 I think that's great, but it's something which we've been looking forward to hearing as we've been here. And with the numbers of people participated, I also know that an hour is not an adequate time. We can do the opportunity to give a full presentation, but because it was advocacy day, we have many other people asking to be heard as well. So after we hear from Commissioner Squirrel, would they agree with the committee members? Agreed. Well, good morning, everyone. For the record, Sarah Squirrel, Commissioner of the Department of Mental Health. Very pleased to be here today to be presenting our Vision 2030, which is a 10-year plan for an integrated and holistic healthcare system. I just think this room is representative of urgency and importance in terms of attention on our mental health system of care. I also want to thank the enormous amount of stakeholders, community members, and Vermonters who came out in our listening tour and participated. I also, we have several members of the think tank who are actually in this room today. I want to thank Vice Chair, Representative Donahue, Representative Rogers, who participated on the think tank. And I would just members of the think tank or the advisory committee, if you could please raise your hands and just be recognized in this room. Thank you. Yes. So from my vantage point, we sit at a critical juncture in our mental health system of care, and also as an overall healthcare system. And in the past 10 years, Vermont has absolutely solidified itself as a leader in healthcare. And at the same time, despite our strength and determination, we still find ourselves having gaps in that system. Vision 2030 articulates and provides a vision and the strategic actions to achieve a holistic healthcare system that we think will benefit Vermonters for generations to come. Today we'll be providing an overview of that plan. And for committee members, in case you're wondering what you might be reading this weekend, I've answered that question for you. It is 80 pages. There's a lot of information in here, including an appendices that really walks you through all of the detail of how we did this work, how we did stakeholder engagement, and other information. So I would encourage you all to take a deep dive into the report. We'll be doing a high level overview today, and we'll likely come back to the committee to do a deeper dive into some of the content areas of the report. So our charge, why did we take on this task? Back in January of 2019, the Department of Mental Health was actually tasked by the legislature to conduct a comprehensive evaluation of the overarching structure of our mental health system of care and to articulate a long-term vision about how mental health care can be integrated within a comprehensive and holistic system of care. We at the Department of Mental Health took that charge very, very seriously. We committed to a process to come together to strategically align around a ten-year vision because I fully believe that if we don't know our end state, then we don't know our next steps and we have to articulate the short-term, mid-term, and long-term strategies and actions to get us there. We are emboldened and inspired by the aspiration that we could build a system for the future and for the now and an integrated system that will benefit us all as we move forward. Vision 2030 is a vision with an actionable plan to help us get there. As I mentioned, it was informed by hundreds of Vermonters residents and stakeholders who came out to participate in our listening tour, and it weaves together the health needs of Vermonters into actionable strategies that will allow us to take policy into practice. One of the foundational pieces of the charge was that this process was inclusive. Inclusive of stakeholders and voices who are absolutely urgently important to our mental health system of care, including peers, advocates, those who identify as having lived experience, providers, health care providers, mental health providers, all coming together to articulate a vision. We conducted our listening tour using the framework of appreciative inquiry, and that really helped us look forward. Forget everything you learned about change management 101 systems and people as problems to be solved. Appreciative inquiry is really about illuminating the best of what is, building on our strengths and looking at what could be in the future. And we utilized that framework to create a context for hopes and aspirations for where we want to go over the next 10 years. We held five listening sessions across the state of Vermont, in Vermont communities, sitting with community members, listening to the needs, hopes and aspirations of those who are invested in our system of care. We then took that vision, the hopes and dreams of Vermonters, and we turned to a think tank, which was an incredible group of stakeholders and other individuals who came together and had the daunting task of synthesizing all of those ideas and vision into an actionable framework. The think tank meant five times full day meetings in early fall, mid fall to early winter. We also had a think tank advisory group that was comprised of other stakeholders. They provided incredible input and feedback to us, were a great touch point for us just to reflect on the report and where we were going, and I want to thank the think tank advisory group for their contributions. The adult and children's state standing committees also reviewed the plan and the review, and they reviewed the recommendations. This was also open to public comment, which we received over 52 public comments online, which were also taken into consideration in the drafting of the report. So Vision 2030 really aims to provide Vermonters with access to whole health, personalized care that achieves the triple aim or the quadruple aim of healthcare. That includes improving client experiences, improving the health of populations, reducing costs of care, and improving healthcare provider experience. We also wanted to illuminate what is the word holistic really mean. And when we think of holistic, we think of it as something that is interconnected and only explicable and understood by reference to the whole. Essentially, what that comes down to is that there really is no health without mental health and that they are connected. By fully embracing this and working to collectively address this, we think that Vermonters can achieve improved access to care, be healthier, and the state will realize significant economic benefits. A little bit about the history and some of the foundational guiding framework for this work. One of the main charges was to really think about the integration of mental health within a holistic healthcare system. And I think it's really important that we understand that is fundamental to this charge. Since the de-institutionalization of mental healthcare began in the 1950s, states have been redirecting their primary services to community-based care. And with the recent passage of the Patient Protection and Affordable Care Act in 2010, the landscape of healthcare overall has evolved towards outcomes-based model of service delivery and system design. So essentially national trends and practices are moving towards integration of mental healthcare and physical healthcare to improve access, quality, parity, and efficiency. And that is really fundamental to our vision for 2030. We also know that successful implementation of vision 2030 will require buy-in and engagement from many stakeholders, both within our mental health system of care as well as healthcare providers. So the Department of Mental Health feels that it is urgent and important that we engage you as the legislature in thinking about the creation of an appropriate structure, such as a council or board, that would actually have the authority to oversee and guide these strategies that require commitment to that vision of integration of mental health within the broader healthcare system. The next slide also articulates one of the fundamental values and tenets of this work, which is related to social contributors to health, a.k.a. social determinants of health. Central to our ten-year plan is the recognition that the health of individuals is improved based on the health of our communities and our environment and the fabric of our society. So we have to consider to think about those areas in terms of the overall plan, a healthy society, a healthy environment, a healthy community, which can support healthy people. Social contributors of health are called out in this action plan and woven through all the action areas. This is a care continuum that we reference a lot in the Department of Mental Health when we think about our continuum of care, that we need to strengthen that continuum of care tip to tail, promotion, prevention, early intervention, treatment and recovery. All areas of the continuum need to be strengthened. Oftentimes, promotion and prevention, as we all know, are overlooked and we prioritize treatment and recovery. We have chosen in our ten-year plan to equally prioritize all four areas of the continuum in order to enhance our system of care for homeowners. This visual articulates how we have created and aligned this process with eight action areas that also align with the quadruple aim of health care. Within the report, we articulate eight specific action areas with those strategic short-term, mid-term, long-term actions and strategies. We'll be walking through each of those action areas very briefly right now to give you a sense of what the think tank and stakeholders were looking for across the system of care. I'll just keep on going. Welcome to you. This is very great. Wonderful. So action area one is promoting health and wellness. So essential to this vision, as we saw in that previous slide when we look at social contributors to health, is the concept of healthy communities and health and wellness is really hinged on that. There also must be attention to providing support and thinking broadly in order to prevent family members, peers or staff from also suffering undue stress in their roles. So thinking about wellness for our care providers. Some of the action areas in promoting health and wellness include ensuring that we have culturally and linguistically appropriate resources in the communities that we're continuing to partner with states, peers and statewide programs to improve and expand resources. To expand insurance coverage for employee wellness programs we have to continue to care for the caregivers and to support the development of trauma-informed diverse workplaces. Each of the action areas is broken down by themes. I would also note that what you see up on the screen here is just a sample of what is in the report. Within the report, the short-term, mid-term and long-term strategies are well beyond what is here. This is just a way to visually see how we're thinking about those short-term, mid-term and long-term strategies that we need to build upon. The three themes in action area one, promoting health and wellness are focused on practice improvement, collaboration and workplace wellness. We want our practice improvement efforts across the state to be aligned with health and wellness promotion, building trauma-informed communities and safe spaces that are person-led. In the mid-term, we also want to focus on our youngest Vermonters, enhancing the social and emotional learning for children which we know is foundational for future success. And to work towards universal screening and assessments and statewide same-day access for care which we know is essential. Long-term, we'd like to implement these approaches, focusing on universal screening, implementation of social and emotional platforms such as MTSS and early multi-tiered systems of support in schools, looking at the health benefits that meet our employees' needs, so that people coming to work every single day in our mental health system of care feel well-supported, and looking at the wide use of wellness coaches. Action area two is related to influencing those social contributors to health. When we think about social contributors to health, there are conditions in which people are born, live, work, play and age that affect a wide range of their health and functioning and their quality of life. The Centers for Disease Control says that these conditions which constitute place must be thought of in the larger context. So ensuring that Vermonters' most basic needs can be met is essential to building healthy communities. Basic needs such as food stability, housing, transportation, affordability, accessible childcare and employment, we know that all of these factors influence and impact our overall health and wellness. We want to focus on ensuring that basic needs are met and develop a social policy agenda that aligns providers and community partners in the wellness model. Another area that was articulated, and this was articulated strongly through our listening tour, is continuing to build and power and sustain a strong peer network through Vermont. That is also up and lifted up and articulated in its own action area that we'll be talking about. The themes related to action area to influencing social contributors of health are in two buckets, the basic needs that we just talked about and enhancing protective factors. In the short term, we need public education on health equity and mental health, again for our youngest Vermonters focusing on social, emotional development and learning. In the midterm, how do we continue to think about expanding support for housing, transportation and food? We have another report that we have put forward analyzing our residential system of care. One of the main barriers to discharge from our state hospitals is not having access to housing. And again, continuing to focus on that expansion of social, emotional development through programs such as multi-tier systems of supports in school. In long term, continuing to address those barriers to employment to housing and continuing to expand access to high fidelity supported employment services and training. And we also, if we can get this right in terms of the social contributors of health which we know impact long term health outcomes and costs, we have to improve our ability to identify and track the savings that we realize by these primary prevention efforts. Action