 Okay, good afternoon. This is House Health Care Committee once again, and it's March 30th, I think, somewhere around 145. So thank you for joining us this afternoon. We understand we have a limited period of time here and we have to go to the floor and I know you have a time commitment as well. But thank you for scheduling this time with us. So, what has prompted our wanting to talk with you this afternoon is the ongoing reports that we receive about the wait times in the emergency departments at Vermont hospitals for patients seeking mental health treatment. And I think it's just fair to say that, I mean, I know that those reports are reports that the department certainly is familiar with as well and having just pulled up the last report. We can see that there's really very discouraging numbers. My point is discouraging numbers particularly for youth waiting in emergency rooms. And it just seemed imperative that we re engage with the department of mental health about this situation and about how we are trying to move ahead. And what in fact we are able to achieve. In a more time frame. So that's the introduction for me. And I see that you have some folks commissioner with you, in addition to your deputy commissioner. So maybe, maybe some people have come and gone, but maybe not. I welcome you to introduce yourself for the record but also your staffer with you and then I really hope that we can in the next 40 minutes or so, really engage again about the wait times in the emergency departments for mental health patients, because it's quite concerning to our committee. So with that, I'll turn it over to you commissioner to start us off. Good afternoon. Good afternoon for the record. My name is Emily haze commissioner department of mental health and testifying alongside me today. I have deputy commissioner Allison crop and our mental health services director Samantha sweet. I'll start by saying thank you for having us today. We are grateful to our legislative partners for your attention and commitment into being part of the solution. And I think that each takes this issue very seriously and we understand this system that this is system wide and requires that I'm going to interrupt you commissioner. I think audio is not very good right now and at least I'm having trouble. Our other people able to understand. No, no, I think it's not just so it's not just me. Perhaps you could get someone or. I don't think it was on this is this better. Oh, that's a tremendous, tremendous better. Thank you so much for whatever you did. You're welcome. Sorry, my microphone. I have three microphones I can choose from and sometimes it chooses one I never use but here we go. So thank you for not letting me get too far down the road without telling you. Here and thinking it might have been. It's a little you can turn it down on our end a little bit now but that's that's better to be able to do that. Okay, do you want to be helpful for me to start from the top. I think I think you can continue. Sure, that sounds good. So what would you introduce Samantha sweet again because I don't think I've met Samantha before, and maybe others have, but. So Samantha sweet is our mental health services director. This committee was probably most used to seeing Frank Reed, who had spent many years as a leader in the department of mental health and so with his retirement. Sam sweet came on board she's been with the department for quite some time as our care management director, as well as our operations planning and development director before moving into the mental health services director role. So she'll be joining us as she's paramount to a lot of the work that the department is doing to support individuals needing services and having to wait for those services. Thank you for Samantha welcome. Good to say hello and if we've met previously my apologies I. That's okay nice to meet you all. So I'll just say that you know dmh takes this issue very seriously. And this is system wide and does require our entire community. We are committed to being a leader and we believe that no Vermont are particularly children should be waiting in emergency departments. We also believe that it's critical to diversify our approach. So we're going to take immediate action for people that are in crisis right now. At this moment but we also need to consider how to set up our system for future success. Therefore what I'd like to do today is to describe our actions in three parts, highlighting what it is we're doing today. Our plan for improvements for the next 100 days, and then our work to ensure long term success. And I'd like to thank this committee for having us here today and I will turn things over to Samantha to talk a little bit about what we're doing right now to support efforts within the emergency departments. Thank you. Okay, is everybody able to hear me okay. Okay, not having the same audio issues Emily was having. So thanks Emily and like Emily said I'm going to start with what we are currently doing in today's, in today's world, and then we'll move forward from there. So we continue to commit our children and adult care management teams here at the department to work with state and community partners in triaging and finding the most appropriate bed for both youth and adults waiting for a higher level of care. Recently, DMH has dedicated care management time focused on youth waiting in emergency rooms, which includes exploring why each youth is waiting and addressing the barriers to the movement out of the emergency room. DMH facilitates a meeting with DCF every day for quick working meeting midday to discuss the barriers as to why that youth is still in the emergency room and discharge for and we also discuss discharge from inpatient units and what are some barriers from discharging from the inpatient unit as we want to keep the flow moving through the system. We want to completely understand why each youth is not moving to the most appropriate placement in a timely manner. In this meeting on a daily, daily mini huddle has been pretty effective to identifying what those barriers are and moving that youth to that appropriate placement. We've also worked to support individuals to be able to have the choice of being home when they can safely and appropriately do so while waiting for inpatient and or a crisis that we have improved