 All right, we are live. All right, thank you. And good morning. This is the Senate Health and Welfare Committee Meeting, April 7th, 2020. And we continue to work remotely while the emergency rule is in order for COVID-19. So today we're gonna start out our committee meeting with Nolan Langwell. I'm not going to have each Senator introduce him or herself at this time. I think we'll just move right into the agenda. So Nolan, thank you for being here. And thank you for bringing us information on what we can expect in the CARES Act for our health and welfare folks. Great, thank you. For the record, Nolan Langwell, the Joint Fiscal Office. The documents that I'm gonna walk through is online. I don't know if you want it on the screen or people just wanna look at it on their iPads and phone separately or... If you can get it on the screen, that would be really helpful. Well, I don't know how to do that, but maybe Julie or Nellie can do it. That's fine, we're fine. We'll look at it on our iPads. Just because I'm working out two things. That's good, we're good. And forgive me in advance if my dog is barking. I just got an emergency delivery of two gallons of maple syrup, so I'm set for the coronavirus. Oh, you are. So my plan today is to just kind of walk through the sheet that I have. I'm gonna break it into three sections. Adam Greshan, when he testified a couple weeks ago, he was calling each federal bill COVID-1, COVID-2, and COVID-3, and I kind of liked that. So I'm gonna call it the same thing, meaning each of the first bill, the second federal bill, and the third federal bill. And I'm gonna just kind of walk through them. What I'll say in advance, because I did this for health care the other day, and one of the questions that came up a lot was what is gonna be the legislative role in this? And the answer is I don't know yet. Senator Cummings might know more, actually McCormick or McCormick might know as well, being on finance and appropriations committees about the conversations that may be happening and the money committees about what the state's role will be in helping to get the money out, whether it's oversight, whether it's priorities, whether it's intent. So I'll just say that up front. Also, the sheet that I'm working off of was from, most of the information came from NCSL or FFIS, which stands for Federal Fiscal Funds Information for States. And it's a service that we subscribe to through NCSL and they provide all kinds of different fiscal feedback for how much states are getting for this or for that. And they released last week a sheet of how much each, how much Vermont is gonna get for each particular piece. And so this particular handout is only specific to health and human services. There's a lot more in the bill that's with unemployment insurance and broadband and education, I'm not going into that. I'm just gonna focus on the health and human services. So with that, if you look at the sheet, do people have the sheet in front of them? Okay. So COVID-1, which was called the Coronavirus Preparedness and Response Supplemental Appropriation Act. It was an $8 billion bill. Vermont is gonna get, from a CDC grant, we actually already got $4.9 million. And that was for CDC response money. Later on, you're gonna see that in the COVID-3, which was the most recent carers act, under that designation through CDC, we were getting another $5.4 million. Oh, thank you, Julie. There's also $1.2 million for congregate in home-delivered meals. And you'll see that in COVID-3, there was another $2.4 million. And then the HRSA Community Health Center, this is basically FQHCs, Rural Health Centers and others, I believe. In the first bill, they got $683,000 to Vermont. You'll see in COVID-3, another $9 million has come in. So that was COVID-1. So that was COVID-1. Actually, what I should have said at the beginning is total between the three bills, we estimate that Vermont's gonna get about $1.4 billion, total assistance. So in COVID-3, COVID-2, the big thing here that we got was the enhanced F-map. And as you know, F-map is federal medical assistance percentage, which is how much federal match we get. It's estimated, it basically provides temporary increase in the F-map of 6.2%, starting January 1, 2020 to the last day of the calendar quarter in which there's a public health emergency is in effect. And so that's estimated to be about two quarters. And so the two quarters, we estimate, AHS estimates gonna be equivalent to $38 million in additional F-map. Now, this isn't an infusion of more money that we can just go and give to other entities. What it does is it just provides less, it provides relief in the state share of F-map. So for every dollar we spend, we get more federal match in return. So this is to provide us some relief, especially as we look in a H742, when there might be some potential for where the states, where the AHS may potentially relieve some of the provider taxes or other stuff, this might help offset some of that. It doesn't in any way, to your knowledge, in any way affect our cap. No, this is just, this won't affect spending like the total spend, it just reduces the state share of that spend. Okay. The cap is gross. So now we have supplement, then SNAP, the Supplement Nutritional Program for Women and Children, it's almost a million dollars. That was in COVID-2. COVID-3, I broke this up into like, which federal agency is dispersing it? The big thing in COVID-3, which was the most recent CARES Act, which was a $2 trillion bill, Vermont is gonna get 1.25 billion. What's nice about this is that there's a, in general, Vermont gets about, on average, we get our spending is about 0.2% of total spend in the federal level. If that were the case, if they split up the total CARES Act money that's appropriate to the Treasury for this, we would've gotten less. But the 1.25 billion is there's a small state minimum in the language. And because that's the small state minimum, which is 1.25 billion, our share is actually 0.8%. So we're getting four times more money than we would if there wasn't a small state minimum. We assume that's what Leahy's doing and we're very happy about that. I was just gonna say, thank you to Senator Leahy for that. Yeah, so the small state minimum is a big deal for us because it means we're gonna get more money. It's expected that the payment will be in Vermont within 30 days of enactment I guess over a week ago now. The trick to this one, the part that's is that it must be used for new government spending in response to COVID-19, which is defined as spending that was not approved by the government recipient of the bills enactment. So in short, you can't really supplant money it's already been appropriated. And that was a question. First of all, that was part of the reason why 742 was delayed a few days. The governor wanted to make sure that he signed 742 after President Trump signed the CARES Act, although there really wasn't a lot of money per se in that bill. The question becomes is, what will the federal government assume is money that was approved before or after? And it also kind of provides limits. And I know that in COVID, there's a potential that there could be a COVID for, I don't know what the status of that is, but my understanding is that a lot of states have been reaching out to their congressional delegation saying that that particular language is kind of hampering them because it depends on when you've passed your budget bills and what about the stuff that's important? And so what is new money versus money that was already appropriated? So I think that there could be a potential, if there's another federal bill, there may be some language that sort of addresses this. The other piece I kind of snap in here with that, they added with known as the Hyde Amendment, or they said the Hyde Amendment applies, and that basically means that this money cannot be used for abortions. So that's the big chunk, and that's coming through the Treasury. There's also from the CDC through the CDC, we're getting another $5.4 million in addition to the $4.9 million that I mentioned earlier, and this is for state and local preparedness grants. And for each of these, I can't actually go into more detail about what specifically that is because I don't have that level of detail, but I imagine this is most of a lot of this is gonna go to the health department to help them with combating COVID-19. I already see a typo. Then under the HRSA, there's gonna be another $9 million for community health centers. So this is FQHCs, and I believe it's also rural health centers and maybe some other stuff. There's also 4.3 million for the childcare and development block grant. This is gonna help childcare providers provide childcare assistance for essential health workers. There's a community service block grant of about 5.1 million. This is gonna help community organizations provide social services and emergency assistance through this community block grant. And there's another 4.1 million additional for LIHEAP, and as you know, this helps low-income households cool and heat their homes. So one of the questions that we've been asking right along and we have been working with appropriations a little bit on this one. Our concern in health and welfare is to understand how to prioritize expenditures that are within each category as well as to establish criteria and so but what we don't know right now, I mean, that would be our policy responsibility but what we don't know right now are what strings are attached to the money. I mean, you mentioned obviously the Hyde Amendment which is politically controversial but beyond that, in terms of the social service agencies or childcare and any, this is a question as well as a comment. What do we know about any strings attached to the funding at this point? Is that something that's still being sorted out? I think the answer to that is I'm not sure. I know that for the first one I talked about, the 1.25 billion there, they did create some kind of inspector, solicitor kind of position that was supposed to oversee this money to make sure that states were spending it appropriately and to potentially sort of claw back per se money after the fact that it was determined that money was used inappropriately. That's, I believe that's specific to that 1.25 billion which is the coronavirus relief fund. In terms of the grants, grants tend to have guardrails. They tend to have different pieces that are tied to them in terms of what would have to be reported back. That's a question that I can't answer. That's a question that would have to be answered by let's say the health department. In terms of like, you get to $5.4 million, what are the guidelines, what are the criteria? I imagine it's no different than any other federal grant we get or maybe it is different because it was done so quickly. I don't know the answer to that. That'd be a good question for David Englender. We'll do that. We'll do that. Yeah, specific to his grants. He would know what was specific to his grants or it could be a question for Mike Smith. I would recommend you ask them. And I can also find out, I can ask some questions around to Steve. If there's anything I can find out. Okay, that would be great. I mean, it would be good to be able to hone in and zero in or focus on exactly what any obligation or responsibility we have. And we don't wanna take up time from people who are trying to implement some of this. I understand, yep. Okay. You ended at LIHEAP, I think. Yep, yep. So there's $193,000 for family violence prevention. Another 86,000 for child welfare services and 1.2 million for Head Start. Under administration for community living, there's a million for supportive services. There's another 2.4 million in addition to the 1.2 that was in the first bill for home delivered meals. 500,000 for family caregivers. 100,000 for protection of vulnerable older Americans. 972,000 for the Center for Independent Living. There's 900,000 for emergency food assistance program. Another 376,000 for what's called T-FAP. I actually don't remember what that stands for. I believe it's food related because it's USDA. 100,000 for vulnerable older Americans seems like a drop in a huge bucket. Yeah, and I think that those are based on funding formulas. Yeah. That I couldn't go into. That gets into the bureaucracy of how federal grants are determined. Yeah, well. So in relative to the other money, and it may just be that it could be in addition to what we get annually already. Again, these are things that I don't know the answer to. Or specifically, does it go to AHS and they re-administer it? Does it go to some other agencies? That's a level of bureaucratic grant administration that I am not familiar with. But there are folks within the administration who clearly are. And I know that we do have processes within the state. The question is, how much of the money flows to the state? How much money goes directly to organizations? For instance, does the federal government pay the FQHCs directly? The community health center stuff through their Medicare? Do these protection for vulnerable Americans? Is that a direct grant to AAAs? Or does that go through AHS? That's all stuff that I am not versed on. Unfortunately, I cannot answer. My goal really was to give a higher level of just giving you a sense of like, hey, look at all the money that Vermont's getting. Under Homeland Security, there's what's called an emergency performance management grant for 863,000. And this is to provide state and local governments, to help them perform essential services. Basically, it's a FEMA disaster. Through the FEMA disaster relief fund, almost $400,000 for emergency food and shelter programs. Under HUD, there's a community development block grant for $4.7 million total. $4.2 million is for the state, but $450,000 is specifically for Burlington because it's a large city that meets certain criteria. And this is for expansion of community health facilities, child care centers, food banks, and senior services. There's a housing assistance grant for $4.6 million. This is to support those who are homeless at risk of homelessness through emergency, it's what's called an emergency solution grant. It also provides eviction prevention assistance. There's also public housing money for $557,000. And then there's a tenant-based rental assistance, and I couldn't tell you what that is either. And that's worth $2.3 million. So again, this is specific to Health and Human Services, and this is about $1.4 billion total, if you add up all of these specific things here. But that, like I said, that doesn't include other money that's gonna go to UI, sorry, unemployment insurance or education or other stuff. So I just picked out which were the Health and Human Services pieces. So there's no special ed. So would this include, this would include, though, the