations and so what what are they they're governed by 13 dsa 4814 and the surrounding statutes um and it's an evaluation of a defendant's competency to stand trial so there are two questions that are asked in this inquiry is the defendant able to understand the criminal charges and is the defendant able to meaningly participate in the defense to those charges as i explained earlier psychiatrists and doctoral level psychologists training for forensic psychology conduct the exam um what it is not though is an assessment of the defendant's sanity at the time of the criminal offense that's a separate inquiry and a lot of the statutory changes that were made in s91 helped to delineate the two inquiries so going forward competency is something that can be raised at any time through trial by the defense the prosecution or the court on itself it is a threshold issue it's not a defense to the charges like insanity can be um it's really just whether it's a threshold issue everyone can be there and really be a part of the the case and the defense um if i thought this one would help me understand what is probably common knowledge to the judiciary folks is this the sole person making the determination that they're incompetent to stand trial or is it debatable or does the judge decide based on their well the judge ultimately makes the the the the order but there's sort of a process that goes along so for instance if the defendant is found incompetent by the psychiatrist or the forensic psychologist um there's a commitment hearing that's scheduled um and to determine whether or not that person is a danger to themselves or others so that would be a different you know essentially an escalating inquiry okay but that one person is the only person who can determine if they've been found incompetent first i'd have to check but my understanding is that they can offer i think a competing um expert if you will but also competency is something that can be that's fluid so they may be found incompetent but if they regain competency and have another exam um proving that uh they can go on with with the charges against them and um and that's what this last point kind of touches on is that someone who's found incompetent who later comes back into competency can then be recharged with the crime so that's again different than insanity where if you're deemed insane it's a complete defense of the charges does it happen is this because clearly i'm just asking all these questions because this person becomes really important like their skill set becomes really important so do they are they the same ones who don't have to find the person competent again or you could get a different expert so the you know what actually they're so it would be you know again the defendant the prosecution of the court he would you know order or move the court for an examination um and it's whoever the court points i'm in that instance and let me review the statute um after this just because i i know that there is a process that addresses your issue i just can't recall it off the top of my head at the moment i do see that there is a hand raise on the screen is there a hand raised it's from yeah karen barber for the record general counsel dmh i can answer your questions if that's helpful sure um yeah so they are not the only person that decides so they are so um competency evals that are um done by the department of mental health or neutral evaluators right and so they do um make a determination as to what they think but at any time the defense or the state can hire their own um and they can contest competency so just because our evaluator says competent doesn't mean the defense can't hire one that says incompetent and then the there's a hearing and then the court makes a decision works the other way as well so if we find incompetent the state can hire their own that says competent and then there will be a contested hearing in the court would make a determination okay thank you and it is not always the same evaluator um so sometimes it could be um so with if the department is ordered to do a second evaluation sometimes it would be the same evaluator but sometimes it wouldn't it just kind of depends who is available thank you okay um continuing on and the point that miss barber just made is really uh from my understanding the threshold issue of why this is there it's availability of the um of the the provider essentially and um my understanding sort of the policy dilemma that came out of the session was on the one hand making more people available because there is a backlog of competency competency examinations and those who are available to do it um and that's weighed against expanding that to people that may not be as accurate in their in their competency so that's sort of the policy considerations facing all of you can I ask a clarification just based on what um was just mentioned it's the department of mental health currently that would do these competency evaluations with the psychiatrists that are currently licensed to do this but they're through the department of mental health is that correct my understanding that's what was I just understood but we have a number of witnesses yeah and I would defer to the but if we expanded they would still have to be under the with the department of mental health but um I do think they're arranged yeah unless they're arranged independently by the defendant might you think that it's otherwise up to the prosecution through the department um and just for that can you talk a little bit about what it needs to be competent because some is frequently confused with insanity and so competent what competency means in terms of understanding the due process and so well it goes back to really those two fundamental questions from the previous slide which is being under being able to adequately participate in your defense so interacting with your attorney um being able to give approval to certain uh legal strategies if you will um but then there's the the initial threshold question is being able to understand the charges against you um and so this goes into I mean just a basic level competency of really just I mean understanding not just what the consequences are of being charged with these crimes and potentially being convicted of them but also um what what goes into that what the court process is what's entailed in that so and that's different than an insanity defense which again is something that is really um the end all be all to complete defense and that's something that's assessed it's an insanity defense that's assessed at the time of the crime that was committed competency is at the time of trial so you may be again incompetent at one point in time but then later regain competency to undergo the process correct it's all about at the time of trial that's time of trial but insanity is at the time and and again part of the statutory changes were uh was to help kind of make a distinction between those two different inquiries um they used to be confined right and so just as a comparison for some other states and who's permitted to do these exams in New York um it's performed by psychiatric examiner which can be a qualified psychiatrist who has a degree you know certified by the board of neurology and psychiatry or eligible to be certified by the board or a certified psychiatrist who's registered um as such under New York law um so they also permit other psychologists it's not as narrow as the sunset that was done in a tiny one where someone trained in forensic psychology but um it does permit for certified psychologists um in Rhode Island my understanding is that Rhode Island is the only other state that like Vermont until this most recent session only allowed psychiatrists to perform the exam um and so again conducted by a psychiatrist with a decision list lit license under Rhode Island law and then Oregon um has a little bit of a different process but as far as who can perform the exam it's done by again a certified examiner who completes forensic evaluator uh forensic evaluator trading program and that um can be a psychiatrist so one licensed by the medical board in that state and completed a residency program in psychiatry and then also a psychologist licensed by the board psychologist in Oregon so just for some comparison purposes any other questions I just want to be really clear this is you only apply competency exams in criminal cases not family court not yes no court right in in this context yes there's a great yeah yeah it's a little bit different and juveniles are always treated a little bit different than adults so