our collaboration with both state and community partners and have increased the frequency of our communication. And in one, one example of this is we started a statewide huddle attending a statewide hospital huddle that occurs every afternoon to highlight the barriers that availability with a focus on hospitals that are experiencing the most emergency department need. This is a meeting that, like I said occurs every afternoon. The University of Vermont Medical Center facilitates that meeting, and many other hospitals join including the Brattleboro retreat, and a new partner that has come to the conversation is Champlain Valley Physicians Hospital in New York, CVPH. And they have become more integrated into our system. Like I said, they, they come to the daily huddle that I was just, that I just spoke about, and they also are included in and update the Vermont bed board on a daily basis. We have a better understanding now of who they can accept as CVPH and why, and DMH has provided CVPH with an overview of the Vermont system of care and who the primary contacts are for any kind of discharge planning. And lastly, we are collaborating with state partners, such as Department of Public Safety. Currently we have eight out of 10 designated agencies that have been able to hire mental health clinicians that are embedded with state police. And I will turn it over to Allison. Thank you, Samantha. Good afternoon. My role is to talk to you a little bit about our, our commitment and understanding that we can't solve this issue with inpatient capacity alone or even triaging emergency department. So we want to highlight a few efforts into inpatient that we need a really robust, sustainable system in the community for folks to access care when they need it. So we want to highlight a few efforts that have happened already, and the outcomes of those actions. We have designated and special services agencies to support their ability to keep folks in the community. And we talked to this committee, I believe, back in December about $2 million that went out to the designated agency and special service agencies in December for a retention plan. I was really hyper focused on 24 seven and emergency response supports in order to retain the staff they have because they were having such a struggle, not only with recruitment but retention. And in addition, as part of that stability package. We have put together a mental health case rate payment model. And with that comes some decisions to be made about how flexible we can be with the target set for the agencies giving the staff and crisis that they have. So we have been incredibly flexible with that model so that we are allowing the agencies to still take in their case rate payments. And then they can hire back the staff that they've lost. And so those were two financial efforts and an attempt to stabilize programs that we believe directly keep people out of needing higher levels of care when possible. We want to highlight one success with the Howard Center. As of February 14, the Howard Center's Jarrett house program, which serves younger children. It's an emergency bed stabilization program is now back to 24 seven. It worked very hard to do that. So the state is not taking credit for that effort but it certainly came with, you know, this type of financial stability initiatives that that have been put forward. Additionally, we wanted to highlight that during the pandemic, some adjustments were made to support the DAs to be able to send crisis staff to QMHP training virtually. And for those who need a reminder QMHP training is the training given to crisis clinicians in the community about what is the threshold for someone requiring involuntary care. And all the pieces that go with making that decision with an individual, because we do not take that decision lightly. And we have found since moving it virtual it was shortened. We're seeing some quality issues and some limitations with full understanding and best practice with making some of those decisions and submitting those applications. We are moving back to in person and expanding that back to a full training to ensure best quality when it comes to arming our clinicians with the good information they would need. So that'll be coming up in the coming month. Additionally, in regards to NFI, so I'm thinking about some of the supports we have out there for children and youth NFI is integral. And they have two programs, one in the north and one in the south of Vermont that serve adolescents who are having a mental health crisis. The state was able to supply a contracted staffing to assist them with their overnight staffing needs that was allowing their hospital diversion program to go back to 24 seven. So that's been something we've put into place a few months ago and is currently in place now that has helped to stabilize that program. Let me just interrupt just to make sure I do understand so both Jared House and NFI crisis that crisis intervention programs which were at 1.5 days per week are, which is the last time I think we had a report or back to 24 seven in both settings or all three settings. Yes, we still have some capacity limitations so they're not back, as in all their beds are open. But they are, but 24 seven yes so I should clarify for NFI they have two programs the one in the south, so has limited bed capacity, but the one in the north has been able to get back to almost there. They're down one bed right now, five out of six. I should probably not have interrupted but to go ahead represent black. I just wanted clear reminder what NFI is. Oh, north. Northeastern Family Institute. Thank you. Yes. They were two different two different programs that are, they're both focused on adolescents is that correct. Yes, exactly, both focus on adolescents. And what's the what's the capacity of each of those programs at this point. I don't want to get that lipid. I don't want to get that wrong off the top of my head. So I would love to just double check it. It's six beds I know at the north program and so it just the south one is new so double check. Okay. Let me not interrupt let me continue because we're very interested particularly in the addressing the immediate situation as well as you know the midterm and long term but the but there's, you know, when I see the numbers and we see the numbers, which I