Department of Health, high tech needs kids? I don't know, actually. So there is money. There's like $35 million that's going to DOE. OK. AOE. AOE, OK. And there's 4.5. That's for what's called the Governor's Fund. And then there's another $31 million that's going through K-12. I don't know what that's for specifically. And I don't know if those high tech kids would fall under AOE or AHS. I'm guessing they'd call a fall under AOE, but I don't know. I might be Department of Health. We'll find out. The other area, of course, that you mentioned that I think is pretty significant is the whole UI issue. Because that's what we've been hearing about from folks about how their lower paid workers are leaving or potentially leaving because of the UI benefit. So yeah. Well, we'll just have to stay connected with economic development on all this stuff as well. Yeah. That's definitely like an auxiliary or external impact, for sure. Julie, you can get rid of the handout. We can go back to the very much screen if you would want. Thank you. Good. Senator McCormick's not back. Yes, he is. Terrific. Are you on your iPad, Senator? Terrific. All right, so committee questions for Nolan on this information. I hear the dog. Chris, knock it off. Everybody. Good boy. Chris, come here. Jenny, I just say thank you, Nolan. This is the clearest. Thank you. Good. And he's on appropriations, Nolan. I know. It's from a high level. It gives you a good framework to go forward. Thank you. I think, you know, it does. I think that's a good point, Senator Westman, because then within each of those categories, we may have, we will have concerns and questions and how to prioritize. We want to get it out as fast as possible, but we don't want to leave anybody behind. I think that's kind of the issue that pops up for us. Any other questions or comments for Nolan? We will have you back, Nolan, as we go forward. And your suggestions on bringing this up with David Englender and Mike Smith. I think we have them scheduled on Friday on our agenda. So I may add that short question for them on that. I will shoot David Englender an email as well so he can be prepared to answer if he's up. That would be great. I mean, just both of them, if you don't mind, that would be super good. Yeah. All right. Hitty, any other questions? All right. We're going to go back to our agenda. And so as we have been going through the COVID-19 emergency response, and we've heard a lot of testimony from a number of folks, we've heard from our designated agencies a little bit, and other service organizations. And the person we haven't heard from is sufficiently is our Commissioner of Health. I almost called you senator. No. Commissioner Squirrel. I almost promoted you, but you know. Great. Maybe it's not a promotion. I don't know. But Commissioner Squirrel, thank you for being here. And if you don't mind talking with us a little bit about what your priorities are, what's going on, I think we sent you a request. And so why don't we let you provide your testimony? And I'll ask you up front, do we have something from you in writing or not? Yes, there was a document that should have been submitting this morning, Senator Lyons. We have it. Great. Thank you. Of course. OK, should I get started? Yes, please. Thank you for being here. Great, of course. Yeah, good morning, everyone. Sarah Squirrel, Commissioner of the Department of Mental Health. It's a pleasure to be here with you this morning. Happy to update you on what I see as our urgent priority areas for the Department of Mental Health, as well as just an understanding of what I see and what we see as overall pressures in the system. And then I'll walk us through some of the steps and actions that we've taken to try to mediate against some of those pressures and to address those priority areas. And I think right now, given the unprecedented public health crisis that we're all facing, the health safety and well-being of Vermonters is urgently important. And particularly, ensuring that our mental health system of care is stable, is solid. And as we look at the impact of the current emergency, what I also anticipate that we will see beyond this immediate impact of COVID-19 is even more ongoing need for Vermonters and mental health. So we've got our eye on the short term, and we're also looking long term. Because currently, what we have is we have young children and youth who are normally accessing a lot of services and supports to their public schools who are at home. We have individuals who are in residential and inpatient settings that are struggling with new information or maybe were appropriately discharged to their home setting and will indeed additional care and support. We have communities who are grappling with how to self-isolate, how to continue to access treatment and care, as well as older Vermonters, who not only are at a higher critical health risk, but who we were also already worried about just in terms of social isolation, depression, and risk of suicide. So I think now more than ever, we have to all work on ensuring that the fabric of our mental health system remains strong to meet the needs of Vermonters today. And that the system will be there for us all tomorrow when we're sure to need it even more. So to that end, I'll outline kind of our three main priority areas right now, number one of which is to support and maintain the fiscal stability for our community mental health and inpatient providers. And I'll talk in more detail about some of the strategies that we've implemented and have put in place already. Priority number two is to ensure continued access and capacity when our community mental health and inpatient system for those who are seeking care and treatment. Our system has changed and shifted. We've tried to be nimble to utilize more telehealth communication, which is a great opportunity for us, but it also changes how people access care. And so we want to be aware of that and be thoughtful about that. We also are looking at, and to point number three, is supporting and sustaining our mental health care workforce. So what I see right now across our community mental health system and in our inpatient settings is all of us grappling with significant workforce challenges. We all know, particularly this committee, that even going in to this situation, we were already experiencing workforce challenges. So what efforts can we make to ensure that we are stabilizing our existing workforce at the provision of mental health services may need to look different? And how do we ensure that that workforce is still there when we come out the other side of this crisis? Some of the overall pressures in the system that I will speak to, again, is maintaining critical and essential staff across our mental health care providers. We see that at our own facilities at the Vermont Psychiatric Care Hospital, Middlesex Community Residence, as this committee is aware, we actually moved the residents from Middlesex to our VPCH facility just so we could consolidate staff, so we had enough nursing and mental health specialists just to meet our basic minimum grid staffing needs. When I look across our residential system, who is doing an incredible job maintaining capacity, that residential system is critical. They're also grappling with similar staffing shortages. And we know that if our residential system of care becomes too destabilized, particularly for adults and for children as well, that will actually put more pressure on our medical system, which is exactly what we want to avoid. So those are some pieces that we need to look at on the bright side in terms of the resilience of our system. When I look, for example, across our network of intensive recovery residences, other residential programs, group homes, our community mental health partners and other private partners are going to incredible lengths of maintaining that capacity and keeping those facilities open. But they need support to do so. I think another pressure that we are all facing is just the fiscal pressure on our providers due to loss of revenue, increased costs, and efforts to maintain staff. So as the provision of services has changed, that has had significant impact on revenue. There are increased costs in terms of, how do we retain our essential workforce to maintain staff and just increase costs in general to try to manage the COVID-19 crisis? We are, again, seeing decreased capacity across the system due to staffing shortages. This has impacted our crisis beds, residential, and inpatient. I would also say that many of our providers across the state are struggling with the procurement and acquisition of PPE, particularly for those individuals who work in our 24-7 facilities and direct care staff. This is an area where the department has really tried to be helpful in terms of kind of shepherding requests through the Emergency Operations Center here at AHS. For example, we just submitted a request on behalf of all the designated community mental health agencies and specialized service agencies to prioritize the provision of a minimal two-day supply of PPE to all of those residential providers. And I'm happy to report that that order did make it in and will be delivered this week. I think the other pressure is just our providers managing COVID-19 protocols and guidance. As we know, this is a very fluid situation. If you're running or supervising a residential facility, wanting to use all of the current guidance that is coming out from VDH and CDC, navigating that guidance, and then, of course, grappling with how to even manage COVID-19 positive staff or patients in your facilities. So that's just, I think, kind of a quick overview of what I see is some of the current pressures across our system of care. I guess what I'll do is shift and just talk a little bit about some of these strategies and actions that the Department of Mental Health has put into place or implemented to address those priorities and to mediate some of those pressures that I just mentioned. The first one, and I've kind of broken this out into phases in terms of our response. And this is focused specifically on our community mental health system of care, our designated agencies and specialized service agencies. So our first goal immediately, which we implemented the week of March 16th, was to really assess and implement fiscal strategies within available resources. So within our provision of resources, what has already been budgeted to the Department, how do we create flexibility in that to basically preserve cashflow to our designated agencies and specialized service agencies and really maximize our payment provision vehicle. So what we did, and we also issued comprehensive guidance to all of the designated agencies and SSAs. So there is a link in this document. It doesn't look like it's a live link. I apologize for that. But there is a link in this document to our website where we have comprehensive guidance that we have provided to the DAs and SSAs in terms of the flexibility that we've provided. We're also holding weekly conference calls of all the designated agency leadership and specialized service agency leadership to ensure that we have a good sense, kind of week by week, minute by minute, one of the things that they're experiencing that they need help with and that we can be responsive to. So just to let you know, the link does work. Oh, great. Yeah, no, it's very good. It takes you right to the full report. Excellent. So that will give you an overview of kind of super not all of the pieces that Department of Mental Health has in place, again, to ensure fiscal stability and create flexibility for our designated agencies and specialized service agencies. One of the big ones that I'll focus on is the case rate. So under mental health's current case rate and payment reform that we had already implemented, which essentially is the DAs and SSAs are paid monthly for case rate services on a prospective basis using an annual budget. So this, having this provision really created some flexibility for us so that we can continue to prospectively pay the designated agencies and specialized service agencies that monthly amount. That average is about $8.3 million a month across the network. We've been able to continue to ensure that those funds go out the door. We have the ability to, on the back end, there's an annual reconciliation process. So as our designated agencies and SSAs are looking at more telephonic services, utilization looks different. The whole provision of care looks different. And we are actually able, under our current Medicaid authority, to make those adjustments to ensure that there's no disruption in the flow of budgeted resources to the designated agencies. We also put into place, because there are some services that exist outside of the case rate for the DAs and the SSAs. One of those are residential programs, private non-medical institutions, which we fondly refer to as PNMI programs. So again, in order to provide fiscal stability to those institutions, we have put in a temporary, I guess, revised process that ensures that those PNMI programs will continue to receive kind of that per diem rate per month, which creates flexibility. So what a lot of our residential providers did was very appropriately look to perhaps discharge individuals where it made sense, where they could maybe be in a different setting temporarily. That decrease in census, of course, impacts revenue. And so we wanna make sure that while our residential programs are having it to adjust to changing needs and census, et cetera, that we keep them whole. Because certainly we're gonna need these programs as we go forward, and we're gonna need the staff. So this PNMI provision provides that consistency and payment that the PNMI programs can count on. There is also an expedited process for extraordinary financial relief due to COVID-19 related costs that any PNMI program can apply for, and that's through DIVA. There were some very specific guidance that went out on the changes to PNMI to move these things forward that went out to all of our providers, and I'm happy to send that guidance to the committee if that would be helpful. Other areas that we looked at, of course. That would be helpful. We'll just put it on our webpage and then it's accessible for whomever. Thank you. I'm happy to send that. And just for the committee's reference, the crisis program at the Howard Center, the Jarrett House does fall under PNMI. So again, this is just another way to ensure stability for our community mental health providers as well. Some of the other areas and levers that we've tried to pull, obviously the ability to utilize telephonic services for approved medical billing for a variety of mental health services and treatment is critical. I would say our designated community mental health agencies and SSAs are really