 Okay, thank you. This is again the house health care committee. It's Monday, March 9 and it's now about 325 p.m. After taking a break after hearing testimony from the commissioner and the deputy commissioner of the Vermont Department of Mental Health. We now have four four different witnesses. Excuse me who I tend to hear from in the next hour. And I'm going, as I mentioned earlier, requesting that Devin Green and her testimony be rescheduled to a later time in order to ensure that we have time to hear from these witnesses. I've also contacted the commissioner and deputy commissioner and they are going to stay throughout this testimony, which I think is important and useful for them both to hear the testimony and possibly if there are questions that would be directed by committee members and not witnesses to them. So with that, let's turn to our first witness because I know they have a time particular time constraint and that's Kathleen Lamphere, who works at health care and rehabilitation services in southeastern Vermont. So welcome. And I'm going to turn it over to you and we're asking if you can keep your presentation to 1015 minutes at the outside so we can hear from everyone involved. But we're happy to have you. Thank you so much for allowing me to speak today. Hopefully everybody can hear me. Somebody will come if you can. My name is Kate Lamphere and I am the director of adult services at hcrs, which is one of the one of Vermont's designated agencies to provide mental health services in the state. I'm also representing Vermont care partners today. I'm a licensed social worker in the state of Vermont. And I oversee all adult programs at hcrs so we cover Windsor and Wyndham County, which includes outpatient mental health CRT, a residential continuum, which includes therapeutic community residences and the crisis team. I come to this conversation with a deep, deep, deep understanding of the gaps in the system of care, serving for monitors with mental health needs. And I also have made a commitment over the last year and a half as a provider to really listen to people who are most impacted by the system that I work in. And upon hearing about the expansion of this secure residential program and the inclusion of involuntary procedures, what I heard loudest was, please don't do that. And so I stopped and listened. And of course now my dogs are going to bark so I apologize. Most of my testimony was about involuntary procedures and how they just simply don't belong in a therapeutic community residents, a resident that it's designed to achieve wellness and recovery does not and should not include forced medications, restraint and seclusion. It's detrimental to the healing of people and it is harmful. So I'm thankful to hear that the Department of Mental Health has also listened to those of our monitors who have said the same thing and and rang the alarm saying those two things don't mix involuntary procedures. They don't belong anywhere belong in a hospital and a hospital only, and not a therapeutic community resident is not clear to me, based on the presentation, if involuntary medications will still be permitted in this facility. Commissioner spoke to no longer having restraint and seclusion, and I believe that includes forced medications, but if not, I want to go on record saying that Vermont care partners, opposes the use of involuntary procedures at the secure residential and all other community based settings, including forced medications, we think they are harmful, and they do not belong at that level of care. Vermont care partners also opposes the expansion of the secure residential from seven beds to 16 beds, until all existing inpatient beds are back online, and the impact of the 12 new beds at the Brattleboro retreat can be assessed. Right now, there are many hospital beds that are just not being are not available to people. So the newly renovated Wyndham Center is is is not available to people. We are encouraging that we have a fully functioning continuum of care with the capacity to meet people's needs before we add more restrictive beds. So we want to see what those 12 beds at the retreat how they impact the needs in the system. We want all the beds that we already have to be online, so that we can then see how that impact the system before adding more secure beds. Vermont care partners does support the replacement of the residential facility at middle sex. And after the assessment is done of all of the needs. There is a need for expansion, then, and only then should it be considered. We believe that the resources that would be allocated to the expansion should go to least restrictive, less harmful community based intervention that are cost effective and are in alignment with the state of with the state of Vermont stated values. We want adequate funding for the designated agencies. And this is where I can speak most passionately about the designated agencies serve some of we serve Vermonters with some of the most acute mental health needs in the state. And we do it often with the most inexperienced staff, and a turnover of staff that is profound and harmful to people who are receiving services. I am a licensed clinical social worker with a high clinical standards. And when I have to turn to an intern and give them their case assignments. And they are some of the most acute Vermonters in my county. It is not a great feeling. And it would be lovely to have inexperienced licensed staff who stay working at the community mental health centers. But they go, they go to work in other places where they can make more money, and where they can, where the acuity of need is, is lower. And I have staff look at me and say, this is the population I want to serve. This is my, this is what I want to do, but I can't afford it. So they get their license, they get their experience, they get their training, and they go work at the FQHC or they go work at another agency where they can make more money. And I welcome in and orient a new group of interns who I might get for three years to serve the most acute need. And that is, that is not the quality of care that Vermonters deserve. And particularly, these individuals who are often disenfranchised across the board, living in poverty, having traumatic experiences. So we ask that some of the resources that are, are scheduled to go for this expansion, go to funding the designated agency system so we can better serve Vermonters. We also think that there's, there's room for further. There's, there's further need within the residential continuum. So looking at less least restrictive options like crisis stabilization programs. We have peer respite programs, safe