it is different but this is just about competency in title 13 and who can um conduct the examination is not necessarily who is subject to so this is all adult any other questions I'm just um curious having not had testimony on this in my committee about um are there were there suggestions in testimony about who the other professionals might be that I I don't know because I was not a part of those it was a it was a it was a psychologist so something somebody other than a doctoral level psychologist is that what they're doctoral level friends so aren't they already able to do that now they weren't till this year and they now and it's sunset for next year so we don't have to make a recommendation but the problem part of the problem is the lack of psychiatrists to do the evaluations and the second problem that we heard about was the number of people who don't make commitments there are scheduled appointments to take what poured by hours to do the competency evaluation and the people though so yeah you heard more than we did yes we did and so so we did hear a lot of testimony and the result was we'd like to have this joint committee look at the issue and provide a recommendation but I think correctly if I'm wrong I think there's one a forensic psychiatrist who does evaluations in the statement now so expanding it made a lot of sense yeah no I'm not I'm not again no I thought we already had but it just passed this year I mean I work for us yeah yeah fine demand yeah I'm dr. level psychologist honestly might I have a broader understanding of competency exactly yeah um what I'm not saying here is that we have a board that certifies who's qualified to do this examination like exists in some of these other states it's through their professional justification okay so yeah I didn't know it looks like psychologists through the OPR so that's what we're talking about in these other states is the same licensure then it's not an extra layer of like yes you exactly so as psychiatrists you know can practice through the medical board here or it's been given a license psychologists it's been given a license through OPR okay so these other states didn't add approval um no I mean organ of the ones that I studied has that requires sort of forensic training course but that's something that's separate and apart from the licensing of their individuals so that's just a policy choice of that state made and as far as who we're talking about representing what in the charge one that's explicitly mentioned is psychiatric nurse practitioners as another doctoral level practitioner that could be considered but it's open-ended to to read any other medical professional that has a doctoral level certification yes along the lines does the person have to go through OPR the regulations for your licensure yes so the licensure if you're going to correct me there are a lot of certificates that you could get after any licensure and after a degree so that then that'll clarify but so they can go through the certification process for forensic analysis so it's it's just it's an educational certificate and do they have to do it within a specific period of time like opiates you didn't find who survives the work and so within five years don't do it you don't get it I don't think that's part of it it's it's it's an external certification it's not an OPR certification OPR so this is over about that yeah it is exactly get you get your license through OPR and you have your license through the medical practice board yeah and then you can go ahead and study other things that allow for you to practice your profession so as a forensic psychologist or a psychiatrist yeah that would you know the license itself is done by either the medical board or OPR but the certification in forensic psychology that's something that would be there are trade groups I'd imagine that there was the American you know association of psychologists and such that we could ask the next witness yeah mission department what no thank you Ben I didn't see the representative I was just wondering maybe if if Karen could speak to the competency evaluation itself and whether that is something that's is it administered with a tool or is there some sort of objectivity to it as we think about what level of clinician or training is required I'm curious just how standardized the process is and then we have a question for myself to go oh sorry yeah no go ahead all right um so it depends right um there is no like set test um there there are certain things they are looking at um but I think one of the things to remember is you can be incompetent for lots of reasons right it could be a mental illness it could be a developmental disability it could be the tbi it could be substance use um so it really depends on what the person presents with one of the reasons why getting records in advance is so important is because the psychiatrist has a sense of any past history and so may have a sense of where their where their questions need to be you know currently if someone has an intellectual disability we refer that to a psychologist because they can do some more specialized testing um but there's no kind of set every every evaluation looks the same it really depends on the person's clinical presentation did you okay did you have a question for for somebody else it's a general question um OPR pays attention to scope of practice so that when a clinician does apply for a license the medical board as well you have to state your scope of practice and I was wondering if forensic examinations might be part of the scope of practice in this context so that's the question that I'm curious about okay so why don't we go with Karen Barber does Emily pause here or just Karen from DMH just me just okay fine um Karen go ahead uh good afternoon for the record Karen Barber general counsel of the department of mental health we did submit some written testimony I don't know if um you had a chance to I'm sure we do so the department doesn't um take a position on whether or not um you should expand um what I can do maybe is answer your questions that may be more helpful and talk you through where we're at one of the things I will say um because there's been a lot of questions about their qualifications so DMH sets qualifications for people we contract with um and so I was just pulling up um our last RFP so we require that someone hold a current uh license in the state of Vermont um we require that our psychiatrists are board certified and then we also require some level of additional forensic training um which could be um a forensic psychiatry review course offered by the American Academy of Psychiatry and the law I can't tell them feedback or someone's asking any questions just feedback um or that they write a sample competency and sanity eval that we review so we um we do set um kind of quality parameters um the same with the psychologist we use that does disability evaluations um I don't have his RFP up in front of me but again we do require some level of specialized training just to make sure that um that people that the people we're hiring are licensed in the state of Vermont and do have a specialized training and are able to do these evaluations the other thing I can say that was talked about in our um in our memo is that um we do currently have 16 evaluators um 15 psychiatrists and then we have the one psychologist that we have um that we had had before the statutory change we have not enlisted anymore evaluators um as I had kind of mentioned in the past for us it wasn't so much the number of evaluators it was the process that was taking a really long time and was administratively burdensome we did just this week roll out a new process that we hope to really streamline our ability to do evaluations and we're hoping we can do going forward under the new process we do um when we submitted this memo yesterday it was numbers from Friday and we had 88 on the wait list right now we have 75 I just checked so we are working we've um we've scheduled 17 in the last uh week so we are working um to to move through the wait list as soon as possible again the problem is not necessarily that we don't have enough evaluators it's actually trying to get them scheduled at this point um there are a lot of really great changes that um were made in S 91 we don't fully know the impact of those yet but we are working on tracking that data much more closely we do still have about 25 sanity evaluations that we need to get through so we are haven't yet seen the benefits of that um but we have um based on the new changes the Novotel was able to