trying to utilize their existing workforce as much as possible, redeploying folks to other programs as needed and trying to remain as connected as possible to individuals who require mental health services and supports. We also expedited the payment. We had monies for the designated agencies related to the implementation of their electronic medical records, their EMR. So we also expedited those payments, which is indicated here, that was a total of $1.15 million. In addition to that, we have expedited other Medicaid incentive payments and have also expedited and are looking at, there's like a 1% value-based payment that's associated with payment reform. And our team right now is looking at how to expedite that payment as well. I wanna take a minute and just talk a little bit about school-based mental health for a couple of reasons. Number one, this is an area that I think we see as potentially an unmet need given that, as I mentioned, we have many vulnerable children, youth and families that benefited and do benefit greatly from the incredible strength of our school-based mental health services across the state of Vermont. As children and youth are now home, receiving kind of more virtual learning, we want to ensure that we were still able to provide mental health check-ins and support to those children and youth across the state of Vermont. I will also note that the school-based mental health and the fiscal provision that goes along with that, which is success beyond six, is outside of the case rate. So when I talk about how we've been able to maintain the cash flow within the case rate, that does not apply to success beyond six. And for many of our designated in community mental health agencies, success beyond six services are a big part of their service provision and also a big part of their revenue. So we have exerted whatever flexibility we can within the existing mechanism of success beyond six for school-based clinicians, for concurrent education, rehabilitation and treatment, which is CERC, which is our alternative schools. We've lowered kind of the minimum thresholds to access that case rate so that those staff can still be doing kind of those daily check-ins with children and youth that would normally be accessing those services and the designated agencies are able to draw down that full case rate. The fee-for-service for the behavior intervention programs, which is more of that one-to-one in the public schools is a little more challenging because that is still fee-for-service. Currently, we are looking at trying to implement an emergency case rate for those services. Number one, to ensure that children and youth can continue to access that level of mental health support and treatment. And number two, to support our designated community mental health agencies in I guess their fiscal solvency, as well as trying to maintain as many of these critical staff, because as I mentioned, when we come out on the other side of this, the impact of this crisis, I anticipate that there will be a surge of mental health needs across the state and we wanna ensure that that workforce is still there for us. So it feels very urgent and important from the department's perspective that we are able to execute some kind of an emergency case rate for success beyond six that will support the designated agencies and the continued provision of mental health services and supports for those children across the state. It is complicated by the fact that the local, the match for school-based mental health services is not general fund match from the agency of human services. It actually comes from the local education agencies at the local level. So I have been in communication with this area of the agency of education. We will be issuing some joint guidance, which is still being vetted through AOE right now, but will essentially kind of the guidance is that we respectively across DMH and AOE want to see the provision of these mental health services continue. We want our local education agencies to continue to support those contracts that they currently have with their local DAs, which will allow us to then implement this emergency case rate. And again, ensure that we can retain those staff and ensure that we can continue to provide those services, albeit in a different kind of format. Commissioner. I'm happy to update the committee. That is a, we are a work in progress right now. We hope to have that finalized within the next 24 to 48 hours. So I can update the committee. That's exactly what I was going to ask for. Okay. We've been very concerned about the issues that you're talking about, and especially with regard to what's happening to kids and how the AOE and our agency of human services are responding. So if you can get us the information, we can put it on our webpage. If you send it too broadly to the committee and then our Nellie or Julie will put it up on our webpage, we'll have it. And if we need further information from you, we can always ask for you to come in, but I think your time is better spent elsewhere, frankly. The other thing I was going to say is, no, no, no, but I do want to say that this is extremely helpful. The update that you're giving us is extremely helpful. And I think if we could move on to the area of your presentation that is next steps, unless you think there's something in the phase two. No, I just want to, yeah, I want to just flag the phase two for the committee just to bring to your awareness that while we've worked with an existing resources to implement phase one, phase two is really evaluating the fiscal pressures that are designated community mental health agencies and SSAs are experiencing that would be above and beyond costs that we need to look at. So we have implemented a process for the DAs and the SSAs to submit what financial pressures they're currently experiencing due to COVID-19. We are prioritizing one of those areas to look at which is related to the provision of hazard pay or incentive pay for direct care staff as well as staff who may be working with COVID positive patients. So we did receive all of the information from the designated agencies yesterday. We have a fiscal team here that is working on that analysis right now. But just important for you to be aware that that process is in place. And of course, there are a lot of providers across the state of Vermont that we want to ensure that we support during this crisis. And so we have to look at all of these fiscal requests and evaluate them in coordination with other relief efforts across the agency of human services. That's very good. I think our committee question. Senator Cummings has a question. Just let me finish my comment and then Senator Cummings. I think the committee is very much aware of the need for what one of our DAs calls hero pay. So rather than hazard pay, but it's either one works. And as we go forward with the funding that's coming in from COVID-3, I think this becomes a very important discussion. This is where the whole idea of setting priorities and establishing criteria might come in. As you're working on this, are you also working with DOL on the UI issue? Department of Labor related to what Senator Lyons? The unemployment insurance issue where folks can earn more by not working. And are you linked in with that whole conversation? Yes, we are aware of that and working with the Department of Labor. That's good. Senator Cummings, go ahead. No, I just wanted to stress the urgency of coming to some hazard pay for these frontline workers. Once they lay themselves off because of hazard, it's gonna be twice as hard to get them back. We learned yesterday that the governor had renegotiated the contract with state employees to provide hazard pay. And I understand additional paid leave, family leave, to do that for state employees and then not for the designated agencies. It's really, if I were somebody down there going into people's homes, cleaning their bathrooms for them, I'd take it as kind of a slap in the face or a disrespect. And I think it's urgent. I don't know where we're getting the money to pay the enhanced state contract. But I think we need to act quickly because we're gonna lose those workers. And once we lose them, they're home and they're making the extra unemployment, we're not gonna get them back. So I just wanted to reiterate that. Yeah, it's a great point. And what I can assure the committee is that it has always been the intention of the agency of human services to implement additional funding to the designated agencies and the specialized service agencies so that they can implement hazard or incentive pay. So that has always been a priority. That has been something that we have discussed at the agency of human services. That's why we have prioritized it in terms of the information that we asked for from the DAs because the state of Vermont did just implement a methodology for state employees which is inclusive of $1.50 per hour extra for someone who's doing direct care. So that would apply to my folks who are working at the Vermont Psychiatric Care Hospital, for example, those mental health workers and then an additional 20% for individuals who might be working in a COVID positive environment. The request from the designated community mental health agencies and SSAs is different. It is more. So I think the request that they have made is for a time and a half, for those direct care personnel and double time for individuals who are working in COVID positive environments. So I think what we're trying to do right now for the committee is get all the information related to the direct care providers across our DAs and SSAs focusing on the residential direct care. How do we look at that within the context of what has been offered to state employees and how do we come up with something that has integrity and a rationale and allows us to retain that critical workforce? I think the issue that Senator Cummings is bringing up is absolutely critical. If the time and a half or the double time covers what they're going to get if they are not working. I mean, that's one of the issues. So there's gonna have to be a check and a balance there determining whether or not the amount that is available and what we're offering is gonna cover what they would get if they stopped working. So I, and also remembering, I think we're all very concerned about the level of reimbursement that we've seen in our DAs and our SSAs over time. We wanna make sure that they are compensated adequately and especially now, we wanna keep them working. So I think we're glad to hear that this is a priority for you as well as it is for us and we'll stay connected on this one. I know it's expensive. The question I have is in terms of building a prospective payment process and then as you had talked about some reconciliation coming up later as the COVID-3 money becomes available, is that something you're thinking about within the workforce reimbursement process? Yeah, I think we're certainly looking at, what will the federal dollars provide in terms of, obviously we're gonna implement some of these things before we have a clear sense of what some of those federal dollars look like. So that's kind of part of what we're doing is mapping some of these priority areas against where we think federal dollars will be coming in because obviously there's an impact point for the state of Vermont, so. Okay. Okay. Just a couple other things quickly, in terms of just additional federal funding, we are submitting a SAMHSA grant this Friday that is for mental health and substance use. It's for $2 million that could focus on expanding crisis services, increasing availability of peer outreach, public health education, employment supports, as well as substance use, additional substance use supports. So I just wanted to let the committee know that we are going to be providing our application on behalf of DMH and ADAP this Friday. We are also standing up and preparing for a crisis counseling program. This is once the governor, I guess, applies for a declared disaster or a disaster declaration. Once that is approved at the national level, then we have the opportunity to apply for a crisis counseling program and grant funds. This would allow us to really focus on some additional mental health supports in our communities. Obviously we'd be looking to coordinate with the designated agencies on that, could help with public education and just more general kind of front facing media and outreach related to access to mental health support. So I just wanted to make sure that the committee was aware of that opportunity as well. In terms of next steps and areas of focus, we are implementing phase two for our designated agencies and specialized service agencies to continue to support their stability. We are prioritizing the hazard and incentive pay to be looked at specifically this week and to make a recommendation. And then all of the DAs and SSAs have submitted broadly their overall fiscal pressures, loss of revenue, additional expenses, et cetera, that we will be evaluating here at the agency of human services. We're also wanting to focus more on the social, emotional and mental health of children and youth, particularly those who are now at home who are more isolated, likely accessing more social media. So we're thinking about how do we partner with the agency of education and our local education agencies to ensure that parents are aware of services and supports and that we are creating some safety net for youth in our system who are already vulnerable. And again, just additional focus on suicide prevention and expanding public messaging about mental health and wellness and then continuing to pursue any and all federal funding opportunities to support the health system of care. So I will stop there. You also have just the general list of all of the guidance that we have provided to all of our providers across the state. Should you be interested? So that's all listed here for you as well. I think you're muted, Chair. Thank you. Yep. Some people would like me to stay muted, I guess. I just wanna say thank you, Commissioner. This has been a good overview of all the work that's going on. And it does dovetail with the interest and the information that we've been hearing from our DAs, SSAs, our AOE. And then as we're going forward with COVID-3, we wanna make sure that we stay connected with you so that we can facilitate whatever needs to happen. If we need to put some legislation in, some policy recommendations in, we will be working closely with our Appropriations Committee and as well as our other committee. So thank you for this. We thank you for taking the time. Of course. I'm gonna ask Julie, you can take the off and Questions Committee, our time is getting crunched, but we have time to hear from everyone we have on the agenda today. So if you have