and supportive independent housing, group homes, other therapeutic community residences and intensive residential programs. Those places where people can truly go and transition into independent. We have a crisis stabilization program at HCRS that has not operated as a crisis stable crisis stabilization program for, for, for a few years now, because, as, as you all know about the, the log jam of people within the hospital setting, we have a log jam of people within the crisis stabilization setting, and there's no safe and supportive housing for people to go to there's there isn't a place for people to go. So that's an area of opportunity that might, you know, an investment in the community and investment in the residential community, as I mentioned, if you will, is what will keep people out of the hospital. It's what will keep people out of the secure residential facility. So until we have a full and robust community system of care. We should focus our attention on those cost effective, less harmful, least restrictive interventions that we think will help Vermonters to achieve wellness. I think that we should invest in community education to increase the ports for people and tolerance and acceptance of people who are in distress that will reduce stigma and discrimination and the harmful effects of hospitalization and other institutions. And I think, you know, if after all of that, if after we have assessed, we've gotten our hospital system up and running and we've assessed our need, we've invested in community intervention. And after all of that, we need an expansion in secure residential to meet the needs of Vermonters, then, then we will will support it, but not until we look at all options and offer an array of supports. I also know that this committee has. You mentioned getting letters and hearing from people. It's been life changing to me to spend time listening to people who are impacted by the mental health system, people who have been psychiatrically labeled people who have been harmed by the system. I encourage you to wait their voices to listen carefully to what they're saying and what might be helpful and invest there to because those creative strategies that have have been untried in the traditional traditional system of care could truly be the solution to Vermonters achieving wellness and living a life free from distress or at least the life where distress is tolerated and accepted. So, I don't think I need to repeat myself, but I will. We oppose the use of involuntary procedures. I do hope that involuntary medications are off the table. We can get clarity on that that involuntary medications are off the table. We expose the week, excuse me, oppose the expansion of the secure residential until we truly know the impact of bringing all of our hospital beds back online, and you mentioned that the Brattleboro retreat and that we invest in least we take the savings and we invest in least restrictive community interventions that we think will prevent the need for a secure residential and hospitalization and we'll better serve our residents. Thank you so much for giving me the time to speak. Please excuse my nervousness that was a little shaky. I appreciate the time greatly. I really appreciate your joining us today and you did great. I think you've been clear. And I want to just be clear. So that again, it's my understanding that you're speaking not just for yourself, but for Vermont care partners that I want to make sure that is understood. Correct. I'm speaking for Vermont care partners, which is all of the designated agencies and specialized service agencies in Vermont, Vermont care partners collectively opposes the expansion opposes involuntary procedures and supports the investment in community intervention. Thank you. Thank you. Thank you very much. I'm going to turn to Ward and Ward, you help me with the correct pronunciation of your full name. I know that you can hear me and I'm just failing my memories failing on the correct pronunciation. It's my, my name is Ward Nile. Thank you, Ward. Great. And I live in South Burlington. And I'm speaking as, as an individual here. I've been involved with very various aspects of the mental health system and advocacy since March of 2016. Right now I'm a member, I'm a board member for NAMI Vermont and I'm a member of both the Department of Department of Mental Health children and adult program standing committees. Over the last several years, I can just give you a rundown on my story. The first year basically involved in law enforcement and mental health issues within Burlington, Vermont, which was interesting year two was really an involvement in the act 82 legislative work groups around emergency department wait times and we do send that. And three got me involved with a group that was investigating and proposing the use of analytical tools to understand that flow of people through our system. That was an interesting, that's an interesting idea there. And for me, got me into hospitals, inpatient and emergency department facility designs, a lot of activity there, and I also spent time doing pet therapy once a week within the University of Vermont Medical Center shop three and shop six. So that was good then came year five and all of us know that was the pandemic. And my focus there happened to really happen to be childhood trauma and the impact that and how that gets people into the criminal justice system and into jail. So, and across all of that time, I learned and was involved in what I would call as alternatives to our normal mental health system is and I think we refer to that a lot of times as pure support that's kind of a true but it's, I think Kate was getting at. It's a little bit broader than that. There's a lot more to it than just calling it pure support. But the two points that I wanted to talk about really was to support the investment in our community resources, and also to oppose the sec the seclusion restraint so I'm happy that that's off the table, I'll still talk a little bit about that. So my real point here with community based services and what I'm seeing is that it always seems like we have this. I hear you community resources are important, but first we need to do something else. You know, I've only been involved here for a few years before that I was in aerospace engineer doing complex systems so I'm a little bit of a, I consider myself an invasive species into this I'm a come about it from a different point of view, but everything is always hearing this, but first we need to do something else and you know now we're look we've talked about a lot of pieces here and you've got the new beds that are coming online at Bradwell