 Thank you. Good afternoon, Mr. Mrs. Vermont, Ms. Vermont, Ms. Vermont, and all the snowboarders on Killington. This is the Senate that's in honor of our chair who is not here this afternoon. This is the Senate institutions committee. I'm vice chair Dick McCormick. We are also Senator Mazza and Senator Ingalls. Senator Parent will be a longies as another obligation. Senator Benning usually warns people that we are public, so no dirty words. We will be hearing this afternoon from the Department of Mental Health, housed in the agency of natural resources, and then later from buildings and general services. And we'll start with Senator, with Sarah Squirrel, the commissioner. Welcome. Thank you. Thank you, Senator McCormick. Good to see you all. For the record, Sarah Squirrel, commissioner of the Department of Mental Health under the agency of human services, although the agency of natural resources might be a nice shift for us as a department. Did I say natural resources? Did I say that? I apologize. No, it's no problem. Like I said, there could be opportunity there. And I'm joined by deputy commissioner morning box, as well as our medical director from the Vermont psychiatric hospital, Allison Richards. So we wanted to share a little bit with you about the future secure recovery residents, what our current planning is, what our proposal is currently in the Capitol Bill. We have been wrapping up testimony in house health care. We'll be working with the House Institutions Committee this week, but I think the chair wanted an opportunity just to get kind of a status update and for us to give you all a little bit of an overview of what we're proposing. So I have a slide deck that I will walk us all through. I'm going to share my screen. And does everyone see that? Yep. Excellent. Great. Thank you. So again, this is just an agenda. Some of the areas that I hope that we will cover this afternoon, just a brief history lesson on, you know, where the middle sex therapeutic community residents came from some analysis on the system of care needs that we've done capacity analysis and cost of care, what we are proposed proposing for the future recovery residents. Dr Richards will share a little bit in terms of clinical perspectives and who are the individuals that are served in this residence. We do not have our national content experts with us today, but in follow up testimony, we do have some national content experts that we've brought in to help advise us on this project. So you may hear from them as we go forward. So in terms of the history, you know, just important to know the current middle sex therapeutic community residents exist on a plot of land on route two in the town of middle sex. It was created post hurricane Irene as part of act 79 part of our work to when hurricane Irene kind of reshuffled the deck chairs in terms of our mental health system of care. At that time, it was determined that a secure residence was really necessary to meet the needs of some individuals across the state. So it was built using FEMA funding. It was designed to be a temporary facility. And then through act 79 the state committed to replacing it with a permanent facility at some time. We have not done that yet. Again, it is designed to be a step down facility for those who no longer are in need of inpatient care, but who will still require services in a safe and secure setting. Any individuals who are at the middle sex therapeutic community residents are on an involuntary status, meaning that they are under the care and custody of the commissioner of mental health. And it also record requires an order of non hospitalization indicating by the court that an individual requires a secure setting. So I'm sure some of you have seen the current middle sex recovery residents was essentially two FEMA trailers that were put together. It is surrounded by a security fence. I'm very clear to anyone who has visited this facility that it has absolutely outlived its lifespan and needs to be replaced. Certainly from an ongoing maintenance standpoint, the age of the facility given that it was designed to be temporary. Obviously, there's a lot of snow permanent foundation. And of course, that creates ongoing, you know, just management issues for building grounds and services. And again, just really, I think underscores the sense of urgency in terms of moving forward with a replacement. The system of care needs. I just want to spend a couple of minutes talking about this. So really in order for us as a mental health system to provide the best care for Vermonters, we need to continue them of different levels of care because everyone has different levels of need, depending on what they might be experiencing related to mental health challenges. Some individuals can be served successfully in the community. Some individuals can be served successfully in residential settings that are aren't secure. And some individuals require a secure setting in order for them to continue on their path to recovery. And so we really see this permanent secure program as a key component when we think about the entire system of care. These are individuals who are transitioning out of our level one beds. Our level one beds are the highest level of acuity in our entire inpatient system. These are individuals who have intensive acute mental health needs. When they no longer need to be in a level one bed, it is critical that we are able to step them down to a secure setting so that we can free up that level one bed who might be waiting in an emergency department. Many of the long wait times that we're currently seeing in emergency rooms are symptomatic of backlogs in the system. And by creating and expanding the secure recovery residents step down, we actually create the capacity to move individuals out of those level one beds, free up those beds for folks who are waiting in the DEDs, and therefore reduce the wait times that we're currently seeing in our emergency departments. Just a little bit on the data, this first data point is actually has been updated over the past two years 100% of the referrals the secure residents are from level one units across the state. So again, just I cannot underscore enough that these are the highest acuity individuals that we are required to serve who have ongoing safety risks and needs, given some of their mental health challenges, and we need an appropriate place to step them down to, so they can continue to access that treatment and support, and then transition into the community at some point safely. We have 53 individuals that we've served there since the opening, the average length of stay, which is the amount of time that they reside in the program is between eight and 10 months. 