 Good morning. This is the Vermont House Human Services Committee and it is Wednesday, January 5th, and we are starting our sort of budget adjustment testimony as well as testimony around what what's happening in various departments as it relates to the pandemic and how that has happened. We're starting off today with the Deputy Commissioner Kelly Gowarty from the from the Department of Health and Kelly, Deputy Commissioner apologize. I'm trying to be more serious. Happy New Year and please go ahead. I don't know if you have anything written for us that we should either you can pull up or Julie can I don't have a formal presentation but I do have some remarks that I can start out with. Okay. Good morning, everyone. I believe that I've met all of you before again I'm Kelly Gowarty and I'm Deputy Commissioner at the Department of Health and welcome back. And thank you for allowing me to address you all today. As you probably are well aware we've been addressing to epidemics over the last couple of years not only the COVID-19 pandemic but an epidemic of opioid overdoses as you are probably aware we've seen an increase since pre COVID era and I want to assure this committee as well as all Vermonters that the Department of Health, even throughout the COVID-19 response has never taken its eye off the ball so to speak with respect to addressing substance use issues. We on the contrary have actually stepped up a lot of our overdose prevention activities during COVID-19 as we saw overdoses and deaths rise. And this is even with, you know, many of our staff at the health department being deployed to COVID-19 activities. But with respect to the staff who are working on substance use issues, although many of them were deployed it was for partial effort, meaning not full time, so that they could continue with their other regular duties. And it was time limited and ADAP was able to be pretty strategic with respect to how they use their staff resources so that we were able to keep up our efforts with substance use, addressing substance use. 100% of treatment providers remained open and available during COVID-19 so we didn't see treatment services with the exception of when there were outbreaks in residential facilities that, you know, prevented admissions. Treatment providers remained open and available. And there were some relaxation of the medication assisted treatment rules that allowed flexibility with respect to people being able to receive their methadone in more flexible ways that allowed continuity of care for treating opioid use disorder. And our recovery centers quickly pivoted to online services during the lockdown. And although it's not ideal because the connection, the personal connection with other people is so important for people in recovery and struggling with substance use. But they were able to do some outreach and stay in touch with at risk clients and maintain connection with recovery supports. But like I said, you know, our overdoses as with everywhere else in the country have increased. And we saw a record number of overdose deaths in 2020. And unfortunately, 2021 is not looking better. And like I said, it's a national problem. We're seeing an increase in methamphetamine in overdoses. We're not sure if methamphetamine, we're seeing overdose deaths involving methamphetamine that also has fentanyl in it. So we don't know if people are intentionally using these things together or whether people are using methamphetamine and not knowing that it's laced with fentanyl. We're also seeing, it's not huge, but there's been some use of xylazine, which is a veterinary drug that is used as a sedative for horses and other non human mammals and we're seeing that start to show up. And we're just seeing very, very potent substances in the drug supply. So far this year 100% of our overdose deaths involve fentanyl. So it's a huge problem. And, you know, our ADAP director Cindy Sebrite sits on a lot of national committees and, you know, is in a lot of contact with her counterparts in other states and I can assure you that there is not one evidence based initiative that we're not doing here in Vermont. You know, we're really trying to do everything we can to address overdoses. The other thing I'd just like to point out is that we don't know how many of our opioid overdoses, overdose deaths are suicides. In the absence of, you know, a note or something like that, you know, we just don't have that information. And I think we all know that the COVID-19 pandemic has really impacted people's mental health. So, you know, a lot of anxiety, depression, and so we're just not sure how many are suicides. So I can pause for questions or I can just sort of run through some of the overdose prevention initiatives that were undertaking and some that we've expanded during the pandemic. Should I continue? Deputy Commissioner, I'm doing a quick look to see if someone has a question right now or whether we want to have you go forward. I think we're good with your going forward with some more discussion in terms of that. I might ask, of course, I have a question before you start. Yeah. Just for sort of level setting, you were talking about how staff were deployed, but not deployed full time. So, and actually we have another question too. But in terms of being the staff deployed, are they all back full time in the jobs that they were hired to do? Or are there staff that are still doing, in what job description language is other duties as a sign? There are still staff who are doing COVID related work. So if you could, if you don't have it now, if you could please provide us with a list, not of the names, but of the positions and their role and how much they are being deployed to do something else. That would be, I think, very helpful. And are you asking just for the division of alcohol and drug programs? At this point, for, yes, but to be honest, we are interested in, or I am very interested, and I think I speak for the committee, what are the personnel resources that are being deployed? Because I am, the health department has been doing Yeoman's work and I'm concerned with what is their ongoing work and how that is being impacted, if not the work on the staff doing double duty. So, I seem to have opened up the floodgates representative would. Thank you, Madam Chair. Deputy Commissioner, if maybe when you're going through the list of resources and tactics that you're deploying, if you could update us on the, on whether the ER hospital quick response referral is, if that's still in place and all the hospitals, I know it had expanded. And if you could also tell us about if there are any special targeted outreach to folks in more rural places, given that places like Lamoille County having, you know, the highest rates of overdoses. And also we saw a, unfortunately, a big chunk of folks leaving the women's correctional center last year, who died of overdoses as they left and whether or not there's any special outreach and coordinated planning with releases from the correctional facility. Thank you. The $12 million that Senator Leahy secured for Vermont and how that is impacting our, our response how is that all string up what we're able to do. That would be great. Any more questions what I would encourage the members of the committee. As we have questions, why don't we write them down and let the Deputy Commissioner sort of begin to outline some of the initiatives that they have taken. And we'll have that ground to