 Good afternoon. This is the House Health Care Committee and it is Wednesday, February 16th at 1 in the afternoon and I want to welcome our Witnesses this afternoon Help us Hear about the important issue of suicide prevention in Vermont and And if the outset let me thank Representative Black for helping to arrange our witnesses for the day. I appreciate that So we have between now and just before the three o'clock hour and Let me acknowledge at the outset that I'm certain we could spend a full day or more hearing from our witnesses and we will Be returning to this subject again for another point in time as well, but this is an opportunity for us to hear from Both some folks who are working in this area on behalf of our monitors at the Department of Mental Health Some folks who are working in our health care settings and educational settings and especially today as well to be able to hear from someone who has the lived experience of Dealing with this as a family And so I want us to be thoughtful as we hear our witnesses And I'm going to ask our committee members if as we hear our first two or three witnesses if we could Kind of keep our questions To a minimum so that we're able to get to hearing all of our witnesses And then if we have time at the end We'll have time for to go back and hear from other witnesses with further questions that we may have Say understandably, there's a lot. There's a lot to know here So Deputy Commissioner Cromp Allison Cromp is our first witness and I'm going to leave it to you to introduce yourself in your role because you have a history of working in this area of work and so welcome and Let's hope our video or audio. Can you? Say hello, and so we can see if we're hearing you properly Yes, hello Can you hear me? Yeah, we just need to adjust the volume. I think and Does that work? Yep. Okay. Great. Yes. I think we can and welcome and And I think you have with you For further testimony at some point also Nick Nichols, is that right? Yes, Nick will be joining Later on to talk about our partnership on the CDC grant Okay, terrific. So let's let's begin with you Allison and I think in order for us to move through the Time we have this afternoon will as I said We're not going to be able to hear everything that you could share with us but if you could give us a sense of where the Department of Mental Health's work is at this point in time and the issue is as You're seeing it from the department Sure, thank you Thanks for having us on this topic today And I am representing the Department of Mental Health and can talk about What has happened in suicide prevention? Infrastructure from the state's perspective in the past and what we're proposing as initiatives through the governor's budget request now And kind of with that package what What we'll get out of it. And so I did want to highlight that there's been work from the state has provided funding to the Center for Health and Learning Up until this point, that's generally around $178,000 a year and that's from global commitment. And then we supplemented every year with federal dollars in the mental health block grant. And that supplemental funds generally support things like the suicide prevention Symposium that's a big event where we bring experts both nationally and in the state and people learn from from that and it's a great place for people to come together. So that's one example of how we supplement those efforts. But what we've put forward this year and we're encouraged that the governor has supported these initiatives thus far around suicide prevention. Is to expand the package that goes to zero suicide. So that's one of the pieces I wanted to make sure we cover today. The state has gotten behind zero suicide as a public health approach. I think you'll hear and probably have heard from John Tarallo who's an expert on that in the Center for Health and Learning folks on what zero suicide is. But I just want to highlight that it's it's big it's expansive. It's not one thing. And so with that funding for zero suicide. We've asked the Center for Health and Learning to support the specifically the designated agencies as a first step. And so things like making sure that their staff can be trained and effective suicide safe care so that those are evidence based practices like cams, for example, or calm, which is a way to talk to individuals about their access to lethal means to ensure that if someone's going through mental health crisis, we can make sure that they have ways to have safe storage of those items so they don't harm themselves. So the Center for Health and Learning has done a great job with that work. We've moved from three designated agencies to seven joining. There are in various stages of implementation. We'd like to get to all 10 and elevate the ones who have already joined in. And some of those elevating activities could be things like follow up. So that's a big gap in the system. We've identified it every year that it's one thing to identify need. It's another to follow up on it. If you've maybe said, hey, you might need some support. Maybe you call the warm line or set up an appointment with therapist. It's that follow up piece and having a way to track it. That's really hard to do and it's imperative. It's where people fall through the cracks. So those are some of the things you want to show up with that additional funding and you'll see that that's expanded to $260,000 in the budget proposal. That's zero suicide. I'll speak briefly about the two other pieces. One is 988. And so I think I've talked to this committee before but I'll just remind folks that 988 is the National Suicide Prevention Lifeline. Even though it's a national number, we need to resource it in state. And it is a major part of that resource is to make sure that whoever answers the phone could tell the person about local resources. So that's why it's so important that it is answered by Vermonters. And we have been able to build up capacity using federal grants over the past three years. Those federal grants have ended and we need funding to maintain that service. So the budget that you'll see the $440,000 for that is to maintain what is existing, which is a small crew of folks at Northwestern Counseling and another at Northeast Kingdom Human Services and they're able to cover those phone lines 24-7 at this time. We currently have an average of around 245 Vermonters calling the line every month. It has been creeping up over the past few months and with a move to 988, we do expect it to increase substantially. The projections are around 500 callers a month. So that is that line item. And then the last piece to the Department of Mental Health Suicide Prevention Initiative is elder care outreach. We believe that we need to do a lot more around targeting specific at risk groups. There are more than just older Vermonters that we need to reach, but as a first step, this was identified as a program that's very helpful and supportive to older Vermonters because it goes to their homes. And it the folks who do that are trained in suicide, safe care and assessing for suicidality. So that would be to expand a program that works well. So that is the package out there right now in terms of the budget proposal suicide prevention and I would just state. We have seen the numbers of suicide deaths go up tragically year over year for the past decade. 2021 is going to be the worst we've seen in a very long time. And we really want to make sure that there's extreme attention paid to this issue and that we really build infrastructure to do this work well. And I think when you hear from Nick Nichols, you hear that a major thing that's happened at the state that hasn't happened. And you know, I don't want to say it's never happened I'm new to the state but more so than what I've seen in the past as a real partnership with the Department of Health to start treating suicidality as a public health issue. And so we are co partners on a grant that is geared towards building infrastructure over the next five years. None of those pieces and Nick will talk about this include paying for services. And so that's the funding that the Department of Mental Health has been putting forward and wants to expand is the actual ongoing costs of providing those services. I'm happy to answer any questions. Just really just really quickly. Do you have updated numbers for 2021 since you last presented to this committee. I do. So the last updated numbers 141 romances lost to suicide. As of the last weekly report. Okay, and how many death certificates still undetermined yet. I believe there were nine. I will double check that for you. It's down substantially from the 50 that when we last spoke. Thank you. Can we just, I just want to make sure we understand the data point that you just gave us which is 141 individual Vermonters who died by suicide in the calendar year 2021. Is that correct. That is correct. Okay. Perhaps Nick has other data that can be shared or perhaps you could forward to us maybe we would just use it that way perhaps you could forward to the committee, the data across the last decade, or whatever numbers you have available so that we can see the unfortunate trajectory of these numbers. Is that something you could provide to the committee. The Department of Mental Health has the numbers through 2020 because the Department of Health does not publish them until they are official and the so 2021 is not yet official. So we can give you the chart that you're speaking of where it really gives you the dismal trajectory of increases over time, and then you can know that it will look to be at least 141 and 2021 and that number may increase. Thank you. We'll, we'll, we'll understand that to be the case. I'm going to suggest we hear next from Nick Nichols, and then we'll continue to hear from other witnesses and hold most of our questions. Nick Nichols welcome you to introduce yourself and you are with the Department of Health at this point, am I correct. That is correct for the record. My name is Nick Nichols. I am currently serving as a suicide prevention grant coordinator at the Department of Health. And as Deputy Krishna Krumpf mentioned, also working closely with the Department of Mental Health to coordinate a lot of suicide prevention work that is supported under my agreement with other activities. And I believe I'm here today to take about 10 minutes just to provide an overview of relatively new CDC grant that Vermont has received and talk about how it supplements and complements some of the work that has already been occurring and it's being planned and if it's okay I was going to share my screen and I have a short presentation to share with you. That's fine with us. Okay. Okay, can folks see that okay. Not yet, not, no, we don't see anything yet. We see you and other witnesses but not your screen share. Let's see. Here it's coming. I think it's coming. Yes, there you go. Okay, good. All right. So, so, so this is as I mentioned before we have a federal grant from the Centers for Disease Control and Prevention. It's a five year grant that runs from September 2020 to August of 2025. And so we're