a question, please let me know. Okay, I guess I have one. And then Senator McCormick has one. My thinking right now is we've been trying to gather data and what's needed. And now I think we're moving into a phase and I think you are as well. What are the solutions? And so that's what we're looking for. How can we solve some of these problems? So thank you. I think that's all right. Senator McCormick. No, I apologize. I was actually waving it off. Okay. Okay. I obviously should not, I need another symbol other than that. Oh, we need to use our hand raising capacity but we'll be fine. All right. Thank you, commissioner. Of course. We're staying on the same topic and we're moving on to Bob Bick who is the executive director at the Howard Center. And Bob, thank you for being here with us this morning. Are you there? Yes, I am here. Terrific. Go ahead. So I was under the impression that you wanted me to talk about substance use services. That is one of the areas. Yes, I, we had you down for substance use areas, substance use disorder and because we haven't had sufficient testimony in that area. And if that's what you're prepared to testify on right now, we would welcome it. You've also heard the testimony from commissioner squirrel and some of the testimony, some of the comments that we've made as a committee on what are the solutions for some of the problems that you're facing. So you can have an addendum if you have any comments on that but please go ahead with substance use disorder. Thank you. Okay. Thanks. If I can, I'll take a moment to just use the addendum in the front end, just to acknowledge commissioner squirrel and hut have really been incredibly present in terms of helping us to try to figure out not what the roadblocks are necessarily, but how we're going to overcome them. I especially appreciate the comments from Senator Cummings with regard to the staffing issues and the necessity for acknowledging really the incredible work that our direct service staff are doing in terms of maintaining face-to-face services across the system, whether we're talking about mental health or developmental disabilities, a good portion of what we do needs to be face-to-face. There's certainly a lot that we've been able to turn to remote work and there are obviously adaptation challenges that we're overcoming, but the work that we need to do face-to-face has really been an incredible challenge. And when we recognize the compensation challenges that we faced before this, even with the enhancement of whether it's time and a half or double time, it still only brings us up to just under what the state is offering individuals for some of the new programs that they're rolling out for individuals that are either homeless or COVID positive. So on the one hand, we don't want to lose our folks to critical state programs, which we recognize are in fact critical, but I don't think that it's unreasonable to recognize that in a lot of circumstances, we have staff who are struggling either because they see themselves in a quote high-risk category, although with the changing information that we constantly get from the federal government, it's not clear if there really is any one high-risk category more than another. And just the anxiety and fear that staff have in terms of being in a face-to-face situation, in many cases with individuals who are chronically ill anyway, and so trying to make the determination of whether they're ill from their chronic situation or whether they're exhibiting symptoms of COVID-19 and placing them at additional risk is a pretty significant challenge for us. So I think the system has truly stepped up. It feels like to use the metaphor trying to drink through a fire hose. And I think at this point in time, if we can feel and believe and know that not just the administration, but the legislature is truly understanding what's happening out there in the field, I think that's offering some significant support and comfort to our staff. I know just personally, the idea of going remote has been pretty difficult to do. It's just hard to get used to it. I don't know if you wanted to say something about that, Senator Lyons. Nope, I was just gonna, I'm agreeing with you. It's hard to go remote, so here we are. Yes, we are. So if I could just move to just talk about substance abuse services specifically. Sure, do you mind if I ask you one question about your prior, your addendum? You just did. I have another one. Okay. So you mentioned that the state is putting in place new programs and it sounds like those are in direct competition with some of the work that the DAs or at least Howard Center is doing. Can you just expand on that a little bit? Sure, and I would not define them as in competition. Okay. I think they're designed to support the work that community agencies, not just the DAs and SSAs, but all community agencies are doing. So there's a site at Goddard College that they're rolling out. There's a site at Harper Place in Shelburne that they're rolling out. They're having conversations with a hotel in Burlington. All of these are designed to provide additional housing capacity for individuals who are either at extremely high risk or are already diagnosed as COVID positive or presumed COVID positive or were in an environment in which, a close environment in which somebody was COVID positive. So I don't see them as being competitive. However, the reality is that there's a limited number of individuals in the workforce who are willing to do this work and we wanna support them as much as possible, but given that we are challenged with staffing our own programs. I mean, as an example, Howard Center has 23 residential programs with 162 people in beds. So, and while we can combine some programs for organizational efficiency, most of them are small operations within the community. I would just point out that one of my colleagues made a great comment the other day. Legislators, the community at large are very much aware of the critical challenge that is confronting hospitals in our system because it's on the news every night and it's visible. And everybody in the community is very aware of the challenges that our educational system faced because you drive by all the schools and the parking lots are empty. There's no traffic jams in the morning or in the afternoon. But many, many people are not aware of the challenges that our system is facing because our system is so embedded in the community that in many ways we are appropriately invisible in the community, which is part of the community. But under these circumstances, that strength has made it more difficult for us to convey some of the challenges that we face. This is very helpful. I think I did understand the concept of having a sufficient workforce, but also for the work that you're doing to be adequately compensated, that continues to be a concern for this committee. And that is we're moving into a need for increased reimbursement because of COVID emergency. That's an additional challenge. So, and then trying to expand the limited resources that we have in terms of workforce. Thank you. That really does put it on the front burner a little bit better for us, just having you say that. Thank you. Thanks, Senator. So, go ahead, move on. I hate to slow you down. No, that's okay. I can move quickly or slowly as the committee desires. So, if I can talk about substance abuse a little bit, I'll use Howard Center as an example, because I think we are across the system of care, all experiencing pretty much the same kinds of challenges, in many cases, taking advantage of the same kinds of opportunities and all trying to be incredibly creative in the way in which we continue to support the folks that are in our care. And so I'll break it down into a couple of different sections. The first section would be individuals that are receiving treatment in our hub system or medication assisted treatment programs. So this is individuals who are receiving both either methadone or buprenorphine. These are folks who by virtue of their presence in a hub were already deemed to be at the higher level of risk for individual struggling with opioid use disorder. And by virtue of that, needed to have much more regular contact with the nurses, the physicians, and the clinical case support folks. So in our hub and Howard Center, for example, we have about 950 clients enrolled in the hub in Chinden County. And typically we would have between four and 500 of those folks cycling into the program every day pre COVID. Right now we have moved all of our clinical support. So the counseling and case management support, that is all moved to be provided by remote services. And so in order to make that happen, we've both had to expand the availability of laptops and technology supports to our staff in the community. But we've also had to either provide Chromebooks or laptops or burner phones to many of the clients who don't have access to that technology in order to ensure that they can stay connected with the program. With the help of Tony Fallon from the ADAP and with the approval of SAMHSA in Washington, we've been able to change some of the frequency with which individuals come in. So we no longer have clients coming in on Sunday at all. So those folks are getting an additional take home dose on Saturday. We had gone out and bought I think 250 lockboxes to provide to clients to ensure that they could safely keep their medication at home. And then we moved patients from either 6, 13, or 27 days of take home. We moved them up to the next level. So if we had some folks who were on six days of take homes, we moved them up to 13, folks who were on 13, we moved up to 27 in order to reduce the volume of folks coming into clinic. And now we have about 180 or 200 folks coming in every day. We've split our nursing shifts so that half the nurses come in and our face to face with clients. The other half of the nurses come in in the afternoon and prepare the take home doses that'll be handed out the next day to reduce the amount of face to face contact that we're having with the clients that are coming into the clinic. Some of the challenges we're still working on in that area of programming. So we get two different rates, they're bundled rates depending on whether we provide enhanced services or not. Enhanced services are defined as additional communications with primary care services like that. Typically in an average month, about 90% of our clients would receive enhanced services but because of the current circumstances that's just not gonna be possible either because we can't make the kinds of connections we need to make with primary care physicians or we've had a drop off in our ability to have continuous case management communications with clients. So we're still waiting to hear from ADAP whether we will be able to draw down those funds in lieu of the fact that the reason we're not able to provide the enhanced services is not really something that's necessarily within our control. PPEs, and I'll mention it here but it's for every face to face population that we're providing services for continues to be a huge challenge. As I mentioned, if we've got 250 clients coming into the Chittenden Clinic every day, arguably that could be 250 masks plus another 100 or 150 for our staff who in the course of the day may be coming into the clinic. We have gone out as part of our system of care trying to find additional services but we are continuing to struggle to get PPE through the state. It was very encouraging to hear from Commissioner Squirrel that at least the two-day backup has been approved. So we'll be looking forward to receiving that. Let me see, what else can I tell you? Security for those clients that are coming into the clinic every day, they are being thermometer tested to make sure that they don't have a fever. And if they have a fever, then they are being sent home and then we have to find a way in order to transport the medication to them. So when you as legislators are thinking about all the folks that are out there that are exposed in some way, that are at some greater risk, the obvious population of folks who are working in bed-based programs but all of our system, whether we're talking about DAs or SSAs have a lot of folks that are out there going into people's homes, picking up medications for people, picking up food for people and bringing it to them. And so folks at our medication assisted treatment program are also providing those same services. I feel like it's important to mention, I'm sure you know this, in all of the populations that we serve, our clients are afraid. Our clients who have to come in to get their medication, clients that are in residential programs by virtue of their chronic illness status are at greater risk. And in many cases are living in more challenging environments and experiencing an enormous amount of fear and anxiety. And while Commissioner Square will appropriately acknowledge that we will be dealing with a PTSD experience after the acute phase of this current pandemic passes, that we will be challenged to meet. But we can't lose sight of the fact that even right now we're dealing with individuals who are having that experience. And since we all experience, it's helpful to have face-to-face connection through Zoom or something in a remote way, but it's not the same as being in the same room. It's not the same as a caring case manager can be physically present with someone. And so this is gonna continue to be an issue for us. Outpatients, can I continue to move to outpatient? Yes? Very briefly, I'm sorry to say that we're starting to run over on the available time that we have, but if you don't mind maybe consolidate some information on your outpatient, that would be very helpful. Sure. So basically, I think the key message obviously is as much outpatient as possible has been converted to remote. I will point out that we've had drop-offs in the number of clients that are able to take advantage of outpatient services, whether by virtue of them not being necessarily personally motivated, but as a result of their connection with the Department of Corrections or Department of Children and Families, they've taken advantage of this as an opportunity to drop off. Interestingly enough, we've seen less drop-off in our court-related clients, both in terms of their engagement and in the number of services that they are receiving. Economically, I would be remiss to not acknowledge the financial challenge. We are right now projecting in our agency alone roughly a $3 million shortfall to the end of the fiscal year. That's absent some of the initiatives that Commissioner Squareau talked about on the DMH side. It continues to be a little bit more ambiguity on the ADAP side for substance abuse services. For example, IOP services, we've not yet been given permission