65% of the residents have stepped down to less restrictive settings or independent housing successfully. And then the next data point is just the occupancy rates. So what you see here is that we tend to run at about 100% occupancy at the current residents at any given time, which is the current seven bed unit. This is just a visual so that you can start to see the continuum of care going from most restrictive highest acuity to least restrictive in the community. So we have our level one inpatient beds. We have 45 beds currently across the state. The Vermont psychiatric care hospital is 25 level one beds. Rutland Regional Medical Center has six, and the Brattleboro retreat currently has 14. Then we have our general inpatient hospital units. So that's six facilities across the state. And then we have our secure residential facility, which is the current middle sex, which is seven beds. We have another aspect of our continuum of care, which is specialized and enhanced funding plans. These are individuals who have enhanced funding attached to them so that they can receive additional supports in the community, so they can be successful. We also have programs like my pad, which pairs supported housing with having staff on site. In addition to our intensive recovery residences across the state, the difference between the secure recovery residents and the intensive recovery residences is that these are staff secure facilities that are primarily unlocked. So for individuals who might have issues around elopement, the intensive recovery residences do not have that additional secure aspect of them to keep them safe. We also have mental health crisis beds, group homes across the state, staffed transitional housing, and then individuals who are living independently in the community receiving some outpatient services, maybe some case management, medication support, etc. So again, just to give you a sense of how this facility or residence fits into the broader system of care continuum from a bed standpoint. It realize we had that many, that many beds for the, you almost 500 there total. Yes, it's quite a few across, I mean this is, I think one of the strengths of Vermont is that we really have built out a continuum. And that's really the key Senator Mazza is that we have an aspect of the system that can meet different needs because everyone has different needs. I realize that that's amazing. Wow. Yeah. And so the secure recovery residence is just one part of our continuum of care. And just I do want to underscore and articulate that the secure recovery residence is different than hospital level of care. So when we talk about inpatient level of care, that capacity is for individuals who are in the acute phase of a psychiatric crisis. So they're in an emergency department because they're experiencing a psychiatric crisis. Our inpatient level of care is really designed to assess and stabilize those individuals. These are individuals who have, you know, of course, potential for harm to themselves or others, you know, due to the crisis that they're experiencing. Some may require court ordered non emergency medications. And some may require the provision of emergency involuntary procedures, such as seclusion and restraint. You know, given what they might be experiencing it related to their psychiatric crisis. The middle sex therapeutic community residents is really a secure step down level of care. So it's designed for those individuals who may have required a level one bed, which again highest acuity for folks across the state. They no longer need hospital level of care. But they can't just transition into one of the intensive recovery residences, which is unlocked, they can't go right back into the community or into a pure crisis bed. They no longer need hospital level of care, but they still require that secure setting. And part of the programming aspects of it are also more enhanced than what you can access and an inpatient level of care, meaning there's more opportunities for individualized and group therapy, working on those skill building skills that you might need to be successful in the community, daily living skills, access to a working kitchen, kitchen, art rooms, therapy rooms, all of those pieces are a part of the secure recovery residents programming, in addition to being able to go out into the community, you know, with staff support, so that you can start to build those skills in the community. So simply because it's a secure setting doesn't mean that those individuals aren't able to go out into the community as appropriate with the support from their staff as they work on their skills to step down. We wanted to make sure in a line with, you know, kind of the continuum of care, also looking at the cost of care. So this slide really articulates our level one most intensive beds in the state, what the approximate annual operating cost is, and then what the daily operating costs are for that level of care. So you can see our level one intensive patient care, hospital level of care is anywhere from 1700 to $2,600 a day, our non-level one general inpatient units are around $1,700 a day. That's per person, that's each person, per person. Yes, I believe so. Yes, that's the this Morning Fox Deputy Commissioner DMH just for the record. Yeah, those are the per bed costs. So per individual. Thank you. The secure recovery residence as it currently is is about $1,200 a day. We are proposing to expand it to a 16 bed residence, which obviously increases the operating costs, which would put it closer to $1,500 a day. However, we have made some substantial changes to the programming. We had initially introduced this programming as possibly having the ability to utilize emergency and voluntary procedures such as seclusion and restraint. We have subsequently based on feedback that we have heard from community partners, the advocacy community, individuals with lived experience. And we have removed that aspect of the programming. What we haven't done is then adjusted the staffing ratios associated with that. So I guess my point is that as we adjust the staffing grids accordingly, we will likely see that daily operating costs for the future secure recovery residents go down. The other thing to keep in mind with the secure residential is that we are able to leverage Medicaid dollars to support the ongoing operating of that. So even as you're looking at a $9.1 million annual operating cost, the general fund need, for example, would be closer to $4 million. So again, we need to revise these numbers a bit, but I think it's important that you see the varying costs in terms of the level of care, the intensive recovery programs that we talked about, the average cost per day. We also have a program called the Satiria House, which is a peer run program, those costs per day. And then the intensive supported housing, which the example there is the