Area 3 is significant and important to our mental health system of care and to achieving Vision 2030 which is eliminating stigma and discrimination. Many people in this room are aware, though and may have experienced that many individuals who would benefit from mental health care and treatment simply don't because of fear of labeling, judgment and prejudice. We have to recognize stigma as a real barrier to accessing care. There are several areas and strategies that we want to employ to address this. Public messaging through evidence based and best practices, things such as mental health first aid, there are other programs out there as well, emotional CPR and other approaches that build awareness and understanding of mental health and wellness. We have to continue to educate and increase collaboration across all partners including our healthcare providers and ensure and work towards the integration of mental health awareness into the structure of our communities through the expansion of wellness centers and other models for community inclusion. The themes related to eliminating stigma and discrimination are education, again, social and emotional development and wellness. We need to continue to support and expand initiatives that will engage the public and educate the public about mental health and supports. Identify and provide trainings for schools and communities, wellness models and education. Our youngest reminders are our future and from my perspective probably the most open-minded individuals in our state. In my spare time I run the Waterbury soccer league and I was facilitating a tournament one day standing under the tent organizing all of the trophies and a couple of second and third graders walked by me and he was looking at his buddy as he was walking by and he said, you know, I was talking to my counselor the other day and she told me this thing that I should do to pull the plug and let all the anxiety drain out. And to me, the fact that this young man was talking to his friend casually walking across the soccer field gave me real hope for the future. In the midterm we have to continue to implement collaborative anti-stigma and discriminations trained for nursing staff. We had many healthcare providers as part of our think tank saying we need training too, we need to understand this we want to support our workforce to be welcoming to understand and to eliminate stigma. So we need to consider opportunities to expand that across our healthcare partners. We also need to assess, measure structure and think about the statewide standards and programming that could support eliminating stigma and discrimination and again fully integrate mental health education in all aspects of education workforce and community partnerships. Action Area 4 is expanding access to community based care. Vermoners came to us in the listening tour and this was reflected by our think tank members very concerned about access to mental health services and what happens when access is delayed. This action area highlights the need to improve that access to community based care. But also the need to have a balanced approach to this as we look at that continuum of care. That capacity and acute care is urgent and important but if must we do it in a balanced way we will unintentionally create bottlenecks and impact flow in other areas of the system. So this area highlights continuing to access gaps in our care continuum improve client navigation supports as well as increase in outreach and education in communities. The themes in this action area in terms of expanding care our public education centralized resources local and regional services and evidence based practices. There was a lot of discussion about how do we create a centralized hub of information how do we ensure that people know where and how to access the care that they need. What could that centralized resource look like, how do we start to build upon it and vision that for the future. Expanding gaps in evidence based services for Vermoners in terms of mental health treatment and training particularly to expand and strengthen our workforce and continuous improvement on expansions to community based programming overall and to continue to monitor our progress in achieving the expansion of our community based programming as we go forward. Action area five is somewhat connected to action area four which is about enhancing intervention and discharge planning services to support Vermoners in crisis. A nationwide study that was conducted in 2018 by the National Council for Behavioral Health reported that those who have sought treatment of those 46 percent don't even know where to begin or how to find treatment. Vermont has 14 emergency departments across the state in 2018 they saw more than 10,000 individuals of which half were discharged back to the community indicating what can we do better to ensure that people know what resources and care and treatment they can access at the community level to prevent them from needing to go to the emergency department. These numbers are concerning since our emergency departments are not currently designed to provide mental health treatment or to coordinate that community based care effectively. Vermoners who informed this plan advocated for an integrated care system with community investments in hospital diversion strategies. We have to continue to address the social and fiscal costs of relying on the most restrictive and highest levels of care in our system and provide more added resources that will save both resources and improve outcomes for Vermoners. So some of the highlights from this action area include clear consistent messaging about where to get support for people in crisis implementing practices that improve an individual's experience while in a crisis education and training for providers strengthening our prevention care coordination and hospital diversion programs and developing alternative options to emergency department placements. The themes in this action area are inclusive of access transitions and outreach and coordination. We are well on our way and one of the questions of the think tank that is reflected in this report which is the implementation of mobile response. Mobile response is an opportunity where we can provide essential crisis services to children and their families in a more proactive way before it hits a crisis point and before a family might find themselves in the emergency department. We were happy to see that this initiative was supported by the administration and is now a part of the governor's recommended budget for FY21. Also looking at approaches such as the living room model as alternative care settings to emergency rooms, the think tank also grappled with and was thinking about innovative ideas in terms of how do we provide more mental health care within our current system of urgent care as an opportunity area to explore and ensuring that all mental health care teams are trauma informed and that care coordination is more streamlined and continuing to assess hospital diversion programs to ensure that Vermonters have access to them in times of need and in their communities and potentially an area for further expansion. Action Area 6 was focused on peer services and ensuring that peer services are accessible at all levels of care. Strategies to expand peer services across our system of care have been shown to have impressive potential and demonstrated outcomes in other states. I think we can do better in Vermont. Peers are a critical component of effective systems that serve Vermonters and can make valuable contributions at all levels of care. However, stigma faced by people living with mental illness affects the ability of everyone to benefit from having more of those individuals with lived experience working in our systems of care and it's something that we need to address. So some of the high level recommendations was looking to a peer led work group that could make recommendations about whether and how credentialing and Medicaid reimbursement should be considered or implemented which could provide a path to expansion for peer work in Vermont. Expansion of peer supported models such as our two bed peer respite program making peer supports accessible in the emergency department as well as inpatient settings. We have pockets in Vermont where we're doing this across the state but we are not doing it a scale that is sufficient to impact the kind of social change that we would like to see. An exploration of new models such as peer navigators that can provide guidance through our system of care. That is one thing we heard over and over again particularly in the listening tour help us understand how to access and navigate the system of care which seems clear to us is not always clear to the individuals trying to help us. The themes and action area sticks are related to standards and guidance and forming program and strategic placement. We need a peer led work group that can help guide us as systems partners in terms of what are the opportunities for credentialing and aligning standards. That could open up doors for federal reimbursement. Guidance and educational opportunities for community providers on the service delivery and continuing to expand peer services and emergency departments as well as primary care settings. We want this peer work group to inform the department of mental health and to work with the DMH leadership on a regular basis to discuss opportunities for expansion and collaboration with mental health and healthcare partners. Action area 7 is also fundamental to our vision 2030 which is ensuring that service delivery is person led. The key to improving client experience in our system of care is building up a culture of care that treats seeking care with respect and dignity and supporting people to lead the development of their own treatment plan recovery and goals. Person led systems provide both expertise and resources to support an individual's goals. Strategies in this section present pathways to providing individuals to prioritizing an individual's needs, their values, their cultural identity and interests even when care is provided in an involuntary basis. Some of the high level areas that we looked at in this action area are reshaping practices to include advanced directives so that individuals can take a lead in their care from a position in it when they are in a position of wellness rather than a point of mental health crisis. Redesigning service delivery to provide sane day access and brief solution focused interventions for people seeking help and incorporating outcome measures and a clear system of feedback to understand how are we really doing in terms of continual improvement of person led service delivery. The themes in this area are services and workforce. These include education for staff on person led service delivery across the state, again ensuring advanced directives are offered and in place for all clients no matter what level of care and to really look at long term how are we doing in terms of implementing and reviewing our progress and ensuring that person led treatment planning is implemented robustly across the state of Vermont. The final action area is foundational to the achievement of Vision 2030. We all know that workforce is essential to our mental health system of care moving forward and to be integrated within the broader healthcare system. Without offering the resources tools and employee benefits our dedicated community care providers deserve we cannot meet the urgent needs of our vulnerable populations. Workforce development and payment parity underpin a strong system that will deliver high quality services and supports. Workforce development includes opportunities to support our emerging professions and roles in the system of care such as peers as discussed in action area 6. Payment parity is also a part of this action area which is something we need to pay more attention to in Vermont and have an articulated strategy to achieve it. It refers to equal rates of payment for the same services when provided by mental health professionals as compared to physical health professionals with the same level of education and training. Workforce development also includes equal rates of payments for professionals that are provided both inpatient and community-based settings. Implementation of approaches from mental health, developmental disabilities and substance use will be essential to achieving this. Development of new professions with the guidance of our peer-led workgroup such as community health workers and peers. Training in professional development and diversity, inclusion, mental health education, motivational interviewing and others. Again, focusing on payment parity across health insurers and expanding coverages for all services from honors regardless of their insurance. The themes of this action area include capacity, quality, training, diversity and inclusion. Also looking at our workforce recruitment strategies working towards parity and reimbursement rates the workforce has appropriate supports education and training to support our staff and encourage professional development. Also exploring additional methods for improving our diversity training equity and inclusion in our workplace and workforce as well. So that was an overview of the action areas in vision 2030. And I have to say getting this plan across the finish line has been an enormous amount of work but I also want to underscore that this is not the end, this is simply the beginning. The key part to realizing the vision for 2030 is implementation and what are our next steps. That will include ongoing engagement with partners continuing to look at empowering our workforce and assessing and aligning resources. I want to talk a little bit about some of the next steps that the department will be taking immediately upon the submission of this report. Number one, continuing to engage legislature in the creation of an appropriate structure such as a counselor board that can help us oversee this important work of integrating mental health and healthcare to ensure that we have buying from all partners and everyone is at the table to help us achieve that vision. The department of mental health will take the lead and have already begun conducting an inventory and analysis of short-term actions and the resource assets that