 Good morning. This is the House Health Care Committee on Tuesday, May 4th. It's 9 o'clock. This morning we are returning to the important issue of children waiting for mental health in patient services in emergency departments across the state. And we had invited Commissioner Squirrel and the Department of Mental Health to come back and provide our committee with follow-up to the testimony that we heard last week, or was it the week before, I think, in terms of the larger number of children waiting and what many of us considered a crisis situation that needed some immediate response. So I appreciate hearing, having the Commissioner of Mental Health and colleagues with us this morning. I'm going to turn it just because we have, we have between now and just a few minutes before 10. There is a document that's been provided, so committee members should access that. And I'm going to turn this over to Commissioner Squirrel to provide us with the information and presentation this morning. So good morning and welcome, Commissioner Squirrel and others. Thank you, Chair Lippert. Good morning, committee. Great to see you all. For the record, Sarah Squirrel, the Commissioner of the Department of Mental Health. Very grateful to be joined here today by several of my colleagues from the Agency of Human Services, Commissioner Sean Brown, Commissioner Corey Gustafson, Selina Hickman from Dale, as well as Laurel Omland and David Retou from the Department of Mental Health. I'm going to go ahead and start sharing my screen. We do have a presentation prepared for you. So just bear with me for one moment. Did that work? Yes. Wonderful. On full screen. Excellent. Okay. So I was not able to join the committee for previous testimony on this issue. We did hear from the committee. We did share data related to the issue of youth presenting and waiting in emergency departments. And there were a couple of goals and takeaways that we took from that meeting. And really what we've been working on over the past week, as well as ongoing efforts on behalf of the Agency of Human Services and the Department of Mental Health. Number one is continuing to identify and address barriers for access and care for children and youth for inpatient. And number two, which I think is what the committee is expecting from us today, is to really present what are those concrete and actionable strategies that we can utilize to A, improve access to care for children and youth to reduce emergency department visits and wait times. And essentially what you see us doing here at the Agency of Human Services is to identify the scope of the challenge and then to work together to try to solve it. I believe that this was noted in our last testimony, but I do think it's important that when we think about the issue of children and youth waiting in emergency departments, it really is a systemic issue. And it's a systemic issue that requires system solutions and responses, which is why I'm so grateful for my colleagues at the Agency of Human Services for joining me here today and who have always joined me in terms of how we address this and how we addressed urgent issues in our system of care. When we see long wait times in emergency departments, whether it's children and youth, whether it's adults, which is another area of the system of care that we have all grappled with, it really is symptomatic of having inadequate flow in the system, which is really our ability to manage individuals and accessing levels of care appropriately and in a timely way. Certainly we know that with the recent surge in youth waiting, one of the challenges and one of the factors contributing to that was that many of the youth who were receiving inpatient treatment at the Brattleboro Retreat, which is our only inpatient capacity for children and youth, about half of them were actually ready for discharge. They were ready to discharge to a lower level of care in our residential system. And we simply had an adequate capacity in the residential system. So our inability to essentially transition those youth to a lower level of care is appropriate, really created this backlog because then you have individuals and youth waiting in EDs because we're unable to move those children and youth out of those beds. So again, it's just important to keep that in mind, particularly as we're looking at solutions. The other thing that I would note is that all of our human services systems have been impacted by COVID, our capacity, our workforce. So I guess I would say that our systems of care certainly not without the incredible efforts of our community mental health and other community providers have certainly not been operating in full capacity over the past several months. And of course, it's essential that we have to be responsive to put forward solutions that are integrated and that really focus on the continuum of care in our systems. Other factors that contribute to this issue, why are we seeing this surge? Why did we see this tipping point? Certainly increased mental health needs due to COVID, particularly for youth ages 12 to 17. We know that even prior to COVID, we have seen significant increases in anxiety and depression. We also know that as a result of COVID, depression and anxiety continue to increase. There was a PACE study that was done by the University of Vermont and the Vermont Department of Health in the fall. And a follow up study done in the winter really demonstrating and indicating that we are continuing to see increases in depression and anxiety for the youth. Also just noting that schools not being fully reopened over the past year also is a factor that impacts child and youth mental health. And the reason for that is that I shared some data, I think at our perhaps in one of our previous committee meetings that in calendar year 2020, almost 50% of children and youth on Medicaid receive their mental health services in a school setting. We have an incredibly robust school based mental health system across the state of Vermont. So when our schools are not fully opened, then our children and youth don't have access to many of those critical services and supports that are available to them, which is why every effort has been made and should continue to be made to fully reopen our public schools. Also, as I noted, we have reduced capacity in the system of care. Many of our community mental health partners and other services and supports are not being offered fully in person because of COVID restrictions. We are working and those are part of our solutions to try to improve that. We look to the slide, I think I will be sharing it in a minute, just in terms of capacity in our crisis beds and our residential beds, as well as what we are all aware of, which is a broader issue for our entire health care system, which our workforce challenges. And then we also see a lot of seasonal fluctuation and