 This is the House Health Care Committee. It's Friday, May 7th. It's now about 12 minutes after two. We were scheduled to start at two, but our vice chair also serves on the House Rules Committee and to be perfectly honest in front, I decided I wanted to wait and have her join us if at all possible and she is now here with us. So thank you, Representative Don Hue, for leaving the Rules Committee and joining us here. And joining us here, let me say at the outset, we had several things on our agenda for this afternoon and I'm going to modify that and recommend that we spend our time on the children's mental health issues and we have some information in front of us from a work group and we will come back to the other topic of the task force around healthcare, et cetera. Well, I need some more time. I don't, we need some more time and I need some more time to do further consulting with the Appropriations Committee in terms of their process. And so there is time for us to still come back to that issue in the early part of next week. So with that, I think the follow-up to our testimony on children's mental health, particularly around children waiting in emergency departments, because after we heard different testimony on that, Representative Don Hue, Representative Goldman, Representative Chiena have spent some time, several times today, looking at, thinking about what we'd heard, recommendations we'd heard and I think you have something to bring to us draft form anyway, but I think it'd be good for you to walk us for the three of you to, in whatever format, manner, walk us through the ideas. My exciting news is that Colleen did a mini training and I'm ready to go. I'm going to do a share screen with our documents so that we can be looking at it. And I can be like Jen and I can write in edits as we go along if people have ideas of additions or re-wording or phrasing and all that. The big picture is we talked about it in terms of the real issue is about accountability, sort of keeping feet to the fire and immediate actions and that the thought was a letter from the committee to the Department of Mental Health and incorporating the Hospital Association as well to ask for specific updates on specific issues. And that's what this, it's not even a draft letter yet. It's a list of what we think it ought to incorporate which we would then follow up by once the committee input if there's agreement to go in that direction we would follow up by asking Katie to turn that into a draft letter. Right now it's just more kind of bullet points of what we are suggesting, something like that would include. So I am going to share my screen. It's really fun to watch a learning right before my eyes because she wasn't able to do this this morning and we had like really different experience. You're cool. That's great. Well, Colleen's cool. All right. So the opening couple of lines is just explaining what we're suggesting which is a letter to DMH that would be requesting monthly updates not big reports, but updates and specific timelines for action items that include some immediate things along with the short-term and planning points for the moderate or longer term. And that we would want to incorporate VAS as requested collaboration on some of the items because part of it is about saying, well, this is really, you guys doing this, DMH would be doing this but they need to really be working together. And then what we have is a list of what would be the requests or what would we be expressing as expectations that would be in the letter. And this is kind of the list of ideas starting kind of with the opening and really thanking them for being very responsive and also making note of the fact of the memo that DMH already sent us on the commitment to prioritize children in. I really abbreviated this but the capital bill RFI process if people remember that was our language about getting proposals from the community agencies for residential programs and that they're gonna prioritize children's responses for children for diversion and step down in that process. But that's obviously not a rapid turnaround for that to be created. So the second point is for a continuation of weekly reports but saying we want it on numbers and the length of stay, the days. And comprehensive regardless of whether they're in DMH custody or not involuntary or their insurance status meaning that needs to be in collaboration with VAS and having that data in alignment. So really getting accurate tracking of the status to indicate that we wanna know where we wanna know where these folks are. That's a very interesting point Art in terms of getting a sense of the distribution in the state. Yeah, I don't know off the time I don't know how heavy a lift that would be it would seem that like VAS is gathering this by contacting each of the hospitals. So they know which hospital. So I don't think it would be hard to make it a chart that indicates. It came to mind because the Rutland legislative delegation heard from Claudio Ford this week and we had some discussion about it in the Rutland area that's why I asked them. Claudio is the head of your hospital, right? Pardon me? Claudio is the head of your hospital. Yes, he is. Okay, look at that. I wrote it on there and which hospitals. This is cool. The next one is the indication that it needs to be immediate that they start soliciting input from the family and peer stakeholders so that they're getting input on identifying both immediate and ongoing process points that so that shouldn't be a delay in how this is being followed up on. The next one is really an important philosophical statement and that that be that DMH needs to start expecting, establishing the expectation for our system that every moment of involvement should be being used to provide treatment and promote recovery. I just said when I read through this for the first time that really jumped out at me and I really appreciated that. Yeah, well, when Brian's the one who said that and Leslie and I both said, yeah, that needs to be there. That's really what it's all about. Then you have to talk