can be further built upon or may require expansion to also begin initiating short-term actions in the plan that can be supported within existing resources and the authority of the department. To initiate forums and partnerships for areas of the plan requiring mutual accountability that are beyond the traditional scope of the department no single group is going to have the answer to some of the challenges that we face. We require a collective answer and we need to partner with folks across our system of care to achieve that. We also want to finalize the department of mental health 2020 to 2023 state system of care plan using information and strategies from this 10-year plan and include in the department of mental health Act 79 report and update the legislature annually on the progress we are making towards achieving this 10-year plan to evaluate and create a framework for monitoring and measuring success of the plan. So that is it, thank you. That is where we are today. Again, this was an overview of Vision 2030 to give you a sense of the direction that our stakeholders and Vermonters came forward to articulate. Again, I want to thank members of the Think Tank, members of the DMH team who have worked so hard to make this a reality. I think it really demonstrates how as Vermonters, when we come together some of the opportunities for a vision that we can achieve and we look forward to working in collaboration with everyone to achieve Vision 2030. Thank you. Bringing this across the line generally and for giving us an overview here this morning I think as we talked earlier there was a lot of work that has gone into being closer in the sense of presenting and so on. Thank you for that. I want to just I'd like to make a few comments and then open it up for some questions from Cody Heisser. I know we don't have time for all of it here this morning. I want to just acknowledge that simply the language of a ten-year plan actually makes a very powerful statement and I feel like I've had the privilege to be present at the choosing of some of that language along the way over the past period of years. The fact that we're talking about integrated and holistic system of care is not something that just we should take for granted. That language itself speaks volumes in terms of what I think this committee has tried to articulate over the past three years that we must see mental health as part of health care and that our actions need to reflect that. I want to particularly acknowledge and thank President Doug Hew as our vice chair who has steadfastly held that vision amidst many challenges that we've shared many of in this body but I feel very privileged to sit at the head of the stables of chair to work with President Doug Hew as vice chair who has championed this shared vision of creating a holistic system of care and integrated and holistic system of care and that alone having that on the front page as the title of this report I think makes a powerful statement and one which I know I personally am committed to and I believe our committee has been committed to as you say this is not the end this is the beginning but it's hard to think clearly about next steps if there's not an articulated vision I find myself wanting to say okay now let's use the term inventory I'm writing down I want to have everything that's being done placed within the vision of care and I haven't a chance to look through it I see that there are references in many programs we are faced with making choices on an ingenious basis let's say we live within a resource finite not completely finite but within a resource restricted environment so choices have to be made priorities have to be set but again where are the priorities how do we make our priority choices but we have a within this vision of care also thinking I'm hoping and trusting that the agency human services stands firmly behind your vision the 2030 vision this is incredibly important we have a structure currently that allows for both siloing but also for integration and so we have opportunities by virtue of the structures that we have and the leadership the buying of leadership is important leadership change we're experiencing leadership changes in this very period of time I've had conversations with other leaders in the healthcare world of Vermont saying how do you intend to have your vision sustained over time so I would hold that out as well I'll do the commissioner forever that's a good thing for everybody involved especially you but I say that meaning that as a complementary you will move into other life changes as will we how do we sustain how do we sustain the vision over time through transitions that are political that are leadership that are societal but I think those are all those are all challenges that we face but we do it within a vision that's shared I think what I'd like to do at this point is welcome our Vice Chair and Representative Rodgers who participated in the thinking if they wish to make any initial comments they can knock it out obviously you can make any comment later and then open it up to any questions well I'll just see very briefly it was really a privilege and really exciting to see this synergy develop where maybe different ways to articulate things in the beginning but so much consensus around what needed to happen the concept that our system of healthcare needs to be holistic and that meant total integration of mental health but even to use references to a system of mental health doesn't really make sense it's a system of healthcare which fully incorporates mental health as with all of the other components of healthcare so it was really exciting to see that so many people gathered together in a dialogue and sharing those values I would pretty much echo that I think the process was really something that impressed me quite a bit and I think coming in as a think tank member after the listening tour had taken place and reading hundreds of pages hundreds of pages of notes from the listening tour I thought it was pretty impressive looking through hundreds of pages of listening tour notes how many themes were kind of shared amongst different locations different groups which was impressive and I just thought it was a really thoughtful process and I want to add it was really the leadership of the commissioner that made this happen I think this committee, this legislature has sort of been pushing for for this to happen for more than the past, just the past year but it was the current commissioner who really took part and made it happen and Robert then hits the road how do you make choices and how do you move things forward and so we're not going to do resolve that here this morning but I think that those are the kinds of things that this becomes the platform for which and then maybe this may need to both there needs to be continuity but there also needs to be a living document to slide and reflect important changes that emerge as new information new knowledge let me open it up I'm going to suggest that we take just 10 minutes more and then we'll take a break and then we'll and then we'll switch gears and we'll hear from other advocates and individuals who are here for mental health Hi, thank you very much this is amazing work I'm thinking about it in the context of my evolution professional evolution through the healthcare system over the last 32 years and how we cultures change slowly but how we in the healthcare system have not in the past done a very good job of prioritizing the person you led as part of planning the plan of care and how especially elderly patients will say to me, if I give them a choice they'll say things like you're the boss and as an opportunity for me to try to turn that around so I really appreciate the emphasis on not only respecting but prioritizing that each individual is empowered and supported in being the focus of their plan of care Absolutely and I think that that really came through from the healthcare providers that were at our table I know in one of the groups that I was working in we had a leader from UVMMC who was really focused on how do I help train my folks to understand what person-led care really looks like and kind of embedding it in the broader provision of care I think on the mental health system of care we work towards it, we understand it but we still have opportunities for improvement also to your good point about our older Vermonters or aging Vermonters I'm not quite sure what the right term is to use Elders Elders Elders Vermonters it is something that the committee chair was referencing this as a living document I think looking at our geriatric system of care is something that probably likely requires more attention I was kind of reflecting on the report and where some areas that we didn't lean into as much that are likely things that we need to be thinking about that would be one of them so just to also bring that to note for everyone in the room that that's an area that we noted in the report that certainly requires further ongoing discussion to think about how we support that system going forward you talked about workforce which we've heard a lot about in the last few weeks but were you suggesting that there might be a need for a different type of healthcare worker in this segment do we need to redesign the way people approach their jobs or what their jobs entail well I think there are ideas related to particularly when we think about integrating mental health services within healthcare we want to ensure the integrity of how we deliver mental health services is held in high regard which will require additional training for healthcare providers in general I also think when we look at our peer workforce we have an enormous opportunity to grow and develop a strong peer workforce and to be candid I think there's some debate about whether that should be credentialed body should it not be and I think that's okay but we need to have that dialogue because we need clarity on where we're going and what that may or may not unlock in terms of additional resources I also think even outside of our mental health system of care our other systems partners are thinking about their workforce differently talking with commissioner shirling the commissioner of public safety and his front of mind is how do I help train my law enforcement officers to better understand mental health so I think it's our existing mental health workforce the healthcare workforce and then more broadly thinking about anyone who part of our system of care how do we educate and train because that will improve the experience for an individual of that given time who might be experiencing a mental health or health challenge I don't know if this is we have a current measure of this but when I was working in with the mental health community some years ago it was while it was evident that the pressures on the community system of care the designated agencies providing community based care was enormous and the resources were insufficient at the same time it was evident that it would be clear that the vast majority of volunteers who are seeking mental health care are going to their primary care physicians and that the vast majority of psychotropic medications prescribed are actually being prescribed through primary care settings and that both knowledge about how to make it appropriate prescribing and how to connect with other services that are needed was essential and I don't know what the landscape of the data would show right now I'd be interested to know that but there are measures that indicate that there is a health care system that's providing mental health care perhaps without the level of background and training and experience a connection to the web of in a positive sense of the supports that are available on to Bill's thing I'm just really happy to see about the navigators in there because people just don't know what to do family members and often I get the calls and I'll get the calls on a weekend you know what do I do hold on I'll figure out something but having a peer navigator also I think it's an under viewed someone with a lived experience who is probably more trustworthy with the patient than you know in the patient size than a doctor saying this is what we're going to do you know where it takes all power and control away from the patient so anyway I was very pleased to see those two two things there and emphasis on navigators because I mean people don't even know how to get a primary doctor but they you know have a crisis it's more to go you're absolutely right our services are only as effective as people's ability to access them so ensuring that they can access what is a very complicated system from the outside looking in and sometimes it feels like eight doors to the same room so that's on us to ensure that our north star of accountability is to those we serve and how do we make it simple to access services and make them more accessible three questions and I don't necessarily expect answers for everything today there's some questions you know one is how much did the think tank that's what the group is called not a task force or a commission the think tank right so how much did the think tank and this process look at the barriers of cost for accessibility like I see a lot about where services are and the different kinds but something I've noticed as a mental health provider is that people are having to pay copays and deductibles increasingly and there's very few patients I have now that aren't on Medicaid that don't have a really high deductible or a copayment and that can be a barrier for people even when the system exists to actually using it so I'm curious how much cost was looked at that's my first question is articulated as one of the action areas within one of the strategies within the actions was looking at the cost to access services regardless of insurance or availability to pay so I think I know that it was not in the plan that was something that the think tank probably I did see a part where it talked about like having more even benefits between plans so maybe in that work it could be addressed to the other two things are more like when I think of the 20 30 and then what and when I think of the next 10 years and what we're facing as a society and what's going to impact the mental health among us people two big things came up which may seem a little far one of them may