demand when it comes to children and youth needing inpatient level of care. This is actually one of the issues that contributed to some of the financial instability for the Brattleboro Retreat. There is significant fluctuations in demand for child and youth inpatient care. We have data that we have shown in the past, particularly in the summertime. We tend to see a pretty precipitous drop in terms of demand, which is why our efforts to move the Brattleboro Retreat to an alternative payment model, that was one of the main goals. So it's just important to note that when we're talking particularly about this level of need and the system of care, we do see a lot of seasonal fluctuation. And I think what that means for us as a system is that we need to have capacity in the system that can be flexible to be responsive to that demand when it does fluctuate. And I think implementing the alternative payment model of the Brattleboro Retreat was a good step in the right direction. And then, Sarah, if I could jump in here, the other thing I would add on this seasonal impact is we do see flow in our residential system slow a little bit this time of year as kids that are ready to transition from a residential care setting to a lower level of community care. The programs tend to hold off because it's close to the end of the school year and to not disrupt the end of that school year education for that child or youth that they then kind of hold off until the school year ends. And so we do see the flow and the residential slow this time of year just because of the timing with the end of the school year not wanting to impact the education for the students. And so that's a factor as well. Thank you, Commissioner Brown. This slide was shared at the last testimony again, just illustrating some of the bed closures that we have across the system and some of the reduced capacity that we have had, particularly in our hospital diversion beds primarily do again to COVID precautions and restrictions as well. And one thing I would just note about hospital diversion programs, which I'm sure the committee is aware of, and our great partners at NFI for their great work, the hospital diversion program really truly serves as diversion. So for children and youth who might be presenting in an emergency department, our care managers here at the Department of Mental Health, working in close collaboration with emergency services, staff across the state are always working to have children and youth admitted into the, or youth, I should say admitted into the hospital diversion program, so they don't need to go to the EDs. So even though it's just a couple of beds that have been offline, given that the numbers that we're looking at in Vermont, they actually make a pretty significant impact. I also wanted to provide some updated data. We have certainly seen a recent surge in youth presenting in EDs, as well as wait times. And again, I think what this chart really demonstrates is some of that seasonal fluctuation. So this chart kind of picks up where our last chart left off. This really is intended to provide a snapshot of what we've seen from the end of April through today. So again, just really illuminating that over the past few weeks, we have fortunately seen a decrease in the amount of children and youth who are presenting in EDs. Again, this is not to minimize the issue. We never want children and youth waiting in emergency departments. It is completely inappropriate. But this does illustrate some of that fluctuating demand that I was referring to. Can I ask you a question? Yeah, go ahead. Representative Dahlia and then myself. Yeah, I know you can't see hands when we've got the screen share. Yeah, I just wanted to I know last time we saw information was pointed out that this is only involuntary or Medicaid voluntary, but that the number of non Medicaid voluntary was fairly small. So it wouldn't be significantly different, just maybe by a few. But 422, you're identifying nine and the hospital association identified 19. So that seems like a pretty huge discrepancy. I know in the past when we tracked adult, the numbers were significantly higher for the hospital what the hospital was seeing and what DMH was reporting. But that was that without including that was involuntary, only not Medicaid voluntary. So the difference between the vast numbers and your numbers is much more significant than I would have expected. Yeah, I think it's a great question, Representative Donahue, and we can certainly go back and overlay our data with Vaz. One of the things that we have been trying to do, the way that we receive this data is for the emergency services staff to call in the number of children and youth who are waiting to our admissions on a daily basis. Over the past couple of weeks in particular, we have been calling around to ensure does this truly capture everyone who is waiting in your EDs. So I am sure there could potentially be some children and youth that maybe are not captured here. But I think even when we look at and overlay the trends between Vaz and DMH, I think you'll still see the trend line moving in the same direction. I think you're right about the trend line. I just think it's worth looking into further because it's it's really about half, half the numbers that Vaz is reporting from the same mechanism of contacting each of their EDs on a, you know, point in time weekly. I realize that's not an average, but it seems it should be closer than 50%. Yeah, and what I can say in terms of the data that we looked at yesterday, we called every emergency department across the state to ensure that this number was accurate. So that was my question is that is this I'm a little unclear as to when the number of youth waiting for emergency exams and Medicaid voluntary, are there youth that fall outside of those categories that might be waiting that would not be captured in this data? Or is it the case that, at least as of today or yesterday, this indicates that there are only three children, not only, but there are three children waiting compared to the numbers that we had seen earlier, numbers we've been provided. Does this is that what this indicates is that there are three children in the emergency? That's correct as of yesterday. And I would say what falls outside of this and what Representative Donahue is noting, which is such a good point, is that four youth who are voluntary but have private pay insurance. That is not information that is always available to the Department of Mental Health. Certainly, as I noted, given the attention on this, we want to make sure that our data and reporting is accurate, which is why over the past couple of weeks, we have been doing even more follow-up with the EDs and our community mental health providers to ensure that these numbers do represent all youth that are waiting. So that leaves me still with the question. Is