work from. Okay, that sounds good. So some of the things that we have been overdosed response activities that many of which were in place before but we're enhancing COVID-19. The first ones and one of the most important ones is naloxone distribution or Narcan. So we really stepped up our Narcan distribution and EMS now carries Narcan and they will are required to leave it at the scene when, when they respond to an overdose, or even if they, you know, suspect that there may be drug use happening so they're leaving the naloxone at the scene. We are distributing what we call harm reduction packs, which are, you know, include Narcan include fentanyl test strips include some supplies some resources written resources on how to access treatment. We're distributing those far and wide, including to the general assistance motels to social service agencies all over the state so that people have those resources available to them. We have some first responder cards that we developed that first responders carry that they can leave with people that are just quick and easy resource cards for people to access services. We've expanded the syringe service programs have expanded their mobile services so now all of the syringe service programs in the state offer mobile services so that people can not only get supplies so that they you know if they're using can use safely, but also it's a connection and a support that can connect them to treatment. Deputy Commissioner I'm realizing I'm realizing as you go through these that maybe it makes sense that as you talk about each initiative that you take a breath. We see if their questions related to that initiative. And then we move on to the next one. And if I may start with the Narcan and the locks on you said it's being distributed to all EMS. So these are the volunteer ones as well as the EMS that are attached to fire departments. Correct. And are they being distributed for free. Okay. And the harm reduction packs that you're mailing out. Are you mailing, where are you mailing them out and in what languages. Oh, that's a great question. So, there are 74 sites around the state that distribute the harm reduction packs. So the syringe service programs distribute them hospitals, police departments, we have we have them out in the probation and parole offices, women's shelters shelters for those experiencing homelessness treatment and recovery facilities like I said the general assistance motels. And they include, like I said, Narcan informational materials about 211 and about safe and safe injection practices. Sanitizer face masks. A mouth barrier for rescue breathing so that if someone does overdose they can safely provide them with mouth to mouth if necessary. I do not see information fentanyl test strips. I do not know how many languages, the materials are in but I can certainly find that out and let you know, I would imagine that we have translated materials but I just want to double check that because it would be important and I don't know in terms of your information and data in terms of where or who is overdosing and whether there are particular populations, communities of color, new Americans, other groups and how we are targeting them. I'm also curious and this will age me. A long long time ago the health department had a wonderful initiative around AIDS, and they put material in bars, and they put wonderful posters in bars. And I'm wondering if any of the harm reduction packs are available in. Have you made them available to places where people may party. You know, I don't believe so but let me, again, I will double check that. Does anyone else have questions about. The second one you were talking about was. I'm sure I do I just can't get my hand up. Okay, okay, go ahead, representative McFawn. I just have a question. I'm sitting here listening to all of these good things that we're doing. And I'm saying to myself, this may be kind of a weird question but how do we ensure that we're not supporting a drug culture. And what do you mean by providing safe. Everything that you talked about. But, but it seems like. Anyway, I believe my question there. I don't even know if you can answer it but through my mind. I said man, it's like we're supporting this, you know in the in the motels and there are all these people just success. No, not all of them, but I'll do it. It addicts. I'm trying to figure out. Because there's going to be a line between providing help and assistance and counseling and all that kind of stuff to help people out, and then just flooding the place with everything except the drug itself. All right, well there's so the harm reduction services if you think about opioid addiction as an illness, and as something that, you know, people don't have control over so the idea behind harm reduction is that which is providing safe supplies is you I want to one prevent people from disease so by providing safe injection supplies you are addressing hepatitis C HIV and other bloodborne diseases that people can get if they're sharing supplies. So you want to try to prevent that if people are using. It's important that they have access to those supplies. Another point is that naloxone is a life saving drug, and it basically can stop it will stop an overdose in its tracks. And because of the proliferation of fentanyl and the drug supply which is so incredibly powerful and dangerous. I want to try to prevent people from dying if they are using drugs and I'm consciously saying I'm consciously not saying if people choose to use drugs because it does it be it is not a choice. So once someone is addicted it is if they don't use they become very ill. And so the other point I'd like to make is that providing harm reduction services through like syringe service programs is a point of connection for people to access treatment. So in this, you may be familiar with the Howard Center safe recovery program in Burlington, where it used to just be a syringe service program, but then they brought in providers who provide medication assisted treatment buprenorphine. So people coming to safe recovery to get Narcan to get fentanyl test trips to get safe injection supplies. It's a safe place for them where they feel comfortable and where they feel welcomed and so when they are ready to access treatment, it is available right there and that is actually a program that we're expanding across the state to embed treatment services in syringe service providers because we know that it's a place where people feel safe and welcome and respected. And so the ultimate goal is to connect people with services. I realize that I just have one more thought fentanyl. I know that the governor every week has a conversation with other governors and the president. So, fentanyl is one of those drugs that at least if you listen to the news that comes across the board. Has that to your knowledge, and I don't know whether you attend the cabinet meetings or not, but do you know of any efforts that are being made to stop that. Yeah, I mean it's a. It is and and some of it comes from overseas some of it comes, you know, across our borders from, you know, the southern, you know, from Central America. And, and, you know, there is the, the DEA and the high intensity drug trafficking entity that really keeps an eye on that but it's, it's just very difficult to control so I don't know specifically if that's something that the governor has talked other governors and the president about, but certainly I