retain many more psychiatrists than they were before and just to give you an example pre-covid we had five evaluators uh we now have as I said 16 so uh we are rolling out the new process um it is going to um hopefully be less administratively burdensome on the department and allow us to more quickly schedule these evaluations I think one of the things to remember right is this is just a very small part of what the department does um and this is scheduling these evaluations is a huge administrative undertaking um for one of the paralegals in the legal department who has many other job responsibilities so she is working as quickly as possible as she can we're working on getting her some support and again streamlining that process um but right now we don't necessarily need more evaluators what we need is to kind of figure out a process um so that we can be referring them more quickly one of the things we've asked of the court is to make sure the documentation right off the bat so that's not a delay one of the things we've asked uh defense counsel is to get back to us more quickly about whether or not a date will work in the past we're just kind of waiting until we heard back uh we've now set kind of a 48 hour deadline and if they don't accept it within that time then we're going to move on and assign that time to the next person so we're really thinking about how we can work some more things I hope to be able to come back in a couple months and have more of an update but it's too early right now to see what actually um how the new process is going to roll out but we do anticipate it having a significant impact on the wait list there's a different testimony than we've heard this winter not from me but yes I know the defender general did feel strongly that psychologists made sense and and I and we respect that right um from our case we've always felt that it was causing some of the delays and you very we do think a lot of the changes in s91 are the changes we asked for such as the orders um separating competency and sanity making sure we could get the records issuing the bench warrants if someone's don't show those are all the things that we really felt like we're going to have an impact and we do anticipate that they are going to have an impact we're just starting to kind of slowly see that um so I'm always curious about places where bias or some discrepancy can can creep into the process so my question and maybe you can help me if I'm not understanding this clearly if they come through your office is that because there was it's a it's a public um payment for this this expertise as opposed to if they get their they hire their own private person to make the evaluation is that sometimes because the the legal team can afford um to hire a different expert and do you monitor any trends in the people that you hire if some tend to find more competency or incompetency do you sort of track demographics of what they find and if there's any age gender or race um discrepancy and who's deemed competent or incompetent I'm just trying to better understand where where someone could use a new category of evaluator to if they have money or resources be able to hire somebody as opposed to what your office does which is it is a public process are you hired by the court therefore you're paid by the court and there's not money exchanging hands from the person who's hiring an attorney so um so the court doesn't pay or hire anyone it's all dmh right they'll make a referral to the department of mental health and we arrange for it um so there's a couple different ways right you can get an evaluation the court can order dmh neutral evaluation um yes or either party can go out and get their own and they're free to hire who they want I think what you heard was a lot of testimony from the defender general that they tend to hire a psychologist it's just like in any other case right you're allowed to get your own expert um if you're the defender general then the defender general pays for it um the state um you know the state's attorneys have a budget so certainly I guess yes if you're also um if you have private counsel then you're kind of privately hiring them but other than that it would be the defender general's office the state's attorney's office who are doing it we don't um dive real deep into the data as to who's found incompetent and who's not again you know these are not necessarily folks in dmh custody they may not even have a mental illness this is a very small part of what we do we do look kind of trend-wise um I think about maybe 50 percent of those ordered are found incompetent I'd have to double check um but we kind of look at it that way um we are trying to think about what data may be more helpful to collect but again we don't we're not a part of these cases um so we don't necessarily know what happens right once they're found confident we are done with that if they are found incompetent they may ask um to see if they qualify for dmh services but they may not right because again you can be incompetent for many reasons so we don't necessarily know the outcome of these cases and we're not a party um hi I'm not a standing member of this committee and a bit of an interloper today but I do have a question um around scheduling it's really important and I'm wondering if you can speak a little bit to what the administrative burdens are around scheduling other than it sounds like the friction of time and distance are problematic but I'd love to hear a little bit more about that sure um so what was happening um was that we we'd get a request um sometimes the court would send the relevant information we needed in terms of like the the charging documents in the affidavit sometimes they wouldn't and then we work to go to our contractors and say we have these evaluations they give us dates and times that work for them and then what we were doing is then going to the defense council and saying hey would this date and time work for you and then they contact their client and it could be a couple days it could be a couple weeks until we hear something um and then we would try to schedule it assuming those dates still worked for everyone um and then if we didn't have the records um the evaluator maybe couldn't finish the evaluation because they needed the records we get a lot of no shows if the person doesn't show then that's all this time wasted no one else can be fit into that spot and the wait list is moving so um the new process is that we're not going to go back and forth about dates and times it's too administratively burdensome it means we can only refer you know a limited number a week versus just sending out a mass um so what we're going to do is we're going to get a date and time from the evaluator we're going to give that date and time to the defense council if that works great if it doesn't the following week and hope that works um but we need to much more quickly move through because we have you know one paralegal who has got money more things than just this she needs to do that was spending all of her time on emails trying to coordinate people's schedules um and it just wasn't working it was really causing um those delays the other thing is you know we're counting on the defense council to try to contact their client a lot of times they can't find their client so we're not we don't know if they're going to show or not um and then if they don't show there was no consequence for them not showing right it just would mean our evaluators didn't want these cases because they were losing that money and it meant that that time was wasted because evaluators set aside huge chunks of of the time of the day to do these um that no one else could use at that point because it was too late so we're also going to ask a week in advance that people confirm that they can still do that date and time and if they don't we're going to assign it to someone else so ideally we're not losing so much um so again we're asking people to be a little bit more involved and help us out a little more so that hopefully we can more streamline the process thank you so um yes Karen the the problem is being solved through the legislation act 28 was to place the competency hearing prior to the any assessment of insanity the that's one problem is being solved to carry to go forward and I think the courts are very thankful that's happened and then uh if someone is declared incompetent to stay in trial as a result of the evaluation what happens it depends which is a very low lawyer answer um we love those black and white answers so clear answers sorry go ahead and