this three youth who are waiting across the state on May 3rd? That's correct. Plus four private pay or is that three youth who are Medicaid and or private pay? Yeah, the information that we have, Representative Lippert, that as of yesterday, there were three youth waiting across the entire state, across the entire state. Again, this is not to minimize that this still is an urgent and important issue. No, and I don't I don't hear you doing that, but it's just really important to try to understand if we're having if we're capturing the capturing, maybe not the right term. If we're if we're identifying the number of youth who are in need of inpatient mental health care, but who are waiting in emergency departments. Correct. Thank you. Yes, this next graph again, this is just a snapshot of what we have seen essentially, I guess, in the first four months of 2021. So again, it really illustrates, you know, kind of the trend lined creeping up, creeping up, going in the wrong direction, the significant spike that we saw in, I guess, early April and continued through April and then kind of the downward trend that we have currently seen over the past couple of weeks. So again, just additional data for folks to have for awareness. We certainly boss is a great collaborative partner with the department. So we'll continue to work side by side with them to ensure that we can provide data that accurately reflects all of the needs in the system of care on a given day. So we were really tasked with thinking about, you know, what are the short term immediate actions and strategies that we can take as well as more midterm and long term actions and strategies, but I will pause for a moment and it looks like there might be a couple of questions. OK, Representative Peterson and then Representative Donahue. Yes, thank you, Chair. Commissioner, could you go back a slide? Yeah, when I look at the slide, the only question I have, did anything happen systemically around January 17th? It seems like there's a significant jump after that date. Did did, you know, we lose some some mental health professionals. Did we change something? Did beds go out of service? Then I'm wondering if anything of significance happened to from that point forward? Yeah, I don't know if at that moment there was a significant systemic change. What I can say, Representative Peterson, it's a great question. I think this is the result of many complex and interlocking factors, as I noted, the ongoing impacts of covid schools not being reopened or provision of services being somewhat more remote as well. And, you know, it's fair to say that we have been grappling with ongoing workforce issues. And that is the need not to mention, I think, what we are seeing is increased trends around, particularly for youth. The impact of covid has significantly impacted their mental health. We are seeing far more depression and anxiety. And so I really think that's what is bearing out here. In addition to some of the typical seasonal fluctuation and demand that we even usually see this time of year, which I think was reflected in the data that was shared last week. And do you routinely track this data? I mean, it wasn't tracked because there's a problem now with what is it? Yes, this is data that we continuously track. We have longitudinal data for a significant amount of time related to this, which I think was shared at the last committee meeting, but we're happy to follow up and share that again. Yeah, that's fine. Thank you. Thank you. Representative Donahue and Representative Page. Yes, if you have this on the next slide, skip the question, but I had skimmed them before and I didn't see it. The length of weight because, you know, a child waiting 24 hours is obviously serious and traumatic in an emergency room setting. But a child waiting three or four days or sometimes more than a week is, you know, more on the horrific end. And this doesn't indicate how long any of these children are the number of hours or average length of stay. Yeah, another great question, Representative Donahue, we focused on the number of youth waiting to be able to pull some current data for the committee today. We can follow up and have our research and statistics team also look at the length of waiting time data as well and to get that to you this week. I think we may get it this afternoon. I think, you know, Voss is doing a weekly tracking as well. So they are tracking both of those in their weekly reports, which I assume or hope they're they're sharing with you as well. Yes, I have not seen the recent data from Voss, but again, that is something that we hope to work in close collaboration with them on. OK, there's a page. Yes, my question had to do also with the waiting times, the three youth that you reported that are sitting in our our EDS currently, how long have they been sitting there? Yeah, I would have to follow up with you, Representative Page, about the specifics for those three youth. And what should be the minimum amount of time that our youth are sitting in emergency rooms? Yeah, another great question. And I think something that we're taking very seriously. I think really this data is meant to illustrate the significant fluctuation that we see in terms of demand for inpatient and children and youth waiting in EDS. So let's continue with. Those solutions. So just to dive right in to some of the solutions that we've been looking at, just the first one that I would note is really related to our system of care recovery. You know, our state is moving towards recovery. Guidance is shifting as conditions on the ground improve. And certainly we want to ensure that that guidance is also applied to our community mental health agencies, as well as our residential providers. Because as Commissioner Brown noted, one of the issues that we need to address is adequate step down capacity for those youth who are already inpatient so that we can move them out of those inpatient beds and free them up for youth who are waiting. So fortunately, we were able to provide updated guidance to all of our community mental health agencies just late last week. This was done in collaboration with the Vermont Department of Health, which really shifted and allowed all of our community mental health agencies and staff to follow under the category of group A, which is low to no touch health care workers, which allows more provision of inpatient or in-person services. That guidance is really critical to our community mental health agencies and leaders in terms of moving towards more full in-person support, particularly in the community and in our emergency departments as well. The other guidance that we were able to update just this week is guidance for some of our residential providers. They, of course, have been operating under restricted distance things that has impacted residential capacity across the state. So