actually already into year two of the grants. There were some delays in the grant getting started just because of COVID and waiting for joint fiscal approval. And then there was also a hiring freeze that occurred last year and so the grant actually wasn't fully staffed until August of last year. And it's a grant award that goes to the Department of Health, but it has two principal investigators and so it's co-managed by both the Department of Health and the Department of Mental Health. In terms of funding, as Allison mentioned, we're not allowed to pay for services using this funding but there are some different elements of capacity that we can pay for to improve services. And so it funds grant staffing and so it funds my position as well as a full time data analyst and communications coordinator. And all these positions are temporary. And so once the grant ends in August 2025, our positions go away. It also pays for things like training, consultation, incentives and staff support to develop and improve suicide prevention services and resources. And it also pays for things like public facing messaging, communication strategies and just general approaches to engage directly with the public to help them find support. And then lastly, it pays for comprehensive evaluation of our grant activities. As Allison had talked about before, you know, this CDC grant and in general I think Vermont is moving towards taking more of a public health approach to suicide prevention. And through this grant, it really enhances and further takes Vermont in a better direction to add on different elements of using a public health approach. And so essentially that means that through this grant, we're focusing on protecting the health of communities and supporting prevention among the large groups of people. And as we know, you know, with a number of people who die by suicide, they're in some cases not engaged with the treatment system, or they're not showing up in emergency departments asking for help and so because of that, using a population approach and including elements of primary prevention are critical to what we do. It's also true, unfortunately, you know, that often first attempts are fatal or sometimes they're fatal. And so we don't always get a second chance on some of these folks who are struggling with suicidality. And so because of that, Vermont needs to continue to not only enhance and strengthen its treatment system, but also expand the strategies outside of our treatment system into communities and other programs. And I would say, you know, a general theme of this grant really is that all Vermonters have a role in facing suicide and so whether you're someone who's struggling with suicide or your suicide out of yourself, or just a community member who may notice that someone is struggling, or if you work in a program that that may interact with people at risk. We all have some role that we can play in helping to reduce suicides and supporting each other. And this image here is just an example of a public campaign that we are going to be rolling out to really connect with the public directly and encourage them and all of us to be talking about suicide and thinking about ways that we can play a role, because as I said before, you know, it's absolutely important that we improve our treatment system, but we all need to get involved as Vermonters to address this issue. The CDC does also ask us to use our data to focus our strategies on particular populations that are experiencing a higher burden of suicidality. And so while a lot of the grant activities will benefit all Vermonters, we also will be tailoring some of our strategies to focus on particular populations that are experiencing either higher rates of suicide death, or higher rates of morbidity, like visits to the emergency department for suicidal ideation or self harm. And so that includes Vermont residents, basically, Vermont residents who are working age 15 to 64, as well as working age males, rural Vermonters, people who live with disabilities, and people identify as LGBT or Q. So I'm going to just quickly summarize some of the strategies that we'll be using with this grant. And, you know, if you have any questions about the specifics of these, please let me know. We're going to be expanding gatekeeper training, which focuses on working with people who are not clinicians, but who may be in a position where they interact with a lot of people who may be at risk and teaching them how to be more comfortable to notice when someone intervenes, support them, and hopefully connect them with other services. There's going to be a strong focus on reducing access to lethal means. Consistently, when you look at the research, there's been a number of different initiatives that focus specifically on reducing access to things like firearms, medication, when people are struggling with suicidality, and when you do that, you see lower rates of death in the attempts. We'll also be, you know, having a strong focus on improving connectedness among focused populations that are at higher risk. And so that includes developing peer support and peer networks among different communities, which will include first responders, farmers, as well as suicide loss survivors. We'll be also looking to improve how Vermont as a state responds when there is a suicide death and how we support both individuals and families who have experienced a suicide death as well as community and organizations and helping all of them get the best support for that very difficult time. Allison mentioned zero suicide, you know, and that's a big component of what the Department of Mental Health has been doing. Primarily their work has been focused on expanding zero suicide within our designated mental health agencies. And so this grant is going to supplement that work by bringing elements of zero suicide into other healthcare settings because we know not all people who are struggling with suicidality end up at a designated agency and they may be seen by the primary care physician, they may be seen in an emergency department or another healthcare provider or even a non-designated agency mental health provider. And so this grant will be adding an elements of zero suicide into other parts of our healthcare system, including emergency departments. And then we'll also, you know, given that we are focusing on prioritizing supports for low-overmonitors, we are also going to be working to expand access to suicide-safe mental health care using telehealth. As I mentioned before, this grant also has a very strong focus on communications and public messaging. And so as an additional strategy, we are going to be having a lot of campaigns and branding social media, web-based supports, hoping to reach people both who are struggling with suicidality to help them become more aware of resources, become more comfortable talking about something and asking for help if they're struggling, and then also encouraging the rest of us to do something if we see someone who is struggling. So technically, we're already into year two of this grant. And so I did want to just highlight a couple of things that have been that have happened over this first year. As Deputy Commissioner Croft mentioned, there's been a really incredible level of coordination between the Department of Health and the Department of Mental Health under coordinate this grant. We actually have weekly meetings where we get together both to coordinate activities of this grant, as well as discuss how this grant best enhances and supports other activities within the state. We've already been able to enhance our data analysis to improve our program planning both at the state level and in regional levels. We're also going to be using this capacity to do what's referred to as a social autopsy. So looking at four people who died by suicide, what are the different services and supports that they have received or didn't receive during the years prior to their death to see if that can help them prove where we intervene and how we intervene. We have also been able to complete what I what I think is the first statewide suicide prevention communications and marketing plan, which I think is really going to be an important component of how we address this issue as a public health issue. Then also through this grant, we've been able to engage with and start working with additional programs and also pull in additional funding to support suicide prevention. And so two examples of that is we're now working with invest DAP, which is the largest DAP provider in the state to collaborate with them to both develop peer support networks for groups like first responders and farmers, as well as engage with employers as a place where we can help support and improve the mental health of people who are working in those organizations and potentially use that as a place where we can identify people who may be struggling and use things like DAP counseling to support people. And we also are very excited to be working with the Vermont program for quality and health care. They've been able to coordinate three different funding sources, our grant as well as another federal grant and a private foundation to pull together a very comprehensive quality improvement project that's going to be offered to all of our emergency departments to implement elements of suicide. And we actually just had our kickoff steering committee today and we're very excited about the possibilities of how that can both improve long term care, but also reduce some of the pressures that emergency departments are experiencing. I also just want to, you know, emphasize, you know, in addition to coordination with the Department of Mental Health. We are, you know, there's a strong emphasis on coordinating with all the different partners in the state who have already been doing suicide prevention work in the state. And so this is just a list of all the partners that we've already engaged with and are working with, you know, Center for Health and Learning has been a long time partner and champion for suicide prevention. I know they were very helpful in helping write this grant and so they're a key partner, as well as a lot of these other organizations that we're working very closely with. And then I do just want to, you know, sort of emphasize as before that, you know, I think when you look at all the needs in Vermont and the strategies for addressing suicide prevention from a public health approach, we feel that the strategies of this grant really complement and enhance the work that has already happened within the state, as well as the expansions that are being proposed by the Department of Mental Health. And so when I think you combine the work of what's being proposed by the Department of Mental Health and what's being added on through this grant, we're very hopeful that that will take Vermont in a really positive direction to address to a significant amount of suicide prevention as a very complex public health issue. So I will stop there and ask if anyone has any questions. I'm sure there are questions and I certainly have some. But let's, I think, let's hold our