seem a little far fresh but it's real so the first one is the impact of climate change and environmental disasters we we're hearing pretty consistent reporting from scientists now and economists that that's going to have a huge impact and people the term climate anxiety or like climate grief you're starting to hear these terms thrown around people are actually coming in and talking about the impact of climate change affecting their mental health so I'm curious if that was brought up at all in the plan the next one I'll wait and I'll ask it well I think why don't you name your the other one is the impact of technological changes so like where technologically is progressing exponentially and there's going to be benefits and risks and the artificial intelligence task force we heard about how in health care there's going to be advances that might totally revolutionize how we treat mental illness because of the interfacing of brains and computers and but there's also risks like the harm that technology is having on developing brains the amount of technologies of children etc so I'm curious if technology was talked about in terms of its role both positive and negative in the mental health system absolutely I think they're great points I don't know that climate change and the impact of climate change was necessarily a focus of the thinking groups but it may have come up in a more tertiary way but I think something long to think about it is articulated in AHS's strategic plan there's a specific section that is lifted up related to climate change so that might be worthy of taking a look at and then in terms of technology I think we were probably thinking more about the benefits of telepsychiatry how do we utilize that just to give in one of our biggest resource burdens right now is that we don't have the workforce that we're requiring or relying on very expensive traveling doctors, locom nurses particularly in our inpatient system of care how do we use telepsychiatry more broadly also recognizing we have real limitations in terms of broadband access across the state of Vermont so we don't want to over rely on technology to provide care for individuals if an individual in a very rural area of Vermont can't utilize it so those were some of the things that we grappled with I was just going to check on something right now it makes me think but how do we protect from the system that we're building now not falling into some of the hurtful traps that as we look in retrospect this legislature actually voted in past legislation that allowed eugenics and sterilization and hospitalization of people for diagnoses that today we would just look at it we would say that was just discrimination that was wrong I feel compelled to just name that when I came into the mental health field the list of diagnoses included homosexuality and that I at that point as a young mental health professional had to look at that and then spend a good part of my professional and personal life fighting to help change a system that was in fact hurtful rather than helpful to a whole group of our society how can we have the kind of lens that allows us to look at what are we doing today that 10 years, 20 years from now we would look back and go how can we have even considered that and that may be asking too much of us but I think that at the same time we need to hold some of our history as a mental health system within our vision as we move forward to not forget that there have been in fact of the mental health system itself and parts of it even today our experience is hurtful rather than helpful by numbers of people and so we need to continue to keep a vigilance there I think that's exactly right today being Mental Health Advocacy Day I'm sure we're going to I'd love to have us hear about that in general but we have had requests from numbers of folks to be heard in front of this committee and we've been trying to accommodate the many requests as possible it doesn't turn out to you Blaine thank you chair Lippert for having us here today my name is Laurie Everson I'm the executive director at the National Alliance on Mental Illness of Vermont and this is our fifth year in organizing Mental Health Advocacy Day and the organizers include Nami Vermont, VanHarr and Vermont Care Partners and we have 47 co-sponsoring organizations here today and their networks I think this is our largest attended event in the five years we've probably about a couple hundred people here in the state house today so very pleased with the turnout and I especially want to thank this committee for all your support with Mental Health and for allowing us the time to speak today because I know you're very busy and we'll try to keep our comments brief and also want to thank you for the resolution that will be read in the House chamber today recognizing Mental Health Advocacy Day so we're really looking to help advance the mental health priorities here in Vermont and like you said we couldn't fit in everybody we wanted to fit in today so everybody will try to keep their comments brief and just to let you know a little bit about Nami Vermont, we're a grassroots volunteer organization and we provide education advocacy and support to individuals with mental illness in their families and we have a new program and we're starting to get back into the schools because we know that's a priority to be able to get education to the children in school and to be able to help eliminate stigma and raise the awareness about mental health and let them know it's okay to talk about your mental health so I thank you for your time today and I'll have the next speaker up yes my name is Rick Barnett I'm a psychologist addictions counselor and I'm the legislative chair for the Vermont Psychological Association and I want to acknowledge as Representative Lippert just did the phenomenal job that Commissioner Squirrel did with her report and presenting it was fantastic and it does fit in with some of my comments today so I want to thank all of you for your interest and mental health care and health of Vermonters it's awesome to be here on Mental Health Advocacy Day I'm very nervous for some reason and I'm going to try to look up from my written testimony which all of you have a copy of I know I can get kind of dry witness reads off of his or her notes but I'm going to try to do that fluidly as I can I'm a licensed clinical psychologist with a doctor and I have three master's degrees one in psychology one in addictions and one in psychopharmacology I have worked on the front lines of addiction and mental health for nearly 25 years I have a close friend who committed suicide 15 years ago I have family members and close friends like many of you who either currently struggle with mental health issues or had at some point in their past that includes trauma, addiction ADHD, depression anxiety, bipolar disorder a number of conditions I myself have been in active recovery from addiction for nearly 27 years and I have you can see I have a personal, professional passion for this field I have served on the board of directors of the Vermont Psychological Association for nearly 10 years currently as the legislative chair and it is in this capacity that I speak with you today for years I've also served the state of Vermont on many boards, committees, councils, task forces, work groups and some of them are listed in the testimony that I have provided to all of you, I won't read through all of them but some for example I served on the steering committee for the SIM grant, the $45 million Vermont Healthcare Innovation Project Governor Scott's Opioid Coordination Council a health advisory group for the Green Mountain Care Board and currently I serve as the president for the American Psychological Association's Division on Pharmacotherapy and as related to the work you guys are doing here, this session Commissioner Squirrel had asked me to serve on the Rural Health Task Force Services Committee this past summer and fall whose report and recommendations you guys have been looking at this week and I find that that actually dovetails very nicely with Commissioner Squirrel's report as well in some very key ways so my voice on the various boards and committees proposals and task forces that I've served on has been a voice for the mental health and addiction workforce that often remains invisible. That voice represents the mental health care of tens of thousands of Vermonters just like you and me that voice represents tens of thousands of hours spent in the presence of trauma anxiety, depression, despair mood swings, violence and addictions and the heartaches of Vermonters who access care from the over and mental health and addictions practitioners who work full or part-time in independent practice. As a workforce, we prevent emergency hospitalizations we provide continuity of care when people are discharged from hospitals or addiction treatment centers we work closely with first responders with crisis teams with designated agencies with primary care practices federally qualified health centers attorneys, schools department of corrections, children and family services department of health recovery centers and more we are woven into the entire system of care we connect with all these different agencies and system excuse me on mental health advocacy day my goal today is to bring into focus one piece of legislation that sits before this committee and in the senate with a total of 17 sponsors H-139 and S-81 are bills that would allow board of psychological examiners to confer prescribing authority on doctoral level psychologists who have completed specific rigorous educational and training requirements thereby augmenting their current skills in mental health to prescribe and deep prescribe psychiatric medications in every single meeting I've attended on health care reform innovation over the last 10 years every group that I've been honored to be a part of there is a resounding and consistent message there is a shortage of psychiatrists in Vermont and nationally this is evidence as we've talked about today already by long waitlist to see a psychiatrist emergency departments holding psychiatric patients for days sometimes weeks and up to 80% as representative Lippert mentioned earlier 80% of psychiatric medications are primary care practitioners that's nurse practitioners primary care physicians physician assistants often in 15 minutes or less and often with follow up visits sometimes months later this message is that we must improve the mental health care of Vermonters prescribing psychologists also known as medical psychologists in Louisiana have been treating patients with talk therapy and the prescribing of psych meds across the country and in the U.S. military for nearly 20 years what started and ended as a successful demonstration project in the department of defense in the 1990s has expanded to over 5 states other states are actively working on passing similar bills and I ask you all here to consider helping Vermonters by taking up this bill for testimony this session Vermont has some of the highest prevalence of mental illness in the country ranked 43rd by mental health America in their 2020 report we have some of the highest mortality rates from alcohol, suicide and drug use a department of health report last year showed the need for increased access to mental health services for those with concurrent addiction and psychiatric issues we're in the midst of a drug and alcohol suicide and mental health epidemic while a promising tool among many telepsychiatry as we talked about many times in the legislation that I work actively on tele mental health with all of you here is one tool but it relies on and competes for the same small number of providers across the country and it's difficult that that would meet the incredible demand that we have for services after over 20 years of safe and effective practice by prescribing psychologists this workforce is no longer considered experimental it is acknowledged as an innovative approach to mental health service expansion at a time when such innovation is desperately needed with such high demand expending independent scope of practice to other health practitioner groups like nurse practitioners and like naturopathic physicians we authorize to prescribe all types of medications including psych meds is always a battle we need all tools to help those in need we need all hands on deck now the office of professional regulation as you all know who's charged it is to protect the public through a system of licensure of over 50 professions has reviewed H139 and is committed to sharing their findings with this committee based on their depth of experience they've concluded that the education and training described in H139 meets or exceeds what is required to prescribe psychiatric medications for doctoral level psychologists especially compared to other prescribing health practitioner groups that it oversees many support this legislation many do not we believe the opposition to it is unfounded we wish to work collaboratively with psychiatry and medicine they insist that this work force is not needed and worse that it is unsafe it is the responsibility of the office of professional regulation not other health care professional groups to help determine scope of practice issues while excluded from the recommendations from the rural health task forces committee they had other very good recommendations in there that have to do with now health including restarting the nurse practitioner program at UVM interstate compact for licensure for psychologists as well as getting masters level psychologists and clinical health counselors to be reimbursed by Medicare it shows not to include this particular recommendation in that report unfortunately I tried so we believe H139 is important legislation that can help the overall system of care in rural settings and hospitals primary care practices and in our communities I encourage you to view prescribing psychologists as a valuable addition to the health care system and the health care workforce here in Vermont and I urge your support for this important bill and I want to thank you all again for your commitment to the mental health and health care of Vermont. Good morning everyone, I'm Christopher Woods I'm the Executive Director for Vermont psychiatry providers I would first want to start by saying