working with VDH yesterday, we were able to put out new guidelines for youth in congregate care that does bring that for child and youth at three feet of distance into play, which, again, just gives those residential providers more flexibility, thus increasing their capacity, thus allowing us to move children and youth into the appropriate level of care at the right time. So I would just note that those two pieces of guidance and change are new just in the last week. Also, the NFI diversion program also moved to that three feet of distancing. That was actually one of the main factors that was causing them to have those two beds at each of those locations closed. So reopening those two beds at both of our hospital diversion programs will have a significant impact. And I just want to express my gratitude to the NFI hospital diversion program for their leadership there. They've just been incredible in terms of being responsive to this change and working very hard to reopen those additional beds as quickly as possible. We also, of course, given that one of the challenges that we were facing is the amount of youth who were at the Brattleboro Retreat, who were unable to discharge. So again, grateful to our partners at the Department of Children and Families who worked closely with us to really triage around discharge options to try to, you know, move those youth out so that we could free up that capacity. And again, grateful for the work that was done there. It always takes time, but they really did step up and allow us to alleviate and open up more of that capacity at the Brattleboro Retreat. The other piece I would note, and this is something we've been working on over the past year, there is another child and youth inpatient unit just across the lake, CBPH. It is a part of the UVMC network. It is run by Dr. Elthoff. We've been working with CBPH for over the past year to try to figure out how can we create a path by which more Vermont youth can access inpatient care at CBPH. CBPH was, you know, getting its feet under it, working on improving its staffing. And fortunately over the past several months, again, with great collaboration with CBPH and Dr. Elthoff, they've been able to admit at any given time, four to five Vermont youth to those child and youth units. It is a little bit more complicated, and there are more caveats any time that you are taking children and youth across the lake, as you can imagine, and into a different state. But for voluntary youth, this has been another great asset to the system and something that we are continuing to work with CBPH around. The other area that we are looking at, as we've testified before, we have a significant amount of federal funding that is coming into the Department of Mental Health. We really want to work with our community mental health agencies to identify and target those funds to specifically address this area. We convened all of our emergency services directors, child youth and family directors, DA execs last week to have a conversation about this. Shared and collaborative planning with them has been underway, but we have a lot of flexibility with these federal funds that we can target to address some of these systemic issues and to create more capacity. And of course, we are constantly working. We have two care management teams here at the Department of Mental Health, adult and children's, whose sole job is to triage and work with our emergency departments, emergency department directors and emergency services teams to ensure that we are triaging around any children and youth who are waiting to get them access to care as quickly as possible. This is just a review of the federal funding and additional federal funding with the Department of Mental Health has been in receipt of and will be in receipt of. We are certainly looking very closely at the supplemental block grant funds. The additional one point four million and two point eight million listed at the bottom here really afford themselves to a lot of flexibility and provide us with an opportunity to really target those investments, you know, with the guidance of our community mental health agencies. You know, we really want to hear from them in terms of where they think the most investments need to be made that will help us continue to address this issue as a system. So can I just if can we go back to the page on immediate solutions because I think that's really the area that we're I think most immediately interested in as well. And I'm wondering it's important for us to also understand midterm solutions as well. But can you give us any sense of what you estimate to be the impact of these plans for immediate solutions? What is there is there a goal and is there a measure that you will be using to determine whether this has an impact and in what time frame? Yeah, it's another great question. And I think that, you know, what we would anticipate to see is that as our systems recalibrate and reopening, including our public education system, we will see increased access to services and supports as a result of some of the changes to guidance, allowing the provision of more in person services, as well as flexibility in our residential providers. It will open up capacity there. We've already seen the immediate impact of our hospital diversion programs, being able to open up more beds, as well as our residential. Can I just interrupt us? Pardon me for interrupting, but so has the have the NFI beds reopened based on the guidance or will that be something happening in the near term? I believe that's something happening in the next week to week and a half, but I will just, Laurel, do you have more insight into that? Laurel, just texted me this week. It's my understanding that NFI will be opening one bed this week. And then the second bed that has been closed will be opened the week of the 17th of May. And there are four beds total, though, that are that have been closed. Is that right? So the two closed beds in the NFI North program are closed because of the COVID precautions that they've been needing to follow. That's where the guidance is helping. The two beds in the Southern program are due to staffing challenges. And so they don't have a targeted date for those. OK, so the code, so that's what I was just trying to get a sense of. So the COVID the change in the COVID precautions will result in the very near term this week or next week, the addition of two beds in the NFI North program. But the South program is a staffing issue and that won't be impacted in the same way. Thank you, Laurel. So I think all of these immediate solutions will contribute to ensuring that there is more timely access to care that we see a reduction in a youth waiting and wait times. However, to your good question, Representative Lepert, I think it's incumbent upon us and probably work for the Department of Mental Health, maybe in