think are accurate of maybe as many as 13 or 15. Youth waiting in emergency departments. I mean I hope those numbers are the same numbers you're working with the ones I pulled up the most recent one. What it doesn't show what I don't get a sense of and maybe others do is any flow. So the turnover. It just continues to be a large number and you don't necessarily get the sense that there's youth being able to move out of that setting, but maybe you could say something about that as well. Yes, it is an issue and in the static reports we get and even when you show a trend it doesn't follow the individual so you're right. We do look at that we look at how many dish, how many people admitted per week which gives us a sense of movement. But that was the rationale for DMH deploying one of our care managers specifically to looking at triage. We have an issue right now with complex youth, particularly those with mental health and in the custody of child welfare, who need very specific safety planning to come out of an inpatient and we're finding for any youth with a complexity like that, the community based services have been really depleted to take them back. And so that's something that we're working on an agency of human services cross department. And so that's why we're meeting with DCF as well to try to manage those needs we're talking about the need for foster care that's been a really limited resource in the state, as well as any step down facility that would require good staffing to support those youth and that staffing has been incredibly depleted through the crisis, the staffing crisis. So those are the areas we're trying to target to build back up, which we think will increase flow again. So we do have a dedicated staff who's kind of facilitating those discussions and looking at them on a daily basis. Is there, is there any indication you can give us because I, when I noted you said you were meeting with DCF on a daily basis and previously one of the questions that have been raised was whether how many of the youth are actually DCF, DCF custody as opposed to youth coming out of the community who are not in DCF custody is there any. I don't know if it's helpful to make that distinction but it suggests that if someone's in the custody of DCF there have been other issues that have been at play already. Yeah, it's a good question we don't have a current analysis that would summarize that an aggregate and because custody sometimes a moving target so they may be in custody in emergency placement custody but that doesn't last so we would have to do some thinking through. We do have that for residential. So we're looking at how many youth are put in residential care, who are in custody of DCF in fact we just finalized that report and that's something we could share, but not at the inpatient level of going in and out. So that's something we would need to talk to folks about how to get that done. I'll just add, is it okay to add something Allison. I would add that we don't have a specific report that identifies the numbers of how many kids going inpatient are in DCF custody right now, but we know on an individual level so when I mentioned earlier about the meeting that occurs midday it's a working we know exactly who is waiting and they're in DCF custody and those are the ones that we're talking to DCF about. Thanks. So, yeah, I'm torn between taking more questions but I want to give you a chance to finish your comments and I interrupted and so let me step back and ask others to hold just so we can at least hear from you first and then I know there are other questions. Sure. And so we'll keep moving. Important highlight is, yes we have some programs that were already in place that we're trying to bolster for this in the community, but we also recognize there's more needed. So, DMH identified that we need to expand community based crisis response programs and we put that in our request for HCBS F map funding. And so I wanted to highlight a couple programs like cahoots. That's a model that there's interest in in Chittenden County. Also, pucks and mobile crisis response teams, those are things that we have asked to secure funding for through the HCBS F map and we. We have been made and we are planning towards towards that end. Lastly, I really wanted to highlight as you all know this is a passion of mine suicide prevention. And when you do a quick analysis of those waiting for inpatient placement. I just looked at the list today. I hope this committee is aware when we say we think about this a lot and it weighs on this heavily. We look at this list every morning. And I look at we get some information from the hospitals about the rat reason for weight. And I just looked at it this morning to get account 65% of those waiting were waiting due to a suicide risk. And that's not unusual. And so really highlights for us that if we can find additional supports for suicidality we may reduce the need for people to go inpatient to meet their, their needs to reduce their suicidality. And so to that end, we wanted to highlight immediate resources we have now that are also going to be bolstered in the future and we'll talk about that in a moment. So the National Suicide Prevention Lifeline, the crisis text line for youth that is a major one that we would love ideas for how to get that out there a little bit more it's heavily used by adolescents in the LGBTQ community, which we think is wonderful. We also want to get the word out to everyone. And so it's been a great support we have great data on it and we think it'd be really useful if we could spread the word. So those are two suicide prevention specific supports that are available right now. And then Samantha if you want to talk a little bit about inpatient bed capacity. Absolutely thanks. And to go back really quickly to answer a question that was asked earlier, and if I south has six beds. I know some of them are currently open and occupied, but they run with six beds. So just wanted to close that loop. So to talk about inpatient capacity. Provided the retreat with contracted nursing supports through TLC, which enabled additional inpatient capacity over the past three months, and that will continue until the end of April. The broader bar retreat has transitioned for closed adult inpatient beds into four open adolescent beds to increase the