what I did not do was look at to say I really want to support this one, this one, this one. I thought it was much more important that you have an idea of what appears as saying across the state about the goals that they would like for each in terms of the way services are provided to them and the common way serving treated them. So that said I am going to redevelop a little bit of this because well I am. So the following is a list of recommendations and policy positions that we came up with, with members and allies while looking at data from around the country around a series of that are undergotted by the advocacy goals that we came up with in our annual meeting as well as conversations. The brief description of the points to follow and I kind of think that I sent you this from a very young bullet point so it's easy for you to digest. So we're going to start with the first one and I did actually send you the light paper it's about 10 inch and face documents but it's essentially a sort of development of a peer center, a peer respite and community center. We brought this idea to you last year what the number of us said and that would be the establishment of six centers around the state which would include peer respite on one type where it would be two beds there and then a community center. The way we felt it was an idea and that we would like for them to have central governance so that all training all the training all the support structure would all be the same but that we would have a series of community meetings so the East community would make their center unique to them but those centers would all have some things in common. Some of those things would be having access to other supports. For example you can all look outside the snow it's cold in the morning even if you often have to walk two or three blocks from the food stamp office to this office it's a barrier and also sometimes just for going to those very big buildings is exciting and driving for people so if you're going to like if so we would not have offices situated there but we would give them access to space so that this day of the month food stamps are there, this day of the month I have all my housing and so on and so on so that people could go to a place where they could receive support from peers but also access to services that they need because that was a better alternative than the privatizing space to go into those places. There are other things we may I know this will be supporting and encouraging greater funding and collaboration between peer communities and substance use communities. A little bit of people that we serve are currently diagnoses so if we're going to give the maximum effectiveness then we should be able to we should be doing more coordination of services and that should be something that in terms of the the almighty dollar that you should also be encouraging to the image to fund and then you increase and I know that there's no extra money but not there's a solution in the bottom increasing funding necessary to enable us to actually fulfill the admins of access we focus on end goals specific initiatives to create opportunities more access to funding outside of the image. For example, instead of asking for money for training peers in the image we believe that funds should be considered as the state's ask for federal funding including that funding being funding for things like for vocational rehab. If I have a physical injury on my job and I can't return to that job I can go to vocational rehab I can get money for training I can train for another job and that's just the way that it works for mental health issues any differently if I have a mental health issue and I could be for training or or wrap or whatever that training would be why are those things not also being before economic services that's where we just got how many million dollars in the rely grant so why are we not doing that that should be something that you as legislators are pushing so that we can take the onus and ask money structure to secure in the next couple of years so trainings like IPS wrap hearing voices to help people to return to the workplace and lessen the burden on the state in general also this tenure plan great but there weren't really many peers who actually participated in that so investment in regular hearing sessions among consumers peers providers and their support systems in the community to do some self-assessment to help DMH plans or have an impact on those using the system and the supporters nothing about us without us plans and evaluations of plans for peers are often done without the query and the very people who are using them at any meaningful way the information most often comes from advocates like me and service providers we each have their own agendas let's be honest about that hearing sessions should be for end users transparent system for pure organizations designated agencies and peers to engage in mediation of conflict face to face but that mediation should include the input of the people who are being served by party in that conflict we all further support the legislation and regulation that aims through structural and systemic barriers to housing for people who live with mental health challenges including discrimination in placement for seniors for nursing homes sheltering for the homeless victims of massive violence and the loss of housing in result of any interaction with the psychiatric system by tenants for next judicial recognition and support of advanced directives I know that might be controversial but when deciding on poor treatment of individuals in crisis in the same manner it should look at it in the same way that we look at advanced directives for people who have other health related diseases if I have cancer and I say I don't want to take treatment and then I'm just going to say I have depression and I don't want me to force struggle I don't see where there's a difference if we're talking about what's going to happen to impact my quality of life so we need to at least give them more consideration in a way that we currently do the provision of a and also in terms of ONA what often happens is you know you're in a facility like you say you're going to be going to help with treatment you go to a hearing there's no one with you there's no one to prepare you you're just there and for the individual who's in the hearing they feel railroaded it's like getting a public defender like there's no one is there they meet five minutes before and they say well I'm sorry take this deal and you'll be fine not so much so we would act for at least the provision of a peer to act in so that for outpatients hospitalization hearings they have at least 48 hours of access to the person to help them prepare information and just organize their testimony so they can actually defend themselves instead of just being in shock at the fact that they're sitting in the courtroom in the first place mandatory training of first responders and how to handle mental health crisis situations as well as support for the law uses the chances of being able to encounter law enforcement so that is the one plus that we'll make for the California standard for use of deadly force and we would like to see in the next six years self-identified peer representation and leadership at DMH at 20% we know that's not going to happen but we can pretend that would be really great in terms of the ultimatum by the Brattle Row Retreat should give us all pause when we're considering the level of dependence that we have on psychiatric stays in all facilities versus communities versus community-based services while there are individuals who might embrace the level of meeting it's inpatient care, meaning when you get a certain community inpatient care is traumatic it's often dehumanizing and it fosters learned helplessness so we support working towards community-based care and support so with that in mind we would like to advocate for the following actions that we consider universally as conditions for continued funding to hospitals that provide care one, that they actually follow the homestead rules regarding discharge so whether a person has a place to go with a support system or they're in need of a community setting like room homes and other places that actually have open beds shouldn't be able to say no we don't want them because there's too much of a problem because that's why we're having so many long stays in hospitals there is a place for them to go you are paid by the state to take them so do your job but you just want you to enforce that happening patients should be included in all aspects of decision-making processes because there are facilities where that doesn't happen it is we work with some facilities one facility where that does not happen you can request the change of your doctor every day if you want to and they will take the request but the policy for the facility itself is that never happens grievances should be treated in a formal manner with written replies and said grievances should be made available to the relevant parties to be an online database relevant parties being Department of Mental Health with the disability rights for months if there's a facility that we have that we are working in with LNP and APS literature about civil rights appeals processes and peer support resources in the community should be included in all and taking discharge packets for patients and not taking away from them that's a big thing you get like everyone always says as they're discharging someone into homelessness but we told them that stuff and when they did their intake I'm in crisis I can't focus on anything you know if you've been to the emergency room and you're in pain and they're like sign all this up you sign away your house and not know it because you just want something someone to help you so putting them in both packets doesn't seem unreasonable and like at some point going over them with the end I said to and then a dedicated and adequately reimbursed slot for community members unaffiliated with the facilities should be established at every employee employee employee orientation to introduce employees to the peer movement and let advocates who into that facility actually do if they actually know what you do you're less likely to have an adversarial relationship and they can see that like hopefully you're there to work together for the benefit of the people who are in residence the state of the march committed to also committing to the elimination of seclusion in our span altogether including stuff through fire and beginning with all direct care staff receiving regular training and six core strategies to reduce seclusion and restraint all of these things come together with the goal with the end goal of resourcing people to engage in meaningful work while being able to support themselves vocational rehab certification all these things will help for people to return work and get jobs where they actually can support themselves rather than subsisting because for those who can and who want the opportunity they should have the same opportunity as in the other systems a greater voice for those who have been marginalized in response to the actions taken by the safety and agencies that are supposed to serve them I can look and I can go into a rundown inner city neighborhood and see like there are lots of people who are walking around who don't have jobs but my assumption is they all need jobs so I've been instituting a jobs training program that's great they all go through the jobs training program and still no one gets a job why? because I never talked to the people who were receiving that service to find out that the reason they didn't have jobs is because there was no daycare no one had any daycare and there was crappy transportation from where they lived so the jobs program was just a bunch of money that I threw in that did nothing so and also access to training and certification as a means of rehabilitation creating peer and resourcing centers with respite beds seeing the flow of tide to inpatient care expanding the network peer services engaging with other with areas other than AHS serving communities with co-occurring issues and the realization of patient rights and the atmosphere that is supportive at the minimum of shared decision making without the threat of coercion and in the least respect of the environment as possible but I'm shh okay thank you very much I'm Scott Accus I'm the executive director of collaborative solutions and thank you for having me good I passed out I just want to introduce you I mean I'll introduce you to Scott and say Lori Emerson some people have houses that certain people are testifying that people are not your name along with others was provided by Lori Emerson to to us and I what process went into that I'm sure I can talk to that briefly but I don't want to interrupt Scott too far but I just realized that at some point I said well I have no idea why the solutions isn't why are they testifying anybody plays so our sponsors were able to sign up to for testimony I forwarded all those requests onto chairs to select who they would like we were lucky to get everybody that was on the list so that was your process good so we're on thank you for having me thank you for having me Scott, say your name again so I can ask about it sure Scott Acus and from Collaborative Solutions and thank you for having me thank you Lori for and thank you for being here so uncomfortable no no thank you we need glasses of water we sometimes don't have a picture of water and glasses so we don't have that today so so I am from Collaborative Solutions Corporation I'm the director there Collaborative Solutions is known most frequently for running the second spring programs and I provided for those who don't know exactly what we do I provided some information in the first few pages of the handout so you can see that as a whole we have 27 beds it's recovery based trauma informed care we've been running since 2007 we have a very close relationship with the designated agencies and we have grown a lot we started out as a 14-bed program we now have 27 beds and there's a reason for that and so my hope is that by the end of my testimony today we may be able to do some lessons learned on the Collaborative Solutions experience in the health system here in Vermont so we have three facilities