about concrete steps, but then saying, and I know the integration council is not something that new members are familiar with. It was something we established in legislation last year and it's been very delayed because of COVID. But I know they were in the process now of starting to set it up. And that's a council that's supposed to be sort of bringing the rest of the healthcare system on board with what needs to happen to implement a 10-year vision that really establishes integration in our healthcare system, the whole parody crisis and that we would be suggesting that they use the emergency department crisis as kind of a first case sample, if you will, of discussing and identifying how does the whole system appropriately respond to working and integrating mental health responses? And then we get into the more direct. Can I ask you just, and I welcome people to just jump in. I think this is a conversation, but I'll just jump in. Say a little bit more about when you, because you use the shorthand and I think it's helpful to have other people talk when you say, well, the integration council will look at how to integrate healthcare. What you're talking about, I mean, you can articulate but I'd like you to just articulate a little bit more about what that means. Yeah, I can throw out some examples. So one of the things that was referenced by somebody in the testimony in the last few times that one of the issues is private health insurance, not adequately providing for the needs in this category that would be consistent with parity. And so that is sort of part of the integration council's role is to be talking about, are we meeting the expectations and requirements of parity? So if they are focused as their first kind of situation analysis of how are we creating a more integrated system that's really implemented parity, they would say, okay, what is going on with this emergency department crisis where the rest of the healthcare system should be playing a role and isn't? You know, Diva is looking separately at this question of daily rates for the emergency department. You know, if for every other condition, you're in and out of the emergency department, you know, in under 12 hours at the outside, then saying there's a one time rate, you know, this is what the ED visit is the rate, makes sense. But if somebody's staying there until we resolve this, this isn't gonna be resolved overnight. If somebody's staying there for six days, that's a very different scenario. So what is the insurance, including our public insurance, but private insurance as well, what is the responsibility to provide the financial support to meet a specific need? So, you know, that's just two examples. There are a lot of others in terms of the other, one of the other issues that came up with transportation. You know, how do we meet the need to get people? And if you have a broken hip and you're being transferred to rehab, you don't need to be admitted after you're stabilized, but you're going to rehab. You're not wondering how am I gonna get there? So how do we resolve this? Recognizing it's a healthcare system issue, not just a mental health issue. So this is not a quick turnaround either. This is more a longer term, but it's beginning that process of making sure that we're looking at it as a part of the healthcare system, not just in isolation, because that's what the integration council's function is. Okay, obviously we can go back to any of these, but just to do the walkthrough, we identified as June one for an initial outline, understanding that it may be very incomplete. And this is not a report. This is a, you know, maybe a one-page outline with columns. What are the current emergency action steps and planning steps? And this is something they will have to do in collaboration with VAS so that they are monitoring and we are seeing which have been completed, which are underway. What is the timeline for completion? And is DMH doing this or is this something VAS is doing? And then after that initial one, they continue to provide updates on that action timeline with the expectation that it'll continue to have items added and progress steps on it, on the moderate and longer-term action steps. So it will be very much a constantly updated, monthly statement, if you will, saying, here's where we are on these items. Here are the items that may have been added because of input we've received or things we've identified that weren't on the very first much briefer list. Here's who's doing them. Here's the deadline and here's where it stands. We want them to, these are things, a lot of this was discussed in the committee. We want them to establish the target date for achieving as a first step that the average length of boarding does not exceed 24 hours. That's not an end goal. That's a, give us a target date for that step of progress. And then the last one, identifying what best practice is for what it should take to assess and resolve a mental health crisis in an emergency department and be moved on, whether it's discharged to outpatient or it's an admission somewhere. What is the best practice length of time? And then based on that, what is the target date for achieving that? Meaning no child waiting in the emergency department, but waiting as defined what is the appropriate best practice of what time it takes to address that type of crisis. And then the second piece, if you will, is about very immediate steps faster than what were defined as short term. And this is a request of us and they may need on some of it collaboration and support by DMH, but this is primarily about what's happening in emergency departments right now with the experience of care for children who are currently having to wait, whether it's 19 kids or whether it's one kid. If they're waiting day after day, what needs to happen right away? And I'm aware they've said they're starting to look at these, but we wanna articulate that we would like to know about and see immediate steps. And we give some examples, I mean, I threw out and it was somewhat ingest, but not really it was symbolic like coloring