questions. And, well, are you going to be able to stay with us during the next period of the next hour and a half in there. Yeah, I'm going to be here for the, for the whole two hours. It's terrific. I just wanted to check because I think there probably are questions to give you an opportunity to say more about. But again, I think we're going to hold our questions for now. And we'll, so jot them down and I will do my best to hold my questions as well. Okay, thank you. Thank you very much. And we look forward to working with you in this role over a period of time. It's very important work. Great, thank you. Yeah, I think we're going to turn next to hear from Terry is lovely. And Terry, there you are. Good. Welcome. And I think we've actually crossed paths along the way somewhere along the way, but nice to have you join us today. And I'm going to have you introduce yourself because I think you wear multiple hats in terms of what you share with us. What your roles are and share with us some of what would be helpful for us to hear about from you today around suicide prevention in Vermont. Thank you and thank you to representative black for inviting me to speak today and for the House committee for hearing me. So in the spirit of transparency, I do wear multiple hats in in Vermont around suicide awareness and prevention. I have worked for a designated agency for 17 and a half years. Although I'm in more of an administrative role of training advancement and development. I have always considered myself a boots on the ground kind of gal and understanding how systems work together. I have carried the after hours on call pager for years I've answered those lifeline calls those crisis calls. So today, I'm coming to you as a field advocate representing the American Foundation for suicide prevention. More importantly, so I can represent the broad scope of my lived experience of what's really going on in Vermont and all these systems and all of the ass that we have in our budget today. So we have put together a plan and thinking about what's going to work for Vermont of sustainability of funding for systems in place suicide is a public health care crisis and nobody comes to this work of suicide awareness and as I mentioned without some level of lived experience. So in transparency also 29 years ago I attempted to take my own life. So I'm an attempt survivor, and I've only been able to recently talk about that and the last year and a half because of the stigma. I want people to look at me like I was incompetent or less of a person. I'm a mental health professional and I've worked in this field for a very long time but I felt like if I told people that I attempted to take my life they were going to look at me differently and not respect my values my views my knowledge my education around this, but that's not really what propelled me into this field. So my nephew lost his life to suicide. And that's really what pushed me into saying we need to do better. We need to do better as a mental health agency as a very rural community, as a rural state as a nation around the work in suicide prevention and awareness. So I found my family with the American Foundation suicide prevention Vermont chapter. I'm a board member of walk chair I trainer I wear so many hats and AFSP world, but field advocacy and I want to just be honest. This is out of my wheelhouse of comfort of like I'm not political at all, but I have boots on the ground lived experience and I understand how all of these asks work together, and are going to support Vermont in the public health care prices of poverty. So that's what I want to share with you today is my lived experience and working in it volunteering being an attempt and a law survivor of how I see these systems fitting together and why we need to fund them, because any area of our request that are underfunded does a disservice to the other areas that we're requesting, we're only as strong as our weakest links in the world of suicidality, mental health, physical health, everything we do we're only as strong as our weakest link and we really need to consider funding all of these areas as asked or proposed to make sure that we're providing a strong sustainability of systems in Vermont. So I'm not sure if I can share screen for a minute, if I can request share screen. I put together this graphic because in my mind, when we think about all of the areas of suicide prevention and awareness it's hard to wrap your mind around the impact of how one area affects the other. And I want to make sure that we're getting a clear picture of we're not just throwing out funding ideas and request without understanding this how the systems all work together. I want to just start on the prevention funding and I do also want to be transparent. The National Association of State Mental Health Programming put this model in one of their proposals and I really loved it and it resonated with me because it's easy to understand. So I borrowed their model and recreated it for what's really going on here in Vermont. So in prevention 988 funding, we're asking for a budget adjustment of $910,000 in addition to the $440,000 proposed for a total of $1.35 million to create a designated 988 crisis trust fund for sustainability 988 is happening. We are not going to change that as of July 15, 1-800-273 talk is going to become 988. We're going, we have a projected call increase from vibrant, which is our national provider of 30%. So Allison mentioned those averages of 245 calls that are coming into Vermont every month is going to increase by 30%. And there's already been a significant increase from October to January of this year in one lifeline center there was a 51% increase in call volume. So 988 is happening whether we choose to fund it or not. We need to look at sustainability of funding 988 is a lifeline. It's a service where you can get a live person on the phone within 30 seconds when you are struggling in a mental health crisis when you're feeling suicidal when you're feeling lost when you are feeling nobody else understands there's trained professionals on the other end of that call that will support you through your 97% of the calls that we receive are handled over the phone and don't require further intervention other than maybe some follow up calls and resource coordination. That is reducing the burden on our physical health providers we're not sending people to the emergency room every time they feel hopeless and helpless, or are having suicidal thoughts. There's a lot that goes into a lifeline call. There's assessments there's imminent risk. There's a lot of things that determine how we can safety plan with somebody to keep them in least restrictive situations in our state. Funding the sustainability of funding for 988 needs to be a line item in that the budget is a trust for ongoing funding within the state and not just temporary increases here it needs to be sustainable funding for the service that we are providing for and the best part about our 988 and our lifeline in Vermont is the call responders get Vermont. We are not the same as California, Massachusetts, other large states where a very rural state. So we understand the grassroots services, the barriers, the transportation, the lack of broadband all of those issues are taking into consideration by our lifeline call responders because we live and work in Vermont so who better to help you through your struggles of hopelessness and helplessness than other Vermonters. Our zero suicide funding. I cannot speak enough about how this has impacted our state on such a significant level. The Vermont suicide prevention center is a private public sector. So there are so many voices at the table of looking at different angles of how this funding house supports how everything we do affects what the outcomes are how we change systems. The greatest part of zero suicide is it really lets each agency look at what's happening in their community what's happening in the Northeast Kingdom is not happening in Burlington it's not happening in Rutland. It's not happening. It looks different in Brattleboro than it looks in Newport so zero suicide allows designated agencies and also we're hoping to extend this project to our physical health providers hospitals primary care physicians we've already started doing some of this work through many grants. Through the Center for Health and Learning where we've invited our physical health partners into the conversation of mental health how to implement program policies and procedures zero suicide is a way to spread evidence based practices through different mental and physical organizations. You cannot just say here here's a pot of money and go do it how are we doing it as a state what systems make sense what are the evidence based practices. Cams care the collaborative assessment and management of suicidality is an evidence based practice. It's proven to reduce the drivers for suicidality in eight to 10 sessions. Quick, easy, done. We need to get more people cams care train. We need to write policies and procedures on safe suicide pathways both in mental and physical health. I'm absolutely honored to be part of this zero suicide project as one of many that have already joined but we need to get all designated agencies, primary care physicians and physical health providers on board with creating the safe pathways. So we know what to do when somebody screens positive. There's policies there's procedures there's evidence based practices, and in my heart of heart I'm a trainer. We need to have a well trained workforce, which is what suicide funding does for the state of Vermont. Other areas in the preventative funding arena that are not in our ass today but I felt like they're notable 10% increase to designated agencies and ssa's. We are the ones doing the hard work where the boots on the ground. We are severely underpaid. We are overworked. We are oftentimes putting our own mental health aside to serve the needs of our clients in our community. We need a 10% increase for DA's and ssa's for sustainability of our mental health systems. Mobile crisis units. I love the analogy of why would I go to the podiatrist for a cardiovascular issue. Why would I send police or an ambulance out when it is not a law enforcement issue or physical health issue. The expansion of mobile crisis units are going to be able to bring the circle of support for mental health crisis, all the way around. We're also going to decrease the use of emergency rooms which will take the burden off from our physical health providers. The pilot program in Rutland has already shown that this isn't a proven way of decreasing emergency use. We're also going to increase the use of emergency rooms and providing that in the field real-time tangible support. Additional hospital support. More psychiatric beds in Vermont. We need more places where we can send people that need help, either voluntarily or involuntary. We're also going to be able to provide a donor and AFSB support the additional funding for any hospitalization or any hospitals that will provide that psychiatric support. So thinking postvention. The 988 funding also allows for follow-up calls. When you're in the immediate crisis and you're able to get through it, that warm handoff, that follow-up call, did you get what you need? Did the resources I give you work for you? Can I help you with anything else? Circling back around to the person that was in crisis prevents future crisis. That's a cost savings on our system. And we have already implemented systems for those follow-up calls from the national lifeline to happen and we're continuing to grow that part of the program while also implementing other initiatives through the 988 funding such as chat and text, which Vermont is about to take on and things of that nature. Zero suicide again with both prevention and postvention. I can't drive home enough how having a well trained workforce. Clear policies and procedures results base accountability to everything we do. Having all seats, all sectors represented at the table of what is going on in Vermont. That is vital to a healthy, strong system for mental health crisis in Vermont. And again, the increase to designated agencies and SSAs is also a vital part of pre and postvention. This is the graph that I borrowed, stole. I made it up myself, but I borrowed the model from the National Association from state and mental health. So this is currently what's going on. We have a person in crisis. This is a crisis line, or they end up in the emergency room, but this our hope is is they're going to use 988, or they're going to call their local DA or SSA crisis number. Most of those calls are going to be able to be handled over the phone. So we're going to jump right to the rock services and supports. 