know that law enforcement is, you know, really doing as much as they can to try to stop drug trafficking, but it's really challenging. Thank you. Thank you, Deputy Commissioner. The other, as we move to the other initiative that you were talking about expand you said we expanded the syringe programs and they all offer mobile mobile, they're all mobile now as well. Do you refresh our memory as to where in fact are the syringe exchange programs. Yeah, so we actually lost a couple of physical locations over since before the pandemic. Some of them have closed, but they've replaced their physical, you know brick and mortar location with mobile. But they are, I'm going to just pull up. The list of them on our website. If you go to our treatment page it will list where all of the syringe service programs are I don't know all of them off the top of my head. But I know that we've got one in Burlington. Well we've got a couple in Burlington we've got Vermont cares and we have safe recovery. There's Rutland, the Brattleboro location went completely mobile. There's mobile services through Vermont cares through the Northeast Kingdom. And then I believe there is a physical location in Springfield but I can send a link to where you can find all of those physical locations. Thank you for joining us after the meeting today. Thank you and we think we have another question related to this from represented small. Thank you madam chair and thank you deputy commissioner for coming in today. And talking about expanding access to syringe service programs. I know statue currently limits the organizations that are able to provide syringe service programs to a service organization. And health care providers and thinking about expanding mobilization. Have you also thought about expanding to community based organizations or other areas where folks are working directly with those at the highest risk. Yeah, I think that as much as we could expand would be wonderful. The mobile services helps because, you know, they travel through communities and so it's not limited to necessarily the specific brick and mortar location. But I think that being able to expand that would certainly be something that we would be interested in looking at. Great. Thank you. Deputy commissioner I think you can go on. Okay, great. Um, so we also have expanded our overdose messaging campaigns. So someone had said something, I believe it was representative would about sort of how we're reaching particularly rural communities so right now we have a media campaign that is called No O.D.K.N.O.W.O.D. and it's targeted to to people who are at risk so and they're their loved ones. So you may not have seen this messaging because it's, you know, social marketing that's targeted to, you know, specific demographics. But it is an overdose awareness campaign that gives overdose prevention tips and also information on harm reduction so really targeted to sort of get the word out that, you know, here's what you need to do to try to prevent overdose. Any questions about that before I move on. Deputy commissioner you said this was the initiative was directed to at risk populations. What are the populations that the health department has identified as at risk. That's a great question so typically it's you know, young adults and folks through their 50s or so so you know sort of that young adult to middle age population. I don't know if it's particular demographics because as you all know this is sort of a statewide issue. But I can find out from our marketing team, you know how they identified who this who's receiving these messages, but they do extensive sort of market research to figure out how to target these messages. Thank you. So, a large grant that we have from the CDC called overdose data to action, we've been able to provide community action grants to specific communities that have been particularly hard hit with overdoses so that they can mobilize local resources to address these overdoses so I'm looking to see if I have I believe it's Rutland Windham Windsor counties but I can follow up to see which specific counties but kind of trying to get money out to community based organization so that they can do local outreach and information because they know sort of the folks in their community that that they need to reach so that's been a big help. I'm curious that this is fabulous information. Are those grants thanks to federal funds. Yes, and how did I mean, and are those federal funds going away, or how much are those of those federal funds are left so that some other communities could access. I don't know how much is left right now but we expect this grant to continue. It was a five year grant and I believe we are in year three. But we expect the grant to continue particularly given what we're seeing across the country with overdoses and it's a CDC grant and you know they've been really the ones who have been putting out the information and the data about the overdose crisis so we expect the funding to continue. So we would certainly consider more community more grants out to communities through that grant. So that's something that you send out to the local districts or to do you send it out to the local health department, you know, count on, or is that something that you somehow. It's to community organizations so you know we would put out sort of an RFP and they can apply to get those funds. We targeted in this first round the areas that we're really seeing the highest amount of overdoses so. I think this may change just given some of the changes we're seeing representative would mention lamoille. So that could be a potential area. Representative Whitman has a question. Thank you. Thank you, Deputy Commissioner. Just quick question following up about the community action grants we actually were awarded some in Bennington as well and I know that there's a lot of different initiatives that were sort of based on I think specific to communities. And I was wondering if there is going to be sort of a point where different, you know, counties that were awarded these grants could sort of compare notes and come back and see if something could be applied statewide. That's a great. That's a great idea and actually one thing that we did during the COVID. Well, we're still in COVID. During the pandemic was we did round tables across the state and every district, every health department district, specifically around overdoses and what communities were seeing what kinds of supports they, they might need. And so what we're doing is we're taking all of those round table experiences all of those notes and kind of synthesizing them and one of the very reasons is so that we can sort of share best practices across the state and if some communities are doing something that they're seeing some success with or just sharing ideas. So I need to loop back and see where that work is now because it's been a little while since we wrapped up the round tables. But when we started really seeing, you know, these overdoses spike we were like we need to connect with communities and not only to hear what they're seeing, but also to find out what we might be able to do to help so. But like I said, another goal was to sort of be able to share best practices across the state. So that's a fabulous idea. Thank you for the question also. I think in, I think, Royal we discovered this committee in particular, but probably others would be really very interested in that synthesis as well