MIPAD programs that are also located across the state. Can we go back to the chart we were just on? Sure. Oops. Nope. Sorry. That's all right. There we go. Okay. I'm trying to make these numbers work. Let's say on secure residential, approximately daily operating costs, $1,200 a day, and that is per bed, not for the operation. It's per bed. That is per bed, and that's what drives the operating cost. Okay. Naive layman's question. Why so much? How does that money break down? Yeah. So there's a lot of factors that go into an overall operating budget for any facility that includes staffing is the primary driver of that. So I think as we look at like the overall operating budget for the current secure residential, a lot of that $3.1 million is staffing costs. And I would say that's probably the same for the new proposal. It's the same for any of the other facilities at the primary cost is staffing. There's other operating costs related to the building grounds maintenance, laundry services, food services. There's a whole host of things that go into the daily operating costs, just as there would be in any business that you're running. You've got your overhead costs. You've got your staffing costs. That's all rolled into it. You include meals in that? Yes. That's correct. Okay. Okay. Thanks. Great question. And again, we need to revise our numbers for the proposed secure recovery residents. So we'll be sure that we have that to the committee in the next week. Just in terms of the future recovery residents. So of course, replacing the current facility is urgent and important from our perspective. And we want to ensure that for any individual in the state that they can step down to a lower level of care. And again, we want to ensure that even for these individuals who may have ongoing safety needs, you know, due to some of their mental health challenges, that we can also transition them into a lower level of care where they can continue to work on their recovery. Again, I want to be, you know, really clear about who this is intended to serve. These are individuals who are subacute, who are ready to discharge from a hospital. You know, one of our values as a department is to ensure that we don't keep individuals and more restrictive levels of care longer than necessary. So these are individuals who are ready to step down, but due to a whole host of things, they need a secure setting in order to be successful and in order to keep themselves and the community safe. These are also individuals, as I noted, who also are at risk. So they have higher risk pieces that need to be considered. These risk factors do impact public safety. And these are individuals who exceed the capacity of our community providers. So these are individuals who possibly have maybe been in an intensive recovery residence in the past, who end up back in the emergency department, back being hospitalized again. And essentially, that intensive recovery residence will say to the Department of Mental Health, they cannot come back here. So it is our responsibility at the department to ensure that we have a therapeutic place for these individuals to work on their recovery. And certainly failed community placements are not good for anyone, nor do we want people being bounced around or living in emergency departments. So for some individuals, they really just need the step down transitional secure level of care in order to successfully step down. And I think that, you know, the other thing to note is that we've had really good success rates in transitioning folks from the current middle sex program to the community. So the elements of the programming that we're currently doing are working for individuals, we're able to get these individuals out of the hospitals, work with them therapeutically, and then transition them to lower levels of care. Senator Mazza? Yeah, if you were to look at this like three years ago, it seems to me we're offering more services today. Is it increasing more mental health issues every year, or does it stabilize like the last three years, or seems to be there's, you hear about more mental cases these days? And is that true? Is that growing population, or are we treating more than we used to? Yeah, I think, well, what we've done in Vermont is act 79, you know, really propelled us forward in terms of rethinking our system of care. So there were a significant amount of community investments that were made. That was when all these, that whole scope of the continuum of care, all those beds that you were commenting on, that's when they all came into play, essentially. So I think we have expanded our community system, we've expanded in some areas in terms of inpatient the 12 new level one beds at the Brattleboro Retreat. But overall, I do think we are seeing increased mental health needs across the state, particularly related to the pandemic. I think that we are going to continue kind of the tail of the pandemic is going to have a big impact on our mental health system. And I would predict across the continuum, we're going to see increased need, whether that's at the community level or even at these higher intensity levels as well. A lot, it's mostly mental health, not alcohol or drugs, it's mostly mental health, right? Well, I think, you know, at the same time, we are also seeing increases in substance use and opioids. So I think they are somewhat connected as well. I think we are certainly seeing increases in that arena also. Thank you. Yeah. So what we are proposing in terms of, you know, not only replacing the current seven bed unit, but expanding it to 16 is really going to allow us to ensure equitable access of care for even for these individuals who have very high needs. I would also note that the residents is also able to serve individuals who might have forensic needs, might be connected to the criminal justice system. That might be how they enter into the mental health system. And of course, as I mentioned, always, you know, do have increased risk. The other thing I would just note in terms of why we think it's so urgent and important that we expand it, is that these individuals represent a large amount of bed days in our level one units. So for example, in 2019 of the five individuals who were admitted to the current middle sex, they had an average length of stay of 300 days in the hospital. So those are a lot of bed days that these individuals occupy. So our ability to transition them to a lower level of care really frees up capacity in the system, which is why we feel it is so urgent and important that only do we replace the facility that we expand it to meet the additional need that we know is there. As I noted before, the secure recovery residence serves the highest acuity population of individuals in the state. 