so the biggest thing is it depends why they were found incompetent um so it was at a mental illness and so do they if so then they may have they'll reach out to the department of mental health and we'll think about is an order of non-hospitalization appropriate is an order of hospitalization appropriate if they had an intellectual disability is an act 248 order appropriate um it was if it's substance use or dementia and we don't really have involuntary programs for those um so it really depends on the needs of the person one of the things we were also asked to look at um in s91 was the potential for competency restoration that could you know potentially change how things go right now how things go in the future but right now um Vermont does not have any sort of restoration uh mandate and so no one is actively restored to competency that doesn't exist they may get there as a benefit of treatment or just engaging but there's no um we're not trying to restore them to competency even if they were to come in to say the dmh system or the dale system and then one further clarification which we probably hear from um dale that an individual with an intellectual or developmental disability would be evaluated by someone who understands uh those areas yes so that that would still be dmh right so dmh is still the one that hires the forensic psychologist so dale doesn't have anything to do with competency evaluations they may end up receiving custody through act or 248 at the end of the process but they are not involved in the initial process at all it's solely dmh that holds those contracts but yes if there is a suspicion of an intellectual disability then we use our forensically trained psychologist to do the evaluation um if we know right away that may be an issue then dr donnelly is assigned right away um if we're unclear then we would um we would first assign a psychiatrist and if the psychiatrist says hey actually I think that what I'm seeing might be an intellectual disability then we would ask dr donnelly to do the evaluation um so they are getting specialized evaluations but again that's all through dmh thank you for clarity um what I'm a little confused by the dale role they don't come into it until after the psychiatrist or psychologist would find that the person has an intellectual disability correct so they're not even that's how somebody gets to act 248 right after there's been a competency determination is there any uh victim involvement in the competency evaluation process or the act I meant in the process they know do they have any um I do not apologies I do not know much about the act 248 process so I am not sure um so I can say on the dmh side no like if someone was getting an order of nonhospitalization there wouldn't necessarily be any victim involvement right because it's a clinical determination about whether or not someone needs their services I don't know how that works on the dale side it could very well be different okay thank you yes um this might be a question for those who heard this testimony but first karen in addition to being legal counsel are you a licensed mental health professional in any capacity me personally yes no okay I didn't ask that is it tack on you but I'm looking around them who were not hearing from our mental health professionals about what this is our first hearing okay that's going to take four meetings okay to get through and so I guess that's why right now we're having that yeah mental health and then explaining what our charge is okay I expected our next meeting we'll hear hopefully from mental health professionals right as well as I mean my only comment in this context is hearing from dmh that they feel like the problem was not a personnel related problem it's a court issue the court the courts were finding a confusion about having uh and I can't speak for the court but certainly the confusion around having competency hearing and sanity hearings going on concurrently and trying to put it into a stepwise progression yeah so you're competent or incompetent to stand trial and then if you do stand trial did you have sanity at the time of that you committed the crime right so the so what we're doing now is understanding that there was a backlog what whatever the cause of the backlog for the competency hearing we're hearing from Karen that some of this is being resolved for whatever reason that's good to hear but for until next year we have a forensic psychologist as well as psychiatrist performing a competency hearing so there's there's a lot going on and things are being pulled apart and solved at the same time that we're still trying to solve the problem right so I would just in the future meetings want to make sure that we're not letting a quality question be answered by a logistical question that changing the timing is different than having different types of professional who can make this determination right but when you have a backlog then you also want to consider numbers of professionals who are available to do that analysis so it's a catch 22 you do one or you do both and so now we're actually doing both so see how it goes and and Ben remind me it's a preponderance of the evidence that must be demonstrated uh for to demonstrate incompetency or competency your committee was the jurisdictional committee came from judiciary okay to our committee so we were collaborative did you hear opposition to this change not opposition to psychologists okay so psychiatrists didn't come in and say they don't have x y or z no i think it's i think at the time we recognized you know going back to the testimony this morning about psycholot you know psycho mental health care and the institutions it's there's a shortage of professionals and that's part thank you i was just wanted to add that there was going to be an all day conference coming up about mental health in the courts and that might be something that would be really and you're all excited yeah might be forget what the day we have judge zoney coming up so shortly but first if there are any other questions for Karen but we will hear from the medical society at the very least well it represents psychologists psychologists it's not the medical society no it's gotta be a and psychiatric social workers yes i'm not sure um our next witness is defender general matt valerio thank you matt good afternoon why don't we just get this on you are on september 14th i'm uh i'm uh yes and thank you for having me i am matt valerio i'm the defender general this uh suggestion of having uh psychologists due forensic competency evaluations was my suggestion this arose out of initially a shortage of individuals were available in the state of vermont who were by statute recognized as competent to do these evaluations vermont was one of only two states in the nation that didn't allow um or recognized by statute uh doctoral level psychologists from performing uh of forensic competency evaluations the other was rhod island and we had a shortage and a backlog and i'm glad to hear that apparently department of mental health has more people who are available to do the evaluations and that the backlog has trimmed significantly from uh six months ago when we were having this discussion in the legislature um there is uh there were a number of questions and comments that i heard during the prior 50 minutes or so of discussion that i was hoping i could clarify um one of the things that i did want to clarify is that competency is an issue also in juvenile cases that is in juvenile court and and hence the family doctoral level psychologists have always been approved for use in competency evaluations in in those cases but it had recognized in criminal cases what the defense defense council because it's you know we don't do we do almost every case in criminal court but not every case in criminal court uses forensic psychologists oftentimes to attack the positions of the psychiatrists who come up with their evaluations if we don't feel that they are appropriate and that might arise out of that probably rises out of the court ordered evaluation and the court has to make a determination based on what they hear in evidence of whether or not the person is competent or not so there is it's a full-blown evidentiary hearing on whether somebody understands the proceedings that they're taking part of whether they can adequately participate with their council in defending themselves in these cases and and as uh Karen paper indicated that can arise out of a bunch of different areas whether it's a major mental illness traumatic brain injury development of disability