adolescent adolescent capacity. In addition, they also have Linden Lodge, which is the newly constructed 12 bed level one unit at the retreat. They currently have 10 out of 12 beds. And that's specifically talking about adults that go to Linden Lodge. VPCH has opened more beds and is now up to 21 open and they were finally able to hire a permanent nurse after having having the position open for a year and a half. MTCR, which is our secure residential facility, has opened its seventh bed last month and is now operating at full capacity. One area of need that we also saw through the pandemic is transportation, the need for secure transportation. Due to the lack of staff, Sheriff availability, which is related to their own staffing crisis that they are in, which actually resulted in longer wait times and emergency departments where we weren't able to utilize these sheriffs that same day, or there were hours delay in transportation. We started exploring alternative transportation companies, and we recently contracted with Youth Transportation Authority, it's YTA. They serve both adults and youth and they are a secure transportation company that specializes in safe transport of involuntary individuals from the emergency department to the inpatient units. YTA is able to respond within a very short timeframe based on the location of the state. So their home base is Montpelier, Burlington area. So if they have to travel to the southern part of the state, it's only the travel time. That's the delay. So we've been able to move people much quicker with this new contract with YTA. Do they operate under the same conditions and expectations that the Sheriff's departments operate under in terms of nature of transport? No hard transport. Yes, we followed the statute, we made sure that they had the training and the soft restraints, and that is all that they use. We still have sheriffs if needed, but we really use the least restrictive form of transportation. So we will always try to use YTA first in order to transport, but if absolutely needed, we still have that contract with sheriffs. Yeah, just to clarify, I mean, I guess it would be good. It's brand new. I'm sure you're going to monitor that data, but it's not just a matter of soft restraints, it's a matter of no restraints as our standards and what those percentages are when they're understanding sometimes they're necessary. Absolutely, we're still tracking all the data. So whether someone needs restraints at all. And so they really highlighted YTA highlighted their training and their ability to form relationships before even doing a transport. So they highlighted how majority of their transports don't even use restraints. And so, but it just started, they were able to hire. I'm using them for about two months, two weeks now because they needed to hire their own staff. And so, all their invoices come in to us, and we track all that data. So representative Burroughs has a question. Let's go to representative Peterson who I asked, wait, but sorry, we just, we've got so many things to know about, but let's just use the time we have. It's very quick. It's fine. What does MTCR stand for? Yeah, middle sex therapeutic community residents. Okay, thank you. You think we know that by now. Well, it's often called the secure. Yeah, that's the short hand that we've used. Yeah, so the other acronym. Well, that's the statutory name is a secure recovery residents, but the department ended up naming it the middle sex. Yeah, so it's that's why. Yes. My apologies. I'll turn it over to commissioner has. I'll just also I'd like to just spend a couple more seconds on the transportation issue of folks getting to where they need to go and how valuable it is for YTA to come on board. So it's not only our challenges getting sheriff's transport, but also ambulance transport, which affects a lot of our voluntary folks who are looking and needing inpatient care. So just to highlight that somebody, somebody's weight for admission could be impacted by a day or two, depending on sheriff availability. And so we are grateful that we have work to find a solution that we hope will get us some better results, at least with transporting folks to the right level of care. So I'll, I'll just highlight one last component, although I'll say that we know that our work is not done. We do have some other more medium and long term things for us to present today but by no means do we feel like we should pat ourselves on the back and think that we're good to go and that folks are doing better so I just I just want to highlight that. So lastly, we did some collaborative work on activity kits coming out into the emergency departments for youth to utilize while they wait for inpatient care. And so some, some hospitals did that went on their own and implemented what they felt was best for their emergency departments others partnered with a state entity. I did have a chance to connect with representative Donnie Hugh earlier this week. And so just to be transparent we have some follow up and process work to do around the kits to make sure that they don't run out and make sure that there's a way for those to get replenished and get out to folks because they, they also serve a valuable piece to the puzzle. That that had been testimony this committee heard in December from one of the parents that said the first time their child was there last year they got the kid it was helpful. The second time they were just told oh no we're out of this. Yeah. So we'll, we'll continue to follow up on that specifically just to make sure that there's some consistent replenishing of those. I just asked this question if I were if I were in the hospital emergency department I'm an adolescent I've suicidal ideation as part of what's brought me there and it's been determined that I should stay and not go home because it's not safe for me to go home. What kind of human contact am I having. No, because it seems to me that's that's rather than just being in a room waiting a sterile room and maybe even with a kit of some kind I mean I don't know what else included but but it seems to me that the human element is part of what I'm always trying to understand like. Many of the isolation is probably a part of what's driving their, their difficulties but. Yeah, I mean I think that's exacerbated for children it's an adult issue