collaboration with Diva and Vaz really do need to set some benchmarks in terms of what do we really want to see as our goal as a system of care in terms of number of youth waiting and the amount of time that we are waiting? And then we need to strategically continue to try to address that. So I do think that's something that is important that DMH does in collaboration with Diva and Vaz and that we set that benchmark for ourselves, maybe based on national standards, maybe not. Vermont is typically a leader when it comes to setting the bar high in terms of expectations of care, particularly for children and youth. So I do think that's another immediate next step that we should also be working on. So we have a number of questions here. So let's pause and take those questions before moving on to midterm solutions. Representative Donahue, then Representative Houghton and Representative Burroughs. Yeah, so two quick things. I thought that there was already an existing benchmark that had been stated out there. And maybe that was only for adults, but that was a four hour wait time. But the question I had prior was looking at the immediate solutions. We know that there are ups and downs continuously. So even if there are improvements in this, what I would almost call a semi midterm, we can anticipate that there will be times when there are spikes, even with improvements, they might be smaller. But for those children, they're not smaller impacts. What I don't see there is anything about crisis management for children who for whatever reason do end up waiting, whether large or small numbers. What we're doing about the immediate environment for those children in the emergency room in terms of supports, space, things that could happen within days rather than weeks for children who are currently there. And I was hoping to see some of those things in terms of a crisis response. Has there been any look at that? Yeah, we did. We did we did pass on a statutory basis several years ago, a specific requirement for DMH to provide ongoing support for people who are waiting through through work with the DA's providing personnel. And I'm wondering if any of that is happening. That was already a directive several years ago. Yeah, thank you, Representative Donahue. A great point in question. And certainly that is illustrated in our midterm solutions in terms of the actual environment of care, if you will, in terms of the emergency departments themselves. And of course, this is where I think the guidance is helpful in terms of the provision of emergency services and supports being more fully in person in emergency departments to ensure that that care and support for children and youth that are waiting is there. And it is true that some of those supports have been offered more through telehealth over the past several months due to the impact of covid. So that's something we really need to work with our community mental health agencies and our emergency services directors and staff to understand what capacity do they have? How best do we continue to focus on that? Also in collaboration with our partners at the Department of Children and Families. I know that for any child or youth who is in DCF custody, who might also be presenting in an ED that there are DCF staff that are supporting them in the emergency department as well. But again, we want to make sure that we're doing everything possible should someone be waiting, whether it's the environment of care, or the supports around the child and the family. Coloring books and puzzles could be provided tomorrow. You know, I mean, there are some crisis things that can happen in, you know, 24 hours or five days, not weeks and months. Yes. And this is why the dialogue with the legislature as partners is so critical and helpful, because we can also take back your good suggestions in the short term and apply them immediately. I can add, this is David Retour from DMH. We are meeting every week with representatives from emergency departments. And one of the things we are implementing is what can we do for youth? That's not just waiting. That's actually therapeutic to them while they're while they're waiting. And and that can take the form everything from supportive psychotherapy sessions to crisis plans to maybe even meditation sessions. People are doing those and trying to implement evidence-based practices. So in addition, people are also trying to figure out a way to make the physical space more therapeutic. And I know some emergency departments are trying to actually create space that is not so hectic and is more conducive for people in the mental health crisis. Well, we can discuss this in another setting, I guess, because that's that that has not been successful, despite those hospitals who would say they have done that. And last week, there was a child who was in a locked quiet subsection with two male adults for an extended amount of time. So it may have been a separate quieter subsection, but I don't think it was therapeutic. Representative Houghton. Thank you, Commissioner, throughout the presentation you've given so far and in other presentations we've had, the Department of I should say the Agency of Education and the need for kids to be back in school keeps coming up as a preventative measure. I will say I am I'm happy with all the agencies that are here today, but I am concerned that the Agency of Education is not represented, nor is there any immediate solution on the Agency of Education and DMH. And maybe there is and it's just not here working immediately as these children go back to school for the last six weeks to be able to assess the situation of the kids in need that are not in the EDS, but could end up in the EDS to ensure that we don't continue this this process. And we have six weeks for kids until they are back for the summer and we lose those connections with the schools. So I would like to hear at some point, not now, more of how the Agency of Education and DMH are working together in the schools themselves. And then to Representative Donahue's point, you know, I just have to say I keep going back to that PUC program that's happening in the southern part of the state where these kids are not in the EDS, they are in a home. You know, how how hard would that be to get set something up in other areas of the state would be an immediate solution? I would like to see. Thank you. Again, all good points and captured on the next slide. I just haven't been able to get there yet. OK, well, I think we were focused on what we were. I would say I would think some of those could be immediate, especially with the kids back in school for six weeks. Of course. And what I can say is that the Department of Education or the Agency of Education and the Department of Mental Health have been working side by side on this. I meet with Secretary French on a regular basis. And this is not