to reduce the number of sessions per week in order to be able to bill that. And so that's challenging. For our crash clients or the IDRP clients, the individuals who need to take the course in order to get their license reinstated, we've not yet been able to get an elimination of the face-to-face as part of that process, which I think could be handled legitimately telephonically or by Zoom. Is this an administrative, this is a rule change or administrative change, not legislative change? Well, and that's a great question, Senator. And I don't know the answer. I believe that these would be administrative changes. Can you send us some information on that, please? That would be helpful. Yeah, be happy to. Good. The only other point I guess I just added in is so our Act One bridge program. So we have two public inebriate programs, one in Franklin County and one in Chittenden County. The one in Franklin County is an on-call program that continues to operate as a face-to-face program. In Chittenden County, it was a site-based program on Pearl Street. And in order to consolidate staff, we combined our Act One bridge and assist, which is our mental health crisis bed program into one location. We did have a staff test positive. And so we stopped admissions for a couple of days while we did a deep cleaning and make sure that we had done the contact tracing that was necessary. That program is expected to reopen in the next couple of days. And then finally, I just want to mention, I know that we're not the only agency that have had clients pass away as a result of COVID. And while the numbers, the statistics are eye-opening and everyone is responding to them, I know that we all recognize that every one of those statistics is an individual who had family members and in the case of our clients had often long-standing interpersonal connections and those losses are really starting to have an impact on our staff. Thank you. Yeah, we can't forget the emotional needs of staff as they work with these folks who become ill and then eventually die. So thank you. Thank you for mentioning that. All right, I think that it's important for us to move on. You've given us a lot of information. And if you can send us the information about the licensing and that other area on your phone, the sessions per week, whether that, how that could be accomplished and if we need to be involved in that, that would be very helpful. Sure, thanks. Okay, we're gonna continue on, this is really for a discussion and I'm gonna ask everyone to be as concise as possible. I know that you, I don't think any of the next folks have provided us with testimony, but if you could walk through your comments and then perhaps what we'll do is to ask questions of the group when you've all finished and that we'll begin with Christy Everett of the Claire Martin Center. There you are. Hi, how are you? Good. Thank you so much for having me come and testify today. A lot of what I would say would echo a lot of what Bob has said, a lot of what he is both experiencing on a positive as well as the challenging side we are experiencing down in our area. We have moved probably 90% of our workforce to working remotely at this point. Staff are feeling really supported along that. What we are running into is a huge technology issue. Our systems were not designed to manage 90% of our staff working remotely. So we actually, our system crashed last week. So we have now had to then reinvest in a new system. So that is now up and running. The other issue that we are running into, and I appreciated Senator Lyons, what you said about $100,000 for older adults being a drop in the bucket. We have a huge percentage of our older adult population that we have not been able to connect with through this crisis at all. Either they don't have the technology capability, they don't have the awareness of how to use the technology. So we're having to do some education where we can. In the rural area, we don't necessarily have the broadband that we need to be able to connect with people. So at least for our older adults program and substance, we're looking at almost 100% loss in that program because we just can't connect with people. We do still have a good percentage of our folks going out into the community doing deist management. Like Bob said, picking up groceries for people who cannot shop, we're in a high-risk category, delivering medications, still doing injectable medications. We do have a small supply PPE that's slowly trickling in. I would say in our residential program, all we have is the two-day supply right now. And that program is really working with almost a house of cards of staff right now that if sort of one thing goes wrong, then we're gonna have major issues and being able to continue to- You froze. And just get a survey of the staff that we have. 160 staff, we've got about 10 people who would be willing to jump into a residential setting with some quick training that we can give them. If we don't necessarily have enhanced rates to provide residential services, that's my pool is 10 people to staff a six-bed residential program. That's not gonna be feasible for me. So I think if the Department of Mental Health can actually work on increasing that rate to be in line with what state employees are getting, that would be a huge help to us. And we just have one residential program, not the number that Howard Center or Washington County and all the SSAs are running to. So that for us is something that we are keeping an eye on. The other thing that we have really started to recognize is the risk that our agency is gonna be at around unemployment insurance. I think we got seven requests yesterday already from staff and very, very basic projections right now. We're looking at least $100,000 as a cost to our agency and we're only how many weeks into it at this point. So we expect that that is going to increase as well. On the good news, there's been a lot of community organization. We have been a part of a number of mutual aid discussions and a number of our towns there. So in Bada says we're kind of the invisible work that's being done. We are right embedded into every single community that we have and we are providing services as much as we can in whatever capacity we can. We have been working with Gifford Medical Center. We have not had to be in the emergency room for about three weeks at this point, but we have been able to do all of our assessments through telehealth, both voluntary assessments as well as involuntary assessments. So that process is really working well for us. We've had the same coordination with our law enforcement. So we don't necessarily need to go out into the community. We do have the capacity to do that with telehealth as well, provided there is internet capacity in some of those communities to do that. So that has really been working fairly well too. The other thing that I would say, we're probably have about a 25% drop off in services now, but we still can do almost same day intake assessments. So even people, we got a call from Dartmouth yesterday wanting to discharge someone and we were able to do an intake assessment that same day and start services in them. So the staff that we do have are really committed to maintaining the client's contact that they do have. So that's gone really, really well. And our system, I think in some ways is because we have done this work for so long in this capacity are able to really wherever the need is step up and we're gonna quickly develop some type of a solution to try and address the needs of the community that's there. And I think that strength of the DA system is really showing through itself through this whole process. I am encouraged by the comments that the funding needs for the DA system do not need to be looked at for just through this crisis, but what is long-term? And I know we have the commitments of DMH to at least get us through FY20, but we really need some assurances past that that there is going to be this intent to really solidify the system that is there. I know I did provide some written commentary to a few of you through email earlier the week. I can send that on to the rest of the committee if you need that as well too, but I know we are. Nellie, Christy, if you send it to Nellie, Marvel and Julie Tucker, our committee assistants, then we'll put those comments on our webpage and that I think would be extremely helpful. Okay, yeah, I can definitely do that. Sure, okay. And I think unless you have something that is critical, trying to just be a creep of a view, so I can step off now and let someone else go. I just have one question. Who, what is your internet provider there in Randolph? We're using consolidated communications, I believe. So Randolph, I think is pretty set when we get into sort of like the Bradford areas, that's more choppy and down in Tumbridge and stuff like that, unless you sort of park at Ward's Garage, you don't necessarily have internet connection. So that's the situation we're in. Okay, thank you. So we're going to move on to Rachel Cummings and Rachel, thank you for being here and why don't you give us your testimony, but from your perspective in Addison County. Great, thank you so much. And if you see my kids Zoom bombing, I apologize. Like many of my staff, I'm a part-time single mom and homeschooling while running a designated agency. So CSAC is a resilient agency and I believe that this has allowed us to transform our entire care and delivery model, to adapt to social distancing and to do our part to flatten the curve during this health crisis and pandemic. And while it's been bumpy, our transformation includes ensuring staff have the tools and the technology they need to be able to work remotely. We're a rural county, so staff don't always have access to reliable internet and sometimes have to continue to come to the office. We've implemented safety and safe distancing protocols to accommodate these staff and provide a safe work environment. And I'll send more details in my written testimony. Our finances and service hours have been impacted because of increased costs, including tech and PPE purchases. We've had a drop in service hours across all payers, school closures and clients who are struggling to adapt to this new way of receiving services. We also have a large amount of staff as I said who are struggling, working and carrying and homeschooling their children. Our service hours have already dropped by about 33% since the start in compared to our pre-COVID days. And I'll again, include more details in my written testimony. I wanted to say that we are very concerned about school mental health contracts. We understand that there is a statement pending from both DMH and AOE to support the continuation of school mental health contracts by school districts. This will be important for legislators to understand and support. These contracts serve Vermont's most high-risk youth across the state. When schools are not in session, we have lost a valuable safety net to protect our kids. Our most stressed families now are now taking on additional stressors, including worry about illness, income loss and expenses and new roles with children of full-time teachers and parents. With families that were already experiencing tension, trauma and risk of abuse and domestic violence, the odds have now increased for more harm to come to children. Mental health staff are working differently now, but we are still connecting and bringing support to children and families. We are having more parent contact than ever before, which we hope can mitigate these risks. These school contracts give us the staffing capacity we need to continue this work. If contracts are reduced or cut, we can expect to see that reflected in the wellbeing of our children. And this will only create a situation of more need and expense in the future. These contracts are an investment in mitigating that risk. I want you to know that we continue to provide essential community-based services and staffing to our residential homes. We have staff who have volunteered to provide care to clients should they become infected. One community support worker with over 20 years of service who also has a family of four children has made a commitment to our DS residential program to provide ongoing supports at the risk of his own health because of his commitment to clients and community-based services. And we have many stories like that, but not enough to really fully staff what's needed in our agency. I wanna say staff who continue to do face-to-face work with high-risk people are nothing short of heroic. However, the fragility of our programs, including our ability to maintain staffing is what keeps me up at night. Many of our clients are at high risk of severe illness from COVID-19 because of age and a multitude of chronic conditions. Some clients struggle to adhere to social distancing, putting everyone at risk. Many staff are scared about becoming exposed or infected and scared for the people they support and they're worried that we won't have enough PPEs to work safely. Due to the extraordinary risk of providing face-to-face services and because the majority of staff are working remotely, we are now paying staff who continue to provide in-person services a higher amount of pay than before COVID. While we are able to get some PPEs, including masks early on, we are running out. We have a limited cash on hand currently to support operations and to be able to weather this crisis and keep staff employed. I have about 40 days of cash on hand currently. Another concern is that unemployment benefits will have the unintended consequence of reducing my workforce because staff after weighing the risks will opt to leave the workforce because it's safer and they can get paid more. This is a scary thought and will impact our ability to provide care, especially in our residential homes. The state is assuring us we will be made whole but in light of diminished revenues and a huge need across all sectors, I remain worried and concerned that this isn't possible. We need assurances from the state with real money backing. I want to say that despite my anxiety about being kept whole, I do want to thank both Dale and DMH especially the commissioners for their help, flexibility and leadership. It has been invaluable and steady. CSAC has also continued to fully pay our staff to work even though some might be providing less billable service or are not working their full amount or regular hours. We are working to leverage all federal and state benefits for staff compensation. We have a strong culture and we continue to retain most of our staff. Our unifying principles at this time are to support staff to remain safe and employed, support our clients and continue to provide essential in-person services, stay connected as an agency and emerge as