97% of lifeline calls answered in Vermont right now are currently handled over the phone without any emergency room intervention. Somebody is feeling hopeless, helpless, suicidal. We're talking them through it. We know suicide is a long term answer to short term problems. And if we can help people identify their drivers, those short term problems, and put safety planning around those drivers they're not going to get to the place the full blown crisis. And the extent that they are those 3% of calls that do need that immediate rescue. Currently, we rely on 911. We rely on Vermont State Police, our local police departments, our ambulance. So when we're on that crisis call both this designated agencies, SSAs and lifeline providers, we're calling 911 and we're sending our physical health providers and our law enforcement out to intervene in the situation. They're not mental health professionals. They don't know how to sit comfortably in someone's uncomfortable mental health struggles. So by creating mobile crisis units through every sector in Vermont, we are providing an enhanced service that's going to actually reduce stress on our physical health providers and emergency room care. We're going to get to the root of the problem quicker, and we're going to be able to respond to the drivers for the suicidal thoughts. Mental health treatment facilities. Again, as we go up this model. We're going to be able to respond to more restrictive, more cost costly supports for individuals. So where we want to go is down the model to the least restrictive so if we can get to people using the lifeline or their local crisis numbers and then wrap supports up, we're going to save Vermont money. And not only that we're going to save our emergency room stress of having their beds taken up for people with physical health systems. We're going to save our police Vermont State Police and local police the burden of having to deal with mental health crisis that they're not trained to do. And they're just going to call us anyways so now you have multiple first responders dealing with the mental health crisis. So mental health treatment facilities. Extremely short in Vermont right now through the pandemic and even before the pandemic, people are waiting up to 14 days in our emergency rooms in our swing beds, waiting for a mental health crisis facility to be available to treat their suicidality. We can't have that that puts too much of a burden on our emergency room departments, too much of a burden on our health care system. We need to have more readily available psychiatric units to treat suicidality so we can go to least restrictive, most cost effective measures, and honestly, people that are struggling with mental health issues and the thought of suicidality hospital is the worst place for them. We can figure out. Can I just interrupt and just say that you do not need to persuade this committee to that track to that challenge I mean I'm wanting to visit that all but we've taken lots of testimony and understand the tremendous pain that's caused by having to wait in hospital emergency rooms for mental health services so there's deep appreciation of that issue. Yeah, and I'm just going to put a plug in for our youth because I'm very active in that community on a volunteer and professional level. It's even more sad for our youth. There's less services available in Vermont to treat youth mental health struggles so please I won't I won't get stuck on that. So wrap services and supports. This is the ultimate outcome if we can avoid these steps in the middle of the mobile response and the mental health treatment facilities and we can wrap people in a war mental health treatment hug, for lack of better words, mental health services case management warm handoffs for people that were struggling to make sure that they're connected to the resources that they need, follow up with the health and care coordination. Ultimately we're going to get over here where we're decreasing emergency service use emergency department use police and first responder intervention jails. This is going to save Vermont millions of dollars. We have to invest in the system as a whole. So I just also want to go back to the Vermont suicide prevention the Vermont zero suicide prevention. We're asking for an adjustment of that budget for an additional $825,000 up from the 260,000 for a total of one, one million, $85,000 to expand that through the rest of the da's that are on board to continue the support of the da's that are already on board ssa's that are already on board, and also bring it out to our physical health providers are hospitals are primary care physicians. So this, this is our way of showing how all this funding is put together because I think sometimes it's hard to think about in Vermont of, there's all these grassroots initiatives going on, but nobody knows who's doing what in what sector with what hat and again I came here today wearing multiple hats but my field advocate hat is on. How are we going to pull this all together. How are we going to pull this all together as a state. The proposed statewide directors position. Somebody that has their thumb on every sector of what's going on in Vermont. The training, the evidence based practices are first responders are physical health providers are mental health providers. How are we all working together as a state. How are we going to pull all of these services and supports together to make sure that there is a continuing of care throughout the systems. And also I just want to put a plug in for the expansion of elder care and the vet to vet visitors program. We have a highly most vulnerable population and in Vermont we have a large vet population and a even larger aging population in Vermont so I would support those as very much preventative and post postvention funding areas to suicide prevention within Vermont. I'm going to, I'm going to wrap it up I honestly could talk all day about suicide awareness and prevention how our systems work together, my lived experience the work that we're doing locally and as a state. And I just mostly want to thank you for taking the time to listen to me today and try to help put the bigger picture together of what's really going on in our city, as far as our funding asked. If that's not funded will directly affect the other. Thank you. Thank you for outlining how things fit together and also thank you for your own. Frankly, frankly, you're sharing of your own personal lived experience as a part of your testimony here today. I think we appreciate what it means as you said, sometimes this years before someone feels able to share much less share publicly in our kind of setting. That's something that's personal and important as that. So thank you. Thank you for having me. And so with that, we are going to turn to hear from Emily Hackett Fisk. Emily is there you are Hi Emily. I'm having computer issues today so I'm on my phone I apologize I tried to get on with my computer but my screen died so I apologize. I completely understand I was in exactly that position last night as I was trying to hold my phone and not shake the have the phone shake in my hands as I was dealing with something else. But we're happy to have you join us today. As I understand, you are with us and are willing to share with us some of your own personal experience with the issue of suicide. And so with that I'm going to turn it over to you Emily to introduce yourself to share your story and to have us listen and listen attentively. Thank you for having me. I apologize ahead of time if I, if my voice shakes. So, one of the greatest, I'm a resident of Williston. One of the greatest things in my life is being a mom to my six children. On September 24, 2020. I received a call. And that changed our lives forever. And my 12 and a half year old son Ryan died by suicide. Using a firearm that was unsecured. And another home. It was very unexpected. So, thank you for letting me come and speak about him today to put a face and give him back his voice. Oh, I know that many of you have read his obituary. Ryan was an old soul. From the day he came home. Extremely empathetic and compassionate. Super friendly, a little shy at first at times but once you got to know him he was very friendly. He was great at a great sense of humor. A lot of kids do. He was his younger siblings world. He was always meant to be the oldest child and the biggest brother. And so, you know, I feel very blessed that I was able to have the time with Ryan. But this is extremely impacted our lives. The day that I received the call. I had been working. And I received a call from a neighbor. And that told me Ryan had been in an accident. And that I was, you know, I needed to come and at the time I was in actually a new Hampshire. And I, you know, I was thinking he broke his leg, or, you know, got hit by a car on a bike or things like that. But it wasn't until later I started to ask the neighbor I called him back to tell them, let them know I was coming because the his, his father was unable to speak with me at the moment. And that's when he had told me. Ryan tried to hurt himself is what he said. And of course, with I think any mom's reaction was what it didn't make sense. Not if it made sense, it was, it just didn't make sense. And I'm thinking, okay, we're going to be at the hospital. We're going to see them at the hospital. We get there. I was two and a half hours away. And I figured Ryan had a severe peanut allergy. Maybe he tried to eat a