level one, and that's intended to and, you know, adjust and improve the emergency department wait times. We're spending a lot of money there. They're not online yet. We don't know what's going to happen. But we've still committed a lot of funds there we have talked and we're deciding to do. You may not be aware of this and the complete committee but there's been a lot of effort to add beds at the Central Vermont Medical Center. And there there really is plan was to add eight level one beds there. You know we spent a lot of money in looking on that the beds are online, we still have an ED problem, you're hearing about it. Again, you know, we're considering adding beds at the secure residential, we're spending a lot of money here, the beds are online. We're making plans to add and as I see it 12 beds at Brattleboro nine new secure residential and eight more beds, all really similar level one high acuity beds. 29 total beds. And, you know, we're not even sure I think as Kate says, what the impact of the beds that we're putting online are, you know, is are these 12 beds that we're adding a Brattleboro enough to have to keep adding beds. So it's this, but first we need to add beds before we do our invest in the in the in their community resources and then so is this really the right solution and I'm going to put back and just, you know, mentioned that disability rights Vermont has did a study on that and put out a report called wrongly confined, and that explains however monitors are being held in a more restrictive environment, because there isn't a place for them to move to. I think it's important because I think in past testimony, the Department of Mental Health has already kind of testified and confirmed that we have this problem with lower level community resources, causing barrier days and causing people to be stuck at a higher level of care than need be. That represents, you know, a possible instead violation so it's just, and I think we need to address it. It's, it's complex so, you know, adding resources. Is this really going to solve these problems of, of, of ED wait times, I think the systems really complex and to be able to say it really is. It's, it's a, that's a difficult answer. What we know is when we increase this capacity we're going to have the capacity more capacity to wrongly confined people so, you know, I'm really hoping that we can address this change the but first to get thing to first let's go to address the community so there really is either a place for people to get served so they don't need to go to the emergency department and then gets sequenced into higher level care, or at least be able to get out. I want to, I, you know, the next point I was making is really, you know, that is against the secure seclusion restraints at the secure residential and I'm glad to hear that that's, in a sense, off the table. And I'm actually, you know, happy that, you know, Kevin Hukchorn and her associate are here, because I did want to encourage that the Department of Mental Health stick with the six score strategies, because I, from what I understand is that you don't really need to do emergency and voluntary procedures to benefit by the process that six core strategies has. It's about reducing and eliminating the situations and what the environment and the conditions are that would cause someone to need an involuntary procedure. So I think we need to, you know, stick with that. It's really good. One of the reasons that initially that the Department of Mental Health was indicating that might need to do emergency and voluntary procedures was this cycling people back to from secure residential to a higher level of care let's say an inpatient where we go through an experience through an emergency department, which is pretty bad. What I'm saying is let's think about alternatives to that path through an emergency department if you're really needing to move somebody back up to a higher level of care why do we need to go through the emergency department. People are being admitted to inpatient psychiatry without going through an emergency department. I'm not saying that's happening a lot, but it's possible we ought to think about it. Again, I appreciate the chance to talk to you all if you have questions. I'll be here and I'll move to Malika and Karim. Thank you Ward. I appreciate you taking the time and sharing your thoughtful experiences with us. I think we are going to hold questions till we've heard from the witnesses first, and I will turn to Malika who is with us and has come on video thank you Malika. Welcome to the House Healthcare Committee, like to turn it over to you to share your thoughts and perspective with our committee. Yeah, thank you so much for having me and making the time also thank you so much for making time tomorrow to hear testimony from other people reduces a bit of the pressure on me in this short amount of time. Yeah, my name is Malika puffer I use she her pronouns. I'm a resident of Wyndham County. I'm a manager and a leader at a designated agency HCRS. I'm also a former patient in the Vermont public mental health system that you all help oversee my former CRT client, I've experienced hospitalization with and without my consent. I've experienced residential step down programs and hospital diversion programs, and I've experienced seclusion and forced drugging. I'm also a very active and involved member of the state at the adult state program Standing Committee, which advises the Department of Mental Health. And I'm an advocate on a systems level and also with individuals so I've spent a good amount of time with folks who are in the emergency department and in the hospital. And I know people who I consider my peers who have been residents at the current middle sex facility. So that's sort of the experience and knowledge that I'm coming to you with on this issue. I, I appreciate. There's a couple of things I just want to note right off the bat that I agree with DMH about that is that of course as we as we all know the current middle sex facility can't continue to be used. And we do need to look towards phasing down our IMDs are large hospitals with more than 16 beds and appreciate the the choice to eliminate restraint and seclusion. I'm going to assume that that includes forced drugging of course we need clarification of that. I feel like that is one right choice that's been made so far and I think there are some more right choices yet to be made by DMH on this issue and you all. A couple process points. I did not I was not informed by the department that they were changing their plans so substantially. I was part of a stakeholder meeting on Thursday and the adult