too but right, while people are stuck and we're trying to address the problem what's happening to them in the moment. And it depends on the individual. We know that we have some youth who are waiting whose parents are waiting with them. We also, you know, it's staff are coming and going. And depending on the particular emergency room, you know what they have available for individual supports. Screeners are also coming and going. And I don't say coming and going lightly like they're saying and assessing and working with those individuals. So it really depends both on what that youth has identified they would find helpful for them, as well as you know if a parent wants to be with them that's an opportunity as well. So, it really depends. I would just say I've been to the emergency room, number of occasions for other reasons and I regularly see many rooms occupied with someone sitting outside with a computer in front of them. And when I inquire because I am interested I say well, I'm wondering how many of people in the emergency room tonight are here for mental health treatment and sometimes it's actually more than half of the capacity or sometimes beyond half the capacity of the emergency room. And I see people sitting waiting for treatment and I, I just find myself, you know, I don't inquire further because it's not appropriate that at that point in time but I've witnessed that on multiple occasions but I've happened to have been there, company someone for something else and I just always find myself wondering like what are the people doing outside the room they're just sitting monitoring to make sure they're, I mean what what are they doing. What are they interacting in any way are they prohibited to interact. And maybe that's appropriate I just but I just would be helpful to understand because usually it's, that's the amount of activity that I've observed. I'm sorry. Yeah, yeah, okay. I don't know if there's anybody who can help me understand what that nature that relationship that the hospitals are, at least the hospital I've seen. And I think it depends on the hospital and Sam you're immersed in this every day so you I'm happy to turn it over to you since you're our lead on that if you want to answer that but I think it also depends on how that emergency department utilizes their staff but go ahead Sam. Yeah, I agree with Emily what she said it, it depends on the clinical situation that's at hand it depends on the emergency department. Some emergency departments are staffed. Much richer than other emergency departments some emergency departments have psychiatry, which you'll hear about soon in a few minutes. Some where others don't unfortunately, some are connected to services in the community and they'll have people stop in their treatment team may stop in. But it's fine. Also, like Emily said it depends on the clinical situation if it's safe to be in the room or not. I see representative Houghton has her hand up and I saw representative but I think he disappeared off the screen so when he comes back maybe we'll ask him to comment or ask this question. And I can wait if there's more presentation. I wasn't sure. Everything I'm afraid to do. Yeah. The question I have is along the same line. Is any psychiatry happening at all with these kids that are waiting in the emergency department. We, it seems to me I mean we're on zoom here. Why can't there be a room where an individual goes in and a psychiatrist or a child psychologist or excuse me maybe not by the right term but a person who can help the person with his problems. I know we're going to speak to the differences and issues with access to psychiatry so if you want I can just jump right to that, because the answer is not everybody has it, especially remote hospitals. And so one of the efforts that's underway is to expand and implement telepsychiatry services to those smaller critical access hospitals. And so DMH is investing $100,000 into that effort but it's a collaborative one that we're doing with, it's more acronym so I apologize with Vaas, who hopefully are familiar with it. So I think the answer is not everybody has it especially remote hospitals. And so one of the efforts that's underway is to expand and implement telepsychiatry services to those smaller critical access hospitals. It's a collaborative one that we're doing with, it's more acronym so I apologize with Vaas, who hopefully you're familiar with in VPQHC, which is the hospital quality network. And so that they have a much larger effort than ours VPQHC is receiving a million dollars through a federal allocation under Senator Leahy's office. And that will be establishing a Vermont emergency telepsychiatry network. And so DMH is at that table, we're providing the funding that we can at the moment, but it is to get at that issue of how do we not have access for everyone. Where don't we have access and how can we bolster that so that everybody can tap into it. So that's one of our, we've moved into the next 100 days phase. And I'll try to be brief because I know there's plenty to cover and Commissioner Haas is going to end with the vision. But I will just note that beyond telepsychiatry, we also need the emergency department staff to have a good understanding of how to interact with individuals who are experiencing any kind of mental health challenge. And so again, a partnership with VPQHC. We have one specifically targeted on suicide prevention. And so it's called the Vermont suicide prevention in emergency departments, QI quality initiative. And so that is an effort that's bringing that training awareness understanding to the emergency department staff, almost all Vermont hospitals have signed on. And importantly, I think this committee knows this and what you're talking about looking at the data but there was a recent study on pediatric patients boarding in Vermont emergency departments. And it was found that the majority of the children presented with suicidal ideation or suicide attempt. That was the most common reason for them to be there. And so this is working towards towards that aim. Additionally, I'm sure Rep Sina can also attest to the fact that Shinden County has seen a real increased need for emergency services. The demand there has increased disproportionately than other regions of the state. And so we're in conversations of how we can support