or the like ultimately the qualification to do competency evaluations whether an individual is qualified to do that really rests with the court but because there has been a presumption that psychiatrists um are are statutory um authorized to do it um where there is a a balance to be made oftentimes the psychiatrists would would get the nod um one way or the other um when the court is trying to make a decision that would be that whole situation is contrary to really what the nation does except for Rhode Island um so we believe that for a bunch of different reasons that and and again I I I wouldn't have made the suggestion if I didn't think it was going to be beneficial that doctor level psychologists um appropriately should be used to deal with these cases now the other the other side of this is it's not just about the initial evaluation that perhaps the departmental health through the contractor is is doing regarding these evaluations but it's the availability of individuals to all of the members of the criminal justice system whether it's the prosecution or the defense um test those evaluations um it's not a monopoly that um departmental health has on doing these evaluations and they really don't have or shouldn't have a um horse in the race of um whether somebody's competent or not but it's the availability of of competent people to um test the evidence that's out there whether it comes from the department of mental health or anywhere else um and so the more people we have available to do it um and competent people and I suggest that doctoral level psychologists is one of the areas uh there is probably you know that's where I would like to see it go I I don't there are some states that allow um you know master's level clinicians and and other types of licensure to do these evaluations and I don't suggest that we go there I I think a doctoral level um of a evaluator psychologist clinical psychologist or PhD level psychologist is uh is probably that that's about as hard as far in the um kind of the credentials as I would want to go I wouldn't want to go any lower than that that's gonna be helpful ultimately it is way too soon right now to make any evaluation about whether or not this is um assisting the system um that's always one of the kind of the frustrating things is a lot gets passed throws into effect on July 1st and then on August 8th we have a a hearing to to see how it's going and basically um nobody's had a chance to take a breath as to what what this is all going to mean and be implemented so as far as we're concerned we we've been supportive of it and we're interested to see how it pans out we've actually been using as I said doctoral level psychologists to test the psychiatrists for decades use the term test the competence of the psychiatrist you know it it's interesting because they psychiatrists and psychologists do very different things when they evaluate a an individual's confidence to stand trial psychologists are trained in administration of a number of different instruments that have been tests and the like that have been validated that's part of what they do the psychiatrists don't administer those tests they have sort of clinical evaluations and talk to the people about the legal elements that are part of it so oftentimes when you are if you're a defense council or if you are a prosecutor and you like the result of the mental health uh um independent mental health evaluation you'll hire a phd or doctor level psychologists to pick apart the clinical evaluation of whatever happened with the department of mental health and the um doctor level psychologists are very effective at doing that because they have more tools at their disposal to make that determination that's kind of in the weeds for for you folks as legislators but um that that's the facts as as the how these cases prove when they're contesting how they perceive um i don't know how i i did receive the uh um departments proposed memo on scheduling and the like uh yesterday afternoon um i will be interested to see how that works out well i hope there's some respond to this but what i'm what i'm hearing is that there might be a different reason to allow psychologists to to engage in these in these competency exams besides the backlog that they might actually be more qualified in certain instances to do the evaluation and i would rather have that conversation than one about scheduling if that makes sense and so i guess my question in that is uh if if the defender general's office has availed themselves of of a clinical psychologist now that it's allowed in this pre sunset period because it was the better evaluator versus like do you see a case coming up where you'd rather have a clinical psychologist and you feel like that would be a better decision not like whoever's available first kind of thing we've actually been doing that for decades well you said for decades but how but you've been doing it as an understudy to the person who has to write off on the evaluation is that right not really a study we have done it as part of litigation to attack the um the opinion of the psychiatrist um who uh did an evaluation that we don't feel is appropriate so this goes back to my like original question for Ben which is the importance of who gets to do this so you're saying that right now in Vermont a psychiatrist is the only one though that can go into court with that initial determination of competency but you could you can attack their report with a clinical psychologist yes the the only thing right now that is the independent evaluation that is ordered by the court through the department of mental health prior to the passage of the legislation that you just passed was a psychiatrist passage of the legislation um qualified uh doctoral psychologists and they may be clinical psychologists they may be phd level psychologists um there's you know there's the psyd's there's the phd level psychologists both of them would be qualified to do these evaluations in the first instance and would and what we are hoping is to attract more of those people to the state because we've had a turnover and a large number of retirements in this community over the last couple of years i know i think i'm more confused about the problem we're trying to solve but problem we're trying to solve yeah is was the backlog but also whether or not because of the backlog which may or may not no longer exist would it be who should be doing these evaluations and so we put a sunset on the psychologist to get this information and take testimony well it's the backlog to be clear i think the backlog still exists it's just not as enormous as it was a year ago or six months ago um and it's really we're about 80 of them backlogged up and people were 80 instead of 160 right and people were spending time in jail because they had to wait for the competency evaluation but okay but the only person who can do the initial competency evaluation has to be through dmh it's a quarter yes it's a quarter it has to be quarter it has to be close so okay so that's what that's why if dmh is saying we're neutral but we're still only using they said they were neutral to the psychiatric social worker and others right oh so they're not neutral i think they were in favor we can check with karen but i thought their testimony was in the letter indicates their favor of the psychologist oh i thought she came on it said they're neutral about us well the question is do we extend i read the letter as being in favor of the current statute and lifting the sunset if i could put that back on so they're here the treatment the department departments dmh and dale do not have a position as to whether to expand evaluators beyond forensically trained psychiatrists and psychologists so they're so beyond what but let karen speak to them make it that was basically what i was was going to say um you know we don't really i think um matt said it really well we don't have a dog in the fight right like it doesn't we our job right is we get an event we get by statute we have been told that this is what we need to do we hire evaluators we do the competency evals we do not have you know our role is to assure that people who need mental health treatment get it as to whether or not someone's found competent and who's appropriate to find them competent you know we really feel like we're a neutral in this and so we're not taking a position on it well it is except what i think i heard was that you're still almost exclusively using psychiatrists so do you feel like there's situations where a psychologist would be a better person