as it might. Suggest some legislative direction or it might suggest some funding kinds of things. I'm going to ask a question that if representative brumsted had her hand up I bet you she would be asking, because she's are are guru in terms of results based and other things like that. When you're distributed to grants when what kind of evaluation or reporting do the individual communities have and and is this so new that it's way too early for them to be reporting back. I don't believe it's too early for them to be reporting back and and anyone who's received a grant from CDC knows that that they do always require an evaluation component and and we would anyway as well because the health department we are really data driven and data based so I don't receive those reports directly but I can certainly go back to the person in the health department who manages that grant and find out what the status of those activities are. Thank you. Are there other questions for the deputy commissioner around the these grants, this this this initiative. Okay deputy commissioner, we keep. So, another thing that we got during COVID was there was a SAMHSA COVID emergency grant that we received SAMHSA's this, you know, substance abuse and mental health services administration. So, that provided funding for us to help expand access to services so like telehealth, being able to provide telehealth services through the pandemic be able to provide that equipment to folks. It also, we've been working with mental health to. So you may be aware of Vermont help link, which is our substance use resource center. It's a website and and phone number. We were able to expand and be able to use Vermont help link to provide mental health linkage to mental health services for healthcare providers. Because we know that our healthcare providers are experiencing high levels of stress and burnout so we were able to add that to our Vermont help link service. That's been really helpful to allow the COVID emergency grant in general has been very helpful to be able to keep remember I said all of our services remained open that was a big part of that. I already mentioned the MIT and SSP co location project and so we are right now. The AIDS project of Southern Vermont and Vermont cares are going to be expanding to have MIT available. The blueprint for health and Ada is working with an organization called better life partners and becoming an office based opiate treatment program in Vermont. And they've developed agreements with syringe service programs and so that they're actively receiving referral so that we can, you know, better link people who are accessing SSPs to treatment. So, like I said earlier we're really trying to expand that safe recovery model to other SSPs across the state. So stay tuned because there will be more on that in 2022. Any questions about that. I'm just curious, Deputy Commissioner, who or what is this group that you that the Health Department is contracting with. They are an organ, they're an organization out of in the Dartmouth area. And I can find out more information about them but they're providing opioid treatment services in New Hampshire, and along the border so I believe that they are connecting with our SSPs along the in the valley, so that we can better connect people who are accessing services through those SSPs to opioid treatment. And I'm going to. Is this a nonprofit is this a for profit is this a group of is this a part of a national corporation is this a group of providers what I don't know the answer to that let me I can find out the answer to that I believe that they're just a private practice but let me find out for you. Okay. So is this part of the initiative to ensure that there is sufficient MAT across the state. It's yes, yes, and it is also like I was saying before when we were talking about SSPs to try to better sort of make MAT sort of connected to the SSP system, so that people who are actively using and getting services through the SSP have a very easy path into treatment. Okay, that that helps so that I'm just because it's been way too long when you're talking about MAT are you talking about buprenorphine and methadone or just okay. Yes, but yeah, but at the SSPs like it's safe harbor. And other SSPs, it would be buprenorphine because the to be able to provide methadone. You have to be a, you know what we call in Vermont a hub. There are lots and lots and lots of federal regulations that and you know sort of facility requirements that you have to meet in order to provide methadone. So these MAT connected with spokes would be buprenorphine. Could you refresh our memory as to where exactly are the methadone hubs. Yes, they are across the state. Let me pull up our directory because I don't want to leave any of them out. I obviously have them in Burlington. There is one in St. Albans there's one in Rutland. There is up in the very area. There is Brattle borough and how many was that there are eight. And I presume I'm from Chittenden County. I presume when you say Burlington you actually south Burlington. Yes. And do the hubs provide both methadone and buprenorphine or are those identified eight sites only providing methadone. They can provide buprenorphine but often people who are transitioning to buprenorphine will go to a spoke. Okay, thank you. We have a question. We have a question from Representative Bromsted. Thanks Madam Chair. I am always interested to hear about expansion of opioid treatment services and hearing more about the folks that you're working with in New Hampshire is interesting. I also, my question I guess is that we have a pretty big motel population of the homeless transit that are involved in the homeless transition programs here in Shelburne. And the rescue is overwhelmed by the number of calls they receive at sometimes four times in one hour. And it's mostly much of it is around the opioid use in the, and I just wonder are you. Is there any specific reaching out. I definitely heard about the kits and that's great that they're going to those sites and is there some training of how to use it at the site because I wonder if it's just sitting there. And how it's, maybe it should be going to rescue but it sounds like it's doing that to their level is what to do. If it's not emergency room needed, and how to help the, even how to help the mental health of those who are not, who are just witnessing what's happening. And so, I'm just, yeah. That's a great question and you know, we know that that's a huge problem, not only in the, the facility in Shelburne but also at, you know, many of the motels that are being used to house people who are experiencing homelessness, which is why that was a huge sort of effort to make sure that these harm reduction packs were getting to the GA motels. So as far as training. Do you mean of the staff or of the residents or maybe a little of both because some places have staff some. Yeah, yeah, you know, those are the. That's my concern is like could you put up a poster that says you know on Tuesday will be here to show you show anyone who's interested how to use the materials in this packet or something like that because I do volunteer at the days in and I've seen the the boxes. And there's nothing. It's very hard to tell if anyone's even open them. Right, right. That's a great idea. Let me bring that back because I don't, you know, those, the packs are kind of sort of just drop shipped to all of the places that I mentioned