fiscally sound as we can so we can ramp up operations once this is over. We aim to come to this pandemic together with our adherence for our practices of quality work in positive culture. I want you to know that we are considered essential healthcare workers and please frame however the conversation and recognize this. We will need your help and assurance that any federal dollars coming into the state also come to community mental health and specialized service agencies and that we are not left out in the cold. I can't emphasize enough how crucial this is to our system of care and to CSAC. If there's any way you can tackle some of these issues on the state level, please do help us. Thank you so much. Thank you very much Rachel and there, I want to say that you have asked us to do something that we're very happy to do. I appreciate that. Yes, if you have your testimony in writing and can get that into Julie or Nellie, that would be very helpful. I'll send it to Nellie, thank you so much. Great, thank you. And we're gonna move on to Beth Seitler and we do have your testimony on our webpage. So thank you for that Beth and we'll listen to your information. Okay, thank you. Appreciate you having me senators and I'm sorry, I know we're running out of time. I'll try to go through this as quickly as possible. I also want to point out that I changed my virtual background so I'm not going to be confused with Bob Bick anymore. Wait, so, but we have the Aurora Borealis on one side and wait, that's a Corona on the other side, right? That's right, that's right. I was in outer space with Bob but then I moved back down to earth for a little bit. Okay. So yeah, I did submit testimony. It's really kind of in bullet form. It's not as polished as I'd normally like it but I wanted to make sure that you had it. Nope, that's fine. Okay, so I'll just go through and this comes from, this is not specific to CCS. I spoke with all the Development of Disability Services agencies and sort of got their perspectives. I'm answering a few questions that we had, hopefully I'll be doing this right. So what is, what have the agencies done? What's working well? What are the challenges that we're encountering and the financial risk? I won't go through all of these, I promise. And I certainly won't just read them off the screen. So the agencies are working collaboratively. We're sharing all of our plans and strategies. Each one of us has created a COVID-19 task force that meets daily, often for several hours. We're all looking at accountability and like the other agencies, we're about 90 to 99% remote. I think most of us are working from our homes with our pets and our children interfering. We've each created backup plans for people in services. So individualized responses to each person to, you know, in case they develop COVID-19, how will support them? Because over half of the people we serve are in residential supports. We've also, a lot of us have had to identify our high-risk people and the high-risk homes either due to behavior or medical issues. So we're trying to make sure that they're getting everything they need. We're also reaching out to people who don't have internet. A lot of the people who we serve are remote throughout the state. So some of those are through phone calls. Some of those are really through just going to the house and checking to make sure that people are okay. There's a lot of cross-training and redeploying of staff, especially around group homes. As my colleagues have pointed out, there's a lot of staff insecurity about, you know, the safety in performing their work and what it's like to be going out in the community right now. So we're trying to work with those staff who have said that they're willing and able to work and keeping them busy. You know, we at CCS did a poll for all of our staff. We have 70 staff and we had nine who replied that they would be willing to work with someone who's COVID-19 positive. So we're, you know, the strategy that I think most of the agencies are doing is, or deploying is just trying to keep people safe and keep them from getting ill. All of us are gathering PPE either privately, we've had some deliveries from the State Department of Health. Some of us are making masks on our own or being creative about what PPE we have. Each one of us is developing safety and communication protocols. We're also sharing them throughout the network with each other. So you know, someone might have a plan for communication, someone might have a safety plan. We are developing, some of the agencies are developing safety kits. We've sent out safety kits to our shared living providers and staff and families and people in services that are just very simple and 95 masks if we have them homemade masks, gloves. Some of us have been able to send out more than others. We're all having staff meetings in town halls via Zoom. I had my highest attended staff meeting that last week. I may just move to remote staff meetings from now on. And the self advocates are still meeting via Zoom as well, which was really cool. I was able to sit in on their meeting yesterday and it's great to see how many people are really embracing this. There's a lot that's working really well. I definitely wanna emphasize what my colleagues have said that Dale has been providing really excellent support and communication, especially around flexibility in terms of making us feel supported and confident that they'll be there for us. What we heard very, very early from Commissioner Hut was that she wanted us to make sure that we're supporting the staff and we're supporting the shared living providers and that they were gonna support us in doing so. I have no reason to believe that's not true, but obviously we're looking for a solid commitment around the financing for that. Agencies have created individual COVID-19 crisis teams. In general, I think that remote work is going pretty well. I think each one of our agencies have created novel approaches to service delivery. I have at the end of my testimony, there's a list of sort of fun things that have been happening. I won't be going through those, but you can look and see some interesting and creative Zoom activities. I have to say that it's wonderful that Vermont doesn't have congregate settings for people with intellectual disabilities and autism because I think what I've seen nationally is that there have been some outbreaks in COVID-19 and because we have people in individualized setting, I think that's gonna prevent some more of that. What's interesting is that I've spent most of my career trying to prevent isolation and push for community integration. Right now it's pretty ironic to be really pushing for isolation and no community supports right now. But this has, as has been said, it's putting tremendous pressure on shared living providers and the direct staff. And remote work doesn't work for everybody. I've had, it's funny to try to be tender with staff who are having a difficult time, who are scared, who are stressed beyond anything that they'd encountered, but it's interesting to see that some staff are responding well and even heroically and then other staff are, you know, ones who you've worked with for maybe decades who are just incredibly challenged by this time. That's been, I think, a real wake up call for all of us. You know, we're making, we're trying to make sure that we're connecting with everybody who we support. I know there are times where that's been missed. I mean, there's, you know, over 4,000 people in services and making sure that we connect with them every week and every day can be challenging for different agencies. I know I thought that we were catching everybody and I just had somebody contact me yesterday who hadn't had the level of support that I expected they had. So I think that's, it's a challenge for us to make sure that we're staying on top of that. PPE, what more needs to be said about that? It's been a challenge for everybody. In the people that we serve, we, I think something that's not always seen is that our agencies are providing special care procedures to many of the people in services. This includes feeding tubes and nebulizers, enemas. Many people have diabetes. And getting the PPE for that on a regular basis can be a little challenging. Right now it's even more so. And these people still need to have that, the direct support. Additionally, our population isn't always seen as long-term care. So when we've needed to have testing, it's been somewhat of a challenge to get people in to be seen as essential workers and for their care to be seen as long-term as it is. Bob spoke eloquently about the effects of losing somebody to COVID-19. CCS had that experience. And last week, we were one of the first agencies who lost somebody to COVID-19. And the devastation to the staff and the additional fear that it brings out in them is incredibly acute. So there's a lot of worry for our staff. As I've said, they've never really worked under these circumstances. And then the communication just across the board continues to be a little challenging. Financial risk, I feel like you've got it. And it's certainly been addressed. The biggest thing for the agencies is that we understand what needs to happen to secure our staff and to keep our shared living providers in place, which is what we've been asked to do by the state. Certainly would be what we'd wanna do. But that takes additional dollars. Shared living providers need additional difficulty of care, call it hazard or hero or incentive pay. They need to be kept in place. And that takes additional money, especially for a cadre of staff who hasn't been supported at the level they need to. So PPE is expensive. Staffing homes that hadn't been home before or redeploying staff and retraining staff is also comes at a cost. Some of the agencies have purchased additional computers for individuals in service to make sure they can contact, connect remotely that comes at an expense. And also some of the online platforms have been a little expensive for some of us. So that's, I'm not gonna go through the anecdotes. Those would just be fun reading for you for later. Thank you, that's great. I mean, I think having the list, the way you have it is extremely helpful. And it resonates with what we are hearing from other organizations and leaders. So thank you for doing that. Thanks so much for having us. It's terrific, thank you very much. So we're gonna move on. Julie, Tesla, you're next on the list. Do you wanna, would you like to add something to what we've already heard from others? No, I would rather you had that time to ask some questions and get a little more depth. So thank you very much for the opportunity. Thank you, thank you. And any suggestions you have in terms for us to identify our role in the solutions would be important. I think you've heard some of the things we're very interested in, but any of the, and there are other details that we can help with we'd like to know. That's great. We can send a summary of ways you can help them. We'll pull it from what everyone has to say. That would be good. Thank you. Okay, we're, we are behind. Unfortunately, we're always ahead in this committee, but today is a different kind of a day. What I'm going to suggest is I know there's another person who wants to testify right now. I think it's, is it not yet? Chad, we're going to have to hold off on your testimony. We may have to put it off to another day and I do apologize for that, but we'll see what we get to going forward. I've asked for Martha Maxim of Wake Robin to come in before we, before we dive into our next section. Committee, do you have any questions for any of the folks who have testified? Jenny, I don't have a question just a heads up. Money chairs, is it noon? So I'll be leaving the meeting at noon or thereabouts. We'll see what we can do. I think everyone who is on the call on the, on the zoom understands the predicament that we're in, but we should be able to cover most of what we have before us. Let's hope. So Martha, Martha. Yes, good morning, everyone. Thank you. Oh, there you are. Okay. Sorry. I needed to unmute. Thank you for being here. I think you've heard the testimony thus far and some of the concerns that you have, I think resonate with what we've just heard. So if you, if you don't mind bringing us up to date on where you are and some of the thoughts that you have for maintaining workforce in particular. All right. I appreciate that. Good morning, everyone. So I'm Martha Maxim. I'm the new CEO at Wake Robin, which is a continuing care retirement community in Shelburne. We have about 375 residents who live there. About 72 of them are in our health center, which includes residential care, skilled nursing and memory care. And then we have about 300 residents who are living in independent living in very stages of ability to be living independently. Usually as they, as their needs grow, we move them over to residential care or skilled nursing or other services that they need. I did send the letter. I won't go over too much of what was in that, but suffice to say that we were concerned when we saw the, the language in H742 specifically related to people being able to resign voluntarily from their jobs, if they were feeling, I'm not gonna get the language exactly correct, but if they were feeling at risk of contracting COVID in their workplace. And certainly as a senior care community, we are probably, if you look at how OSHA defines workplaces, we're probably a medium to high risk workplace. And some of what OSHA requires of employers to keep employees safe includes access to PPE, which you've heard now over and over again, the limited supply of PPE, I would just echo that. And we're in a situation as well where we have some residents in our health center who actually have non-COVID contagious diseases or contagious viruses right now, RSV, pneumonia, the flu, other things. And so we're using PPE on a regular basis. So, we just got a hundred gowns the other day, which is our monthly allotment that we are allowed. And with three patients with other contagious diseases, we'll be going through that pretty quickly. So we're trying to sort of keep what we can. At the moment, we have no COVID cases at Wake Robin, although I just got word we're testing someone in the health center this morning and we have had been testing people. So we're hoping that we can continue to have no cases, but we are under no illusions that that could be our future. And so I think just our concerns are just again, that if we start to see people who are leaving because of the unemployment benefits tied to the fact that we are a workplace that probably there is some higher risk, that it just felt like we needed to try to, I'm not in any way begrudging what's happening with unemployment, I'm just thinking about how we can