that region to make sure that they're able to commit to engaging their reassessments. And back to the conversation of who's able to visit treat assess with the people who are in the emergency departments there's an expectation that somebody goes in and reassesses, and that becomes really difficult the more and more and more people that you have. And so the Department of Mental Health is trying to work with that with that region on that issue. And we're aware that we've received a mobile crisis state planning grant. And so we're in the process of soliciting stakeholder input on all the things mobile crisis needs strengths gaps, and how the new Medicaid benefit could best support individuals and families. And lastly, I will just note in this 100 day effort, we had engaged in stakeholder input. That was an ask back, you know, we go back to last spring, youth waiting in emergency departments was it was always an issue but it really had an issue at that time. We did some really, what I consider meaningful engagement with the community throughout the summer, and we had some follow up since then we have another one in May. And the things we've gotten out of that are for example, a mother who has said to us how badly she feels the community needs cahoots. That particular model is something that felt promising and had all the right ingredients and due to that feedback we were able to explore that and begin partnership with the mayor and Chittenden County. There are other examples, but it's been invaluable for pushing us to continue to have our eye on on the ground. So I'm going to turn that over to Commissioner Haas for the future. Commissioner, if I may, before we hear from you about the future because that's right. I'd like to give represent China represent a chance at least to pose their questions again. I agree I was going to pause I think a lot of the things that will highlight for the future are things this committee is aware of of what we're we're working on so I certainly want to make sure we're getting to the questions. I'm going to turn it over to Commissioner and then represent. Yes, I raised my raise me in a while ago and then zoom did something hasn't done in a while and it like ejected me and I couldn't come back. We saw you leave and come back. Well, yeah. Okay, but I did take notes so I wouldn't be unfocused. One thing I've noticed is that there when clients are waiting in the emergency room, I get mixed messages about my role as an outpatient therapist like sometimes the client or family or other team members or someone at the hospital will repeatedly call me and be like you need to come in and see this person. They need like you know they've been here for days and they're like lonely and it's you know they just need someone to come see them besides their family, but I don't get paid for that. So, and I'm not allowed to do therapy there so I literally have to go there and keep telling the client up. We can't talk about that because now we're it's becoming therapy, which is frustrating for them because they just want to talk with me while they're there about they just want therapy and they can't get it while they're sitting in the ED, no one comes in and gives it to them. And then a reassessment is not therapy. In fact, as a clinician crisis clinician like reassessments are as soon as quick as possible. You're just going in and trying to prove that they still need treatment in like five 10 minutes and then you leave because you have like 30 people or something I'm not even joking or like 20 people you're trying to get through in a day. I guess my question is, why can't we pay therapists to go do therapy with their clients at the emergency room if that's what the clients really need. If it works for a therapist because I know there's some of my colleagues are probably a cringing hearing me say that like oh, we're going to be expected to go there too. But I already feel like there's this pressure to not abandon a person in that moment of crisis. And but yet I'm not allowed to provide the service they need to them there. And I'm expected to go for free and provide like whatever you want to call a 15 or 20 minute visit is, which is actually an hour of my time by the time you park and get to the person you know what I mean in the middle of a day with 12 other people it's really hard. And I just don't know if there's a way that we can create like therapy in the emergency room just like if a person was waiting there for some other medical reason you wouldn't deprive them of heart medication you wouldn't not go in and do their physical therapy for their breathing or whatever you know whatever it's called to be no like respiratory therapy, if that's what they need every day like you wouldn't tell a person with cystic fibrosis they couldn't get that like shaking thing to you know make their lungs whatever it's called. So like, I guess my question is and I don't expect an answer today but it's like, can we do something about that. And then. Oh my god I took notes or there they are okay. And then the last thing is just because those were three things and one right there is. You were talking about like suicide prevention and I'm wondering where we're at with the camps trainings because I did the camps trainings. I was in the management of suicidality trainings for, and I just wonder if we're doing more of that kind of work because it does seem to keep people out of the emergency room. And then the last question is, is, um, what about like harm reduction, and how does that play into it because harm reduction research is showing it can be applied, not only the substance abuse, and like risky sexual behavior but to any risky behavior and cutting and suicidality or risky behaviors. And also when a person's in the emergency room the way they're treated can be harmful and if we were training emergency room staff and harm reduction they might think twice before they say a judgmental thing. And I won't even go into the things I hear said when I'm in that environment that are like horrible for the clients to hear and be and be subjected to. And so I guess that's just another thing is like how can we like use harm reduction in the emergency setting so that we're not make causing more damage to someone while they're waiting for help. I know it's a lot but that's everything I thought about