before where they're going. And I don't know how much contact. The facilities, you know, if they have staff. They're sort of getting with our ADAP staff and we could certainly offer to go out and provide, you know, information and training. The materials that are in the harm reduction packs like there's like I said there's naloxone in there and it's their instructions that come right with it so and that's pretty easy to use. But if folks don't know that it's there or if they're, you know, if they're not getting out there, you know, then that'd be a problem. Another thing that reminded me of is that we were working with DCF, the Economic Services Division to establish more recovery or friendly motels. One in the Chittenden County area and then another in Rutland, because, you know, one thing I know and in my prior, before I was in this role, I worked for a domestic violence organization in Chittenden County and, you know, there were people that really served to, you know, when our shelter was full they would go into the general assistance motel program and one thing that we often heard loud and clear was that they didn't want to go to a particular place because they were in recovery and they knew that there was so much alcohol and drug use in the motel that it would be difficult for them to maintain their recovery. And so ADAP worked with ESD to help sort of, you can't really ban substances altogether in a motel setting but to try to really send people with those concerns like a facility that is more tailored toward people who want a substance-free environment, but certainly just given the crunch in housing and the crunch in the motel system, you know, it's probably kind of a drop in the bucket but at least it was a little bit of an effort. But I'll follow up on the harm reduction packs in the motels and, you know, how we might be able to make those more, make people more aware of them and also see if training would be, if folks would be interested in that. Thank you. Representative Small has her hand up. Thank you, Madam Chair. Going back to something you said earlier in regards to flexibility that the department has created around accessing MAT, are you able to share some of the learning that you've gained through this pandemic as to what that flexibility has allowed and people accessing the services that they need? Yeah, so we were able to, and it was in thanks to some relaxation of federal rules that folks were able to, and part of the reason at the beginning of the pandemic when we were, you know, in lockdown. I don't know if you've ever been to, I know Representative Small, you're in Chittenden County, if you've ever been to the South Burlington hub, but in normal times and pre-COVID times, you know, crowds of people, you know, showing up and waiting in line to get their methadone. And obviously we couldn't do that during the pandemic, have all those people crowded together. So there was expansion of take home medication, there was also delivery. So people were providing, delivering people's methadone to their homes. So that was really helpful, particularly if somebody was in isolation or quarantine because of COVID. But, and then just the expansion of telehealth with MAT, which, you know, it's a blessing and a curse because I think that we've seen, we've had some concerns about quality of care, you know, with substance use treatment and telemedicine, but for many it was really a lifesaver. And so we're waiting to see, you know, how, whether some of these relaxation, whether some of the relaxation of these rules will continue post COVID, because I think it could really make a big difference for people. And that relaxation is on the federal level, you're saying? Yes. Wonderful. And just a follow up question and thinking about how this is impacting the hubs themselves. Are we seeing increased wait times for folks accessing MAT? Or are we seeing the opposite as I'm seeing your head shake? Yeah, no, we don't have any sort of waiting list per se. I mean, people, you know, but we do know that sometimes it's difficult to access just because of transportation and the rural nature of our state. But if you want access to medication assisted treatment in Vermont, you can get it. You don't have to wait. I mean, you need to have sort of an assessment and evaluation. So it's not like I decide right now I want it and I'm just going to show up in South Burlington and get it. So you need to have an assessment and a medical evaluation and all of that, but there isn't like a wait list. So, Deputy Commissioner, how is that different from the what is available in the emergency room and what is available at, let's say, a place like safe recovery? Because my understanding of the assessment process on the hubs is that can be upwards of three or four days at the quickest. And so I might say I appreciate your comment that there's no waiting list. However, for someone who is ready for treatment three or four days is not access to treatment. Right. And right. And so I just want to make the distinction between what I mean by there's no waiting list is that there's capacity in the system to treat any, you know, treat people who need to be treated. It's not like there's a list of people who are waiting. But I take your point that it isn't immediate. So we have what we used to call RAM or RAC that access to MAT, we're shifting to call rapid treatment access, because we're expanding it to not just opioid treatment but to any kind of treatment. So, so the way that it works is three days or less from first point of contact with a treatment provider when an individual until an individual receives their first treatment service. So we do have in the emergency departments, people can be inducted on buprenorphine. If they present either with an overdose or they present and you know, are diagnosed with opioid use disorder, they can be inducted on buprenorphine. So basically to allow them to start to recover or not relapse or not use and potentially overdose again to tide them over until they can be evaluated at a hub. So, and so our goal is to get them connected with the hub within three days. I might call it low barrier access through emergency rooms is that same low barrier access, what in fact is available through safe recovery that you're trying to expand now. Yes. Yeah, so you know they would have providers available there, you know at the SSP so that when people were ready to access treatment they could be inducted. When we talk about the federal rules for methadone and other. Is there a caseload size. I am. I am aware, sort of informally that some of the hubs, for instance, the hub in the recovery area that counselors have caseloads of 75 to 100 people. And so I'm, and this is, you know, this is not evidence, you know, this is not testimony through the legislature this is through we, we all have friends and family. And so I am curious as to what kind of, I'm presuming that the health department is has some kind of contract with these or who is the area of this, you know, and so what kind of oversight is there and expectations in terms of staffing, etc. So the hubs do work directly with the health department they're part of our, they're part of our provider system. And so, you know, they're part of our preferred provider network and so you know they do. We do work with them and there are certain standards that they have to meet. I don't know specifically if there is a caseload sort of threshold or a