books, but this is a little bit more concrete. The scope is about available resources or training to improve the current physical and social environment with input from families about what they need. But so this is not about CONs to redesign emergency rooms. This is about right away. And examples are like emergency department or crisis staff being there to provide more direct emotional support and activities and regular information to parents, to families who have described, being there for hour and hour and hour and not even getting an update on when to expect something to happen. Kids not being asked if they need food and so forth and not having engagement with even the people who are monitoring them. Ensuring that children and adults are not being held together in the same area, which we had one report, I think I shared with the committee and family had written about that. The increase in just comfort items and environmental things like being able to dim lights to try to sleep at night if you're gonna be there overnight. Use of telehealth if it's gonna be things that can improve the patient experience of care. Particularly, for example, transfers from the emergency department, from the Northeast Kingdom, for example, where there's no admitting psychiatrists on site and this might be a way to expedite things as long as this is part of an improved patient experience of care and not detrimental. But these are really just a list of examples. We're not asking these specific things. We're saying this is what we mean about immediate actions. And then the final point is just that we're gonna be off session. So it would just note in the letter that we'd be asking for these updates to be sent to the leadership of the House Health Care, Senate Health and Welfare, the Joint Health Oversight. And obviously, I think the way it's usually worded, obviously we would be forwarding that to all of our committees anyway, members, but so that's the outline. So people wanna go back to anything or reactions or responses. I wanna just go ahead, Lori, go ahead, representative Houghton. Oh, you can go ahead. No, I just wanted to say how much I appreciate the thoughtfulness of what's articulated here, both in terms of being setting some timelines, expectations and some values that are combined in this piece that I, that's really, I mean, there may be other specific suggestions, but that's my most immediate response. And I wanna express appreciation for those who have worked on this. Lori and then Elizabeth. Thank you. And yes, thanks to the folks who did this. This is really great and such a good step forward. I know I have specific recommendations. I think the things that come to mind are just, I was concerned, I believe, with some statements that were made by those who've come in to testify that it's a seasonal issue. So I just, I wanna make sure that we're, this isn't a, let's get everyone out of the waiting rooms in the next 30 days and not worry about the fact that, what is the issue? And shaking our heads, I think you probably understand what I'm trying to say. No, exactly. And I think the hospital associates can point it out. Yeah, you can say that. There's ups and downs. There are more intense times, but the long-term, the long-term grass shows that it's going up. And when I said before, in terms of best practice, and whether it's, if there's one kid who's waiting days, that's not okay. So the fact that it's 19 versus one, really is not relevant to any of these. Exactly, thank you. Action's needed. And then the second thing is, we had several departments come together last week or this week, I forget when that was. And I wanna make sure that collaboration amongst them continues because it's not just the ED we have to worry about. And I'll go back to something I said last week or I think it was this week that, agency of education, although they are doing work, they weren't at the table with the rest of them. And I feel like we're not really hearing from the agency of education. They, you know, DMH, which is great. Keep saying they're doing these amazing things, but I mean, there's such a link between the schools and children's mental health. So thank you. I guess changing that to AHS helps, but I would also like to have a reference of the agency of education in here. I put that here too. Oh, thank you. Collaboration needs to be with us and also with the agency of education. Great, thank you. But you're right. I mean, one of the things I mentioned in our meeting this morning, I don't know how many people saw the Digger article, which kind of really annoyed me a fair amount because it was, you know, DCF saying that they're doing this whole new initiative about enhanced foster care for kids with special challenges to bring them in from out of state and there was a reference to, and this is a big piece of, this will help keep them out of the emergency room because these kids in DCF custody are a big piece of this emergency room issue. DCF was in our committee room Tuesday and never said a word that a significant subgroup of these kids with long waits in emergency departments are kids in DCF custody. So clearly, I mean, it's really good point to change it. It really needs to be to AHS so that it's involving. And, you know, I don't know, it might be too hard. I mean, it would be really good to identify in those weekly reports and how many of those kids are in state custody. We want the numbers regardless of custody but we wanna know which hospitals and in whose custody. You know, one other thing I'd like to say is the foster homes, you know, some are very good and then we also have some that are not. And, you know, with issues of manpower and people out there to support, it's just a concern. Let's just put it that way. But actually, I think it's a good point Woody and if they on their internal end or working together among the departments, you know, it's gonna help them see if there are certain children who are showing up in the emergency department more often who are with the same foster family, you know, that's gonna help them identify where they need