peanut or, you know, you think, did he get some pills or, you know, did he try to hurt himself. You know, by a fixation or, and that I was going to see him in the hospital, but I was preparing myself that he was going to be in the hospital, you know, maybe on life support or something. So it was a long two and a half hour drive up part way through the drive. My husband's a police officer so we we under, I understand when an officer is telling you, when will you be arriving over and over every time you speak to them. And I kept asking, well my meeting with the hospital, and they wouldn't answer I knew what that meant. And while I was driving up with my husband. We found out that he had passed. I can't even explain that moment. And my, my older daughter happened to be home with her brother, their fathers, and she came home here, and a family friend came over and stayed with my parents and my daughter. She came home and tell her, and that's a screen you'll never forget. But it wasn't until that moment afterwards. I never even considered an unscured firearm. It wasn't until that moment that she mentioned a gun and I didn't I was, I didn't understand. He had asked some people to kind of describe Brian. And one of the women that has taught him swimming over a long period of time said he was very determined. He liked to challenge himself and he was compassionate towards others. His school teachers always said he was kind and caring to everyone. Parents of girls in his class. His life, his female classmates wrote how wonderful he was, but he loved a kid but he was never mean to anybody. People always want to reason why things happen. And there really is no reason right there, there were no signs. You know, we all talk about suicide prevention and look for the signs well the signs are not always there. And speaking to one of his teachers he said he was the last kid they would have ever thought would have done this. The impact of that death has rippled through as far as, you know, other states, not just here not just our home, not just his school. He has many friends that attend other schools. The means really matter. If he had not had access to an unsecured firearm. He most likely would be here, he would have been in the hospital. A gun is the most lethal way that someone can take their life. Can I just say, can I just say in a way that you do not need to apologize to us at all for your emotion, your voice. We appreciate you just taking the time to share with us. And that's his voice back, and that's what I need to do for him, and for others so this does not happen again. If we can interrupt the moment by keeping our children from having access to a gun. It could save another child's life. Thank you for your time. Courage and your willingness to be with us today about what has to be one of the most difficult experiences any mother or parent, family member can experience. I hope as we listen to others talk about prevention, that you'll know that we may never be able to prevent every tragedy. We, I think I dare say are committed to preventing every tragedy that we can. We will continue to take further. We will listen to other proposals, take other steps. Today is only one part of what we're what we will undertake over the next period of time. So, you're, you're sharing with us today is very powerful and touches touches me deeply and I'm sure it touches others as well. Thank you. And as with the other witnesses, I'm going to encourage our members not to pose questions at this point in time, but to just sit with your testimony, your story. And so, know that we're thinking about you and what you shared with us as we listen to other witnesses as well. So, thank you. So with that I'd like to welcome Rebecca Bell. I see on the screen it says Becca so I'm and actually is Dr Bell I believe but we're never quite sure how to handle titles. But welcome to our committee. You've been here to hear some of the other witnesses perhaps all of them. And to hear the story that we just heard as well. I welcome you to introduce yourself to us and know that you have a play a part in this important issue and welcome to here. Look forward to hearing what you have to share with us today. Thank you. Thank you so much for having me. I'm going to introduce myself, and then I'm going to give Dr Tom Delaney a chance to introduce himself and then we actually have a few slides that we're going to share together. So if I could also get screen share available that would be great too. So I'm back and I'm back about I, I'm a pediatric intensivist so I work in the pediatric intensive care unit at the University of Vermont Children's Hospital. So I care for infants children and adolescents who are critically ill or critically injured. And also, the third year I've been the president of the Vermont chapter of the American Academy of Pediatrics. And I do injury prevention work with the Vermont Child Health Improvement Program through the modern College of Medicine at UVM, and the Department of Pediatrics at UVM. And I'm an associate professor of pediatrics at the College of Medicine. I also relevant to this discussion, part of the statewide suicide data suicide prevention data work group. And I sit on the child fatality review team for the state of Vermont so we review child desk, unexpected child desk, including suicide. And I'll hand it over to Dr Delaney to introduce himself. Hi, can you hear me. Can you speak up maybe just a little bit more. My name is Tom Delaney. I'm an associate professor in the Department of Pediatrics at the UVM Laurier College of Medicine and I also work in the Vermont Child Health Improvement Program. I don't do any clinical work. I'm very involved with program evaluation and applied research as it relates to different mental health topics though and I teach in the medical school and in the Masters in Public Health Program. Becca, if you want to start sharing the slides, I can do an orientation. So, Becca and I have collaborated for about three years now on one public health prevention strategy aimed at preventing or reducing the burden of firearm deaths, specifically firearm suicide deaths. And we're going to, Becca will actually talk about that. I'm going to TS up by just talking about some background about patterns and epidemiology of suicide deaths in Vermont and drilling down a little bit on the firearm deaths. It's important for us to acknowledge that the opinions we're expressing are our own opinions and they don't reflect any, any of our employers, which is the University of Vermont Medical Center for Becca and University of Vermont for me. It's also important for us to acknowledge some really key partners in this work so a lot of the data I'll be showing you was actually compiled by the Vermont Department of Health or the Vermont Department of Mental Health. VDH is an amazing resource they've produced more and more powerful data briefs over time, including out of great mental health topics and some very powerful informative ones on suicide prevention. We were also supported in our work by the Freymoreer Fund at the University of Vermont and the University of Vermont Larner College of Medicine educational technologies. Next slide. So just a quick overview. I'll talk a little bit about recent trends in Vermont firearm suicide deaths. And then we'll transition to Dr. Bell will talk about risk factors for some firearm suicide death including impulsivity access to firearms. And then she'll also review some public health informed strategies for reducing firearm suicide. And then at the end we have a review of what we talked about and opportunity for discussion questions at that point if it works for the committee. Representative Lippert you mentioned wanting to see the trend data earlier. So this is 10 year trend data from 2011 to 2020. It doesn't have that shockingly bad number that Alison Croft referred to for 2021 because that hasn't been finalized. But what that number is going to do is make the red line on this chart, much higher at the right end. What we're expecting at the suicide death rate for 2021 is going to be higher and potentially substantially higher than it was for 2020. But with this graph shows is the red line is for Vermont rates of suicide death per 100,000 population. We use rates because it allows us to compare across populations that have different sizes. And the blue is the US national suicide death rate per 100,000. You can see that the Vermont rate is more variable and that's just because we are a smaller population. You can also see that the Vermont rate is consistently higher than the US rate. And that currently there seems to be a trend where we're, we're getting differentially worse in our rate over time. And I can I interrupt and just I apologize for interrupting you. But we just need to check. And this is for you but also for our committee assistant as to whether what you're sharing on the screen now has been posted on our committee page I don't believe it has. I think that has this been provided to our committee assistant and if not, at some point we certainly would want it to be. And when it is clear I'm speaking to our committee assistant Claire, if and when you receive it if you could post it on our committee page so members and the public can access it as well. Yeah, I apologize. It was not shared before the this session started but I think Dr bell has the final version chill. She'll send that to Claire. Okay, great. And if she receives it, even while you're talking we can post it, but it's not will do after after it's been after we've been reviewed it. I apologize because I was interrupting your train of thought and you were talking about how the Vermont suicide, the rate of suicides in Vermont is higher and differs from the national average, and I ask you to kind of recap some of that again. Absolutely, it's, it's no problem. The Vermont rates are the the red line over time, and they are consistently higher. We've actually done this graph going back to 2004 and even 17 years ago is still the same case. The general trend is that in the last three four or five years for months rate has been significantly higher than the US rate. And we see individual years where we approach the US rate in subsequent years we get higher again so it does, it does imply that there's something different about our population about possible factors influencing people's mental health and, and perhaps having to do with resources. So I can again make sure that we're clear we're talking about all suicide deaths here, not strictly what you were referencing earlier with to fire firearms suicide. This is all that's all all deaths by suicide. Absolutely. Yeah, and then we'll, we'll drill down a little bit on the firearm deaths and the next slides. Yeah. Okay. Next slide. Thank you. This is from the Vermont Department of Health. And what it does is it shows you these two pie charts the pie chart on the left shows self harm visits that were seen at Vermont hospitals. This is from the Vermont Uniform Hospital discharge data set for the year 2020. And then you can see that people who engaged intentional self harm, which includes suicide