as you will, we like to call them homes as you look through the booklet you can get a little bit of a snapshot of each one our original home in Williamstown and second spring north which is actually sort of closer to Westford but it has a Westford address so and then finally Pierce House which is a very small program of three beds very individually tailored program and I'm going to get back to that later on it was established in 2016 we have very intensive clinical care and we're very proud of the excellence of that care so the care that's provided in home so the typical length of the day for our folks is about nine months it ranges all over the map it can be as little as three it can be fifteen or eighteen and most of our folks have some label diagnosis of schizophrenia it gets affected disorders severe bipolar disorder or some of the other more serious labels that are applied so what we're able to provide from a clinical perspective is on-site psychiatry we have psychiatrists who come to the homes at least weekly we have a primary care APRM who's able to prescribe and who cares for the medical needs of our residents we have nursing care every day and round the clock nursing on-call as well as physician and therapy on-call case management psychotherapy, vocational rehab creative arts therapy we used to have a music therapist now it's a drama therapist and that's a well-loved program substance use disorder nice that's great, thanks do I have control of that? yes so I might actually ditch this that's super I didn't realize you had submitted one thanks so much we provide peer support in collaboration with Vermont Psychiatric Survivors who is a great partner of ours and we coordinate with scores of off-site providers so what is our impact on the system as a whole? I wanted to take a look at that so there you have our utilization rates you see the straight line across the just above the swiggle line that's 100% I don't know if you can read those numbers but we're typically in the mid 90s with our utilization there's been a little bit of a dip over the past six months but we're pretty much full and so that's 27 beds we normally have 25 of them full usually the couple of beds that may not be full are not full because somebody has just moved out and we're waiting for somebody to come out of the hospital and so that leaves a little bit of lag time there we are even with the intensity of clinical services we're extremely cost conscious and come in under $900 per bed day and I have a comparison there those are 2017 figures the more recent ones I've seen are similar so recently our bed day costs over the past four years have gone down really significantly and it guesses as to why it's because our utilization is up so the cost so we're actually running on the same pot of funds but the number of people who are with us has gone up so those are folks who are not in the hospital but are actually using our services so the device are as larger yes I think it's self upgrade math so I think by all accounts this has been an incredibly successful program when people came up with it in 2007 it was a collaborative effort and it always just warms my heart to hear how second spring was born out of a community collaboration that involved people served family members of people served NAMI psychiatric survivors as well as providers and professionals and I think that a lot of the success in the way that the program has been set up to be able to accomplish for the system of care what it has been accomplishing is due to the fact that it was set up by people who knew what they were talking about from real life so one of the lessons we can learn from that I want to move to that before I do I want to talk a little bit about our mission so this is our mission statement it's to create caring communities where people seeking mental health people who are out looking for mental health they find hope, compassion and excellent clinical care those are equally important hope, compassion and excellent clinical care so I have a couple pictures under engagement I think what I want to say about the compassion and engagement part is that what puts somebody at risk of not doing well it's when we can't we actually have staff members in the room today so it's really like it's really great to be able to talk about this and see the look of recognition what causes us to not be able to be successful with somebody when we can't reach them we can't figure out what is that how can we engage with them, how can we be compassionate towards them, we're doing everything we can we're being nice, we're looking for hooks in there and we just can't figure out in our context with 7 other people present or 15 other people present we can't find a way and those are the people that we lose and that's a sad day every time it happens so when we talk about compassion you know I think what I want to say is what I ask if people were comfortable here I intended that actually to be a part of this so people who have mental health diagnoses have a history for thousands of years and in most places on earth of being alienated from the cultures from their home cultures and this is a sad but true fact of civilization not just western civilization but worldwide and so when we try to reach out and form a community remember the mission statement with folks who have these labels it is challenging there can be a lack of trust there people have been excluded and alienated from families, cultures, towns schools and most of our institutions so when we reach out and try to engage with folks that is sometimes quite difficult because of a person's personal history and the it's the key that we're not going to get clinical care unless people don't feel alienated unless people do feel comfortable where they are even if it's a little hot second thing hope I'm going to give this slide a little bit more in more detail so this is on the stages of recovery at second strength and you'll see the block of three bars on the far left that's when people enter I'm sorry I switched this around this is people who are expressing no interest in recovery now we know probably underneath there probably is an interest in recovery but they're not to the point where they can even talk about that when people prior to being admitted to second spring 54% of the people are expressing no interest in recovery verbally by the time they've been with us for a week that number has dropped to 32% and by the time they graduate that number has dropped to 10% people talking about recovery maybe not doing a lot of action on it yet you've got 25% are talking about recovery from the hospital environment before they're admitted with us 30% are talking about recovery by the time they've spent a week with us and 14% are talking about recovery by the time of graduation as you can see the pattern continues through trying options I'm not going to walk you through that but actively pursuing recovery I've committed to recovery I'm trying everything I can I'm taking advantage of whatever resources I can find in my environment 7% of the people are there prior to coming to us 42% of the people are there by the time they graduate I want to warmly in the hope that's being expressed and actually played out in people's actions during the time that they're with us I want to spend just a couple of minutes talking about one particular story we have a three bedroom program it is designed to look very to support very specifically three individuals of a sort of institutional environment and more it's in a house and we work with those individuals to figure out specifically what their needs are and not having anything to do with the organizational environment of a 14 or 16 bed program we have an individual there we're going to need to try to bring this to some closure shortly because we have other witnesses that we have here I'm not trying to find this balance between getting one off and being respectful that we have other folks who wish to let me not tell the story let me just tell you that when you reach out to somebody it works that's the point of the story and that that's not always possible in the 16 bed mental health facility and that while the intensive residential programs are highly effective we believe that there's a place for more of those that will be successful what needs to happen is see this pie chart we need the 21% that are ending up back at the hospital we need to reach those guys how can we do that how can we reduce the size of that piece of the pie and increase the size of the orange piece here are the special populations we're working with we've gone from 25% substance use disorder to 85% since the time when we opened 1% opioids to 37% of our population is opioid addiction we have a younger population people over 53 more who are under 27 in fiscal year 19, 25% of the residents used amulances in the ER were admitted to the hospital for non-psychiatric reasons so we have a real medical need we have a very medically needy population so if we're going to build our system can anybody guess remember this pie chart where do you think that blue triangle is coming from I'll tell you it's coming from people who are in the populations that we're not able to reach because we have a sort of one size fits all situation so people with severe medical needs are very difficult to serve they don't always feel like all their needs are being cared for people with LGBTQ identity that's a very difficult thing in certain circumstances and their fellow residents are dual diagnosis substance use disorder mental health those with significant forensic histories or potential violence and those with a labeled diagnosis of personality disorder those are all very challenging populations not because of themselves but because the home has been built for a very specific type of resident with schizophrenia and sort of your classic mental health psychiatric patient so the takeaways I'm wrapping up are that when collaborative solutions does its good stuff its heart oriented stuff Vermont does well financially it pays when we do the right thing we have people by the way calling from across the country asking how we're doing this and that's because it makes sense financially but it's also the right thing we have success in both of those cases requires adequate resources we if we're able to produce more intensive residential beds it'll mean there's less ER boarding and less hospitalization but here's the crux of it they have to be beds people want to be in so what are the beds people want to be in how are we going to plan that if we were to decide we're going to do a new IRR for the state of Vermont who's sitting at the table remember who was sitting at the table when 2nd spring was born that's who we got to put at the table and maybe even a little bit more of a specialized group maybe making sure that we're including people who have not had a great experience in residential facilities people who fit some of these you know minority group bullet points here to help us craft something that's going to work for them and so with that I'll conclude the presentation thank you very much for having me thank you so much I would also just close the question not to be answering now because we do need to be here in Vermont to you to help us think about how perhaps members of our community or our committee might be able to have a first-hand opportunity to visit knowing how to respect patient privacy and all the things that must be thought about but there's nothing like a first-hand opportunity to visit that makes the world that you're working in to come alive to hold an honor to throw that out there as a possibility my name's Karen Crowley and I'm here from the Vermont Cooper's Practice Improvement Innovation which is part of Northern Vermont University to talk to you about a collaborative approach to workforce development for mental health and resources which may take up my entire time to keep up all of this information I'm really going to ask you to hold it to 10 minutes absolutely I will absolutely be quick just to give you a few highlights because our program is relatively new in fact Sarah Squirrel was the first executive director just a few years ago and because she believes in collaborative approaches to mental health and substances so we are a statewide collaborative that represents higher education, mental health and substance use providers state agencies, hospitals, professional associations peers pretty much anybody who has a state in the system of care would like to help figure out how to make the best improvements so we are focused on trying to build the highest quality of services and utilize the economies of scale by working together as that collaborative so our members pitching time, money, expertise great ideas and we build things together many of them things that have come up today in the conversations so the priorities that we set are based on what our members are telling us are important to them and then the membership has the opportunity to steer some things in the various settings that they're in so we have done a number of things as we do that one is that we provide a lot of training to that very broad constituency that we have we also provide coaching, consultation learning communities again the members decide what is it that we should be building that's going to serve our community best we research and assess evidence based practices what might work well here in Zomot what would our membership feel like we're missing, where are the gaps in fact when Scott was just talking about that specific population one of the newest things that we're doing in the state is recovery oriented cognitive therapy which comes out of the University of Pennsylvania so people in the mental health designated agencies have been receiving a lot of training and consultation on that one but that's the kind of thing that we do we also, I have a list of some of our most recent projects on the back but six core strategies is one of those so we bring in those expert trainers and coordinate that process we are also we're part of Northern Vermont University because of the fact that they and the Vermont State College system is so committed to figuring out ways to make sure that their programming is serving the community as a whole so they have a lot of questions about what should our coursework be in order to fit the needs