to evaluate competency that they're not getting a psychologist they're getting a secretary we and when in cases of intellectual disabilities we do use psychologists okay but you weren't before this law no we were yep no that it was allowed i think what changed now is that psychologists can also do people who have primary mental illness we are continuing to use psychiatrists for that but we use psychologists when intellectual disabilities are when aren't indicated so it can seem like it's going to be a major change any comments further i'm sorry senators say that again any further comments from you on this issue yeah i i was around obviously for pretty much every part of this and and i know that there are obviously members of this committee that weren't part of that testimony and um you know the horse was beat pretty dead about the this this issue of uh the doctoral level of a psychologist i didn't think that there was any real i didn't think there was any opposition that i didn't hear even opposition from i didn't hear opposition from the psychiatrist who testified um were anybody else the the question as i understand it is whether it should be expanded to people beyond doctoral level psychologists um and i would not be in favor of that but i i would play out again we've had a month so far so it's a little early to make an evaluation i'd also want to comment on i had on my list here uh but i do know that our what psychiatrists in the in the past you know who who finds it who finds everybody competent he doesn't find everybody competent um we didn't break it down on a great Catholic background this question was brought up earlier but we definitely know who the ones who are more likely just as a matter of statistics to find somebody competent versus not so it's it's like you could be judge shopping yeah except for we don't assign any of them so um and the department of mental health and uh and and um the name comes up and we say oh that one is very very likely to find this person competent um you know then we have to be more uh we have to take a look at that closely and and see what we're going to do with it do you use Ramon or out of state psychologists when you're we have used both depending upon uh the appropriateness in any given case um i there's there's there are people we bring up from Harvard i'm a clean medical who are you know one of the guys behavioral pharmacologist exactly a phd level psychologist who talks about drug interactions and how they are mental illness and and that's somebody who's not he's not a Vermont guy but he's you know one of the world leaders in the in that area we bring him up there there are people from around who they're not just not just from Vermont um but the statutory presumption of psychiatrists is something that um really was only part of Vermont and Rhode Island law and we thought it beneficial that it if we could get in line with the rest of the country i have one more i'm sorry i maybe i've had too much caffeine um so Representative Emmons help me understand that the second part of the question is whether others would be included and so i guess my question for our defender general's office is do you see i mean the only reason i could think of including others is because there's not a lot of diversity in terms of who is a doctor a level psychologist or psychiatrist we struggle with that a lot in the mental health field writ large for people of color um you know i can probably think of other discrepancies too but it's a huge discrepancy among someone you might find that's a black mental health professional or otherwise so i just wonder in your perspective if you think there are cases where you would want expertise from somebody um who has a perspective that might close disparities beyond people who are licensed uh doctoral level psychologists or psychiatrists i haven't thought about that to be honest you know i would hope somebody who's a doctoral level psychologist or psychiatrist would have training do i recognize those issues i don't know that if you gotta had a master's level person in color looking at the issues that you would be any better or worse off i don't know the answer honestly haven't haven't thought about it that in that in that term well maybe let's not think out loud about it but if you could come back with an answer any empirical studies or we could ask the medical community you know that that to me is the question i want to answer for that second part is is there a gap because it's very hard to make it to your doctoral level of psychology or psychiatry if you come from a marginalized background i think one of the questions to ask is really maybe a little bit flipping that so is there sufficient diversity within our doctoral level psychologists and psychiatrists to account for providing adequate representation for these evaluations for people of color yeah i would like to know that yeah that's probably a better question for the for the doctors to be honest i um final question for me is a geographic disparities in terms of or is it just individual psychologists or psychiatrists to find out that you're not yet you know with with mental health now using the you know the video evaluations over computers um the the that issue is is less of an issue the issue that arises more is the availability of and and how people are kind of respond to the video as opposed to in person um but it's i don't think it's uh i don't think it's as geographic as it as it used to be i think it is more um facility with technology and just comfort level with using that many of our clients and this is going to be this is what i foresee by the way with the proposal that department of mental health has with these many of our clients are transient some are homeless they don't stay the same place over and over they are either they do or they don't have some level of mental illness they aren't always they are particularly reliable when it comes to their scheduling um and um or they're i think that i guess if everything was a perfect world the departments memo with these 48 hour deadlines and the like are you know that would be wonderful if that would work i just don't think that's the way our clients work and so um we're either going to have a lot of arrest warrants or we're going to have uh you know there's going to be some level of disruption with the clientele that we deal with anyway that are you know qualified to have uh competency evaluations um and uh and and getting them scheduled and that's part of the world we live in i think so uh while i um i guess we would aspire to be able to uh work with the department of mental health i don't have great hopes that our clientele are going to be amenable to that but we'll see because i got it yesterday afternoon so we'll see what happens i hope we'll be back to this and i'll put here for you later can't just ask another question for matt larry oh no it's actually for karen can i ask another question for karen if you're available hi thank you um i i'm just uh curious if there's any background questions or information that's gathered from the um the person to be evaluated in order for the department to understand whether or not you need to seek an evaluator that has some uh potentially you know specialized um skill or background um that would be relevant to assess so whether it's a person of color or an lgbtqia person or a look you were talking about person with a disability it is um it seems as though um that was considered for people with developmental intellectual disabilities or brain injury i'm just wondering if other characteristics are taken into consideration when assigning or requesting an evaluator um no so all we get right again we're not a party we're not at these hearings um all we get is a referral from the court which generally includes the charging documents and an affidavit that talks about what the crime is um we may know the person um which is made why we may know a psychologist is indicated or it may indicate they can ask for a psychologist they can indicate there's an intellectual disability um again i think the thing to remember too is you know i haven't this is a competency is a legal question right it's do you know how to talk to your attorney do you know i i don't know how much um they're not super in-depth evaluations right it's not like we're doing a mental health assessment where we're really trying to think about what programming does the person need it's it's very different it's can they are they confident to engage with their attorneys so we don't have a lot of background information we again we're