100% of our referrals over the past two years have come from level one units. This again will allow us to alleviate pressure in the entire system. And I think it's, you know, it's the right thing to do for Vermonters. Without this level of care, these individuals remain in our inpatient beds who could be accessed and utilized by others who need them. These are also individuals who are community mental health partners who are incredible partners and do great work have said to the department, we cannot serve them, that their clinical needs or safety needs or both exceed our capacity. So while the residence, you know, the current middle sex is full pretty much all the time. And any given time, we have seven to 10 individuals in our inpatient beds who could step down if we have the capacity, which again, is why this expanded capacity is so important to us. And then of course, as we think about, you know, these kinds of programs in the system of care, you know, we work closely with our partners at stakeholders, which is why we took into consideration some of the thinking and recommendations from community partners and advocates. I want to talk a little bit about some of the data that we've used to support expanding the capacity because I think it's our job as the department to really articulate to you why we think we need expanded capacity, even beyond just the current seven bed unit. As I noted, we do have very good success rates in terms of transitioning folks into the community. To Senator Mazza's good point, the impact of the pandemic is only going to escalate mental health needs even more. I think the demand for these kinds of high intensity services is not going to go down. And again, when we see our level one beds also running it almost 100% occupancy, the long lengths of stay that these individuals have, you know, really point us in the direction of we need additional capacity for this level of care. Excuse me, excuse me. Sorry for interrupting. Denise, Senator Parent is trying to get in. I'm sorry. No problem. Okay. So you can continue. Oh, okay, great. Again, we also, I believe presented to the committee, our analysis of residential bed needs, which also underscored this at any given time. We have seven to 10 individuals who are currently in our inpatient facilities who could step down to this level of care if we had the capacity. So when we think of the seven current beds that we have that are always full, you add on an additional, you know, eight to 10 individuals at any given time that gets you to the expanded capacity of the 16 that the Department of Mental Health knows that we need to meet need in the system of care. I would also just note that one thing we also have to keep in mind is that our 10 year vision across the system is to decrease our inpatient capacity overall. In order to achieve that, it is absolutely critical that we have this kind of step down secure capacity. Also the centers for Medicaid services are requiring us to phase down our utilization of institutes of mental disease, which would be our larger inpatient facilities. So again, having this critical step down capacity is really crucial. And we at the department are not looking just at the short term, but 10 years from now, what are we going to need as a system? And we think that this will be essential as well. So I'm going to pause there. I'm going to turn it over to Allison Richards. She is our medical director at the Vermont Psychiatric Care Hospital. She has worked directly with many of these individuals who require the step down capacity at Middlesex. I think it's important that you as committee members really understand who are we talking about? Who are the individuals that this serves in the system? So Dr. Richards, are you still with us? Yes, I am. Can you hear me? Okay. Yeah, maybe a little faint, but okay. Can you hear me better if I just talk loud? Is that better? Yes. Thank you. Okay. You're a little muffled rather than too quiet. Oh, well, it's probably my technology. I apologize if you need me to repeat something. No, I think we can understand speak loudly and slowly and clearly and we'll get you. Okay. Thank you. So thank you, Commissioner Swirl and thank you to the committee, senators for letting me have the opportunity to speak today. As the medical director of the Vermont Psychiatric Care Hospital, I have the privilege of being able to work with the individuals that I'm talking about today. And they have very high complex mental health needs. And I appreciate the attention that this project is getting because I've been in Vermont since 2007. I came here for training because I knew that Vermont had a different way of being and a focus on therapy as a psychiatrist was very important to me. And so I worked at the old state hospital before the flood. And I came back to work at this facility because I feel very passionate about the care that's provided. I will just share a little bit that I have, you know, there are lots of perspectives about this facility, but I wanted to let you know that I also have a story in mental health with a father who was hospitalized psychiatric in a son with very complex neurological psychiatric illness that has led me even further into the work that I do. But it also helps me come from a place of compassion for the people I work with. So I mentioned to you that I've been in Vermont since 2007. I have also worked at the current middle sex community residents over four or five years off and on. And as you are aware, it is in much need of being replaced because of the two trailers being placed together. And the residents that live there really deserve a different place to be. So I hope that that is clear. You know, the individuals I work with aren't able to be here to speak for themselves. And oftentimes I think because of the complex mental health needs, their voices sort of get lost because they aren't the types that would be talking at these kinds of committee meetings. But I want to try my best to advocate for them. So the residents that've been proposed, they would have their own rooms, their own bathrooms, a place to recover. And again, as the commissioner mentioned, these individuals have, there's nowhere else for them to go from the hospital. They stay in the hospital for longer periods of time and they would be able to get out into the community if this facility was built and able to admit some of them. So I'm going to tell you about some of the people that I have worked with and have been impacted by not having the capacity that we're talking about. So it's a new facility, but also higher capacity to be able to accept some of these individuals. And again, I mentioned that they're voiceless, but they, when I, you know, when I talk to people who don't know what I do and the individuals I work with, oftentimes they are kind of like, you