really honor the people that are coming to work and staying at work who don't have the ability to remote work. Certainly where we have employees who can be working remotely, we are, but we need housekeepers and dining staff and security staff and others to be on site every day. And so we really need to keep our staff. Something that we have been able to do, we had received a grant from a foundation to use for transportation assistance for some of our employees, which is one of our highest needs that employees have articulated. And we got permission from the foundation to repurpose that grant. We just got that permission late last week to repurpose that grant to use for a salary bonus. We went $3 an hour for anyone who was actually coming in every day and working on site, which is sort of a start that's still for our, we have salaries, the group that I was referring to in my letter as anyone earning between $12 and $24 an hour. The unemployment is more advantageous for them. Even with the $3 an hour bump, we don't really get there, but people absolutely appreciated it. We've also applied for one of the payroll protection loans through the SBA. And if we were to get that, we would actually use that to supplement salaries to be able to keep people as well. So, I think I wanted to just raise the issue as an essential employer providing healthcare to a number of really vulnerable seniors that were just certainly challenged as well, trying to keep people who again are, their kids are at home now, they may be caring for other vulnerable people and the risks are pretty high. Other things that we're starting to do is we're looking for some housing for staff who if we do have a COVID case and they need to be caring for the person, is there some housing that we can be providing to, so they don't have to go home? We're now going to be providing uniforms to all staff so they don't have to work all day in their street clothes and that they can sort of take off uniforms and we'll wash them every day. We're providing, now all of our staff are wearing at least cloth masks, which had been made and donated. It's the best that we have and the best that we can do. We're providing free meals to staff who are working access to some limited groceries if they need them. So we're certainly looking for really creative ways to keep folks feeling appreciated, especially in these really difficult times, but anything that you can do, in my letter, is there a GI bill that we could have right now for employees sort of on the front lines that are working in essential workplaces that we collectively or the state could craft to really support frontline workers. So I'll stop there. I appreciate the opportunity to just echo what all of my other colleagues have been saying this morning, it's a problem and I would hope that collectively we could really look at ways to really honor the incredible work that's being done by the frontline workers right now in all of these workplaces. Thank you. Thank you for that. I think you did send your letter. I think that members of the committee may have received it, but what would be helpful is if you would please send it again to Nellie and then it'll go up on our webpage and constitute your testimony. If you have any additional comments, add those in. That'd be great. Okay, great. Thank you. For us. I'm gonna have to step off soon. I have a board meeting at noon, but I can answer any questions as well if folks have any. Questions, folks. I think we're good. Okay, great. Thank you so much. Martha, thank you very much. You're welcome. Appreciate it. Good luck. Thank you. Thank you. You're awesome. Thank you. We're moving into the substance use disorder services. I think there will be some continuity but also some overlap with what we've heard. So I'm gonna ask both Tony and Grace and I'm skipping over Bob Bick because he gave us his testimony earlier to be as concise as possible. So that's a heads up. Before we get there, I asked Laura Pelosi to come in and provide any updates on workforce issues within your area. So Laura, why don't you go ahead? Good morning, Senator. Thank you. Nice to see you all again this morning and all looking healthy. So far. Yeah. So you just heard from Wake Robin, which is a member of the Vermont Health Care Association. So a couple of things. I think Martha's testimony really hit on something that we started to talk about late last week. I think it was Friday morning and the impact of the unemployment insurance benefit with respect to the ability of providers to retain staff. So we are seeing that this is becoming more and more of an issue. I have been in communication with the administration because these are costs that additional costs and burdens on top of PPE, on top of sort of normal preparatory things, but these potentially significant labor related costs that facilities have to invest in to try to retain staff is an immediate need. So I'm working with the administration right now to figure out how we might be able to get some funding and reimbursement to facilities for those costs. I think it's gonna depend on the type of provider. Nursing homes are complicated because of their rate setting process. And then our ERC and ACCS providers already have pretty significantly low reimbursement rates to begin with. So it's probably easier for the state to address things for Medicaid providers, but for a provider like Wake Robin, it's a different scenario. They're under the exact same pressures with their revenue streams and having to increase costs to support their workforce. But it's not clear yet on how that might get addressed at the administration level. So the question I would have is some of this will definitely, I would say, definitely require some kind of legislative action either in reducing pressure and reducing pressure. So as you're working with the administration, that's very valuable, I think, to everyone who's in on this call. But also with your expertise, it would be very helpful to know what you identify as legislative fixes. And we're gonna be looking at that as well, but it's nice to have a little team approach going on and we appreciate your investment in this. No, I appreciate that. And I think part of what we're trying to do is identify what can be done under the existing structure and what we might need your help with. So that's the purpose of the conversations. And just FYI for everyone who's listening in on the call, that whatever we learn, we have to do, it becomes an emergency piece of legislation. This has to happen yesterday. So that just heads up. And I will just quickly pipe up on, but I represent Bayata Home Health and Hospice. As you know, it's a similar issue for the home health agencies and Jill Olson and I are continuously talking about it there as well. So it's a continuum issue for sure. All right, thank you. Laura, thank you very much. And please keep us posted. I will do that. Thank you. Thank you. Okay, so we're going, we are going to be able to move on to substance use disorder. And Tony Folland is here as well as Grace Keller. So let's start with Tony and why don't you, where are you? Tony, Anthony Folland is here. I see your name on the screen. Tony there. Let's move on to Grace Keller. Can you hear me now? Yes, I can. Thank you. Okay. My apologies. I'm computer literate in many ways and trying my best to make this work. Okay. Well, this, you know what? This whole process is going to make us all that much more technologically aware. So that is correct. Why don't you introduce yourself for the record and then do we have any testimony from you? No, ma'am. I didn't provide written testimony because I wasn't entirely sure what folks were hoping for. So I was just going to give kind of an overview of the current status of the SUD system and the remediation steps we've made to try to balance the needs of treatment versus the risk of disease transmission. Okay. That would be helpful. And we are a little bit under a time crunch. So I think moving to the second part. Rather quickly would be very helpful. Certainly for the record, my name is Tony fallen. I worked for the Vermont department of health division of alcohol and drug abuse programs. And my formal title is the clinical services manager as well as serving as the state opioid treatment authority, which basically means I have oversight of the hub and spoke system. Thank you for having me. I think to do the second step in is really what we've tried to focus on is the balance of risk. We know that a substance use disorders on their own are a lethal illness. And we are trying to balance the lethality risk and the risk of serious, you know, injury to people from their substance use disorders versus also trying to be respectful and ensuring the risk mitigation strategies related to COVID-19. So in many ways, that's taken on a depending on the level of care that we're providing, that looks a little differently on an outpatient service system. And I'm aware folks had already talked earlier about kind of the extra undue burden that is faced by people who probably have lower pay scales and job duties that require them to be on their own. So we're trying to balance the level of care that we're providing versus being able to provide tele-remote services. To every extent possible on our outpatient services, anybody who could provide remote care, we have offered to provide remote care. So for the most part, our substance use services are being provided telemed and through telephone calls to try to ensure that we give support and stay consistent with the governor's stay home and stay safe directive, that if we can reduce the amount of burden on people by coming out, we're hoping we'll flatten the curve. And residential treatment services, which much more is akin to, as Ms. Maxim had spoken to, one of the things that we've tried to do is that's really a revamp of services. Historically, those have been really built around people kind of coming together, you know, communal meals, communal everything, and the support of one another. So we've really had to reduce the amount of admissions so that we can get to the point of six feet distancing to ensure people's safety. So it has put an extra burden on the service providers to reduce their number of admissions so that we can ensure the safety of everybody who is currently admitted. So it's really now as somebody leaves the services, we're able to admit a new person, but a lot of the internal structures that people were describing in kind of nursing home settings or subacute rehabs is really what we've had to do in our residential treatment program. In our outpatient medication programs, and Grace will speak to this, I'm sure, related to Howard Center's safe recovery program, what our real goal was to balance the lethality risk, particularly of opiate use disorder and the insurance of making sure that everybody received life-saving medication at the same time as reducing COVID-19 exposures. So we assembled all of the medical directors from all of the clinics. We walked through kind of a group process of how could we reduce daily traffic visits. We looked at anybody who was stable currently on their medication. We gave them maximum doses of duration, knowing that they could be safe and we could monitor them telewise to make sure they continue to do okay. And we risk stratified every kind of individual down to the people who were the most unstable and still coming in every day for medication. And we actually, to every extent possible, have moved them away from everyday dosing, most often to every other day, with the exception of a very small cohort of people who the risk of the other substances they've been ingesting in conjunction with the medication we're offering them actually had a higher lethality potential than the COVID-19 exposure. And we really needed to make sure that they're safe by seeing them frequently. As they stabilize, we are moving them out to less and less frequent visits to try to reduce the average daily census and the number of people that are being exposed. We've been fortunate that our federal partners have been really quite outstanding in this, I'll say. Historically, in order to start somebody on any form of a narcotic replacement treatment, they used to have to have a face-to-face visit. In order to reduce face-to-face visits, the Health and Human Services has given us a waiver on that nationally so that we can actually start people. Initially it was by telemedicine. Now it's actually down to a telephone call if necessary to be able to start somebody on buprenorphine to limit the exposures to the healthcare provider. And for individuals that needed medication out of the hubs, particularly methadone, historically it had to be the patient that came and picked up their medicine. We've now gotten the federal government to agree that they could have a proxy safe person come and pick it up. If they are in fact quarantined or at a risk level to the other patients for themselves. And last but not least, I want to thank our partners at Medicaid who set up a, not only have done some renumeration around the ability for folks to get Medicaid retainer services knowing that this is financial impact, but also by changing their processes which allows us to actually just do telephone support to people as a billable service for those folks who just don't have space time or any other kind of technology device. I think that's it. That's very good. Thank you. I think that this committee in particular worked very hard on the remote telephonic telemed piece that was passed in H742. And we're happy to hear that the extensions of that, the implementation of that is helpful. That is very helpful. Thank you so much. Well, that's good. Tony, we may have questions. I'm going to move on to grace and allow for her to provide some testimony. And I see that David Englander is here. Welcome. David, I'm. We'll see how far we get. I might ask for you to come back another day. I don't know what your schedule is like. And I don't want to ask that up front, but we'll hold that thought for now. And we'll move on to grace. Okay. Everybody. Thank you so much for having me. I'm grace Keller. I'm the program coordinator at Howard center, safe recovery program. For those of you who don't know, because it's been a while since I've testified in this committee, safe recovery is Vermont's oldest and largest. It's a state-wide program. We have clients that come from every county in the state. And sometimes as high as 30% of our clients come from outside of Chittenden County. We are located in Burlington, though. We're also the first and largest Narcan and lock zone community-based pilot site. We've distributed over 25,000 doses of dark and to this point. And I've trained over 1500 providers. On how to respond to. Overdose. And we're most recently, we started one of the