attempt, non fatal suicide attempt. We're seeing it at Vermont emergency departments, most often for poisoning, and then after that for cutting and then some other sources as well so suffocation, fireflame injury things like that. On the right, these are the actual suicide deaths. So these are what was recorded by the office at the chief medical examiner and then shared with the Vermont violent death reporting system and the Vermont Department of Health. You can see in this chart that firearm deaths actually account for about three out of five of all suicide deaths. This is in contrast with the US so US nationally firearms account for about half of suicide deaths in any given year. Going way back in time for Vermont data, we've seen that we're consistently higher than the national averages for firearm suicide death rates. Next slide. This is a really important slide, and it gets at the idea of lethality and irreversibility. So if you look at the top part of this. It shows us that for the injury bar that most of the firearm injuries, this is all firearms data. Most of the firearm injuries that are seen in Vermont emergency departments are unintentional so they are accidental discharges or things like that hunting accidents, followed by homicide or assault. There are some suicide and self harm attempts represented in those data. And there's also some attributed attributed to legal intervention. If you look at the bar immediately below that that's the death status. These are all firearm deaths that occurred in 2019 and 2020. And you can see the vast majority of those over 90% of those were actually suicide deaths. This really drives home the point that when people attempt to take their life using a firearm. And this point was made earlier in the session, but it's highly highly lethal and it's also largely irreversible so I've heard Dr Bell make this point several times that she doesn't get to see the children who attempt to take their life by firearm really because they don't make it to the pediatric intensive care unit where they don't make it to the emergency department. And that again has to do with the lethality of the means that are being used. If we look at the bottom we can bottom chart just organizes firearms suicide deaths so specific to firearms as a function of age category and biological sex. And that is the, the dark blue bars are males and the lighter blue bars that are lower our females. And you can see that across all the age categories, males are at substantially greater risk of dying by firearm suicide then females are dying by firearm suicide. So, you know, males are at greater risk for suicide, but that disparity is even larger. When you count for firearm suicide deaths. We can go to the next slide. This is a slide that really drives home the fact that there's a lot of geographical variability in the state when it comes to firearm suicide deaths. And what that is for every county, the yellow lines show firearm injuries, and the, I guess purple dark lines show firearm suicide, or this is just death rates. And these, these actually collapse across all types of intent, so it's suicidal and non suicidal intent. You can see that in Orleans County, the rates per 100,000 for firearm injury or high that's 15.4 per 100,000. And then for death for firearms it's substantially higher than that it's about 4040% higher. And then you can see the rates go consistently down all the way to Grand Isle where it's such a small county that there were not actually any firearm deaths recorded during during the time for this chart. Generally seen that more rural counties do have higher rates of both firearm injury and firearm death rates. And that's that seems to be true for suicide firearm deaths as well. You see that there is a lot of variability you can also see that firearm deaths across all these counties are much more common than firearm injuries. And that ties back to the issue of lethality firearms are just inherently more lethal. If you're going to be injured by firearm then say, accidental poisoning or intentional self poisoning. We also know that most of these deaths in this chart, 90% are actually suicide deaths. So you can interpret this chart largely as reflecting suicide deaths across the counties that are attributable to firearms. And finally a really important note for us to make is that we, we may think that firearms are not actually that common. You know when I lived in Chittenden County. I don't think any of my neighbors had firearms and I didn't have firearms in my house. So in the 2018 or 2019 behavioral risk factor surveillance system, however, we got a pretty good picture of the prevalence, if you will, of firearms in Vermont households. And we found that 43% of all Vermont households by self report had one or more firearm. And that's going to be really important point for what Dr Bell is going to say about increased risk in firearms in homes that have firearms. Okay, so I'm going to take over and go through a few slides and as a reminder, I'm a pediatrician and so my work is really with youth. But Tom really has a good handle and others on this here today have a good handle on like the statewide data that includes adult data. So, this is the most recent data we have for this is through the CDC fatality reporting system. I just pulled this up this afternoon. This is the last 15 years we have data for and you can see just a wide variability in suicide death rates among states across the country so this is youth. This is the age of 18 by any cause for the last 15 years and Vermont stands out especially, especially in our region. And this is if you just pull out by firearms. So, the maps, when you compare suicide deaths both for young people and for adults and compare them. When you take all cause and then you just take firearms, those maps look very similar. And that is because firearms are a real driver in the disparity we see in suicide rates when we compare states with each other. And this is a study that just kind of drives that home this is. This is from about 15 years ago, where researchers took states that had high gun ownership, and then states with low gun ownership and compare their suicide death rates. And Vermont was not included as in one of the high gun states but would fit, I think would was going to be the next state that would be included so sort of fits under this first, under this first column here. So they, they gathered the, the population of these states that they would, they would be equal and then looked at their suicide death rates, or death numbers and, and what they really saw this was sort of looking at the, what really is a myth but a common refrain which is, you know, some may have heard people say well if they didn't have the gun they would have found another way they would have used something else and the outcome would have been the same. But if that were to be true, you would expect that when you compared both non firearm and firearm related suicide deaths that in the states with low, low gun ownership, when they, these folks might not have firearms as accessible to them. So you would expect them to have higher non firearm suicide death rates. Those are about the same across so this is. These are female here, these are male rates. So really the disparity when you look at the total suicide, which is about twice, twice the rate. It's really coming from firearms suicide and it's not compensated by people finding another method and using another method and dying by suicide in another way. So this is, this is a group out of the Harvard School of Public Health, who have looked who really looked at this and they've really looked at, you can see at the top there the who what when, where and why and that's something that, you know, for a good reason we focus on when suicide prevention and, you know, there's a big focus on why why did this happen. But their real focus is is on how and that the how really matters, probably more than definitely more than most people recognize or realize and that the means really matter when we're talking about suicide. Here, there are a few, many studies on this but this is an example of a study looking at survivors of near lethal suicide attempts and found that about a quarter spent. And these are also young people I should say this is 13 to 34 years of age this is on the younger age spectrum. And a quarter spent less than five minutes between the decision that they may when they made the decision they were going to attempt suicide and the attempt. And it's, it's not intuitive at all but that impulsive attempts are more likely to be violent. So with a firearm or or another method that tends to be more violent. They tend to have, they're less likely to have a history of mental illness less likely to have history of depression and less likely to have made other attempts in the past but maybe more likely to have done other impulsive things like gotten into fights, or other impulsive behaviors is really the impulsivity as opposed to a long history of mental illness. Tom talked about the lethality when we, when we think about firearms and suicide attempts but here's really when we think about lethality it's really determined by the inherent deadliness of the method. So, so certainly firearms, you know, are very deadly accessibility. And that's where we see that difference when we look at states where there, there's just more firearms in the home they're more accessible. Ease of use. So if somebody is comfortable with a firearm if they know how to use it, they're more likely to, to use it as an option. And then the ability to abort mid attempt. So I take care of lots of young people, unfortunately who end up in the pediatric intensive care unit after a suicide attempt. Most commonly from an ingestion and at the time and they can get, they're in the ICU because they're very sick. And, you know, they often, oftentimes we have to use pretty extensive measures to help reverse the effects of those medications or whatever it was that they had ingested. But, you know, the next day or whenever they're feeling better and we talked to them about what happened what they often describe is a crisis, a temporary crisis usually like an interpersonal crisis something with, with friends or family or a relationship. And they feel what they described to me often as if they're feeling a lot of pain and they're feeling really upset, and they want that pain to go away. But at the same time, often have not really thought about the consequences or thought through exactly what they thought was going to happen. And will often talk to me about long term plans that they have, you know, I was just thinking about what I was going to sign up for for my college courses when I start college in a few months like that sort of thing. So in the moment, they're having a crisis, and they turn to what's available and, and oftentimes what's, you know, accessible and what they can use. But then they either have someone has a chance to find them, or after the attempt they reach out to friends they reach out to family members and let them know they made this attempt and then they can get help and