to maybe strengthen their system if that is, you know, one sub component of the problem. Well, and you also don't wanna see them shuffling off to different homes after such a period of time. And, you know, it's a very difficult process, you know, and, you know, I know DMH has had, or is it the Department of Families, you know, they've had their issues with some of these homes and some of these families, you know, I don't know, it's just very sad. It is. I could tell you horror tales from when I was a foster parent and... I know, when you had those wonderful little kids that you were looking for. Oh no, I'm not telling you, I wasn't, no, I was a DCF foster parent many years ago. So I'm gonna just encourage Elizabeth and Art to just chime in and step back from moderating this afternoon, but I think we'll manage amongst ourselves a bit. So Elizabeth, Art, feel free to... Go ahead, Elizabeth, you were before me. Thank you very much. I feel like one of the things that's being left out of the conversation is the family. And that, you know, I haven't heard of a protocol for families being at the emergency departments with the kids or whether there's like, you know, services that are being wrapped around the whole family. I know there are outside of the emergency department, but when a child is in crisis, a family is often in crisis at the same time. And I'd really like to at least learn more about what's being done for families, but also know that there is some kind of protocol being provided for what family members should do. Or, you know, it's sometimes like in our family until the last year or so, we all had to go to the emergency room because we don't have, we have one car family. We don't have the resources to, we don't have one car family anymore, but we didn't have the resources to be able to manage, you know, doing that. And so what, what happens then? Yeah, so I've just added, and their families, the experience of care in the ED, we already had like examples being staff who are actually giving support to the kids and giving updates, and maybe updates isn't good enough, giving support and information to parents. I mean, that's not to say, sometimes the family is the problem. We know that, but sometimes it's not. It's the nature of the... I'm sorry, I'm gonna jump in, Art here, but when families and children go to the ED rooms, and there's an issue with the child, is that child taken away from the parent? Brian probably has more directX, my experience and information is no, that they are not unless, unless there's some kind of an allegation or indication that there's abuse or something. Yeah, yeah. The family waits with the child. In fact, that's one of the issues where when we were talking about designs for the new emergency department at UVMMC, the family input included, you need to have a shower accessible for family members who are waiting for days with their kids and can't even get away for a shower. So, yeah. I think I would say, it depends what you mean by is the kids separated from the family because, because if you mean like custody, then Anne's right, like if there's an issue of child safety, a report would be made to DCF and DCF would make that decision, not the providers in the emergency room, but that if the other situations I could imagine where there might be some separation would be if there's some kind of safety or health concern like during COVID, for example, but even then like recently, when I've been in the emergency room, parents were with children in the rooms. So, I think the practice generally is to keep children and their caregivers, whether that's their parents or foster parents or DCF workers or a provider who brought them in. The general practice is to keep them together and to try to include the support for the children in all of the, you know, in all of the actions there. Yeah, I might comment, maybe not so much to this letter, although it has a bearing on it. When this all started to happen here recently, and Chair, you can answer this probably, did we go to DMH or did they come to us? And the only reason I ask is, it seems to me, and if this stuff is happening, that the people in the agencies and departments that have permanent jobs in those divisions should be doing the, you know, if I worked in DMH and saw this, I think I would jump right on it and let's get a fix. Is that happening or is everybody kind of dependent on the legislature to do something? I don't know, that doesn't come out right. I don't know. I think I hear what you're asking and I think in fairness, this is an issue that has come to the fore previously. We've talked about it and Department of Mental Health has talked about it. And I think it has, it's received, and just waiting time in emergency rooms generally for mental health services, adults and children, but particularly adults, it has been an issue over a period of years. And so we've met, we've had, we and the department has engaged with emergency departments of hospitals. I mean, there have been numbers of activities to try to address some of this. In this particular instance, I'll give credit that in part, this was prompted by a letter that was sent to Counterpoint Newspaper by a family member, not there with their child, but there for some other reason, and observing children, numbers of children waiting in an emergency room and being the editor of Counterpoint, reviewed the letter, we talked about it and... Yeah, I'm kind of surprised we got it that way. So I think it's kind of like, the frog in the boiling water and you get used to it. It has been a serious problem for a long time and it does get worse and better and worse and better, but it hasn't gone away. But it, unfortunately, it falls off our radar in terms of urgency. And I think the same thing happens in an agency because that's, it's human, but it happened us as well. So it got... I see, I see what you're saying. I mean, this is all gone on and on and on. So this is no different to them than any other time. Except that it got really bad again. Really bad. Nobody raised the red flag. And so it was this letter