standing committee meeting yesterday and was not told that so coming to this a little blindsided and just want to request that the DMH or the committee somehow inform the people who are planning to testify. Tomorrow about the significant change so that they can speak to the the updated plan. So there's a there's a few things concerns I have still of course the restraint seclusion and forced drugging was a big concern, but I like others who have spoken before me do also oppose the expansion of this facility, and very much question the need for locked doors and fenced in yards. I know from my own experience that, of course restraint seclusion is very traumatic but so is confinement. I saw the pictures that Morning Fox shared of the facility and I had a visceral sort of trauma reaction to the to the way the space looks because it looks just like a ton of hospitals that I've been in. I imagine myself there I do not see or imagine what Dr. Huck shorn and Dr. LaBelle imagine as a trauma informed space, you can't lock people in a cage and then call it trauma informed traumas fundamentally about a loss of power and control. And so locking people in a spaces is a way of taking away their, their autonomy. I appreciate several questions that were asked. And I guess, because there's not a lot of time I want to prioritize those and speaking to those. I have a question that representative boroughs asked was a great question which is about what alternatives have been considered to serve the population who are currently being served at middle sex. My, my take is that they're not there have not really been alternative seriously considered as a very engaged and involved advocate I have not been invited to or privy to any conversations, considering alternatives. I just did mention the sort of outlier enhanced funding programs like my pad. And you sort of individual staffed models. And, you know that there's a big delay and getting into those programs. That is a problem that can be solved. That is a potentially a route to serve people in the community in a way that is actually trauma informed and conducive to real healing by by expanding that capacity by investing in housing and supported housing. And also, it's of note to me that in a 2019 report to the legislature. One of the things that DMH mentioned regarding the secure facility. I'm just going to look up the language right now is that in the future, the population that are currently being served by my pad and those other sort of outlier funding might be served in the physically secure residents. This to me is is very I don't know if that's still the plan because the plan is like constantly moving and there's frequent contradictory information. But if, if there are people who can be served in the community. It is a violation of Olmsted to support them instead in a locked environment. That's the concept of least restrictive. And I concur with Ward and DRVT that people in Vermont are regularly supported and more restrictive and more coercive settings than it's necessary because of the department's choice and the state's choice to continue to invest in locked settings and inpatient settings and coercive settings as a higher priority than investing in the community. And there's also a question from representative black which which I thought was a great question about what percentage of residents in middle sex currently end up going back to level one beds and is there sort of a revolving door there. I do have that data at hand. But I don't know how to interpret that data because how do you decide what is an acceptable read mission rate I did a public records request some time ago with the department for the same data from other residential programs from the city. And I don't know if I'm getting met a view hilltop. So Terry had those, those other unlocked places and that was never supplied so I don't know if that data doesn't exist or if the department hasn't been willing to share it. But it's a good question. The range is zero to four times per year, the average ish I would estimate just looking at it of about two times for you people go back to the hospital that was one of the rationales from dmh for the need to use eps for emergency procedures in the new facility because what they were saying as of last week was that it isn't working to not have eps there and they have to call the police and that that people are going back to the hospital too often. I think that represented by the data but I'm, I'm very confused about sort of the rationale for the different decisions, and there certainly is not data really to back to back up the the expansion of this program is certainly not the use of EIP so I'm glad at least that has has changed. I think it's super important to speak to the issue of ED wait times that damage has consistently claimed that that's part of why we need this facility to address the length of time that people are waiting in the emergency department. I do not agree at all that this facility will reduce ED wait times, or that expansion of inpatient generally is the solution to ED wait times. I know from my own experience and from supporting so many people in the emergency department, I would wager that I might be the the person in this virtual room with the most time spent actually with individuals in the emergency department. And I know that so many of us end up there because we don't have another place to go. When I first moved to the area I live in now. I didn't have an established community I didn't have people who I felt like I could safely call on to support me when I was in big emotional distress, and so I called the crisis line. And what I was told was if you want to connect if you want to talk to us, we don't have time to talk to you on the phone if you want to talk to us you need to go to the emergency department and be screened. And so there's, I think there's this idea that people who are in the emergency department must necessarily need to be there, and they must necessarily people who are admitted to the hospital must necessarily need to be in a locked setting. And people who are on orders of non hospitalization and involuntary status must necessarily be dangerous. But in reality, so many of us are simply experiencing unmet needs in the community, unmet basic needs like housing, which you can simply get by saying that you want to kill yourself, and then you're in a hospital and you're counted by the system as someone in need of hospitalization when really what you're in need of is housing. And so we just end up there because what we need is simply human connection and someone to be with. So I, I would love to see DMH prioritize instead of