just a new issue. You know, we've been working incredibly hard over the past year just to include the provision of school based mental health services, even if not being offered in a school are still afforded to and provided to children, youth and families, even if it is remote. One of the three pillars of the, I guess, the three-legged dual of the Agency of Education's recovery plan is social emotional competence, mental health and well-being. Part of the task for local education and supervisory unions is to actually form recovery teams that bring together their community mental health partners to really address this. So I think what I can say is that that collaboration is happening that we are working very hard to ensure that as children come back to school, that we have the right services and supports in place. And I think that's where at a real advantage, you know, we have one of the most robust and revered school based mental health services programs in the country. So as our children and youth come back to school, that partnership and collaboration between our community mental health agencies and our local districts will become even more important. In addition to the Agency of Education being very clear and somewhat directive to the extent possible that the local districts need to be targeting some of their ESSER funds to support social and emotional development and support for children and youth as they come back to school. So let's take a couple more questions and that's that's understand that we will want to we want to allow the commissioner to move on to the next set of slides, which are touching on issues that are being raised. Representative Cordes and then we'll go on to the slides. So in recognition that you still have more to show us, Commissioner, I'm just going to put my question in right now and feel free to wait until you get to that slide, if it's represented there. We know that I'm thankful to see the information about how we're responding to this, both the the recovering from the pandemic, but also the latest crisis in the surge of youth in emergency rooms. I would I look forward to seeing more about how we can strengthen our system outside of a surge outside of a pandemic. The pandemic has shown a light, as we know, on so many gaps and deficiencies. And we also know that. Therapeutic care for children with mental health needs. We had a need for that before the pandemic. And I know that families were not happy having to send their kids all the way down to Brattleboro if they lived up north or across the lake. And I know we are building capacity, but I would like to hear more about that so that we can use all of the aspects of our mental health care system in Vermont and truly create some systemic. Have some systemic success so that we have therapeutic millions in place instead of just responding to crises. So let's let the commissioner respond to that in the course of her continued presentation. Thank you, Representative Cortes. Those are excellent points. So moving on to midterm solutions, which many could be articulated as more immediate solutions. Again, I don't want to get hung up on semantics. Certainly it is the goal of the Department of the Agency of Human Services to be very responsive to this current need. And also, this has been an ongoing need and issue in our system of care. Number one, as we noted before, and our immediate solutions would be to work with our community mental health agencies to identify where we can target this federal funding. We want to then distribute that funding appropriately to address those mental health service needs, as well as opportunities to expand and support workforce development as well. We also want to ensure that we also prioritize funding for peer support services for children and families, just like in our adult system. We have great nonprofit partners who work and providing peer based supports to families. So that is another area that we want to look at. And to everyone's good point, we have two opportunity areas as well. Mobile response has already put forward as a direct solution and response to this issue. Our ability to respond more proactively in the community to a child, youth or family in their home as an evidence based practice that other states have seen significant returns on investment is a huge opportunity for us, which is why we are so excited to be piloting mobile response with our partners in Rutland. What I would also note are also working on an alternative to Ed's as part of their work with mobile response. So they're supplementary. So not only are they working to advance mobile response, they're also working to create alternative spaces similar to the Puck program to divert children and youth from emergency departments. The other thing that I would note from a policy perspective, which is significant, is that we are looking at the opportunity to leverage increased F map for mobile response services over the next three years. The federal government has indicated and provided guidance that effective April of twenty twenty two, we will potentially have an eighty five percent match on mobile response services. This is huge for us as a state, as we look to advance those specific programs as well as continuing to look at expanding and scaling up alternatives to emergency departments such as the program at the same time. As Representative Donahue noted, one of our other pieces here was working with us collaboratively to support the emergency departments. You know, what are those short term, I guess, easy lift? As Representative Donahue noted, pieces that we can do in the immediate that just require some people power and thinking and follow through. In addition to some of the bigger issues, I think about environment of care best practices and how best do we support our E.D.s in advancing that and committing to that with us. Two Representative Houghton's good points, continuing to collaborate with the Agency of Education, as I noticed, as I noted, their recovery planning is hinged on social emotional competence and well being. It is clearly articulated in their recovery plan and directives to their local education agencies. They are also working with us to expand access to youth mental health first aid training, training through Vermont Care Partners, again, in addition to just the incredible collaboration that we've had over a decade and implementing school based mental health services with our education partners and given the influx of ESSER funds coming into the education system, that is a huge opportunity to really focus and target those investments to the social emotional well being of children and youth. I would also note this probably is more midterm to longer term that the Department of Mental Health is really committed to really articulating probably very similarly to what we did with the 10 year plan. What is our