especially around substance use and mental health and they use our membership as that vehicle so there's engaged conversations with anybody and everybody people who are receiving services people providing them to make those kinds of decisions together so for an example what the things we've recently been working on is how can we package some of what is in master's degrees at the Vermont University so that we're focusing on the specifics that need to be taken in order to meet substance use licenses not necessarily speaking with them all over several years but not how can we package this together with courses, workshops then that's the kind of innovation that we're doing with them that we find to be very exciting and thrilling we do put things online we are in the middle of launching a learning management system and that platform will allow us to do more online but we also hear very clearly from our members that they do not want just online training they really want to connect they want face to face they want to have options as to how it is that they receive I think that as I was listening to people today one of the things that's really clear is we have this particular mission and agenda but if somebody asked how I spend most of my days it's in connections it's talking with everybody who's doing everything in order to figure out where those connections are and keeping the membership all of that flowing so when Christopher stopped me in the hallway today he was talking about that both we had the idea I was able to say hey I'm going to hook you up with this woman from the Department of Labor that has this new grant and she wants to open so those kinds of things happen among our membership all the time just something else to be aware of and I don't have it asked here I figured you know we'll all figure out how you can be helpful if you understand what I'm trying to do but we are currently working to apply to a USDA grant that focuses on increasing telepresence capacity in rural communities in order to help those communities thrive so our collaborative group has been working together to figure out a strategic way that cites across the state everybody from recovery centers to designated agencies to libraries wherever it is that the membership decides makes the most sense they will be receiving telepresence equipment that is top notch stuff that I don't think anybody who Vermont has yet and the training to make use of it and then own that equipment going forward so it's kind of a gift to Vermont so we are in the midst of doing that we're still looking for match on that one and we're waiting for the announcement to officially come out we have a grant writer you have the technology we have the distance learning people so figure we're going to have a good proposal so I'd like you to know that and then on the back there is just some information about who's been working on that grant and a few of our initiatives so people have some idea of what we're focused on which as I said is pretty clearly some of the things that people have been talking about here today because our members despite what's important and that's that thank you it's very good to know my name is Joe Allen I'm the executive director the center for health and learning we're a 501 3C spent around in Vermont for 20 years we bring capacity to state initiatives that address priority health issues we were the lead designated agency on behalf of department of mental health for two youths suicide prevention grants that started in 2008 and ended in 2014 since that time we built out the Vermont suicide prevention center which is a public-private partnership with the agency of human services and a number of foundations that we built projects out with donors about 50% of our budget comes from a base allocation from department of mental health for $190,000 and that is what we have done our work on and we built out the rest of our budget to double that to focus on suicide prevention to try and keep a focus on the issue we are guided by a coalition that is cross sector across education, human services community providers health care and highly represented by people with lived experience so we hear about two to three suicides a week in Vermont we hear about most of them because of our new matter for schools which has been designated as a national best practice program we often provide initial response to schools in the form of resources and ensure they are connected to their designated agencies who go in and do life saving work because what we know about suicide is that postvention what happens after an event is critical to prevention we want to get upstream of that and we want to divert the crisis so I do want to say that suicide is complex and I'm going to speak briefly about health care today but it really requires comprehensive solutions it cannot sit just on the shoulders of mental health alone certainly and it requires very integrated pathways between mental health and health care and the kinds of innovative community health team work and hospital team work that we're seeing in communities where they're connecting with the kind of organizations who are in this room where there hasn't been a strategy that's presented that isn't part of a comprehensive suicide prevention system those are really, really great and really effective because we know that the demographics that risk for suicide often have social determining issues which need to be addressed so the extent that health care connects with those kinds of social services in an integrated approach is really, really important and it's starting to happen with some good models in Vermont I will point to the Northeast Kingdom whose CEO of their hospital has absolutely put some really great track in place for community partnerships across sectors so the solutions are the issue is complex I do want to say that underlying suicide in the research and we've been doing this progressively for ten years now there are three major individual level risk factors precursors feeling alone feeling a burden or feeling hopeless because of a lack of personal purpose and feeling isolated so the extent to which we make connections between people in family systems between family systems and human services between human services and mental health and health care and within health care the more likely we're going to be able to build a system of care that can prevent suicide and of course the connection to co-occurring issues such as substance misuse it's estimated that 50% of suicides have a substance misuse component so it's all connected so everything we do to strengthen a system of care for suicide prevention and I believe there's a very really sophisticated model called zero suicide also contributes to building Vermont's mental health system of care and there really isn't anything in the overall plan that Commissioner Squirrel has laid out that isn't vital for suicide prevention in the long run the issue with health care is a double whammy the first thing is that most of the people who die by suicide are not engaged in the health care system and then so that's the question is how do we create a system that's empathic and responsive and timely and you know engages with people and then the second thing is that very often when somebody seeks care in the health care system it's not at this point in time prepared to respond with evidence based practices and pathway that's going to ensure they don't fall off the pathway somewhere so those connections care coordination follow up that's all really critical so I asked the health care this committee to support the allocation in the governor's budget for zero suicide which is a set of evidence based practices that comes out of some national initiatives that show that with these evidence based practices you could actually bring suicide in a health care system down from very high to zero and then keep it at a very very low level so we would ask you to do that and also to leverage any influence you have with one care and with the blueprint to work with our designated agency system to continue to keep independent providers looped in so they also have the skills to do evidence based approaches to suicide assessment and I'd like to say that in the research hands down evidence based approaches to screening and assessing patients trumps professional non structured approaches every time so it is important that we provide the kinds of tools that show outcomes and that are collaborative in safety planning so it's with us we're doing this together because ultimately it's the patient who has to ensure their own safety after the period of crisis I want to make one other point and then I will say that I'll save the lessons learned on how to effectively do zero suicide in a system of care for the presentation on February 13th at Suicide Prevention Day but we are learning a lot about the need to identify specific subpopulations and their particular risk and protective factors so I'll give you a couple of examples youth new Americans and refugees middle aged and older Vermonters LGBTQ incarcerated people veterans each of these subpopulations have particular risk factors and some of those are unique and therefore the strategies and recommendations we use for them in culturally appropriate clinical care are really important and we're starting to put more emphasis on that in terms of providing support and workforce development in the field so again all these approaches increase connection and connection underlies every protective factor for suicide on an individual and a systems level we look forward to working with you further and thank this committee very much for the support you can give to suicide prevention thank you good morning thank you for a little time listening to talk with you about our psychiatric urgent care kids program in Barrington and the executive director I'm sure that you are all aware of our statewide crisis that our emergency departments are experiencing it's a result of overutilization for mental health supports I was in here earlier when Secretary Swirl talked about 10,000 Vermonters going into an ED for screening more mental health support and that 50% of them left the emergency department without service or without the emergency plan and so in Barrington we are no different and so Southern Vermont Medical Center and the United Counseling Service got together and started talking about how we could effect change for those with mental health crisis and we know that the intervention during mental health crisis is often more traumatic when we send them to the places they should stay out of which is the emergency department and more concerning to UCS and Southern Vermont Medical Center there's a rising number of children that were in the emergency department the experience of being removed from the classroom often by the police department and then being transported in a police car the arrival, evaluation and stay in the emergency department is often traumatizing and sending kids to the emergency department is really unnecessary so when we got together about 18 months ago to start talking about what can we do to effect change for kids and their mental health we were looking at some data and what we learned at the time was that in the fourth quarter of 2018 there were 294 assessments completed at the emergency department 82% of the children that were assessed were sent home without a treatment plan without a basis for this is in Barrington specifically in the USVLC a much larger group of your talking about just Barrington in four quarters in the fourth quarter the average length of stay is 20 hours and sometimes kids are in the emergency department for 31 days again just in Barrington now imagine if those kids didn't have to go there in the first place so along with our partners we applied for and received a one-time funding innovation grant from one care to start up what we have referred to as the psychiatric urgent care for kids or PUC so what is PUC PUC is a child and family centered recovery oriented trauma informed approach that is designed to keep children out of the emergency department while providing a therapeutic environment that offers the right level of care for kids once rather than calling the police schools are calling our family emergency services being able to get assessed as to whether or not it's appropriate for them to go to the emergency department majority of the time for the kids that we've seen it is not appropriate and so rather than going to the emergency department our staff is driving a child from the school to PUC and being able to be in an environment that you see here on your right and then being able to receive supports from master's level clinician who can assess where they're at provide screenings for things like anxiety, depression, suicidality, trauma psychiatric consultation either to the family or to the child's primary care physician as you know there's a psychiatry shortage as well so primary care physicians are often prescribing psychiatric medication to children and being able to have a psychiatrist who can consult with them is a much better way to be able to use our limited resources they can also participate in having a complete intake so when their family comes to the urgent care center they can have same day intake for services ongoing if that's necessary information referral development of a crisis plan parents and family meetings among other things including follow up with the sending school for consultation and determine how the child is doing in the school after going to PUC we also have a sensory room that allows for children to use sensory tools that are often used to help learning new coping skills be able to provide a moment of calm particularly for individuals who are agitated or distressed that's anywhere from kids yoga to the sand tray you can see a swing and a body sock that helps with movement and resistance that really helps kids learn to calm and to kind of get that kind of agitation settled in their body and I want to tell you about actually one of our first kids that came to the psychiatric urgent care at the beginning of the school year she's an eight year old girl she went to the school this year she could not sit and attend in the classroom she could not participate in any of her academics she was running in the hallways she was banging her head she was