know, there were people like that in our community or our society. And, and I kind of say yes. And they also have families and they deserve the best that Vermont can give them. Because I think Vermont always does take things to a different level and does the best that it can for the individuals. And I truly believe the department of mental health does that. So I'll talk a little bit about the individuals on the screen. They're not, they're fictitious, but they are all people. And these are the individuals, they're made from many people, I would say. And they're all individuals that would be the kind of patients that would discharge from my hospital into this new recovery residence. So Gretchen is a 38 year old woman. She has a history of many long hospitalizations and inpatient stays. They include a history of needing to have court ordered non-emergency involuntary medications. And unfortunately, when she has medications, that her response is sometimes marginal. And she doesn't get all the way better. She remains psychotic. And during her hospitalizations, she has moments where she gets disregulated and will destroy property or assault other patients or staff members. And it's at a frequency of every four to six weeks sometimes it's unpredictable. And other than those, although she remains psychotic and delusional, she's behaviorally stable enough and doesn't require this most strict level of hospitalization. And so due to her ongoing aggression and violence and property destruction, none of the other community providers feel that they can manage her and guarantee the safety of the other residents. And so we'll make referrals to other facilities, Second Spring Meadowview and Soteria and they will decline Gretchen and say, you know, we really can't safely meet her needs or our residents. So she would be able to transition to this new program. So the next individual is Randy and this talks a little bit about some individuals who end up with criminal charges. He's 45 and he has been charged with murder and has been found incompetent to stand trial due to his mental illness. He refuses to take medications, which is his right. And yet he's stable from a psychiatric perspective. He remains delusional, but stable. And because of this, the court has said they're not going to grant the order because Vermont statutes are really clear that the the intent of the medication is to benefit the patient, nothing to do with the criminal charges. And so for a second, Denise, can you let Senator Benningen? He's waiting in the waiting room. Sorry about that. That's okay. So because he remains delusional, yet psychiatrically under treated, there are concerns clearly about public safety due to extreme violence that he's allegedly committed when he wasn't treated. So it's essentially saying we're going to, you know, not treat him and let him return to the community. So no providers again feel comfortable treating him in the community without a different level of security. And he would be someone that would be referred to this, to the new secure residential program where he can work on his recovery and whatever may be in terms of criminal court or not, but the program would be a focus on his well being and recovery and keeping everyone safe, including him. And then one last vignette, Greg is a 40 year old man, and he has a history of numerous hospitalizations as well. And has been at this point, he's already been at all of the other programs, so Second Spring, maybe North and Second Spring South, Meadowview, Maplewood, and other settings in the community and group home situations. And they have ranged from a matter of days to months with the transitions typically resulting just back him returning into the hospital due to aggression or violence or elopement. He has also required medications when he's been in the hospital, he stops them when he leaves the hospital. And because of his elopements, assaults, the community is just kind of said we can't manage him, it's just not safe. And so he's back in the hospital again, stabilizes and he would also be someone that could return to the community in the new program. And I will just say that, you know, I've referred many people to the current middle sex facility. And because of the state that it's in, there's not a lot of space in psychiatric care. A lot of the focus is on the environment of care and the milieu. And so the new facility with the space that it will allow, you guys, you can probably imagine putting up seven people in a small facility that's temporary, is stressful. And this new facility will allow people to have space from one another. We all have had brother, well, most of us have had brothers, sisters, children, and it gets the more you're cramped in if you're camping or whatever, you get on each other's nerves, maybe, but having space will also allow someone like Greg to go into the community and maybe have that space to be able to work on his recovery. And then eventually the goal for most every individual there is I would say it's always recovery and reentry into the community as long as it can be done safely. But these three individuals right now, I could say are at my hospital, any number of them or at hospitals across the state. But I just wanted to make sure you understood that we send many people out into the community every day. We discharge individuals to these other programs or to apartments or to their family. There's a group of individuals that really need this level of care and the expanded level. I really wanted to say thank you for giving me the time to advocate for the individuals I work with. I think they would say they would like to be able to get out of the hospital and to be in a place where they can reopen their windows with their safe windows to open and breathe fresh air and work on their recovery in a place where they can feel part of a community. So thank you. Senator Benning back yet? Senator Benning is back but I'm going to let you keep, I'm going to let you keep on going, Dick. I realize you don't have to take medication. If you don't want medication, you don't have to? That's correct. In Vermont, unless it's felt that an individual really needs it and it's really only in a hospital setting for the most part, we can get people on medication but the courts don't always approve it. And then when someone leaves to go to the new facility, the new recovery residents, those individuals, I believe Fox or Sarah, you could jump in, but they're on an order of non-hospitalization, which it's a legal document that says that they will take their medication. The mechanisms are complex but there's not really, there wouldn't be any forcing of medications at this new facility. It's just, it's an expectation and an agreement. Chair? Yes. Yes, Senator. So on the previous guy, Greg, I mean