that raised the red flag that, whoa, it's gotten really bad again. Now, I want to bring up one other thing if I can. It had a bearing on this. I referenced, you know, every Wednesday, we have a Rutland delegation meeting. We've met with Claudio Fort and this came up. And I was going to bring it up if it didn't, but it came up. He was very concerned about it. But someone else in the meeting said, well, the 12 beds of Bravo Retreat are going to take care of it. Is that happening? And I know you're on top of that, or what's the... No, no, that's something that's, that's one of those items that like, there's so much to monitor. As far as I know, you know, the staff recruitment phase has not reached a point where they, I mean, they have not opened any beds that I know of yet. They are still supposed to happen. You know, we really would need an update from DMH as to, or from the retreat itself as to where exactly they stand. But they're not going to, that's not going to resolve a single thing for kids. Okay, all right, that's good to know. Okay, that's an adult facility, okay, well, there you go, then that was inaccurate information. Okay. Part to address the level of urgency of the problem of adults waiting, extended periods in emergency departments, not enough capacity for high need adults. Okay, thank you. Can I ask one thing? So in this section, and that you guys put together about, are you folks? I always had to not say guys, sorry about that. That you put together on the stats that we're supposed to receive weekly. Yeah. Sometimes I feel as if we don't ask, if we don't know the questions to ask, we don't get the answers. And so can you, is there like a general statement that you can say any other information that you feel is important for us to know? Just, you know what I'm trying to get at? Yeah, yeah. I don't want them to get this and say that this is all we want. Spoken like a true Lexis-Nexis employee. Exactly. Exactly. Or no, Tilia, right, you don't know. Right. Again, Leslie, just jump in. I'm not monitoring this afternoon's conversation, just welcoming us to monitor each other. Sure, thank you. I think one of the things that came up in our conversation amongst the three of us was sort of this overarching philosophy that although we don't wanna have any kids in the ER, there will be times that children are in the ER and that's what this is addressing, but that what we were hoping was that there would be enough community supports that would preclude emergency room disposition for children so that in fact, kids would not be going to the ER. And one of the things that came up was some regulatory comments from VOS, like CONs and all that jazz. And we were saying, no, let's not even go there because if we start doing, yeah, let's redesign the ER for this, then it takes away from the community supports and emergency programs that we would like to have in place to deal with a pre-ER. So this is sort of our interim so that we could get to a system that will be pre-ER as much as possible. I don't imagine it would always be that because there will be crises. So we wanna have it both ways, I guess. Well, I think, and I forgot, I lost that from the list of our earlier discussion and I don't know quite how you say it in the negative, but maybe there's a way. What we talked about is that we did not wanna see proposals that basically institutionalized the status quo rather than resolving it. That's right. And maybe that comes with, maybe when we get, when we start getting the action timeline on what the stars are and if one of them says, well, you know, doing an emergency room expansion, maybe that's when we say, no, no, no, that's how we meant. But maybe there's a way we can say it right from the get-go in this letter saying, and by the way, don't be coming at proposals that make assumptions. And maybe that's saying it by saying, we wanna know the, I think when I'm thinking aloud, as I say this, but when I look at these last two bullet points, when the target date that we wanna hear from them to bring it below 24 hours and then the best practice and achieving it, that assumes if that's what we're trying to achieve that we're not doing things that allow, that accept stays in ED as a norm and that we build emergency department capacity to accept that as a new normal. I think when we talk about it, it was sort of like, well, that's a long-term vision because we were talking about more about short-term, medium-term. And maybe that's the way to think about it is ultimately the community supports will be robust enough to not require ER stays, period. And that's just the issue. And that may be in the introduction. You know, it's sort of a philosophical statement that that's the ultimate goal is kids don't, we were able to intervene ahead of needing the ER. I wonder if that's part of our expectation, establish an expectation that every moment of involvement shall be used to provide treatment and promote recovery and- Actually, I'm gonna say no. No, I'm gonna ask you not to do that, but I don't wanna dilute that line because it's so good as it stands. I would prefer another bullet just saying, you know, ultimately, you know, that the emergency room is a place, you know, I don't know. I guess what I'm saying is that the community supports for mental health will be so robust for children that interventions can occur prior to the need for ER, something like that. Yeah, I just wanna say that I totally agree. I think we all do about that, that we need to kind of shore up the bottom before, as much as we need to worry about the top or the, you know, that we need to also put a lot more focus on the bottom. And I think that's well said, so thank you. And I think that that expectation is kind of, it's good to focus on it that way, because otherwise it's only implicit. It's implicit in saying, and you better come back with something in that RFI process for diversion and the emergency room. And step down and, you know, and we do ask for longer-term progress and not relying on EDs, but this lays it out more directly, which I think is good. We had talked