really very much in distress our family emergency services staff went to the school made an assessment to bring her to PUC and while there we were able to meet with her father do a complete intake and at that time it was discussed and agreed to change her medication she was able to access a clinician access the sensory tools and start learning different ways of dealing with her own trauma and anxiety and she was there for about four hours but it was a very relaxed and comfortable environment that's there without the distress of going to the emergency department she was able to go back to school when we did a follow up observation in the school the next day she was attending she was accessing her education now it doesn't mean that she stays there it doesn't mean that she doesn't need ongoing treatment but she stayed out of the emergency department because if she went once she's more likely to go again and again and again and so we know that we have not that child has not been in the emergency department for the school year and it's a trauma to go to the emergency department it absolutely is because everyone so of course once you're in the emergency department there's nothing medically wrong with you they have to do the whole complete medical clearance which also means as a child could be a nine year old child who has to disrobe put on a hospital Johnny all their possessions are taken they're in a sterile room and they wait and then they get prodded and poked and talked to six hours later because we all know we've been there six hours later they go home because they didn't need to be there in the first place and it is very traumatizing and so when we wrote the grant to one care our anticipated outcomes were a reduction of the emergency department admissions by 20% a reduction of the average length of stay by 50% so we do have kids that end up in the emergency department either because schools don't call us first and they just send them what they really need to be there and what we've started to do also is those kids that started the emergency department really didn't necessarily need to go anywhere else they come to pop right afterwards so then we are able to again have them see a clinician have them family meeting have them have an intake for services right at that time we anticipated a reduction in the cost of unnecessary ED admission and improve the patient experience by patients and caregivers what we know now for stats is that we have seen a 40% reduction in ED utilization for children children are receiving the right level of care 100% of the parents and caregivers actually are talking about how they are much more satisfied with the service and feel really good about the service that they received and only 23% of the children that we saw in crisis were actually sent to the emergency department sure of the children that we've seen in crisis only 23% have been in the emergency department cost savings as you see is to be determined we're working on that it's really rather complicated to identify what the cost savings are and make sure they get the numbers right and we hope that we continue to provide the service the grant that we received from OneCare was $125,000 that helped start the program it's not to sustain the program and so we obviously need funding we have had great relationship with our local police department with our local hospital and we know that that will continue to grow after this morning and listening to Commissioner Schorl we believe and we know that this supports the ten year plan for the mental health plan looking at the quadruple aim of decreasing cost increasing caregiver experience increasing client experience increasing overall health absolutely aligns with the quadruple aim and also aligns with the recommendation of alternatives to the emergency department we are excited about the possibility of moving forward and expanding and hope that that happens and just very quickly we saw these dolls I just want to tell you very quickly what that's about we actually we see these dolls in a collaboration with the Vermont art exchange and the Vermont school for girls which is a residential program they make these dolls, they donate them to us in their hearts and the pocket is a message from an older child that's in a residential to a younger child in Puck basically saying that you can make it I did too and these people will help you and the children who come into Puck if they want to take one home with them they can have it and take it home so thank you for allowing me to share about this work really well my story I'm going to tell you how my story is avoid war is very crucial in the workplace my life was like living in the dark I could not see the light at the end of the tunnel I didn't want to come out of my house I wanted to stay in my enclosed box with the help of my team and peer support I wouldn't be here I wouldn't be where I am today I was in added to law schools I didn't care about life I thought everything would be better off because I wasn't here I was told to do DVT, dialectical, behavior therapy CPT, cognitive behavior therapy and recovery I thought everybody on my team was nuts thinking about the classes would help me but I took them anyways even though I hated to the process is not easy I would take two steps forward two steps forward and one step back and if there wasn't the faith of my team I would consider peers my team I would not be where I am the process took years little by little I could see the light at the end of the tunnel if it wasn't for peers I would never be able to get a job at the suit kitchen I just wanted I used to work at Nationwide in the treasury division so in the treasury division so the process and career flow was at during the suit kitchen I did the catering for sunrise and my supervisor told the supervisor of support team I might be a good fit to drive clients around to doctor's appointment, grocery shop and because I was a peer my team had an opinion I interviewed for a time position and I accepted the position I was doing such a good job when the supervisor trusted me enough to be the backup for assisting assisting is where you go deliver my clients there was a staff back when I first started as a support person that was telling the supervisor that they shouldn't have hired me for the position but when I wasn't well so they were actually being not well compared to how far I went in my recovery I felt like I had to show everybody they were wrong that I was getting better I was asked to do the position of teaching at Maple House was a big step for me but I like challenges Maple House is a place where we have two beds we have a Maple House bed which is a crisis bed but it's more than just a crisis bed it's also a cold current because the people that you come into our bed has cold current issues and we also have a transitional bed that's a 30 day stay for a homeless person but being a peer the peer people we understand people better than I'd say someone that came out of college they're both smart but not common sense smart get my supervisor for the coordinator for assistance for step down I applied for the position and got the job my new title is oh my god sorry coordinator peer support I supervise 16 people I do half and half a Maple House and half of assistance support staff and carers that help me accomplish a life commitment myself and others I think care services are crucial to helping clients or guests in everyday life the guests are quite comfortable because staff have lived experiences that can relate to their issues the strength of having crisis beds we don't have enough of because we need more funding there are one in all right here are they going to let me in? can I let me in? peers can actually understand what the guest is going through and they support and not judge they share parts of their recovery story takes this helps take away from isolation not feeling alone my census I think that we should have a lot more crisis beds run by peers because this will help not being an intimate ED which costs a lot of money and our peer staff makes our crisis bed unique and valuable because we can relate to the client's guests so we have a better understanding so if they say you don't know what I'm going through yes we do so I would like to have more crisis beds around the central Vermont area because we really the only peer run bed is at 19th Street Monterey we have one bed and that's very hard to feed three people that need to step down from the ED and we don't have space so if you can think about or just talk about a little funny because I know it's very hard because there's not a lot of money out there but we can save you money we can save lots of money from having more crisis beds than ED and before going to the ED thank you if you can still I don't know Isaac he's not joining us here okay let me just check we didn't know that we would have time but if you can hear from him we're checking to see if he can forward to ask if you've heard she had to do the testimony okay well there's lots of things going on in other committees the senate help them up our committee is also hearing from folks today Courtney are we still here Courtney it's nothing but I want to just maybe bring to our attention how he submitted written testimony as I looked at it I'm not looking at it closely but I see that amongst the things she intended to talk about was the importance of school based access for services which I know that we all are very interested so I just asked the committee members to take a look at her testimony as well I'd like to just maybe say a few words for the morning I'm not going to be surprising but these are issues that are near and dear to my heart personally and professionally some of you now I've worked in the community mental health system 73 to 1996 I worked my way up from a part time summer day camp provider to eventually being the executive director of the counseling service in Addison County and I say that because I congratulate you on continuing to take on new challenges what we're faced with here in Vermont is again I'll bring us back to what we were we started this morning here for the commissioner school how to move we're moving we're collectively trying to move what is bigger than a ship that isn't turning fast it's much bigger than that because we're we're simultaneously trying to move societal issues of discrimination historic hurtful prejudices having to do with everything for racism to you notice how many times LGBTQ issues were brought up I worked personally to try to change this ship for my entire lifetime with some success here in Vermont I think we had some success significant success but when I can't help but sit here and think of a young woman and I'm acting as a witness now and I'm ashamed of myself when a young adolescent girl wanted to do a school project she said I wanted to do a school project about what it means to be LGBTQ in the community that was her way into finding out making contact so they said we should go talk to Bill with her so I sat down with her and I she asked me questions and I talked about the things about how in Vermont you know why it's important that she was that in Vermont and then I stopped and I said tell me your story I didn't admit it three times to an inpatient psychiatric unit in Vermont for suicide it's seriously suicide attempts once in those inpatient admissions had she ever been asked anything that would allow her to reveal her personal struggle about being queer never once would she refer to outright Vermont she went to an outpatient therapist who never said anything about her and finally she went to someone else who said you thought I'd write Vermont and she went down to Vermont because outright Vermont is committed to an affirming approach to LGBTQ queer youth and I mentioned that only because as a part of that's my world of commitment in mental health is driven from my own personal struggles of facing the discrimination and the fear of reaching out to the mental health system for what the mental health system might have done to the mental health system I think there are a lot of people who are living in fear still fear for what the mental health system will do to them rather than how it can help them when I hear of suicide I think the number of people who have made it a suicide which is a far, far greater number and I think there's so much for us to do there's so much for us to do long but there's so much for us to do there are many, many secrets around sexual abuse there are many secrets about other kinds of life traumas that people live with on a daily basis I know this from my work from my work in the LGBTQ community my own personal life and so I commend each of you for keeping moving forward on a daily basis to finding ways to make change I became a psychotherapist a substance abuse counselor and I wanted to become the supervisor because I wanted to influence the things that was happening and then I became the supervisor I wanted to figure out how to have more influence and so I became the director of that section of mental health and then I had an opportunity to become the executive director because I wanted to learn metaphorically because I kept wanting to paint on a bigger canvas and I said and I sit here giving me to this building for the very first time to try to change health insurance access around the alcohol and drug abuse and I really wasn't ending and that was many years ago now we were successful and I just decided I wanted to share some of this with you sitting here to chair this committee that has a responsibility around mental health I came here because I wanted to make a change it's painfully frustrating to see how slow that change is at times but it's profoundly satisfying when we do make a change and we have had the opportunity to change and we will make more change and you will be frustrated with us because we don't get as far as we want to believe you we are frustrated and I want to thank those who are continuing to do the work on the front lines that work informs our work here for you if we need to interact with you and I'm confident that we will make more changes and I personally committed to doing that I believe those committees and we will work with our colleagues to do what we can do without all the resources that we would like to have but thank you for indulging my personal sharing