this project to invest in community solutions, like to read something from their. The vision that the 10 year vision, if I can find it easily, which I might not be able to. Oh, no, I don't have you. But basically in the 10 year vision, one of the things that DMH identifies as a short term action is to create places for people to go in the community instead of the emergency department. Like a living room model, there are many different models of what that could look like but a 24 seven community crisis center essentially that is what would reduce wait times and backlogs in the emergency department. And that would be acting in good faith with the Olmstead mandate of least restrictive level of care. And I think this project should be totally scrapped we should go back to the drawing board and think about what are the needs of the, the people who are currently at middle sex, rather than saying well we think what we've done so far is probably good because we, we feel like it, not because it's based on any actual standard or measurable data and and bring together different community partners and stakeholders to, to come up with a solution that that best meets people's needs with the least amount of harm with the least cost to taxpayers, and at the least restrictive and coercive level of care. Happy to hear any questions if people have them. Thank you. Thank you Malika. Appreciate your articulating your concerns to our committee. Again, I think it's my intent right now is to hear, hear the other witnesses and then hold questions in order to hear from other witnesses. At this point. Again, thank you. I'm going to turn to Kareem. Who I'm searching. Oh, they're high cream. You're on our screen. Welcome back to the House Healthcare Committee. We appreciate hearing from you previously. And in the interest of time we're going to turn the committee attention over to you. And introduce yourself for those who may not know, but certainly our committee members remember you and hopefully others as well. Right. Nice to everybody again. Good evening. My name is Karim Chapman I am the executive director for Vermont psychiatric survivors and a member of PWD I steering committee. And thank you for this opportunity to share, you know I come to you as not only ED, but also a survivor as well. Okay, I just want to start with that. So, it should not hurt to help. I'll repeat. It should not hurt to help. The starting part is when the community based organizations like myself, we struggle to support people due to lack of funding due to trying to figure out how do we expand our program to support and make it to where people don't have to or need to go to the emergency room. Where people every day trying to figure out I mean families, individuals are trying to figure out how to support themselves, their family members during this time. And I got to say, we have to get this right. We have to get this right. We the responsibility is so heavy that if we don't get it right. That window opportunity that we have right now to get it right will pass as we'll be right back at the drum board. VPS, you know we are very is so good to hear that there won't be any restraints to close your rooms and hopefully any forced medication happening at this this of new facility. We don't support it. We don't support the expansion, because we really don't understand why there are other beds throughout the state that have not been filled. And we wonder why that haven't happened. We wonder why that we've been brought to the table so late in the game, for as input, you know our perspectives. And you know I've been a part of many meetings with different folks and the consensus that everybody wants to figure it out right everybody wants to get it right. But it's this tension of who is going to do it right. I believe that that everybody plays a role here. The clinical people play a role I believe the peer support the survivors advocates we all play a role and I will repeat, if we don't get it right. People are going to suffer. That's what's at risk right now that people who are revolving through these doors, not being supported adequately. Now, the evidence the evidence is there. Your support works, it's been proven throughout the world that when you when you support these community based organizations like VPS that it lessens the fact that people will need to go into a hospital setting. And me myself working at a definitely before VPS. I can tell you firsthand that out of all the people I worked with, maybe only one or two went back to the ER. And that was due to the intimacy, me sitting on the couch, me taking walks in the park, me being there during during good days and during bad days. So I will repeat, we need to get this right. I would rather see the money go to know, even before I go there. I definitely understand the, the importance of renovating this old middle sex facility. It's no place, I don't want to be, or have my family member want to be. Yeah, that responsibility is on us to get that part right as well. So, again, the tension really from from our perspective, the sites of virus is that we weren't brought to the initial conversation. And now we're here trying to figure it out. And now we're being heard. Again, you know, it is so good to hear that it won't be in the restraints of seclusion rooms and forced medication. That that that that is that is part of the battle that that is part of, of the fight right. But just to reflect, you know what my like has said earlier, you know, we can't come across at what a band aid approach, like we'll do this now and maybe it'll be later, we need more concrete evidence of what can actually work. Right. And we know what works for sure is community based organizations then being funded properly to be able to support and help people. So, I'm going to leave it at that because it's late and I got to pick up my kiddos. But you know, again, I can't stress enough, the importance of getting this right. It should not hurt to help. When we are at the level of community work, it hurts to not be able to help people in the right way. It hurts to not be able to tell someone we're working with that we can't help house you. We can't do this for you because I will resource are limited to that effort. And then if there's any questions out of mind at answering, but I hope this was short and to the point, and you kind of kind of got understanding of where I'm coming from. And I hope that was helpful. Thank you. Thank you, I appreciate it and yeah your kiddos need you as well. So thank you for making time for us as well as for them. I promoted just at this point, because I did it, even though we have a little bit of time left. I