actually in the subgroup about listing examples for those moderate and longer-term things, and then decided that, you know, they've already got ideas on that. We're telling them to also listen to families that listing them out here was maybe micro work, because we had things listed like, look at expanding the PUC model, do early reviews of how the mobile, new mobile crisis program in Rutland is doing to see whether it should be expanded and adding a lot of detail. And we kind of pulled back on that, thinking that, you know, that might be micromanagement, particularly because that was really already their list of things, you know, we don't need to repeat the things they already said they're gonna do. We just want them, we want those in the timeline, in that action timeline on progress points towards those things, but we don't need to spell out what they should be. Hey, Ann, when, and I'm still struggling to get this through my thick skull here, a child in a family goes to the ER, the child needs to stay. I don't know what the capacity is of a hospital in terms of other patients and other rooms and other things. Can they not put this child in a room that's empty if they have it? On another floor, you know, take him to a place that's comfortable and nice with a bed. Well, how many beds? Yeah, I mean. How many beds are in an emergency room? Well, that's one of the things, that's one of the things that are in those VAS weekly reports that they're also copying to us now. It talks about what percentage of emergency room beds end up being taken by some of these both children and adults who are staying multiple days. And in some cases, it's like a third of their emergency room beds, which is a huge problem. So, yes, UVMM, VAS talked about that they were occasionally, and I think this is part of what we're asking them to look at for the environment. You know, they actually have a pediatric unit and to temporarily hold a child there, which they said they have done, they discussed that, you know, that seems to be something they ought to look into more. You know, as long as it's not a child, sometimes a child in crisis is extremely disruptive and you can't have that child on a pediatric unit where they're very physically sick children, but other children could be waiting in that much more comfortable environment as an executive. Okay, okay. So it's hard to place them in a hospital. I'm talking about, well, I can only judge by Rotland Regional because it's all one building. You come in an emergency room and if you were there and you were seen by a psychiatrist and he said, well, you need to stay in a room. They could go to another part of the hospital, walk and take elevators and get in maybe if it's bare, a room, but you're saying some, a lot of these rooms are not, they might have a disruptive child who doesn't fit into the... Or they might be rooms where the hospital would be in trouble with the licensing folks because it's a room, if it's a normally equipped hospital room, it's got a lot of equipment in there that could be dangerous to have if you have, say an adolescent who's very suicidal and might grab something. Yeah, I think we need to recognize, I think we need to recognize that there are protocols within which the hospitals need to operate to provide for appropriate safety and also appropriate protocols around. Yeah. Okay. So I see, I was stepping back, but I see, Mari, you have your hand up and Woody, is your hand up or is that, yeah. Okay, well, I'm gonna ask each of you to chime in and then we'll see where we are. Woody was ahead of me. Okay. Yes, but you haven't asked any questions. So you go ahead, representative course. Well, thank you, Woody. You're very welcome. It dovetails with arts question anyway and just a reminder that even if you, if the hospitals could find a space or a room, you also need to have the staff with the clinical competency and skill that could go work in that room. So there's, yeah, there's that. Yeah, that's why we didn't wanna micromanage and even the examples we gave, we said, this is just to demonstrate, we're thinking about things you could do quickly and maybe none of these are viable, but we wanted to give some examples, but yeah, we can't tell them how to do any of that because we don't know all of the limitations. Right, Woody. Yes, I've just kinda mentioned and it's been partially mentioned before, Department of Education know our teachers probably see a lot of these issues come up beforehand or nurses, school nurses. It'd be nice if there'd be some sort of interaction. Not saying there isn't, but there should be some working together with these different agencies. It's like somebody said, you put the emphasis at the very beginning rather than in the emergency room. Right. They are actually doing quite a lot. There's a lot going on. I think it's fairness to them. Yeah. Well, there's- It happens everywhere and all the time, but there's a great deal of- There's a, this year there was a statewide trauma-informed training for teachers all over the state just to get ready for reopening the schools and looking for, to try to be careful with our students. So I think that teachers are doing a really great job of that actually. Yep. And then the other issue is the age of the children. Quite often when a child reaches 18, sometimes that's it for health and healthcare and health. And we have a lot of high school students that maybe it's their last year, they're 18 and they may be having issues. I don't know what the age limit is to help some of these children that turn 18, but that might be something that you might wanna consider. Woody, that's a big problem that really is. And in terms of even the emergency room crisis, the problem with adults, which run the range of adolescents like what Bill and I heard last fall from Spectrum in Burlington, that includes 18, 19, 20 who are not the same as somebody who's 40 or 50 with those needs. I think what we're trying to do here is focus on this specific subpart while knowing that it then needs to broaden out and deal with a much, we have a system as a whole in