written down at once thank you. Just briefly I would love to respond quickly your to your question about billing in the in the emergency department. That's something we can talk about payment reform was intended to break down those barriers and we allow designated agencies to pay for for payment reform. If someone's impatient, you should be talking to them about their services after impatient right from the start. So, two years ago we remove those barriers and you can bill for that. So I there's, there's things that I would need to look into specifically location code so I don't want to get into that now, but that is something that the door has been open for and I could circle back to find out if there's anything still standing in the way. So that's the beauty of moving away from fee for service is that it's not about an hour spent in one location it's about what the client receives. And so that should be a change. The second to cams is yes, we put it in our grants to the Center for Health and Learning and that's still a major focus of the department. So they have done some and there should be another big training coming up so I can try to get a date. I think that's for harm reduction. I would say, I'm going to speak for all of us that I don't think anyone here would disagree with you there and I think it's about the types of trainings and getting them implemented. And thus far I think the system's been under such stress that it's been difficult to push additional trainings during coven and I'd like to see an endemic change that. And what I would say is like, you know, I'm curious like how it applies to private providers versus the designated agencies because I just don't know. And then if indeed we find you find that private providers can be billing in the emergency room. I think that there it would benefit like I get other kind of emails from the state all the time about trainings and regulation stuff and it would be great to like do some kind of campaign to help people learn how you know how that works and then also to maybe talk with crisis about it because when they do follow up with a therapist they could say, Hey, if they're here a few days is there any way you can come see them. And there might be some moment there to create like warm handoff where like they can help set up a therapy session in the emergency room for the client. Anyways, I think we coordinate better. If this is indeed true and I think that would actually make a huge you might see people just leaving the hospital and not even going to the inpatient bed if they start getting therapy in the emergency room, which would definitely save the system a lot of money, because you're talking about paying someone's therapist $65 instead of hundreds and hundreds of dollars if not thousands more. Anyway, so I'm nice to hear that that might be possible for people. I want to clarify to your point that is for designated agencies because they're in this new payment model. Yep. So perhaps yet perhaps the answer though is maybe the designated agencies can come up with a way to have like a position that does I don't know it's not the same though honestly is like having your therapist come see you it. So I don't know what the answer is exactly. Maybe maybe we need to change it more. I don't know if there's a way to do that. I think one other suggestion I know we're short on time here but we're here we're benefiting from representative chinas expertise because he actually happens to be a crisis worker he happens also just happens to be a legislator. And I mean not just happens but he is a legislator and we so that's why he's able to bring this into this conversation. So if there's not an opportunity that there would perhaps be an opportunity to hear from his colleagues who are not legislators as to their experiences in emergency room settings with these same young people or adults and benefit from their suggestions which I think you know they're on the ground. I'm just in the interest of time I'm going to ask representative home to just be able to weigh in with her question and Commissioner house I'm not trying to diss your vision for the future but there's more time in the future to hear about that and there's more immediacy, I think on the minds of those of us who see these numbers continue the way they are. So represent home. Thank you and I appreciate all the efforts and the explanations that have been provided here. And I know no one has a crystal ball but I'm just curious. What you think as the experts in this field, when we will see the downstream benefits of everything that's been put in place and that these, you know, children and adults will not be waiting this long. I think that is a very good question I wish I had a crystal ball because we, a lot of other states have been trying to solve this for a really long time. So my hope is some of the things that we're doing are drastic enough that we're going to be able to make, you know, change on the short term. I don't have a crystal ball but this is the stuff that keeps us up keeps us all up at night right, trying to work to get folks to the right level of care when they need it. So, I don't have a crystal ball, but hope for getting there. Thank you. Okay, I'm sorry I allowed myself to have a side conversation I missed your comment. I missed the comment and it gets me emotional like it gets the rest of us. We don't like folks suffering. Yeah, well, I appreciate that we're all share that share that importance. I think represent page. I'm going to particularly want, and I want to just say that represent page has been consistently raising the issue and concern, along with others on our committee and not to say the others have it but just this is this is an ongoing issue and I just want to make sure you get a chance to weigh in. So, I think we all, as you said we all have our concerns over this. We speak up a little, what do you want to share? Yes, we all have our concerns over this. Questions on the treatment. How many of the of these young adolescents, children, and even adults, how many are are repetitive patients that we see in emergency rooms. How successful are we in treating these individuals. And then finally, we probably have less than two months remaining and in our, in our term here. Before we adjourn and then come back next year, maybe, maybe. Or what, what