then we can help them. So firearms are the ability to abort after the attempt or during the attempt is just not there. And that's what it's another factor that makes them so lethal. We keep driving this home but I can't think of many other things in medicine where there are more deaths than there are hospital visits. So this is data from, this is from 2018, this is from the health department but firearms cause 74 deaths each year in Vermont, but only 39 ED visits, CR visits, because again it's instant, these are instantly fatal. In many cases, the children that I've taken care of in Vermont who ended up in the pediatric intensive care unit who I, who I care for with firearm injuries are unintentional injuries as opposed to self inflicted. So the, the, the upside of this though is that we do have evidence that if firearms are stored safely that these injuries and deaths can be reduced. So this was a study that was a case control study where they found households where a child or adolescent under the age of 20 shot a firearm either intentionally in a suicide attempt or unintentionally and injured somebody like themselves or somebody else. And then they compare those storage practices of firearms in those households to other households that also had firearms but didn't have a shooting incident. And then they looked at the way the differences in storage, and what they found was if the gun is stored locked. If it's stored unloaded, if the ammunition is locked and the ammunition is stored in a separate location, each one of those storage practices helps reduce the likelihood of a shooting incident and all four together have a cumulative protective effect. If storage, this is what we're talking about these four, these four aspects of safe storage, the gun is locked, the gun is unloaded the ammunition is locked and it's stored in a separate location. So the, the, this is a 2018 behavioral risk factor surveillance surveillance system which Tom had alluded to. So first we have just under half of Vermont households reported that they have firearms in their home. We expected, you know, these are folks responding to a telephone survey so it may be a little bit higher than that. And then when, when then the researchers asked about storage practices. Those with firearms in the home 17% of them kept them loaded and 65% of those kept them unlocked and here you have the breakdown of what that would then look like for if you just took all of Vermont households so you look at all of Vermont households. To extrapolate this from this survey, then about 7% of all Vermont households have a loaded firearm in the home and about 5% of all Vermont households have a loaded firearm in the home that is unlocked. So this is something that I talk about with Tom and I talk about with healthcare providers because we should just be assuming that the families that we're interacting with that they have firearms in their home because about half of them do and of course it varies by geographic assumption but we should just make that assumption and be talking about safe storage with with everyone we interact with in the clinical setting. The other question is what about how firearm ownership in Vermont homes that have children and don't have children and there's no statistical difference there so about equal. So this is really likely in the start among the survey respondents to say you have firearms and you have children or don't have children in the home. So, knowing, knowing much of this Tom and I now this is like pretty old. It's like from four years ago now. We actually, we had, you know, so many people really wanting to know like how do we even have this conversation we're not well trained healthcare providers don't feel well trained to have a conversation about safe storage. So it's really effective that can be non judgmental that we can get people to change their behavior. And so we looked at all of the available. Really, all the available research to see, you know what people knew and what kind of training there was and there, there really wasn't much. There were good trainings but they were pretty long. And so we decided to make our own module on for really for healthcare providers, but really anyone could probably benefit from this, which is free and available on the Vermont child health improvement website which we can share the link with you all on how we talk about firearms safe storage and it really revolves around presuming that there are firearms in the home. Just asking how they're stored instead of trying to ask, do you have firearms, do you not have firearms and and how do we encourage people to get to a place where they're storing their firearms safely in their home. So we can give you an example of that work and then I then was asked to help consult on a national project doing that a similar thing and our work that Tom and I and our partners did on the V chip module was some of it was used in this national module called this called a safer program storing firearms which prevents harm through the National American Academy of Pediatrics, which was, you know they had a little bit more of a budget so it's a little bit more high quality videos and they got actual actors but really looking at how we can have these conversations to be effective and to to impact, you know really meaningful change in people's behaviors around storage. And we can, I can talk about this more people are interested in what kind of language we use when we talk about this. But this is just became now available last month. It's also free and available for anyone it's really geared towards healthcare providers but really anyone can can go through it and learn from it. So I'm pretty happy about this product. And this is just our last two slides so really in, in summary, I, I again like I take care of young people who attempt suicide, and I know that in, you know, in the moment. They are oftentimes feeling pain and they oftentimes want that pain to go away and they make can make very serious attempts. But we know that 90% of people who survive near lethal suicide attempts do not lead or go on to die by suicide. Every one of those young people that we work hard to make better. We feel, we feel good about, we are so happy that they are okay I mean that's the first thing I always say when, when they're able to talk to us again I say I'm, I'm so happy you, you texted your friend about this I'm so happy you. You called your mom after you did this and we are so glad that you're okay. And know that they will likely not go on to die by suicide. Those who attempt suicide with firearms compared to other methods, they almost always die if they don't die they have significant significant morbidity. They're more likely to have made the attempt impulsively, which again is not intuitive to most folks, a lot of times people think well if they use a firearm they must have been very intent on dying and that it tends to actually be the, the opposite. And they tend to be less likely to have depression or other mental illness compared to those who use other methods and so it's much harder to identify signs and symptoms ahead of time or warning signs and really what Tom and I believe and pediatricians and other folks who tell their healthcare providers believe is what we really need to do is create this environment of safety, so that young people, when they're in that crisis moment, don't have access to that firearm. We know that we cannot prevent protect young people from ever experiencing a crisis but we can prevent them from dying during one. This is just our last summary slide that Vermont suicide death rates are consistently higher than the US and recent years and this is true for our entire populations also true for our youth population firearms are used for. It's the most common method used in Vermont, more than any other method combined firearms make up the majority of our suicide deaths in Vermont. And that we know from research at safe storage is a key aspect of reducing firearms suicide risk, and that educating healthcare and other types of providers to engage their patients about firearms safe storage is a promising approach and we also hope that in talking to this committee and doing other types of outreach that we can encourage people, everyone to talk about safe storage, just in our general practice, you know we've talked a lot about COVID conversation about what you're comfortable with doing with friends and family. And I think this is an opportunity to, you know, as we maybe potentially start to hang out with people more and engage more to actually start talking about you know firearm storage and safe storage in homes in our own homes and places that we visit in a way that's just, again, non non judgmental but that we make as an important sort of safety checklist in all of our lives I think that can go a long way. So I'll end here and thank you so much for for the committee for first taking time to address this really important issue for all the work that you do in general on this on this topic, and for inviting Tom and I to speak to you today. Thank you, thank you so very much. This is really important information for us to have in front of us as we look at the issues in front of our committee in terms of funding suicide prevention but also understanding more in depth about suicide prevention, particularly in suicide prevention here in Vermont. We do have, I think we have some time, and I'd like to open it up to questions from the committee and first go to represent black. I think that Emily has indicated to me that she had wanted to add one additional thing so maybe if she can absolutely. Thank you, Emily welcome back to our screen and we welcome you. Thank you. Thank you. A little bit more composed right now. Thank you. I want to really reiterate what Dr Bell was talking about. Our son didn't have a phone, he had, you know, a computer and a, you know, an iPad. And when they did the forensic on it, they found nothing on the device to suggest anything until five minutes before this occurred. And so how do you not had access to a gun that moment could have been interrupted. And he could have gotten help in that moment for whatever crisis, none of us know what that crisis was, but that, you know, having that moment interrupted would have probably saved his life. So just really wanted to reiterate that. I feel that's really, really important. Thank you. Thank you for sharing that and underscoring that that. Let me let me turn to represent black and then. Well, I have several questions of several different people so I just thought that we're going to start. So, first of all, question for Nick. I think you're, you were talking about data. Is there data we're not collecting that we couldn't be collecting. I, I'm not sure. I, you know, we, in the legislature, we have the ability to receive data and then be able to target solutions for that. Is there any data right now that we are not collecting as a state that we couldn't be collecting so that we would have more information when forming policies going forward. Thank you for the question representative black there, you know, that's