Randy, and he's committed for murder and he can be helped with medicine. That's, that wouldn't be the case right there to where we would try to medicate him to keep him stable. So to, to respond to that, there's, there's a pretty high bar for being able to go to court to get non-emergency in voluntary meds across the state at the level one facilities, Brattleboro, Rutland and VPCH. We have roughly just over 50 people a year that the court grants us permission to involuntary medicate. That being said, that can really only be for psychiatric treatment. And so if they're seen as kind of psychiatrically stable, which could still be somewhat delusional or psychotic even, but they're stable, we're, we're unable to go forward with getting involuntary meds. And one thing that, that Vermont does not allow us to do is to seek involuntary medication for the sole purpose of trying to restore someone's competency to stand trial. And so we would not be able to go to court to in, to get involuntary medications for the purpose of restoring one's competency. Well, we can go in the other direction as far as a judge can rule that somebody who was not consumed alcohol or any illegal drugs, it's, it's not the same. Correct, it is not. Anyone else in the committee? Okay. Thank you. Thank you. Is that Thank you, Dr. Richards. And I think we're really just wanting you all to be aware of who this is designed to serve and that there are individuals in our inpatient beds who are ready to step down, but who still pose a risk. And we need some capacity in a secure setting to be able to continue to provide treatment for them to keep them safe, to keep others safe, and to keep the community safe. There's no, there's no question of, of letting them out into the community. Am I correct in that? Depending on an individual's clinical needs. We do not anticipate that. Someone who has been violent, someone who has been violent, who probably would be charged with a crime and put in jail, except that their mental illness makes it impossible to give them a fair trial. That person is, is kept locked up. That person is not going to be allowed out of the street, is he? I can't really speak to ever in a circumstance. I think we look at, at clinical needs individually, but given, when you look at someone who has criminal justice involvement, especially for violent crimes, and if they are medic, medication-wise untreated, then it would be unlikely that they would be going out of the, out of the facility, especially anytime soon. If, if their circumstance changed, medic, started to take medications, clearing of their thinking, et cetera, risk factors and doing risk assessments, show them to be at a lower risk, it is possible that someone might go out maybe with two-on-one staffing or something of that sort, but as long as someone remains kind of under-treated, then that's, that's significantly taken into consideration. Hey, I guess the other, on the other side issue is the people are kept locked up for long periods of time without having been, that decision haven't been made by a court. That's a medical decision. That's a, it's a psychiatrist's decision. Right, and I'm saying that the psychiatrist may feel that they need medication, but if the person refuses and the court refuses to give an order to provide non-emergency medication, there's not much a doctor can do beyond that. But he, he can keep, he can keep the guy and not appreciate, in the hospital, appreciate it. Thank you, Lesh. Senator Mazur, you're not muted. I'm muted? No, am I right about that? I'm on mute. And I think it's, am I correct about that? And I, I, I think I understand the question, Senator. And so I think for the most part, where we are talking about people, and that's what increases lengths of stay for, for our forensic population is, is those risk factors and whether or not someone is, is engaged in treatment or not. And so when people are not engaged in treatment, that has a significant impact on any clinical decision making around discharging. Part of the, part of the issue is that we also look at someone's psychiatric stability. And if someone is psychiatrically stable, we are an acute care hospital and CMS funded and, and, you know, Medicaid funds, you know, the, the great portion of, of VPCH is kind of operating budget. And we are really only allowed to have individuals who are in the hospital who require active treatment. And so at, at some point they may no longer require active treatment in that they're stable. But there may still remain some of those public, public safety risks and concerns. And that's why many of the, the intensive residentials throughout the state that are unsecured, that are unlocked, will say that they feel that they can't safely accept that individual. And so it's for that reason that we would look to being able to move them from a psychiatric hospital, which is the most secure and most restrictive place and move them to a place like the recovery residents here. Okay. Thanks. Senator Benning, what time did you plan to hear from VGS? Unfortunately, Dick, I've just gotten home and I don't have the schedule of events in front of me. Denise? Yeah, I'm just wondering whether or not to rush these people. VGS is actually here for backup. If there are any questions about the buildings, etc. They're here. Oh, it's all part of the same discussion. Yes, they're here for support. Oh, okay. We're a package deal today. Yes. All right. Great. Great. Well, if it serves the chair and vice chair, we'll continue. Okay, please. Excellent. I'm going to turn it over to Deputy Commissioner Morning Fox, who's just going to give you a high level walkthrough of the current design of the recovery residents. Thank you, Commissioner Squirrel. So in the interest of time, I will try to go through these next four to six slides fairly, fairly quickly. But we just want to give the committee a sense of what the facility looks like based on the work we have done with the architects and design team with input from various stakeholders, advocate community, people with lived experience of mental health crises and mental health issues, as well as other providers, current staff, current residents of middle sex as well, have all provided input into the design here. What you see here in front of you now is what is an artist's rendering of the entrance or front of the residence. And so it's a little pull-up, drive-up loop. Residents would be admitted through the front door like any other residential facility. It is a locked facility. The doors are locked and such. But we wanted to make sure that not only the interior design has an impact for people, but also the exterior design that it blends in. It fits well and doesn't, we're not trying to build an institution or another hospital. And so we didn't want to look