caseload requirement at the hubs, but I can certainly find that out. Thank you. And I want to welcome to other committee members who were able to join us now who weren't able to join us at the beginning, Representative Rosenquist and Representative Greg war. And just one deputy commissioner I'm not sure how much more you have for us, but just to let the folks know we know that the deputy commissioner is walking through some of the initiatives that the department is has been doing during the pandemic to address the continuing opioid crisis and opioid deaths. And the way we've been doing is she's as she's gone through each initiative. She's been asked her questions and she's gone through quite a few. And so it's been fascinating, and we keep interrupting her deputy commissioner. You have gone through sort of the grants and some of that what else. What, what have we not asked you or what other initiatives have you not talked to us about. There are a few more that I'd like to highlight and one is we've expanded the recovery coaches and emergency departments. So we have recovery coaches who are either on call or who have scheduled shifts in 13 hospitals across the state and I believe that we're going to hit the 14 this year. And so the idea around that and this, this helps with that wait time that you were talking about Representative Pugh, because what what happens is if somebody presents to the emergency department either with an overdose or with another targeted issue or if that comes to light during another type of visit recovery coaches will come and meet with that person and sort of they're either people who are in recovery themselves or people who are interested in recovery services who've gone through training to be a recovery coach. And so they will partner with that person connect them with recovery services and they will stay in touch with them every day until the person accesses treatment. We made this available in hospitals, all but one across the state and so that's been huge and we've gotten a lot of positive feedback about this program. And so it's great to have seen it expand during the pandemic. When people really needed it. Any questions about that. Deputy Commissioner in the expansion. Did that mean that the recovery centers individually got additional resources from the state to enable them to staff the hospitals. I believe they have there are some that the coaches are on call and some that are actually like physically have shifts in the hospitals but we did provide extra support to the recovery centers for this initiative. And they have also just a really praised the the connections that they've been able to make through this program so it's been, it's been wonderful. Representative McFawn has a question. Thanks madam chair. I'm interested in the recovery coach in the hospital and staying in touch every day with somebody until they get treatment. These people that we're talking about. Because I thought I thought you said if they come there and they're for an overdose. If they're not ready to get treatment, then having this person in contact with maybe they is that to try to convince them. Well, I can just seen somebody in this situation calling every day or meeting them in person for nothing. You raise a good point that you know people have to be ready for treatment so it's certainly voluntary for them to engage with the recovery coach so you know they're certainly not going to force themselves on them if the person says thanks but no thanks. Then they'll give them some information and sort of be on their way but you know, I think making that personal connection, at least, you know, even if it's just that one time is important because it shows them that. Hey, there's there's a here's a connection point and their people out there, you know, maybe the person maybe the recovery coach themselves had been in their shoes and can share their personal experience and so it's a connection point. So they would give them information and but they certainly wouldn't. If the person refused then they would, they would back off. Thank you we have a lineup of questions, representative noise and then representative Whitman. Thank you madam chair. I just, you had talked about it being between one to three days for access to MAT and I was wondering if you're tracking that like how many are many people are one day how many two how many are three, and then along the same lines with the recovery coach. So once somebody makes that initial interaction with an individual. What's going on with like the next step kind of inpatient treatment centers or detox facilities or you know what the wait times are there, and are there supports, both in our more urban areas and also more rural areas as we were talking about with the like right now. Yeah, so we do have recovery centers across the state so there are 12 throughout the state so there are those services available as far as residential treatment, you know we do have three residential treatment facilities in the state of Vermont. And so people can, you know, obviously access those they it's you know it's been a little challenging for our residential treatment system, particularly during coven. You know, they've had outbreaks, you know, over and over in their facilities they've been able to make some changes so that it doesn't shut down admissions and they can sort of quarantine and isolate people when they first come in. But it does, you know, you know, the residential treatment system is not an emergency. It's not like going to an emergency room. It's not really intended to be. You know, like a same day admission so even if there are beds available it doesn't necessarily mean that I'm going to, you know, if I decide today I want to go to residential treatment, I may be able to get in the same day but it really depends on you need to be medically cleared to go to a residential treatment facility because you know it's it's not a hospital so if you have significant like co-occurring medical conditions or other things, you know you really need to be evaluated before you go to a residential treatment facility. And if you are on methadone, it takes some time for the residential facility to set up what's called guest dosing so they work with their local hub to be able to get the methadone that they need for a particular patient so that might take, you know, a day or two to get set up. So there are a few things that play that affect how quickly somebody can get into a residential treatment facility. Thank you and representative Whitman. Thank you madam chair. Quick question. And I guess it's a bit leading in Bennington I know one of our community action grants included recovery coaches accompanying EMS for emergency calls like two motels and you know in the case of an overdose where that's needed to respond. Are any other counties doing that kind of partnership. I believe there is one or two other places that are doing that but I don't know off the top of my head where that is but I can certainly find that out. Great. Thank you. You're welcome. Representative Whitman just because I'm keeping notes. Can you clarify what the question was you asked. Well, that's my kind of be a follow up for my last question as well. There are in Bennington one of our community action grants was a partnership between recovery coaches and our emergency medical services. Remember there's a call for overdose where emergency medical services will go out to respond. They'll