five year workforce strategy? It is certainly lifted up as an element of Vision 2030. I think we need to really get down to brass tax of what do we need to advance and stabilize our mental health workforce in a comprehensive way. A member of my staff will be convening leaders this week to start having that conversation. We would welcome input collaboration with our legislative partners. But I do think that this workforce issue is a big part of the solutions to ensuring that we have a strong continuum of care for children and youth. I'm going to turn now to some of our other partners at the Agency of Human Services. Again, grateful for their joining us today, who will, as I mentioned, this is a systemic issue that requires a systemic response on behalf of all of the Agency of Human Services. So Commissioner Gustafson as well as Commissioner Brown and Selina Hickman will be sharing some of the work that they've been doing to contribute to solutions to this. So I will turn it over to Commissioner Gustafson. And I'm going to pardon me. I represent Burroughs had her hand up earlier and I failed to acknowledge her. So I do want to get that her question on the table so that if it gets answered as we go along, represent Burroughs. Thank you very much. I appreciate it. I had to take a quick call from my my son's school, speaking of children's mental health. I have a couple of very quick questions. One is how many people are in the Rutland catchment area for their mobile response? Oh, I will have to follow up with you, Representative Burroughs. I don't have that off the top of my head. Well, is it is it like five thousand or is it a hundred thousand? I mean, is it? But let's get back to that. OK, OK. On on a slide, a few slides back, it had the amount of money that was being given to different areas. And I noticed that SAMHSA was getting. I think four separate grants. And I wondered how those monies would be. How much of that would be spent on our youth since it was all included in the amount being spent? And finally, I noticed in the the midterm and long term solutions that that there doesn't seem to be an inclusion of. Integrated whole family supports. And I wondered whether this was being taken into account as part of the problem or solution. Thank you. Thank you. Great questions. We provided some more detail on those buckets of funding that are coming into the department. Some are more prescriptive than others. For example, the SAMHSA COVID Emergency Grant was really focused on funding for emergency services. So we have to deploy those funds to support that. The supplements to our mental health block grant are much more flexible and it will be up to the department as well as our community partners to determine where we target those resources. And that is the work that needs to be done. OK, and to your last question, Laurel can maybe follow up with you. There is a lot of work happening in terms of integration, particularly with pediatric practices and our broader health care system. So it's not noted here, but it probably should be. Maybe it's more longer term, ongoing problem solving and support. We have utilizing some of our block grant funding to support psychiatric consultation and pediatrician's offices. Some of those efforts that, again, we need to continue to focus on as well as part of this continuum of care and treatment for children and youth. So let's let's we really only have a short period of time left. But that's here that's here briefly from the through the rest of the presentation. I know the commissioner has a commitment needs to leave at 10. Good morning, Corey Gustafson, Commissioner Department of Mount Health Access. I really have two quick points to make. I'll actually make the second one. First, evaluate payment rates for hospital diversion. That is the NFI hospital diversion program evaluating the methodology for which those rates under which those rates are set. Setting up a recurring review of those rates for scheduled updates and utilize the existing contract that we have with them as the as the sort of parameters under which those rates would live. So we're in that process right now. This is the first opportunities for alternatives to waiting in emergency departments. I think under the laws letterhead, you saw a few recommendations, including moving from episodic to per diem. We're certainly open to a payment methodology that fits the incentives and outcomes that we're all looking for. I think replippers point to what's the metric. What are we trying to accomplish is a great point and that will help us determine what is the best way to approach that reimbursement structure. The the you know, the balance of that conversation is episodic was intended to sort of incentivize movement for the system. But if there isn't movement in the system, is that incentive is really, you know, not very useful. So the per diem is perhaps something to explore with some sort of parameters in terms of care delivered. If someone is in a crisis state and is in an environment for an extended period of time, we would always love to see that there are services provided along with those changes in payment. And so that's a conversation. We have explored opportunities or are exploring opportunities to pay for temporary placement placements on the pediatric unit at UVMMC as a movement from the ED. And the partners at UVM have been really good about thinking in that in that space and hoping that that would lessen the acuity and allow for the transfer of the last restricted placements. So those two points of the time is where I'll stop. Rep Lippert, thank you. Thanks, Corey. And then Selena Hickman from Dale has joined us today as well, Selena. Thank you for the record, Selena Hickman, Director of Developmental Disability Services at Dale and I'll be brief. Sean, the Commissioner Brown has his own slide as well with more information. So we're really looking at three areas aimed at reducing emergency department and hospital use, looking at local crisis capacity, statewide crisis capacity, as well as an RFP creating something we're calling intensive transition supports. So at the local level, we've heard from DS directors statewide that there is a need to expand local crisis capacity. We've connected with a few individual agencies regarding their current planning and we're also preparing a survey to ensure that we understand what is available statewide. It's not it's something that we currently look at at an individual level of approving local crisis supports, but not systemically. So that's the first step there. Looking at our statewide crisis capacity, we currently have two statewide crisis beds operated by the Vermont Crisis Intervention Network under the Upper Valley Services umbrella. These are available for people who exceed local local crisis capacity. They offer consultation, training, mobile supports as well