as such. You can go to the next slide. And this replaces the trailers. Correct. Correct. And so what you see here is a general drawing of the overall site design. The site, as people in this committee, as the senators, you may remember, this site is where the current Woodside facility is located. And that will be torn down and this building will be built on that site. The existing gymnasium that is there at Woodside, we are keeping so that we have the access to that as well as being able to have sort of an outdoor space, if you will, indoors during the wintertime and such when it's prohibitively cold out. But it does have a fairly large yard and spaces for walking, gathering. There's different gathering spaces, raised garden beds for the residents to work in. It does have security fencing around it. And to be clear, it's not that the building is within the fencing, but the fencing will go from the building and around the back and sides. But as you drive up to that front of the building, you would not have to go through gates or fencing much like you might at, say, a correctional facility or something of that sort. You can see at the bottom of the drawing where it says drop-off area, that's really where that first image was looking at, was that front location. Okay. This is one of the larger rooms in the residence. It's really meant to be multi-purpose to be able to suit various functions within the residence. It can be just a place for people to hang out and have some space, kind of unplanned social gathering and relaxing. It could also be used for groups and individual work. And just to be clear, the fireplace in the background is electric and not real flames or anything of that sort. One of the things we wanted to make sure, and this is that same room from a different angle, is that you'll see top-to-bottom windows on a lot of the walls. Really trying to bring in a lot of natural light. There's been a lot of research in the last several years of the impact on one's mental health related to natural light and bringing in, so to speak, from a designer's perspective. They'll use the term bringing the outside inside. And so really trying to have that type of experience. What the residents at the current middle sex have are very small windows that are not able to be open. And so it's very kind of dark and not positive in any kind of fashion from a facility perspective. You'll also see that round little round window on the wall there that goes directly to the nursing station so that there's many avenues of lines of sight for the staff to be able to look into those rooms. Make sure what's going on is okay as well as having enough staff to be in there when there are residents there. Go to the next one. Just another example of a gathering room, one of the more quieter spaces in the building. This residence in the design has some of these multifunctional rooms, a serenity space. There's an exercise room as well and different art spaces, places to do different types of group and therapeutic work. You can go to the next slide. And in here what you see is the, this is one of the largest areas of the residence really a main congregating area. This is the dining space. You'll see four tables with four chairs at each for the 16 residents. There's also space at the counter over in the kitchen. It's a fully functioning kitchen where the residents can ad hoc with with staff, prepare meals or snacks, do groups where they can learn the skills to be able to cook on their own. So when they do transition back out into the community, they're able to function and live safely on their own or with other staff supports. There is a commercial kitchen in this facility that will be providing all the meals for the residents. And there will be times where we may have residents working with our cooking staff to create meals for special occasions or other things like that. You'll also see on the right side that doorway there leads to a greenhouse area. Again, research has really shown that there's a significant impact on one's mental health and mental well-being in being able to work with soil and work with nature and things of that sort. And I know that before testimony started, many of us were talking about gardening and getting out and hiking and the positive impact that that's had to maintain our own mental health during the pandemic. And so it's similar for the residents here. And then the work that they do in there gets translated back out into the yard into the raised beds and the gardens that they can grow there and then use those vegetables and whatnot in their own cooking here. Just another area within the building. We really tried to create different places within the residents for the residents to be able to relax or be or just have some space that's beyond just taking a time out, if you will, in your own room. That there are places where you can sit down and just kind of have an impromptu conversation, maybe with a social worker or another peer. And so you'll see kind of these kind of nooks and little seating areas in various places throughout the residents. And then lastly, I just wanted to show the artist's rendering of one of the residents' rooms. All the rooms are pretty much exactly the same. We did make sure we wanted to intend to get away from kind of the institutional twin bed type thing. I think most of us as adults don't sleep on twin beds. And we wanted to make sure that the residents here also had that level of comfort. There's a desk area and seating to be able to do writing and journaling or any other work like that. Plenty of storage space. Again, windows to the outside that they are able to open and or adjust. However, there is security screening and such like that so that people would not be going out the windows. And every room is designed to have a private bathroom as well. So there's no concerns of having to either wait for or share kind of communal bathroom spaces. And then finally just from a treatment perspective and how we're looking at operating the residents really want to take a trauma-informed approach to all the design and the staffing and the programming of this residence. And a big part of that for us is the work with peers and peer supports. And it's our intention that part of the staffing model includes peer counselors on every person's treatment team as well as working with organizations outside of the residence like Vermont psychiatric survivors and others to bring in other peers that can not only help advocate for the residents who may be struggling to advocate for themselves but also to help inform other programming and or even provide other programming within the residents. So I will leave it with that. Thank you Fox. Deputy Commissioner Morning Fox. Thank you. We do have some national content experts that have been