think I'd rather open it up for questions and I'd ask Devin green if she would reschedule with us and she I think agreed to do that. So are there questions from committee members for members of the for the witnesses, and there's certainly, and well that's that's here from committee members are certainly the outstanding question which I'll just name, which is is in voluntary medication. And maybe I asked the commissioner to comment on that. If you remind before we hear the other questions because I think that's been an outstanding question that people have had. And so let's ask the commissioner or deputy commissioner to comment on that. When you said that. Well, this is commissioner squirrel I'm happy to speak to that. It was actually never part of what we were initially proposing so there will be no involuntary medications. Thank you. I think it's important to have that clarified it was clearly on the minds of many of our witnesses today, and it'll be important to have that clarified for potential witnesses tomorrow afternoon as well. So thank you commissioner for for making that clear. And to, I think I think represent court is you may have been the first to the hand up and then represent golden. Thank you everyone for your deep and compelling testimony my question has both short term and long term answers the long term answers we don't have time for but I might appreciate further opportunity as a committee to hear those answers either in written questions that we submitted to our committee assistant, or if we have another opportunity to have you testify in front of the committee again, and that the question that I hope you can provide very short answers to and this would be anyone, or two of you that would like you have answers. We have talked a little bit but not very extensively about children with children in crisis children with psychiatric psychiatric needs that may need to be met on an inpatient basis and I know that we have as a state have been lacking in the capacity to provide for those individuals so my question is in your capacity. And I would say, I'm going to ask the people that work with and provide community services this where the where are our gaps in in providing services for our pediatric populations. Who wants to comment. Okay, I'll let Kate go. Okay. Yeah, appreciated. I am the adult services director and although I think I could give you a lot of information on that what I think are the gaps I think I would ask somebody from Vermont care partners to provide written written testimony for you to be sure that we get the voices of the children's directors if that's okay. I just want to ask who is here wishing to comment on that to representative court is this question at least comment today and perhaps with further testimony later. Okay, I think I think at this point we'll turn to represent Goldman. Thank you and yes thank you everybody for your testimony today. So, Lampier raised sort of a bunch of sort of a series of questions for me, and I just want to throw them out. They're really for the commissioner and the assistant commissioner because of her testimony, raise some curiosity in me. I'll throw them out and I don't know that you want to answer them now but she raised the question of how many beds are not online and I'm curious about that number, and why they might not be online it was a workforce issue issue and those kinds of things. I also raised the question of how does the new beds of the Brattleboro retreat fit in, and I'm very interested in that. In terms of reducing ER bottlenecks and those kinds of things, and also how they fit into the levels of care. And the last thing that came up for me was, I think I heard you say that middle sex staffing was like 70, if the new facility was built. And I'm just wondering if there's a workforce for that because we also know, and I also think Kate mentioned some of the problems with workforce there. So those are the kinds of questions that I'm wondering about particularly at this moment the Brattleboro retreat beds and how it fits into the whole system. I'm happy to speak to that I think in previous testimony I have addressed the closed beds that we have in the system as a result of the COVID pandemic. That is a national issue, you know, if you look across the country, due to the impact of COVID and workforce challenges. There are many closed beds in the system of care. So I'm happy to provide more information about that. But that is certainly something that we are seeing and experiencing. And of course, even on the community side, we have seen decreased capacity due to workforce challenges and the ongoing impact of the pandemic so that's, you know, statewide and hopefully as we continue to move towards recovery as a state. We have more vaccine deployment that our workforce will recover our, you know, capacity will come back online. As we certainly pre pandemic, we're also experiencing long wait times for emergency departments. The 12 new level one beds were something that the legislature supported to advance in terms of meeting the needs of the system of care. I think that there was continued need and demonstrated need for these higher acuity beds to support individuals and moving them out of emergency departments so that decision was made years ago to move that investment forward. And also, part of that thoughtful discussion was, you know, as we advance our system as we realize some of the impacts of overall integration and support of the community that maybe, you know, down the road we won't need as many inpatient beds and perhaps those beds could be repurposed for other uses. And also in response to the pandemic converted a 10 bed unit at the Wyndham Center to a COVID positive unit. Again, I felt like it was my responsibility to ensure that we had capacity for individuals who might be experiencing a psychiatric crisis, and to ensure that we were also COVID positive. We were also able to utilize funding to actually upgrade the facility so that they could accept a higher level of care. Due to some of the lacking in the environment of care, the Wyndham Center actually was not able to accept involuntary patients prior to the upgrades that we made so it was only serving voluntary individuals. And as we continue to assess the conditions on the ground. Then those, the 10 bed unit at the Wyndham Center would be coming back online as a general adult unit, and then the 12 new level one beds the Brattleboro retreat would also be coming back online. One thing I would just note is that, you know, we, and I think Vermont care partners and others have articulated what we are going to see as increased demand in our mental health system