first in the country, low barrier, Dupodorf being programs. That is set in the syringe service program. So we are still on the front lines. We have our syringe service program is open as the same hours. It was previously nine to five. Monday through Friday. We outfitted our back windows. So we are operating outside of the city. And we have a high volume. And we have a lot of 85% of our clients have been homeless. A lot of them have a lot of other health issues. So we really wanted to make them feel safe as well as clients. It's not doing safe. Really making them know that it's about them too. Protecting everybody in the situation. But we still have quite a few people coming. The exchange. And one of the things that I'm most concerned about, and then we can talk about the ways of mitigating it is yesterday, I got an email from the Vermont intelligence, the Vermont intelligence center assesses with moderate confidence. That there will be a surge in overdoses in the quarter two as a result of COVID-19. And as, as we continue to do that, But in the case of the Vermont intelligence, that's the Vermont intelligence center assesses with moderate confidence that there will be a surge in overdoses in the quarter two as a result of COVID-19. And as, as we don't have recent statistics, but the most recent is the statistic I have is that safer recovery provides 70% of Vermont's North Canada, and that's just to our clients and their family members. That doesn't count our training. So for our staff, it was really a high level commitment to stay open, sure that we're giving people Narcan in education. For overdose, one of the best mitigation strategies is making sure that people don't use a loan, that if there is an overdose, somebody is there with them. And obviously, while incredibly necessary, the social distancing puts people at higher risk for overdose too. So the way we're working on that is really making sure that people and their family members have Narcan. But also, our low barrier of guprenorphine treatment is on demand. So we're taking people in still. We're doing our guprenorphine program move remotely. But we're able, like Tony said, to now induct people over the phone and over Zoom, which has made a big difference. We have people coming out of the Department of Corrections that were either already our patients or new to us. And we're really prioritizing getting people on treatment because any day that somebody takes guprenorphine is a day that they're very unlikely to overdose. So we have staff on the front lines. I'm at the office today. There's usually two of us here. And really, for our staff, we've always worked with clients unconditionally. This is just part of what we do. It doesn't mean that people aren't very afraid. And we're really trying to mitigate that. And you really see it day to day. We lost more clients to fatal overdose in an 18-month period than we had in the 17 years prior to that combined in 2017 and 2018. So our staff has dealt with a high level of trauma around losing clients and know what that feels like. And then we had a huge success in reducing over to 50% last year in Chittenden County. So we're really just focused on trying to maintain, keeping people healthy. A lot of our clients don't have a ton of information about COVID-19 and how to keep themselves safe, especially since such a high level of them are homeless or have significant mental health challenges. So we're just really focused on engaging and keeping our clients supported during this time. Our low barrier program target population is really people that the traditional system that struggled in the traditional system, either through behavioral challenges or for mental health issues or other barriers like transportation or job. And so that's really where that focuses. So that population is also a harder, it was a more challenging population to serve remotely. And we worked really hard to make sure to get them telephones and access to treatment and access to recovery supports like peer support groups and things like that. But really just trying to make sure that we can get people into treatment as quickly as possible, that we can continue to support them and retain them in treatment when we have them in. And that we can work to keep people safe that either aren't able to engage in treatment or aren't ready right now. So that's pretty much what I wanted to get to. We have 170 individuals that we've inducted in our low barrier program. 91 are currently in the program. We've worked really hard for people who do stabilize that can be in the hub and spoke to move them along into a hub and spoke, the hub and spoke system. The 91 that are not our patients and will probably stay with us for an extended period of time because the low barrier model is working for them. And in that we've had a very high retention rate. We've only had seven people that we've had lost to contact out of the 170. So one of our focuses is and always has been reaching out to people, making sure they have case management and counseling and wraparound support. And that hasn't changed in light of COVID-19. We haven't heard from somebody really trying to make sure that we know where they are, what they need and getting them the services that they do. The state has been great about getting people housed to our homeless and putting people in hotels and that's been a huge relief to all of us and to our clients. So we're very grateful to that. But I think that that's, I'm trying to get you it all as quickly and as densely as possible. If you have questions, feel free to reach out or ask me. Great, Grace, that's amazing. The work that you're doing, thank you for your testimony. If I don't wanna ask you to put this in writing right now, but if there are additional, if there's additional information that we need to know, it would be great to have you share it at some point. But the question I was gonna ask was how many folks you've lost and you said seven, that's a pretty minimal number. And does that represent the entire state? Well, we've lost seven to contact. So that's not retained in treatment for the low barrier program. As far as, yeah, it's just low barrier, just seven people, but that's a high engagement rate and that's something we're really proud of. That doesn't include three that have passed away. We don't consider them lost to contact, but they have had three people in that system that have passed away from various issues. It shows you that getting people into treatment that are people who struggle with opiates to sort of are very high risk to die from anything and really keeping them in treatment is critical, especially at times like this. Thank you, thank you for that. I'm sure you're interested in hearing more as time goes on and thanks for the time that you've given us today. Appreciate it. Thank you so much for having me. No, it's great. Any questions, committee, for Grace or Tony? All right, I know that Chad Viger is on, but I'm gonna have to hold you over for another day with apologies, your request did come in late to add to the testimony and we will want to hear it. So let's make sure that you stay in contact with us and we can put you on another agenda. And David, you are here and we have only six more minutes. So I'm gonna ask you, David, the request that we had was to look at the health alert network and just to inform us about what that is. Honestly, if you have time on Friday, we also have some other questions. I think that you'll get an email about with respect to financing, but how much time do you need for the health alert network? I think six minutes, five and a half minutes is probably perfect. Perfect, go ahead. I can probably do this quickly and then I can take your questions to the extent you have them. So the health alert network is somewhat of a misnomer to the extent that the network itself. We can't hear you. Oh, at all? Now I can. Now I can't, you're muted. How about now? Perfect. Perfect. Okay. So the health alert network is the means by which the Department of Health and the CDC distribute information primarily to healthcare providers on a different subject matter. So the network itself is somewhat of a misnomer to the extent that we don't think about the network. It's just the means by which we distribute information. So somebody might say in the hallway, we're working on a HON, a health alert, which simply means a release of information. And a HON, and I'll just, so I sent the committee a link to all of our HONs. They are publicly available, but they're not released to the public. They are typically targeted piece of information for the relevant audiences. So this is a HON. This was the first HON sent to the noble coronavirus. This is January 23rd, 2020. And this was sent to any person, any healthcare provider who might come in contact with a patient who was displaying symptoms as we knew them at the time of having a coronavirus. So there's a, I'm just looking at it very briefly. There's sort of a summary of this is what we knew. There's a novel, this is before it was named COVID-19. This is, there's a new, there's novel coronavirus. It's coming out of Wuhan. And it provides information specifically to the healthcare providers to identify and evaluate patients who might have this. So for instance, at this point on January 23rd, when there was one death, I'm sorry, there was 18 deaths and there was one case that had been reported in the United States two days before. It asked all healthcare providers with patients who were presenting any kind of upper respiratory element or fever if they had been traveled, if they'd been traveling recently. Because at that time, that was a relevant question, of course, since then it is no longer relevant. In more typical times, a health, a HON would be, let's say for, there could be a pertussis or a measles outbreak. There was a measles outbreak, folks will recall, last fall. So we sent out a HON to all healthcare providers saying, if patients are presenting with a fever, you might consider whether it's measles, would you might otherwise think that it's the flu or that it's some other ailment. We have various lists. So we have listservs for HONs. So we can, they can be broadcast, they can be broadcast out to everybody who is relevant, but not to everybody as a whole because we wanna make sure that healthcare providers specifically or the intended audience is getting that message. So first of all, the thing to know is, they are sent to a specific individual email and they're sent, and they're also, there's an automated phone call that goes out to all those, all the intended recipients. So in the case of coronavirus, just over 39,000 people in Vermont are getting calls and email saying, here's some relevant information to you. So for instance, I'm just, so it goes out to the 24,000 nurses, 4,000, 4,000 pharmacy, licensees, you know, 5,000 doctors and so on. But for instance, a health, a HON concerning pertussis wouldn't necessarily go to an audiologist. We wanna make sure that we're getting people the information they need and not information they don't because we don't wanna overload folks. You did it. As usual. I'd be delighted to take any questions. He's got a whole minute to spare. Questions committee and we'll extend it to Grace Keller as well, she's still here. Senator McCormick, you're on mute, Senator. I just meant one, we asked one minute for questions. Maybe you have a question for Grace, actually. Go ahead. Yeah, so Grace, I would imagine that you're, the folks who work at Safe Recovery probably have some, maybe they're a little more high risk than some other folks anyway, right? Because the clients that you deal with, the patients that you deal with, is that, I mean, would you say that they're probably a pretty hearty group, the folks who work for you anyway? But my staff, you mean? Your staff, yeah, your staff. Yeah, the staff at Howard Center Safe Recovery is really mission-driven, really focused. We have a lot of clients, a lot of staff with lived experience. Both themselves are familiar with the experience. And there's very few jobs in harm reduction in the state, so they're quite competitive, and we have longevity here. We have a high tolerance for behavior because we feel like we provide life-saving services. As a result, we have very low safety issues that are building. We've only had to involve police or anybody for safety twice and both of them weren't a client. So I think because we really try and work with people and meet with people where they are, we have a really great rapport with our clients, but our staff is, harm reductionists are used to moving quickly, are used to adapting in situations like this. So it's never, nobody's ever prepared for COVID-19, and I don't take it lightly what my staff is going through. But the overdose crisis for us, I mean, we've had 18 or 19 overdoses on site where I've had to do rescue breathing five times. All of those required in our can. So nobody's prepared for what we're dealing with, but we do have a hearty crowd at Howard's, but our safer coverage, that's for sure. Yeah, okay. Great, thank you for the work you do. Thank you, yeah, very much. Thank you. Any other questions? David, you are now exactly in style and what we all need to do when we go outside and become less isolated from the public. Please. We will. First job is, we as a committee, we don't have masks. I don't know if anyone on the committee has a mask, except for Senator Westman. So we're going to have to put an order in so that we can have some protection. Oh, Senator McCormick is ready. All right. I do have a neighbor that takes orders. Okay, we will be in touch about that. Listen, I know that we had an overly full agenda this morning. Everything that we heard is absolutely key and important for our moving forward. As we look at the funding issues and what our priorities are and how we can establish some criteria for that in working with the Appropriations Committee and others and economic development and so on. This was extremely valuable information. I wanna thank everyone who continues to be on the Zoom with us and Chad, I know you're there and it would be helpful for you to get back in contact with Nellie and Nellie Marvel and Julie Tucker so that we can put you on another agenda. All right, folks, we do not have a meeting tomorrow. We're on the Senate floor tomorrow morning. I believe the time's gonna be 10.30, but don't hold me to that. And then on Thursday, we have a full morning and on Friday, we have a full morning. I have tried to leave some time for committee discussion. So go through the information that you've received to date and try to find some recommendations that we might be able to think about going forward. Thank you all. Any last comments? Thank you. Okay, good. Take care, everyone. Thank you. Thank you. We're finished.