advising the department on this project. They are not with us today but certainly at subsequent testimony we're happy to bring them in to share their perspectives if that would be helpful for the committee. In terms of next steps and this is where our partners at BGS are instrumental and critical in terms of the overall construction timeline. We had an initial capital bill allocation in FY19 which was $4.5 million. That got us started in terms of some of the design work, site selection, etc. The current capital bill request I believe this for an additional $11.6 million. The overall project total around $16 million. So this just gives you a timeline of where we are headed in terms of continuing to work and finalize our design development demolition related to the current Woodside site. As Deputy Commissioner Morning Fox noted we would be demolishing that current building, retaining the utilization of the gymnasium and then pending that we have approval from the legislature in terms of the capital bill request starting construction in June. And then all things proceeding as planned, wrapping up construction by the end of 2022 with occupancy of the facility in January of 2023. But I will pause there and see if Joe or Eric from BGS have any clarifying comments related to the construction timeline. Good afternoon. Joe Agier with Buildings and General Services. I'm the Director of Design and Construction. As Commissioner Square laid out, she did a great job of the scheduling. We are a little bit behind on the front end of the schedule right now partly in due to the fact that the Woodside site has to be pre-loaded. The reason is it's a condition of the soils. So when we do demolition of the building, we have to put weight on the soils to compress them. We did this similar in Waterbury when we did the new building. So we have not started demolition of the existing building yet because of that because it's not the same footprint. So what we want to be able to do is we got to have the frost out of the ground before we can start that process. So we'll be as soon as we can get in there, start that demolition and get the ground pre-loaded, we will. Now pre-loading just amounts to hauling in additional soils to a certain weight to start that compression of the soils. And then we just sit back and wait until it's compressed enough. Technical engineers will give us those dates. And then we'll be able to move forward with the actual construction. During that time though, there's still work that can be done on the gym, site work, the additional extension of the water and sewer lines, things like that. So it just won't be an idle site. We still will be working. It just won't be constructing other building at that point. The substantial completion date, which we will be looking to take actually owner occupancy of, is actually the end of August. At that point in time, we also start commissioning. The commissioning goes into making sure that all systems are functioning. So when you're looking at the springtime doing that to the summer, we can check to make sure that all the air handling systems are functioning as they're supposed to. So when there's a load in the building, whether or not the AC makes it cool enough, takes out the humidification and the likes of that. And it extends into the fall because we want to get in there into the beginning of the heating season to make sure that that too functions properly. And then during that time, you'll see there's the fit up and staffing that goes on. And they have to go through their training. Our maintenance people also be going through the training of how the building operates and that whole thing meshes together. And then we have the actual occupancy. Any questions on the schedule? Wonderful looking building really. It's, I can remember that middle sec was only supposed to be a very, very short, temporary stay. And you made it work. And I don't know how you made it work, but it's been a challenge. I'm sure to, this is so beautiful to, there's nothing like, it's going to be like day and night difference for the middle secs. Wow. That strikes me. Middle sec, you could put a person in there who was perfectly healthy. Yeah, right. It was supposed to be very, very temporary as we all know. Just stretched on and on and you couldn't, nobody could do anything about it, but it's amazing they're able to work with what they worked with for all these years. How long has it been in middle secs? How long have we had it there? Well, Irene was here after Irene. Yeah. Irene was 2011. Wow. Wow. Maybe 2012. Well, quite a ways. Senator McCormick, can I jump in for a question? Yeah. Joe, the people who are currently at middle secs though will have to remain at middle secs until this is officially opened or was there a short term plan to put them somewhere else? I'm sorry, I got here late. I wasn't sure whether you would ask that or answer that question before. I would have to defer to Commissioner Squirrel on that one. Yeah, thank you, Senator Benning. Our current plan is our current plan, which is continuing to support the care and treatment of individuals at the current residents until the new facility is built. BGS wasn't the answer I was hoping for, but I understand. Right. BGS operations and maintenance will do the best they can to keep this building going for the two more years that it's going to take until they leave. Okay, thank you. You're welcome. Well, for the chair and vice chair, I think that does all stop sharing my screen. That does conclude the prepared information that we had for the committee this afternoon. Thanks, committee. Any more questions? No. Thank you. Is there any possibility of temporarily housing the people who are in middle secs now someplace else in the 18 months or whatever it is before we're done? I think based on our evaluation and despite the building being solely inadequate, moving residents unnecessarily is also not in their best interest nor for the staff. We think for the overall stability of the programming and the residents and staff that just maintaining the status quo for now is probably the most advisable at this time. And I would just add that not all the residents who are there will be there this entire time. We continue to admit and discharge individuals as well. Had a new admission just yesterday and expecting another in the next week or so. And so that will continue, that process will continue as well. So just so the committee is aware, not every individual that's residing there now will be residing there two years from now when the new facility is built. Thanks. Committee, last chance or I'm going to wrap it up. Okay. Thank you all for a good and informative presentation. Great. Thank you all for your time. We greatly appreciate it. Take care. Thank you all. Well, enjoy.