not even in court when these are done we just get emails us we take it we um and we just assign it we don't pick we don't we don't tell people we're not picking certain psychiatrists based on who we think right we just we send it out and whoever can take it takes it the only difference is that if there's an intellectual disability we assign it to a psychologist but otherwise whoever gets it gets it i will just quickly respond i know that there are times when we do hear from um mainly defense bar that they have a concern with an evaluator if we do get that we we have our own medical director read the evaluation to see if she has any concerns and then we also a novital has a head psychiatrist who oversees um and so we do if someone raises a concern with us we do make sure to go back and and make sure we feel comfortable with the evaluation but we don't we don't assign special psychiatrists for certain so i'm presuming you um have interpreters available for people with different languages we do yep okay thanks question representative i couldn't put an answer okay um someone earlier mentioned in ovitel karen i think it might have been you i'm curious if dmh is using um in ovitel clinicians for evaluations remotely via telehealth and if you are um are you using in ovitel scheduling services too to schedule this no we schedule them have you considered using in ovitel scheduling because i know they offer that i'm just curious whether that might help with addressing some of the backlog um we haven't i we haven't we have not it i don't know the logistics of that again it's i think the most of the delay is just trying to make sure that we're working with the defense council to find a date um but could we we could we do that in the future i don't know thank you okay tim what is the representative of the state's attorneys hello mr chair and i think i'll be pretty brief because you've already had uh the experts going in front of me um and so yeah i think we're we're very hopeful that many of the changes to s 91 put into um place we'll we'll eventually um bear some results um for all the different parties and and you know the question about no victim notification as long as it's allowed by law our victim advocates inform victims as to every step of the of the process when there's a criminal justice involved um individual um and you know we do think that s 91 will be helpful and the competency evaluations going forward we are we were supportive of the bill as it passed um and we uh agree with the defender general's perspective that it's important to have as many qualified evaluators as possible for the state to um make sure that individuals are being evaluated as soon and as close in time to potential court hearings as possible um that said if there's going to be an extension of the sunset as to doctoral level psychologist or an expansion that this group considers um i had sent along a mostly technical recommendation to attorney nova growsky that you then also amend 13 vsa 48 16 e which is the presumptive allowance of relevant portions of what was previously just psychiatrist reports to include whatever the list may be so if it's doctoral level psychologist which it is now um or other individuals who are professionals uh in this area that 46 sorry 48 16 e in title 13 is amended to reflect whatever the list is um and next session we would we would recommend that 38 a 13 vsa 48 16 e include doctoral level psychiatrist if the sunset will be extended and i've i've sent that along um to um ben so he has it uh as well but really that's the extent of our comments we're meeting every couple of weeks with dmh and dale um to make sure that if we can be helpful on anything we will be and we're certainly interested in seeing if there's any progress that can be made in competency restoration going forward the state's attorneys have any recommendation regarding those other than doctoral level psychologists we leave that in your learned hands mr chair um okay any question hey that that was briefed him and thank you very much thank you all good to see you forward to seeing you coming south it's one of these days i look forward to that as well the the blue ben uh i understand the menu hasn't changed so i know exactly exactly well that's why it has but still the same old blue ben with a new owner and doing a great job um our next witness is the honorable judge don't they so good afternoon are you open today we are we're in a different location but we are certainly open for business today it's good to be here tom so he has a sign behind him saying open so i i too think i can be brief we the judiciary supported the expansion to include the doctoral level psychologist for the evaluations and i think what i've heard during the discussion this afternoon ties into the idea that well perhaps people started to look at this because of the backlog and because of the delays but the question really becomes even if you took that out is it the right direction to go in and if you look at 40 the other jurisdictions they go there i believe 48 of the other states were already there and they found that having a broader pool than just psychiatrists enabled the effective administration of justice and from contacts with my colleagues across the country when i've asked about the timelines i am sorry to report that the timelines between getting reports in vermont and getting reports and other jurisdictions don't match we take a lot longer when we had the backlogs and even in the normal course i suggest we took longer to get our reports and evaluations i believe for instance new hampshire requires that if someone's incarcerated the report has to be submitted within 45 days if they're not it's within 90 days there are jurisdictions that have actually much tighter requirements than that and by expanding the pool of qualified individuals you're adding a diversity to the evaluators that doesn't exist with just one discipline of psychiatrists and you're reporting the opportunity to have more reports done by more people thereby the time frame so we can get the cases into court sooner and and that loses part of the issue that we heard about from mr valerio also and that is you lose touch with people when they have extended periods of time we saw that during the pandemic so the more we can do to shorten those time frames i suggest that it will also mitigate the potential of defendants losing touch with their attorneys perhaps and it should help all of us move forward in the criminal justice system not just again to address a backlog but to keep the system moving with case flow as efficiently and expeditiously as we can and i as far as lowering i won't say lowering as far as expanding who can do the evaluations i was just looking at a document put out by the national center of state courts from a number of years ago and they mentioned that there are some that allow master level with licensure mental health professionals with forensic training i'm not prepared to weigh in on whether the vermont system should go any further than where it has right now but we do support the idea of the doctoral level psychologists continuing not just during this period but after the sunset question to the judge judge thank you very much thank you so judge johnny i do have a question i'm going to follow up on senator ron hen sales question and the question uh is any data that you keep is there any data that you or perhaps it's the department of mental health keep with regard to who is declared competent versus incompetent based on gender or gender identity race ethnicity is that is that pertinent data that you have and do you see that as an issue in the process of competency determinations we do not keep that data and it would be difficult to assess whether it's if you will an issue in the process right now because i don't have the data to compare it to and to understand see how things came out but we do not keep that type of data i would note that the judiciary does have a commission on diversity equity and inclusion justice cohen is working on a committee that is dealing with data i submitted a report last year to the legislature regarding certain types of identifying and demographic data uh relative to civil cases and i know that the dei commission is looking into different areas for data so i will mention this inquiry to justice cohen and see if it's something that they are looking at thank you very much that would be very helpful great thank you all so much thank you i'm wondering um i'm wondering who you would like to hear from besides someone from the american psychological