as onsite supports for short term stays of one to three weeks for many years. This level of two statewide beds has been sufficient. However, since before I came to the department, we had been hearing that additional capacity was needed. And so we are currently looking at our ability to expand hopefully by July 1st, although that's still in the works. And then finally, exciting news that we have an RFP that's currently open that creates something called intensive transition supports for individuals experiencing extended crisis, including children and youth with complex needs. This is a level of support for between one and six months. So this is these are time limited supports for people who are eligible for development of disability home and community supports who are experiencing crisis and whose current needs exceed other available clinical crisis supports in the DC services system. So these are a lot of the folks who are kind of bouncing in and out of emergency departments who have intensive behavior challenges like we have co-occurring diagnoses who just need additional time and consultation and expertise in order to develop a successful community-based support plan. So we're quite excited about this RFP and our intended start date for a vendor is August of 2021. And I'll stop and hand it right over to Commissioner Brown. Thank you. Thank you. We're going to need to come back to these because I think there are certainly questions, but let's not take them now. Sure. You know, at DCF, you know, we have a large number of kids in our care and custody who need, you know, varying levels of care and services. Much of our care right now is skewed to the higher level of care. And we have a lot of kids in higher level of care and youth out of state. And one of my goals as a new commissioner was to reduce that reliance on out-of-state programs and bring kids back to Vermont and have them served in Vermont and at the local level as much as possible. So it helps keep those kids connected to their community and make transition back to their community much easier. So one of the things that we've been working on is we're looking to create a group of high level, high end stabilization foster homes across the state, at least one in every district and several in some of the larger districts. You know, we would provide specialized training to these foster parents and also connect them to community services to make sure that they can meet the needs of these higher level kids so we can keep them in their communities. These foster homes would receive a higher level of support and financial support as well. We're currently recruiting for these foster families and so far we've had 18 reach out to us and express interest to work with us. And so this is something we're hoping to roll out in the coming months. This has clearly been a need out there and this should help relieve some pressure in the system as well. Cause these kids would then end up in higher levels of care which then forces us to move kids out of state care. So we kind of wanna shift the dynamic and bring services back to a more local level as much as possible. Also, you know, we've had an ongoing level of need in the Northwestern part of the state. And so we've been working with the designated agency up in that area to create a stabilization program for youth, again, to try to keep youth in their community. This would be a two week program where we would stabilize the youth and then transition them back into a community setting with wraparound services for a period of time to help stabilize them. We're currently working with NCSS to come to an agreement on this program and develop it. Our goal is to roll it out as quickly as we can. And then also we're working with an organization called Families First to create a in-state capacity to serve youth who are struggling with mental health issues but also developmental disability. I think one of the areas we've seen in Commissioner Squirrel can touch on this a little if needed but some of the youth staying a little bit longer in emergency departments fall into this category. And so there's certainly a need for this type of program in Vermont and many of these youth end up eventually in programs out of state and it takes time for them to get connected with those programs and also takes a lot of time for them to come back and transition to back. So that's important for us to develop this in-state capacity here. And so they provided a proposal to us and we're working with them, you know, again to hopefully roll this out as soon as possible. This would be located in the southern part of the state right now as well. And so these are just some of the programs we're working on to kind of help build more capacity at the community level to serve youth. Cause right now our systems are more geared to the higher end and it just creates a lot of capacity issues. And we want to keep kids connected to their communities as much as possible. So I'm going to, we're all operating under competing schedules here and I'm going to suggest that we bring this to a close because we are actually also doing the floor, the floor, the Zoom floor. Thank you, Commissioner Brown, Commissioner Squirrel. We're going to clearly return to this and there's lots here to digest. There were a lot of questions and I know that you, Commissioner Squirrel, have a commitment you need to leave to get to the governor's press conference as well. So if there's any final comment, you wish to make Commissioner Squirrel and then I think we need to wrap for the morning. Yeah, I want to thank the committee for their time this morning, for their great and thoughtful questions and ideas. Thank my fellow commissioners at the Agency of Human Services. We do see this as a AHS issue that we're all need to be responsive to. The only two final things I would note is that we did have a residential analysis report and recommendations that we would love to spend a little more time with the committee on, which I think will also something we need to take into consideration and just be remiss without mentioning mental health parity. Just again, as one of the solutions we need to look at ensuring that private insurers cover the same levels of medically necessary mental health services for children and youth, especially in home services. And I will leave it at that. Again, thank you. There's much here for us to dive into more fully. We do have some testimony this afternoon as well and we will be following up because I think one of the things that's key here is to put some metrics and some measurements and timelines among the number of initiatives that you've laid out in front of us today. So we will look forward to doing that collaboratively or hearing from you about that. So with that, we're going to bring this to a close. Thank you, Commissioner Squirrel and staff who've joined her.