crisis in terms of community support. Just in case people weren't watching, I was listening and adding some pieces here from what was being said and that this action timeline that gets added to as input comes in, specifically says inclusion of the input and involvement of the agency of education and the relevant, the other relevant AHS departments, children and families, you know, Divas so forth who will have to be a part of a lot of these action planning. Go ahead, Elizabeth. I was just gonna ask who do you foresee signing this? It would normally be the committee leadership on behalf of the committee. Okay, just wondering. And I think, I mean, frankly, the whole committee has been so involved. I think we could have it come under the signature of all the committee members. Leslie? So I just like to comment on this question of, you know, sort of older adolescents, young people. I think in the beginning in the data collection piece, Ann, if you slide it down a little bit. Yeah. It does say children and adults. And it might be interesting to add there only a comment about analyzing the adult trends to inform future policy or something like so that it does, we don't like just drop that idea. Particularly, I think there's a reference to transitional youth, which are often thought of as 18, you know, in that period of 18 to 20 who are captured when you collected the data for youth. And sometimes when you say children actually, it's like, you know, 16 to 20 or something. Yeah, so we could use that data, you know, that's collected as just part of the whole process then, you know, as we go on, I guess, is what I was wondering. Well, that's not what I was thinking, but it's complicated. What I was just thinking is that we use the opportunity and maybe we just say length of stay for all children up on the first line of that bullet and transitional youth. And that's where that gets captured. And then later on, say, also analyze the adult data to inform future policy. Because we say length of stay for all children and adults. So that's what I was thinking about. Okay, yeah. So what we have to, I mean, I don't want to create a weekly report that's, I was going to say look up. Yeah, that's no longer going to be a brief weekly data report. And we have to also keep in mind what we already require as data. And that may be what needs to be changed to draw from, but, you know, we do have existing reporting requirements that unfortunately is not broken down by age. And this really may be a separate bullet that says, you know, revise, look at revising data collection to be able to effectively do planning that incorporates the needs of transitional youth. Something like that. Yeah, I just want to include adults too. I mean, maybe it's just say disaggregate data by age and consider policy as, you know, as identified. But I mean, what if there's, you know, I'll be ridiculous. What if there's, you know, 50 adults in emergency rooms there over two weeks in the entire state? And because no one wrote a letter to counterpoint, we don't know about it or whatever. So I just don't want to lose track of that potential problem is what I'm wondering about. Right, right. So what we're really talking about is, I meant this to be a separate sentence, not to, that we want them, you know, it's probably, it's not a part of these weekly reports, but that we want them to begin to maintain disaggregated data by age in order to inform future policy. Yeah, something like that's good. Yeah. And then maybe up at the top. So since you've said that there, then in the bullet up above, take out for all children and traditional youth add that and then remove adults there. So I'm gonna suggest that we step back from, micro, perfecting the letter at this point as a whole committee in this, I mean, I think getting ideas out there and then given that you and Brian and can help integrate further suggestions, I think would be a good way to go. Yeah, because I would really be pushing back on that, Leslie, because I think getting this immediate reporting is very different from beginning new systems of reporting and they do not currently break out ages like that. So I don't think we can really say report on weekly numbers of children and transitional youth. Yeah, because that's what Voss is doing anyway. They're just doing it on kids and that's fine. But I- So they're doing it kids and adults. Oh, well, that's good because that's what we, well, I know that we don't want to continue- You're not breaking out transitional youth ages. So that's more a future to maintain it. So put that at the bottom of that census and identifying transitional youth who identified it in data. How does that, you still want to keep that in there? No, to begin to, oh no, right. No, no, we wouldn't be putting it here. Can I suggest that we kind of step back from too much further word smithing at this point? Yep, okay. I just want to give Katie at least some logical thing here. Oh, I think you have. Oh, good. Yeah, and she's been listening too. So, I mean, I think we've got here good input and good, you know, a good product to turn over to the skilled writing of our legislative council. No, I think this has been a good, I thank you for the work on it. And I think the input this afternoon has been helpful as well. Can I just say one more thing? Sure. Can you move up the, move up to the top the sentence about that we all really liked? Oh yeah. This one. Yeah. Why not move that up higher so it doesn't get lost? Make it, it could be the opening. Yeah. Or you could bold it, just so Katie knows about it. That's all. Yeah, we'll put it top. So that Katie knows we want it on top. I think she's still here listening, so. Hard to know. Yeah. Anything else that folks want to bring forward and just to suggest that, you know, if you have further thoughts upon reflection be in touch with Ann, Leslie or Brian. And we will take a look at this again in a more formalized form early next week. Before we wrap up, Mr. Chair, it would there be time to take the two minutes to hopefully have a poll on the shackling issue now that we actually