definitely part of the work of this grant is to focus on what don't we know and what other information do we need. You know, and there's probably a lot of different examples where we could collect additional information and so what what might make the most sense is to follow up with you with some some some of the suggestions that have been raised. We are as I mentioned before, going to be kicking off the development of a social autopsy data linkage project to kind of look at for everyone who dies by suicide. What other information can we pull from our both state and community partners to better analyze kind of what you know what's happening to people during that last. Last year and I think as we go through that process will also start to identify other data elements that aren't collected or are really hard to get. So if it's okay, we might follow up and give you more information about that as the session goes along. I'm glad to hear that's going to be taking place. Dr delay me. I know I know there's a number and I can't pull the number out of my hand but to me the most important thing that we can stress and Vermonters need to know this. If you have an unsecured firearm in your home. I know that there is a number that makes your child much more likely to die by suicide. What is that number. There's an actual number on that. The tip of my tongue I'm sorry. There's, there was an epidemiological study done a while back, showing that overall risk of any violent death in the household was about 20 times higher. If there was a firearm in the household then if there was not a firearm household. So just just having the gun in the home is a risk factor for suicide as well as homicide. I really, I really feel like Vermonters need to know that that you know if you have. You have particularly young people in your home. You're putting your home at risk. By doing that, by trying to protect yourself from outside, your risk is really in your putting yourself at risk inside. Regarding, we have a, and I'm not sure who would be able to answer this, if anyone there is a, there's the gun shops project, where FFLs gun shops will give out information regarding suicide I'm wondering. Does anyone know if they're being given information about safe storage to give to customers, encouraging safe storage when somebody purchases a gun is anyone know if that work is being done at all at the transactional level. I know that it's being evaluated so that the group that Dr bell mentioned at Harvard, the means matter group is actually working with the state of New Hampshire and some other states that are implementing the gun shop project to evaluate the effectiveness of the interventions. One thing is that Vermont Vermont piloted the gun shop project for a couple years, and it really was about distribution of materials so we didn't have a really robust study of what was happening in the actual interactions but we did, we had a bunch of gun shops that agreed to distribute materials. This is my very last question, I promise, Terry, you had mentioned about director, and I know that the administration Alison you've, there's a request for a coordinator can, can someone explain what the difference between the two that of what's being requested regarding that a statewide director and a statewide coordinator. Terry, I don't know if I mean it's, it's a proposal coming outside of the state so I welcome you to start and I'm happy to jump in. If you think about the roles of a coordinator and you think about the roles of a director there are two very different roles. A director directs the services. A coordinate a coordinator coordinates the services is more of that boots on the ground. We have tons of boots on the ground people that need to be directed. So, we already have many of those coordinator positions in place Center for Health and Learning the Vermont Suicide Prevention Center. There's the services are already being provided but how do we pull them together as a state to make sure there's a cohesiveness and the continuity of care in the world of suicide. So we, we don't need more. We don't need more Indians we need a chief to pull everything together and I hate to put it even in in that kind of form, but we need somebody to direct the services and to take information from all stakeholders, including our physical health providers are law enforcement and it's not just a designated agency or Vermont Suicide coalition center question it is getting all that information together and directing how the services and the funding is going to be distributed. And that is my 300 mile snapshot in my head of how I think all this is going to work together. And what our group thought would be most beneficial to make sure that the continuum of care of all the services and all of the funding asked work together. And just add. Sure, when this came about. And so, right now, we have like the National Suicide Prevention Resource Center requires that someone's listed per state as a lead for suicide prevention efforts and that position is called the state suicide prevention coordinator. So when we were, and right now my name is on it, but we need a full person. And so that's where that came from. I think the department is open to looking at language and, and considering, you know, in more detail about what type of role would be most beneficial. Okay, that's helpful to know. Thank you. No, I think, let me just say just for ourselves, I think we should probably set a time what 10 out so that we can get to the floor, which we have a floor session at three o'clock today. Thank you. I really appreciate you presenting this problem as a public health issue, because it is. And for those people who work in medicine. You know, the opiate crisis was a public health issue as well. And there was a connection with licensure and CMEs that were required so that clinicians were required to interact with patients about this issue. Or the opioid issues. So what I'm wondering is, is there a parallel between this kind of issue of preventing suicide and communicating with clinicians to talk to their patients when they see them in their offices to try and reduce unsecured guns. That question makes sense. Yeah, I can, I can jump in and answer if that's okay with folks I think. I think it's very important. I think with the opioid crisis, the particular very important and very necessary sort of regulations around training and oversight is a little bit different because physicians were were part of the problem in terms of the prescriptions and not right so that is an unusual case and but a very necessary case where these, this is sort of strictly strictly regulated in terms of we all have to do a certain amount of training every year and and see me around this. So, but that you know that being said, I think, you know, Tom and I have been asked by, you know, Vermont Medical Society Vermont, the pediatricians in Vermont and family medicine folks in Vermont to speak during we've done a number of sort of CME and other other talks about this I think one of the challenges of this conversation is it's it's counseling. People are nervous about it. They're nervous that they're not going to say the right thing. They're nervous that they're going to I didn't you know we have some data on this to I didn't present but people are nervous. You know they feel like they don't have the training to do it which is why we've set out to create this training module because people need more knowledge and they need more confidence and how to have this conversation so they're worried. I'm going to alienate this patient. If I don't say it in the right way. I'm going to ruin our therapeutic relationship so that so there's a lot it's it's it's it's sort of complex. You know and other other studies have looked at. I know in the world of pediatrics like do you do you have something like fire and safe storage on like a checklist or an intake checklist like lots of different ways to look at it. And there are pros and cons to that which I can get into but part of it is that people are nervous and less likely to have to to to really acknowledge like in in writing like they don't want their the information about firearms and their home to be like in their medical record and so what Tom and I recommend in our training is that we don't actually like write it down or look like we're asking anyone to write it down it's a conversation and we make it a part of our safety conversations and in pediatrics we recommend that it's part of our general well child care. So you're going through you're like talking about by comments and you talk about you're talking about home safety and you talk about firearms as part of it. So I think there's opportunities to do it with every visit with every like a well child visit or an annual visit. And then of course when you're you have more concerns to is and is another place but but yeah we I mean physicians are worried and other health care providers are worried about how to even have this conversation so that was sort of the like intent behind the modules that people just weren't having these conversations because they felt like they didn't have the training. So the question is like our medical school is going to start incorporating some of the stuff into their training going forward that needs to happen as well and something we're advocating for and you know that module I showed you from the AP I mean that just came out last month. That is the first time we've had like a really nice comprehensive training for our pediatrician like this is pretty late. It's new and late and as needed to be happening for a long time so a lot more needs to happen and then there's mental health providers and lots of other people interact with families that want to have this training which is why we want to make it free and available to people outside of the health care field as well. Thank you your your data was so compelling I'm just feeling like yikes. That's all. Thank you. Well, Yeah, I think I think we need time to spend we need time to go to the floor. So, let me thank everyone, each of you for being part of this discussion this afternoon. Thank you all. And, as I said, I'm sure we're going to return to this issue again at another point in time. But this was very, very, very helpful. So thank you for making the time to be with us today, and especially realize that sometimes this format is not the most personal. But we recognize that number of you shared some very personal stories as well and we appreciate your willingness to do that in this format which we're all accustomed or growing accustomed to but not quite completely comfortable with. So, thank you for. Thank you for being adaptive in helping us here to hear your stories. I think with that, please, yes, let me represent. I wanted to acknowledge Emily, and I wanted to wish her son a happy birthday. I mean, I know how hard birthdays are and the fact that you did this. When I know what you're going through right now. Very, very great. So thank you. And thank you. Thank you and thank you for having me. Thank you. Thank you for being here. Thank you so much. Thank you representative.