i think it's the mon chapter mon chapter american psychological association i believe that would be appropriate and the monday society would probably have psychiatrists the the the testimony that we heard from the psychiatrist psychiatrist affiliated with the howard center would be useful okay and and and perhaps um to have a a psychologist a doctor level psychologist who's currently involved what about the other groups that were mentioned in the legislation so and then beyond that um i think opr might be practical and identifying master's level uh nurses who else is it psychiatric after nascit nurse practice thank you mental health providers psychiatric ms practice maybe a closer maybe hearing from the local mental health center you said that yeah yeah so so uh when we were taking up s91 i was contacted by a doctoral level licensed psychologist uh who i think we should probably reach out to as well uh he he could serve that role he is familiar with these issues his name i don't know it's possible you've heard from him as well thomas powell is yeah well he used to work for the correction so i know right yeah i think he may have reached out but you know we can certainly beggy can get in touch with him who else martin i have a question because now i'm very confused but before i say that before i ask the question i do sometimes wonder historically there's a little bit of bias toward or against psychologists and psychiatrists i just it has come up in our health and welfare committee before and it just i just want to throw that out there my question though now is it seems our what question are we asking now well the the legislation requires us to consider whether or not to lift the sunset on the psychologist okay and whether or not to add other professions to the list and that's where the other professions come in now whether we heard it from actually matt larry or that that he thinks psychiatrists enough and we heard i thought tim space and i think karen was neutral and so i don't remember what i don't think i think he said this this sunset has not been lifted yet no that would need to be in the legislation next year the sunset's july of 24 july of june 30th of 24 thank you so we can lift it or you can extend it for another year or or do away with it and be like the other 48 then the next question is do you then one thing that he was it was it um tim mentioned or was it matt someone mentioned about the time frame yeah some states have i think time frame which i've donated and i think that's probably something to consider as we consider recommendations because i people the testimony we heard everywhere probably in judiciary was that those weighing competency evaluations were in jail longer on detention than any other group other than those with charges that like murder that would take you know all the time to resolve are any folks who are required to go through the evaluation are any of them held with the state hospital or they all held you know i don't know can anybody answer that that's still on is that karen i can um so it depends um you can be ordered to have an evaluation or an out patient evaluation um if you're ordered to have an inpatient evaluation uh we have a psychiatrist that then assesses the person to determine whether or not they meet hospital level of care if they do meet hospital level of care um then they would um go to an inpatient unit wouldn't necessarily be bb ph could be any hospital um if they uh do not qualify for an inpatient but instead an outpatient evaluation they could be in doc or just in the community so karen would i know we're talking about a future possible forensic unit would any of these folks were waiting for a competency evaluation or have been deemed incompetent to be housed at the forensic unit so the way the legislation was written at the end of last year um it would um be only for people that have been found incompetent or insane so it wouldn't be um before that determination was made and then it would be only for people that were incompetent or insane does that make sense it does so right now if someone has been deemed to be incompetent stand trial are they housed at the state hospital or a doc in a correctional facility um so again it depends on their clinical needs um if they're incompetent they wouldn't remain in corrections um the the reason we propose the forensic facility right is because there's a gap between the folks that need hospital level of care and those that do not that still remain in need uh intensive services in a secure setting um so right now they could wait in a hospital again doesn't need to be vpch could be any hospital throughout our system if they need that level of treatment right it depends on their clinical need not whether or not they're incompetent um or they could be in the community or in some sort of residential setting if they on an act 248 order then dale provides services to them so there is a uh s 89 i forget the act number working group right now uh looking at the gap issue so there's another working group looking at who would go into a forensic clinic wasn't that 91 or was it 89 it's in yeah that yeah i'm i keep what's the act number a 27 thank you yeah i keep confusing 89 and 27 i thought i was a root number to come up here 91 and 89 heart but at any rate sort of that's that issue is whether or not developing those eight votes right would be that's a daily or if there's a number of questions that are being asked and steward shore is the expert in that area but i think that's not part of what we're going on we're not justice oversight it's not taking that special committee for that you were on that one too we're going to go i wrote down a meeting for a win for a win the second meeting i wrote it down for wednesday and i was online and all set to go on and they wouldn't let me join the team because i was so on it's easy to do all right okay we don't have meetings scheduled i think we have an idea of an agenda the next meeting but we also have other issues we have to take on but we don't have a meeting scheduled yet for september october november december so peggy will do a doodle poll everybody um and then for our guests we can send you the doodle poll but i think we'll at least do one more meeting on the on this question although it was i found it pretty helpful today what the practitioners had to say did you do the thing for what was it the letter yes and then we have the letter why don't you send it to the committee can we act on that today well it'd be helpful if we could talk about it briefly you don't have to share it on the screen yeah i'll share it on the chat that could be a lot easier let's try another one it was just a letter of recommendation absolutely there's a public maybe a situation so the question that so my committee members had was whether or not they should be voting on this letter of recommendation since they're the health care and human services participation and health and health care and human services 12000 senate specific to act 28 competency so we would not vote on this letter okay nothing again yet you can deal with it come january you got a heads up better than i cover with them oh yeah that's where you get paid the big bucks for that is what it i'll move that we have to be the senate senator please help we call it programs in the second line we call it program in the first paragraph so we just be consistent i think it that second it's the fourth one in the first paragraph the first word i think it should be programs in and it says programs in the second so i like the first one so i'm just wondering should we thanks the journalist should we um in that second paragraph ask them to i mean we heard from these two areas we don't know what the status is in the other areas should we be asking them to look at the status in the last sentence yeah i will cross the state i missed that okay okay thank you so i was like in that motion if nobody else thank you maybe there's martin all in favor say aye i opposed what's unanimous are we going to get a copy of that letter it's sounds good is there anything else we'll do the duty poll and thank you with us to contend the duty poll to all members including those else in welfare and even service to members thank you for including us thank you for including us by thank you oh by uh wasn't just a nice josh oh you did it so they're required they should put in for prudine yes we should put in for prudine in expensity well i think he does that which thank you for reminding me he got an email saying he puts us but i'm not sure thanks everybody good to see you all