can we do now in this committee to help you, you know, help, you know, from honors. Thank you for that question we represent page. That's a, that's a wonderful question. I think two fold, we do have some information about readmission rates, which is a very specific term measuring someone who would be readmitted to a higher level of care in a short term. And so, we could get you that information. We have that for Vermont psychiatric care hospital I would need to double check about, you know, say the Brattle borough retreat. We don't have it off hand. But that would help to I think answer your question the goal is to get people the treatment that they need so they don't need to come immediately back. With that said, sometimes someone may need a higher level of care. And that that's okay too. If that's really you know what the person wants and needs. That's a great piece of your question I think there are a few things going through the legislature I'll name the bill as 69 that has a lot of pieces around suicide prevention efforts that would bolster the system, as well as you know some of the support we're doing to try to help the community. So, some of the services have a focus on holding folks who would otherwise need higher levels of care. So, some of the things that you'll see we've asked for, you know, RFI is around different residential programs that we've also asked and are looking for initiatives for peer supports. So, we need more staff out there in the community who could help peer supports could be in the emergency departments being supportive to individuals waiting for care. So that is an initiative that we're looking to support we have $30,000 set aside to do some research on that. And then the other is the alternatives to emergency departments so pock cahoots, mobile crisis response, those are things that meet people where they're at and give them a chance to get those services in the community. And we see those as major pieces. And then the last thing I'll name is we're looking to do some diversifying from from the battle borer retreat as a sole provider of inpatient care for adolescents. And that's something this committee I believe is aware of, and we do have one respondent to that, which is UVM Medical Center. And we do think that's incredibly important because we're moving to into a future where you can't have siloed care and needs to be integrated care and we need more capacity to serve the whole person which would mean attached to a medical facility. So those are a few things that we're putting out as major priorities, if anyone else would add anything. Can you say anything more about the timeline in terms of the RFP for youth or children's inpatient services that you mentioned where there's been one respondent. We have a follow up meeting with UVM scheduled either the end of this week or next. And then it, we're looking at potentially two to three years. It's, it's a ways out, but we have our first follow up meeting from the closing of that RFP scheduled. I believe it might be next week, mid week. We'll have a clear picture after we have a chance to sit down with them. Right and see representative quarters as a question but I just wanted one last in terms is that RFP. Does that focus on a certain capacity. Or is it wide open. With what we we structured it as around 10 really allowing an opportunity for facilities to come to us with what they with what they think their community would need or that they would would serve from a staffing perspective. It takes about the same amount of staff to staff 10, eight beds or six beds as it would perhaps 10 or 12. Yeah, but the target of the RFP was around while we wanted to have some flexibility for the folks who responded. Thank you. So, I think representative quarters you may get the last question, the impression. Yeah, unless this was answered when I was out of the room, what was there, has there been any discussion about what would need to happen for hospitals to authorize clinicians like Brian from providing services in the emergency department. Yeah, we did talk about that. Okay, I'll catch up afterwards. Yeah, okay. Yeah, we had some discussion about what's what's involved there, what where there's actually some flexibility that may not be being realized. That was a great question. Yeah. Well, I think we need to stop. Now I know we've gone past the time when you indicated you were available and we have our own deadlines but I appreciate each of you participating in helping to update us it helps. I think we just need to stay closely connected on this issue because it's such such a pressing and important issue it's it's one that and one that doesn't seem to go away despite all efforts. Yeah, but it's also helpful to actually have a sense of where there is some movement and initiative. Even in the midst of the frustration for those who, frankly, are bearing the brunt of this by having to wait. It's helpful for us to know I guess I just lastly say, I've had this set to be by a number of people throughout different parts of the system. What if this was my child, what if this was my family member, how completely upset would I be that they that I reached out for psychiatric help for a family member who might not have even wanted to help or might not have realized that we were saving them from some other tragic tragic and and only to find that. What I found out was that we didn't really get help what we got was waiting and more waiting and how increasingly frustrated that family and that family member might be so I think it's very it feels very personal at a level that I don't want to explain but I think everyone on the screen understands at the same time. So I can I trust and know that you do share that concern, each of you. So, thank you for your work. And let's let's stay connected about this. And I welcome you. And I say this in a, let me say this in a way that's an invitation and not a, not not not not any kind of veiled coercion or something but please feel free. I think it's helpful actually, frankly, for you to take some initiative toward us on this issue periodically as well, because sometimes it just feels like we're kind of sitting waiting to hear something and then then that raises the frustration level I think all around when you're working very hard to try to address issues. Thank you. Thank you. Thank you.