across all levels of care as a result of the pandemic. But pre COVID, even with all of our bed capacity online, we were experiencing long wait times in emergency departments. So yes, the 12 level one beds will serve to help address that need to alleviate some of the pressure on the PDs, particularly in the areas that we need at most, which is access to these high acuity beds. So I just want to note that, even when all of our beds were online. We were seeing increased wait times. So that's just something for us all to take in consideration. And then when you layer on top what we would see is possibly increased demand. That is something we want to ensure that we are well prepared for as a system of care. The other note, I guess that I would make is that as we've articulated the step down capacity at the secure residential is a different level of care than hospital level of care. And so, as individuals are able to appropriately access that level one care as they need it, it is incredibly important that we have capacity to step them down to so that, you know, we know that the individuals the data that we have related to individuals who have benefited from the secure residential that they have these enormous length of stays in our inpatient facilities. So it would seem wise, prudent, strategic and in the best interest of the system, that we also ensure that we have that adequate step down capacity, in addition to all of the community supports that we need to continue to pay attention to so I guess those are a few questions and then I might have missed one but I think your final one was workforce. And as I mentioned, I think our, our staffing needs will shift based on some of the changes that we're proposing for the program so I do want to follow up with the committee in terms of what that looks like. You know, and I, I, I don't want to minimize what we see as workforce challenges across the system of care, but would hope that we are able to recruit individuals to work in the secure recovery residents. We were trying to be somewhat thoughtful about it being in an area where possibly workforce recruitment would possibly be enhanced, given its proximity to Chittenden County. And I think I'll leave it at that. So can I just follow up for a minute because I was trying to do an inventory in my own mind about closed beds. And you mentioned the Wyndham Center which is 10 beds which is actually available for COVID, COVID related COVID involved patients, which I think has not had to be used particularly is that correct. It has been used for COVID positive psychiatric patients. But at a minimal level, is that right in terms of numbers. Yes, I think the numbers it's kind of actually I'm not there's not a criticism it's just to understand it's a low frequency high intensity and then of course but yes, the numbers have been small. Yes. And so then, and then there's a 12 beds coming on at Brattleboro as you mentioned, are there other beds however at Brattleboro that have been closed as as those beds are online to come open or are there other beds in Brattleboro retreat that have actually been closed due to workforce or other issues so that the net gain at the Brattleboro retreat is actually not a net gain of 12 beds is that is that accurate. Yeah, so. Yes the Brattleboro retreat as we all know, even pre COVID was on somewhat shaky fiscal ground and the capacity to that system of care, of course, was very crucial in terms of timely access to care given the volume of individuals that it serves. So as a result of COVID and impacts to the overall workforce. They have taken one full unit offline. And they have closed beds on their system just as we do in other areas of the system of care we have closed beds at the Vermont psychiatric care hospital. It's simply because of workforce challenges. So I just across the board I think that's something that we're all grappling with this inpatient partners. So, the intent is to fully reopen capacity at the Brattleboro retreat. I do not have a crystal ball to determine, you know how workforce how quickly will that recalibrate, how quickly the retreat will be able to staff up in that regard. So I think that is something we'll have to continue to monitor. And then we have, you know, within the workforce there are very specific pinch points for all of us. One of them is nursing shortages and doctor psychiatrist shortages. So I think that's a real reality for us as a system of care and something we also need to take into consideration as we go forward. So just, just to try to put a final point just so I understand the capacity in terms of the number of additional beds that have been closed at the Brattleboro retreat due to workforce or other issues. Can, is there a number that you have. Is that when you say a whole unit has been closed is that how many beds is that. Yes, I think the rich I think in total right now as of today we overall have 53 beds closed in the system. And includes the psychiatric care hospital. It does and other, you know closed beds and other inpatient units. I think the retreat might be closer to 35 of those but I need to follow up they also have some closed beds on their child and youth unit as well. So, so I think it leaves the question, certainly for me just trying to do the numbers that the system has potentially 53 beds that can reopen in terms of added capacity. If workforce or COVID or other issues get resolved. Is that, is that a fair, is that a fair statement. It would be reopening back to our original capacity. Yes. Right. So, but, but nevertheless right now there's 53 beds are closed so 53 beds reopening actually brings us back to the same level of capacity. Without the 12 beds at the Brattleboro without without the additional 12 beds so we actually have 53 plus 12. 