have a draft written? Yeah. Sure, why don't you put it in front of our committee and I think we can perhaps just, I think there was a strong consensus to support that. Yeah. Right, that's why I didn't think it needed more discussion. We just didn't have any language to actually have a straw poll on and I emailed the language to everybody. It's just a sentence that cross-references the prior. If you want to take this off the screen and now that you've learned how to put it up, can you learn how to take it down? Well, there that's it. Oh, there it is, stop share. Cool, okay. So I can, if people don't have it handy, if people don't have it handy, I can read it to you. It simply says that the report back from the Joint Justice Oversight Committee, if they come up with new proposals that the new proposals have to meet the requirements of that session law that said, we have to enforce the shackling, but let me find the exact wording to that. That's section E314. Is that what you're referring to in our email that came at 11.35? That I don't know, that might help me, 11. It's the one that was sent at 11.29. 11.48, the later one was giving the cross-reference language, but the actual language proposal, it's in a section that requires a study and report from the Joint Legislative Justice Oversight Committee, which includes potentially recommending changes to the existing system of contracting for county sheriff transports. And what it adds, the sentence it adds says, any recommended changes shall comply with the agency of human services policies on the use of restraints in accordance with 2017 acts and resolves number 85 E314. So that's what the proposed amendment is, adding that sentence. That basically means that they should have the proper protocols to not use inappropriate restraints with children. Right, right. It's cross-referencing when in 2017, we said the agency can't be contracting with, you have to cut off the contracts with sheriffs if the sheriffs aren't complying with the law. So does that mean like, I mean, how many sheriff departments are there in the state? So like each department has county, just by county. Okay. Yeah, each county. Was that 13, 15? I can't remember. But then it would be individual, each sheriff would have to acknowledge their knowledge of this law or something. Is that how it gets? The agency of human services already, I don't know what they have set up. They already have it set up. They already have a system. This proposal in the budget is to re-look at the system whereby we contract and maybe having it shift just to county regulation. And so all this is saying is whatever you recommend, you have to keep this in force. Right. Which was an important policy implementation. I'm just going to take as a sense of the committee that there's a consensus to support having that embedded in any change that that is moved forward by the agency. Is that fair to say looking around the committee? Yeah, I'd say that you have that. We have the support to ask to have that integrated into the language of the budget. Great. Thank you. Good. And thank you for following up on that. So again, I think you will work with Katie McLinn to bring a further product to the committee. We'll work with, and again, a reminder that the Appropriations Committee is in the beginning process of the Conference Committee. And so they will be updating us. Lori is providing them with information based on what the work that we've done over the past several days. And there are a few more items that will come before us over the next period of days as we move into next week. And we have in front of us, Representative Black will be presiding 430 on Tuesday. And that will bring that to a close. And we continue to have S22, which we will put on the calendar at the appropriate time. Which will bring that to a close as well. So there may be other issues that emerge that we're not aware of that could be brought to our attention by the Appropriations Committee or by others. And my understanding, my latest understanding is that so we may, our schedule next week may be slightly different, but we haven't heard for certain. But as we move into the final weeks of the session, we can anticipate that there will be some times when we will meet and other times when we will be attending to other issues, such as conference committee, following conference committees such as S3, which is also coming to the floor next week, I believe, where we had a significant input to that bill, even though we never had possession of the bill. And just to be clear, the chair of the judiciary committee has reached out and asked if our committee would present those sections, five, six, and seven on the floor of the house and represent John, he was prepared to do that. Yes, that's one of those fluky things where I won't be presenting it when the committee presents the bill because I'm not a member of the committee and can't. So they have to actually hold off and just say, you'll hear about this later. And then after they're done. They will. And after the vote on the appropriations amendment, whatever they do, then I'm the first one to rise. And then I say, and now... Okay. Well, we'll trust that all gets sorted out procedurally. So good. Got that with Betsy Ann, all straight. Great. Well, we appreciate your willingness to do that because it's an issue that's important. It's also an issue that's difficult to convey and understand at times, but we're confident in your willingness and ability to do that. So anything else with that, I think we'll bring our committee meeting to a close for the day and we'll see each other. Well, keep your eye on the agenda because I think Tuesday could be a very full floor day given that a lot of things are moving on and there is a token session on Monday. So Tuesday could be a very full floor day and it may mean ultimately that we do not have committee or that we have a very brief time for committee but then things will move them along into Wednesday and Thursday. So do stay in touch as we try to make decisions about how best to move our work to completion.