be recovered by a recovery coach, similar to what we're seeing in emergency rooms. And my question was, to what extent those are implemented in the state. Is it just Bennington County or other counties and I guess the follow up would be, you know, what are the results from that. What's the sort of evaluation of the effectiveness of the program but yeah. Okay. Thank you. Deputy Commissioner I believe you said you had had one more that you want to make sure we knew about. I actually touched on it earlier but it's Vermont help link which was launched in March of 2020 coincidentally, just as the world was shutting down and it's been a great resource for people to either get a referral to treatment, or just to get information about substance use issues about accessing treatment or recovery services. And the one thing that we heard loud and clear, particularly when the opioid coordination council was still active was that when a family member of someone who was suffering with substance or the person themselves were ready to access treatment like they didn't know what to do or where to go. And so you know you just start like Google searching and, and so this provides a one, one stop shop, a single phone number a single website where people can call the number and get a referral, you know, get connected directly to a treatment provider in their area so that they can be assessed and find out what level of treatment. They need and so we've had over almost 60,000 visits to the website, and we've had almost 2000 calls, just in 2021. And then, since it, since it's inception there's been over 4000 referrals to treatment or recovery services through Vermont help link so we've seen it continue to grow and I just want to make sure that you're aware of that resource. Thank you Deputy Commissioner and as you were talking about it. I pulled it up on my iPad. And it seems very, very accessible to me, and it is in English. And it require, I guess it, it assumes access to the internet, and it assumes a mobile, a mobile device. Actually, is there's also you can access it by phone. So you can either call the number or use the website and if you call the phone and you need interpreter services, those are available through the phone number. You know, nothing about this kind of web stuff, but there might be helpful if somewhere on the website. There was something about if I if you have no idea what these words mean, where you can go. Because last I knew in Burlington and I don't live in Burlington but there were 26 plus languages spoken in the high school. Deputy Commissioner, this has been very helpful and very informative. And I very much, I think speak for the committee for your appreciation for your going through this. I am wondering, and it is fine. If you do not, if you at all can speak to what is in the BAA budget adjustment and if not, there are no policy issues related to ADAP and the BAA so there's really nothing to speak to on that. But there is one other thing I'd like to just bring your awareness to and I'm sure it's not going to be a surprise if that's okay by say one more thing but the biggest challenge that we have right now in the substance use treatment world is workforce. We are really, really struggling and so it's no surprise, you know, all providers are struggling and so many sectors are struggling, but we just particularly in the outpatient system and in our residential system the hubs and the spokes are doing okay. But our residential treatment providers are, you know, paying for traveling nurses, they've had trouble keeping people. We've been assisting them with paying the difference between what they would normally pay their nurses and what they're paying for travelers because it's like a huge discrepancy. But particularly in the outpatient system, our providers are just really struggling to get and retain staff and it's impacting the availability of outpatient treatment services. So I just want to put that on your radar. Just thank you for putting that on our radar, Deputy Commissioner, so that we're all so that we have the same understanding and are talking about the same workforce. Who are you talking about the example that you gave was nurses, and you talked about outpatient. Yeah, when you talk about providers, are you talking about nurses and nurses only. Are you talking about substance use professionals who are licensed to provide outpatient treatment. So, when, if you could explain. Yeah, so it's really across across the board. So nurses have sort of been in the spotlight because, you know, they're such a hot commodity and because so many are leaving their employment and then signing up for to be a traveler and basically being assigned back to their same place to make, you know, a lot more money. So, so that's certainly an issue but we're seeing it across the board and in, you know, for milieu staff in the residential treatment facilities for, you know, counseling staff in our outpatient programs. It's really been a challenge. Thank you. I guess I have two questions for you. One, just to edify myself. What is it that the nurses do as as contrasted to physicians or nurse practitioners or PAs and what is it that they do differently than outpatient therapists or residential providers. So in the residential treatment in a residential treatment facility, particularly if somebody is going through detox or withdrawal, you know, there's a medical medical management component to that. So the nurses are really, I'm speaking about nurses really mostly for the residential system. Yeah. Okay. Thank you. The second question is, where will we see this in the budget adjustment. If this is if this is a problem, and one of the ways the department has been responsive to the community need is to provide whatever the difference between right and that for nurses. And now I'm wondering what in fact ideas or have have you been doing for the other professionals who work in there. And so where do we see that in the budget adjustment because I presume that wasn't anticipated in the budget we passed. So there will be something in the home and community based service through diva through the their budget adjustment for retention and sign on bonuses for staff and the substance use treatment system as well as a rate increase. And that is, and that is for all the providers or only the medical providers. I believe it's for all the providers. I wish we were in the committee room, because what I'm seeing is a crinkled forehead, which I interpret as, but you're not sure if we were in committee room there'd be someone sitting next to you going I can find this out for you quickly. But if you could just confirm that for us that would be great. And now that we've opened up that question. We have a question from representative McFawn followed by a question from representative Whitman. Thank you madam chair. My question is the money that is going out to the community action agencies. Does that go directly or does it go through the state of state office of economic opportunity. I'm not sure I know which money to the community action agencies you're speaking of. It was. I thought you said that you were sending money out. It was community action agencies. Because they know who might be using. And I guess it was those kits. Yeah, I apologize what I said was community action grants. It wasn't to the community action agencies. I apologize for the miscommunication. Community action grants. And represent Whitman. And