65 beds, more capacity that are not currently available. Yes, and I guess the only point I was make was that even when we had all of our beds open. We were still experiencing long wait times to access and patient care. Yeah, so I appreciate I do appreciate that I just, it's just hard to keep the numbers clear in terms of what where we are in terms of add capacity and so then the additional capacity would also be the additional beds at the middle sex, or the new fit the replacement facility for middle sex would be the additional beds. I wasn't tired and do the math quickly. So that that would actually add capacity but at that level of care, which is a different level of care as you pointed out, right. Correct. Okay. We're fast approaching the end of our time here for the afternoon. So I'm going to just really quickly turn to represent Peterson represent page perhaps you can name your questions and then, as I said we're going to need to come back and have more opportunities with the commissioner and others represent Peterson represent page. Thank you. Thank you chair of lipid. I now don't know if I should pose this question. Your discussion just now with the extra beds kind of tilted me off and into space but at the end, you said that the, I and I assume. I would verify that the, any of those beds have nothing to do with the seven beds at middle sex correct. They don't translate because there's a different level of care at middle sex right now is that not correct. Commissioner you want to respond to that. I think representative Peterson that's a really good point and something that we need to continue to keep in mind that when we're talking about impatient, most restrictive level of care, most expensive level of care. It is different than step down capacity. Okay. And so that leads me to my real question. To me, you know, you, these folks got flooded out. We put two trailers together how many years ago now nine. And they've been living in that facility for nine years. It would seem to me that it's logical what you're what you're trying to do. It's a facility that's new and modern. And my question was to the other folks here who gave great testimony this afternoon, given the fact we need to do something with the folks in that facility. The time has come I think to do something different than what we're doing. What have you got as a proposal. It is something to say you're against the plan is fine. But let's assume that we have to do something. What's your proposal. May I respond very briefly. Please do. Yeah, I think it's a bigger question than we can answer right now but a few ideas that come to mind are using more of those enhanced individual funding plans individualized programs like my pad. Great solution. Moving folks who are currently in middle sex, moving the program keeping the program as it is into the VP CH facility as happened this past year clearly there's the space. Or creating more intensive residential capacity that is staff secure just a few options that come to mind. There are more I'm sure as well. Okay, thank you. Thank you represent page and then we're going to finish for the afternoon. Yeah, just quick question. And this would be for Commissioner squirrel. Regarding middle sex, we all know we need to do something there. But with some of the recommendations that have been presented today from our witnesses and such. Is there still an opportunity to make necessary changes to perhaps, you know, turn the ship around and make these necessary changes or these recommendations that have that have come before us. And I don't have, I can't give you what those changes. But is there still time to, you know, to change what we all what what you presented to us today regarding the new middle sex at the old Woodside facility. So I think I caught most of that representative page it was a little bit faint. And as the commissioner of the Department of Mental Health, who is responsible for the care and custody of individuals across the state of Vermont. I have presented to you, what I think is in the best interest of Vermonters, what I think will help us transition those individuals who have the highest level of need, safely to a step down program, which will support their ongoing success in the community. We have seen increases and acuity of need. We have seen these individuals and this cohort of individuals occupying incredible lengths of stay in our inpatient beds. It makes sense that we expand the current footprint of the facility to create the step down capacity that will then lend itself for success for these individuals in the long run. I think I would invite you to also go back to reflect on Dr Richards vignettes and the individuals and the acuity of need that we are talking about. It is always the department's priority to serve individuals in the community. We also need to recognize when due to their own safety, and the safety of the community that some individuals will benefit from a step down capacity that can provide that ongoing treatment and support. So that's the key. We need capacity in the system for all levels of need. And that is the proposal that we have presented. Again, we have continued to listen to our valued advocate partners. You know, I as someone who also has a family member who has been served by the system of care. I think it weighs heavily on me as well. And I am putting in front of you what I think is in the best interest of Vermonters and that will serve the system of care in the long run. Thank you Commissioner thank you Woody represent page for voicing that question. We've gone over slightly, but I think we'll we'll call it a day here. This is this is clearly very important deliberations, and it deserves our attention that we're giving it really greatly appreciate Commissioner for the willingness to both present and to have modified a proposal that had been put forward previously in response to concerns that have been raised. Thank you to you and Deputy Commissioner Fox. We are going to hear more testimony tomorrow afternoon from others. I think that Devin Green will be able to be part of that as well. We received many letters, both opposing the proposal. I think it's now important for those who wish to comment, and we're concerned about seclusion and restraint, and the possibility of communication for them to recognize that that I believe it's fair to say has been taken off the table by the department today during testimony. And so I think the hopefully that will get communicated as so people as they testify tomorrow can take that into consideration still perhaps comment on it. With that, we're going to adjourn for the day. Well, this is this is important. It's also challenging as we're doing it on zoom, but I appreciate everyone's effort in being part of this. And I think this has been a successful afternoon for us to hear many points of view. And for us as a committee to continue our challenging deliberations on this. This is a pivot. This is a pivotal decision point. Thank you all a reminder to our committee. We are, we are convening tomorrow morning at 830. I have to check in with Colleen who has been busy scheduling some witnesses for us for tomorrow morning still been there've been things moving around. I will be checking in with Colleen as soon as we finish here. But let's plan to check in at 830 tomorrow morning please I know that we have one witness who has to be hurt before nine o'clock and so tomorrow are we move our attention to house bill 210, which is the bill around health equity and addressing health disparities. So, thank you all.