I'm going to go ahead and say thank you to the commission chair and deputy commissioner just want to start by saying thank you so much for all of the work and the initiatives that you've described. Just wanted to ask one other component kind of the flip on the workforce issue is looking at what are the sorts of how is employment seen as a part of treatment, or what are the collaborations between the department of labor vocational rehab. Well, like, is there any evidence to suggest that employment has an effect on relapse or anything like that. Yeah, that's a that's a great question and that's something that we did have an employment and recovery services pilot that is sort of being re looked at with voc rehab. We didn't see a tremendous amount of success with that pilot but it also could be confounded by, you know, COVID happening, you know, sort of in the midst of it. But certainly there's been a lot of work around sort of recovery friendly workplaces. You know, there was some steam around that pre COVID that we're, you know, looking to sort of rejuvenate because there are employers out there who've really embraced hiring people in recovery. And we know that sort of like having a sense of purpose and a, you know, connection with other people is hugely important for folks in recovery so that's definitely something that is still on our radar and that that we're going to be connecting with voc rehab on, because it is, it is important. Thank you. And actually part of our stigma campaign that's running right now I don't know if anyone has seen it. There's a media campaign around stigma and substance use and one of the spots is actually an employer talking about hiring people in recovery. Deputy Commissioner, am I making this up, which I could be, but isn't there some federal from time to time, I'm don't business can't a business access some federal support when they hire people with disabilities and a person in recovery might be identified as a person with a disability, if they have an alcohol substance use or mental health issue. So I mean, that's my understanding is that. Yeah, yeah, I mean, I'm going to have to look into that I think I think you're right I don't know if if any of our employers here in Vermont have been using that for people in recovery. If I haven't made this up, which is always a possibility. You know that might be something to encourage. You talk about and how the department is going to connect with voc rehab, or Department of Labor. Is that what it is the Department of Labor with this employment issue. With voc rehab, with voc rehab. So, so the, the, the, the pilot or the grant was not renewed, and we are now six months plus since it has not been renewed. So, in that six month period, what has been the connection and outreach between the book rehab and the recovery centers. My apologies for some reason when I use zoom my audio cuts out so I heard that six months and then it wasn't you read the question. It really has to do with the decision, which I understand had something to do with finances. I couldn't be wrong. And so curious as to how much that really how much of an impact on the Department of Health's budget that is or but that at one point you there was a pilot to use people who were in recovery to coach and otherwise connect with employment opportunities. You said that the results weren't what people were looking for but maybe that was compounded or compounded by the pandemic. And my understanding of the reason there was the pilot was because the initial connection to the Department of voc rehab hadn't been very successful. So they were trying something new. We've gone back to the book rehab. In the six months since we have not been funding. The pilot, what has been the outreach and connection between book rehab and the recovery centers. I think that it has not come to fruition yet, but it's something that we've been talking about internally. What has happened to the money that was saved by not renewing the pilot. I will have to get back to you on that I do not know. Thanks. Deputy Commissioner this has been very, very helpful and it has been a great review and and and not a review in fact giving us information because as you started out, you said the state has been experiencing what many would call to two pandemics or two crises to public health crises. COVID-19 and the other the increase in opioid addiction and deaths. And you've outlined sort of things that we had that the department is moving forward on. And what we would be interested in you said that there's no. There's no policy changes in the BAA. I think we'd be interested and if you could come back to us with that with any kind of ups in it, you know, how, how, how is the state. How is, how are we funding some of these new initiatives that we did not or the expansion of the initiatives that when we were perhaps more hopeful last year when we passed a budget and we didn't think some things would need to happen. My understanding is that you were you're going to come back to and you could do it in in writing or if you think it's easier to come back in person, let me know. Okay. That sort of some of the things that we were asking for is who are you targeting the messages to and what language is in terms of outreach. That sort of the grant results for those that I guess we are the sub we we get the CDC grant and we then push them out to the communities that you are going to look to see if there was any federal or state requirements or expectations around caseload size or the hubs in terms of that and sort of how widespread or not what I want to say is the Bennington model for recovery coaches or whatever and EMS and that that and that I wrote down diva for something. That was the home and community based services and the intention and the retention and just a clarification or a confirmation that this that the workforce targeting is for work for an inclusive workforce, not solely nurses. Yeah, I actually virtually had someone whisper in my ear that it is all event is all okay then we got that one all answered from from. I think it is important in terms of educating or informing the body, the legislative body as well as the public that when we are talking about workforce issues as we as it relates to substance use disorder opioid addiction and medical and others is that we are not that we are talking about workforce not just people with a medical degree. Right. And that's that that's that that's what we keep hearing about is nurses and doctors and it's more unfortunately it's more widespread than that. I really deputy commissioner really again appreciate appreciate and if you would pass on to your staff appreciate the work that they've been doing and trying to do their jobs and then in doing other duties as assigned. I appreciate the fact that so much of our work in this state around substance use disorder and, and especially as it relates to opiate is based on science, and based on best practice and what the literature and research says is what is effective. So, thank you. Thank you very much. Thank you. Nice to see you all. Nice to see you. Committee, if we could take a 10 minute break and then come back for just a. This is what the rest of the week looks like and this is where we're going forward and to talk a little bit about what to expect, as we have five days to provide feedback to the appropriations committee so we will be doing it a little differently than perhaps we did it last year.