 Good morning, everyone. This is the House Health Care Committee. It's Thursday, May 13th, and it's nine in the morning. This morning, we are going to turn our attention again to the issue of children in Vermont waiting in emergency room departments, which we've taken testimony about. We've had committee discussion and decided that, given that it's the end of the session and how important this issue is that we crafted a letter that we directed to the agency human services department of health to the Vermont Association for hospitals and health systems and the agency of education. And this morning, we invited folks to whom we had directed the letter to join us to give us further comments. And I really appreciate each of you making the time to join us again this morning as we continue to work together to address this critical issue for children families. The Department of Health Services and the issue of emergency room waits. So, I'm going to. So I see that we have the commissioner from the Department of Mental Health and several of her staff. We have welcomed Heather Boucher from the agency of education and Devin Green and Emma Harrigan, again from the from boss. I'm guessing but I'm thinking I might turn turn first to the commissioner of mental health. Does that, does that make sense. Commissioner. Yes, good morning. Yeah, that makes sense. Thank you representative. Okay, great. Well, let's, let's, let's begin by turning to hear from the commissioner of mental health and welcome you to have others chime in along the way we're interested in hearing from everyone involved. Thank you. Good morning, everyone. Great to see you all for the record Sarah Squirrel commissioner of the Department of Mental Health, joined here by my colleagues, Laurel Olmland who's our director of our Child Youth and Family Division, and Dr. I'm going to turn to who is our child medical director. On behalf of the agency of human services and the Department of Mental Health, I want to thank the committee for your attention to this urgent and important issue for your thoughtfulness and the memo that was prepared. We all recognize that children and youth waiting for extended periods of times and emergency departments is completely unacceptable. It's the appropriate setting to treat youth with psychiatric needs, and it's a crisis point for them, the youth themselves for their families. And it's very difficult and frustrating for the providers who want to help them access the necessary care that they need. As we presented in our previous testimony. This is a systemic issue. It does require a systemic response, which is why I was joined by my colleagues from AHS that are last testimony from the Department of Aging and Independent Living Dale DCF and diva really trying to underscore that it will require all of us and collective action to make meaningful change and to really implement many of the solutions that we've put forward. I also really appreciate the committee's recognition and fully agree that our responses and solutions need to be holistic and integrated and considerate of all aspects of our continuum of care. I also appreciated that the memo articulated that the standing up of the Mental Health Integration Council will be a great opportunity for us to really focus on this have a laser focus on this as part of that council's work. As I noted in my previous testimony, there are a lot of factors that are contributing to this issue. We know even prior to COVID we were saying increased mental health needs due to COVID, particularly for this 12 to 17 age group. We have been sharing publicly at the governor's press conferences are concerned about the state of mental health for youth in particular. The public health emergencies have both short term and long term consequences for children and youth. Also it is great to be joined here today by leadership from the agency of education. We also recognize that our schools have not been fully reopened. We know that particularly for youth child children and youth receiving Medicaid. We know that a portion of those children and youth receive their services through their public schools. So having our public schools more fully reopened will certainly create more access to services and supports. It's also being to be a moment where we will identify even more need. And again as I noted in previous testimony, we have had reduced capacity in our child and youth system of care, whether that's due to COVID precautions, whether that is due to residential and diversion capacity being reduced. I also noted that, you know, one of the contributing factors to this moment in time is that many of the youth who are receiving services at the Brattleboro retreat, which is our only inpatient provider for children and youth were actually and continue to be ready for discharge. But we lack the appropriate step down options for them. So again, that all to be said to contextualize the issue. Also, I would just note that in talking to my counterpoints from other states, Vermont is certainly not alone in this. I was speaking with my colleagues in Massachusetts yesterday. They have over 100 youth waiting in their EDs on a daily basis. I was speaking with her to try to get a sense of what solutions are you implementing. Many of them are very much aligned with some of the suggestions that were in the memo, some of what we have put forward at the agency of human services. Again, I think there is an urgency here, not just something that Vermont is experiencing, but fellow states as well, related to specifically to the memo that came from house health care. I just wanted to highlight some of the areas and our response to them I think that's probably something the committee is looking for today. A couple of them in particular, which I really appreciated was underscoring the need for input from families and peer stakeholders. I was actually going back to pre pandemic over a year and a half ago. I really convened a group of stakeholders from across the state to address this very issue that was inclusive of the Vermont Federation for families, families from across the state. And I think, you know, now is the time to reconvene that group. We heard loud and clear from families, what their needs were what the gaps were what they may be experienced a decade ago in terms of services and supports and what their experience has been now. It also really articulated the need, which we also I think could be embedded into the work of the council is the need for parity. In terms of insurance payment, particularly for in home services we heard that loud and clear from families. If they have a, you know, blue cross blue shield for example, their ability to receive in home services and supports looks very different. Again, these are just pieces that we need to continue to look at. There was a significant focus on data benchmarking and accountability in your memo, which I also think is appropriate, timely, and necessary. If we're really looking to move the needle on this issue then we need to know what our targets are we need to know what our data is. And that creates accountability, which is essential for improvements to the system of care. So the weekly reporting that was indicated, obviously that is something that vase is has already picked up the ball and is doing. We need enhanced collaboration between boss and the Department of Mental Health. I think one thing that has been clear is that we have access to certain pieces of data, vase has access to certain pieces of data, and the two need to be integrated so we get a full scope of the picture that is consistent. So that again we can continue to address the scope of the issue. We met with boss yesterday we had a very productive discussion about how we intend to move that work forward together. And again the targeted benchmarking I think is also critical in terms of you know what are the wait times that we are looking for, if not zero, and then what are we setting for a goal and a date to achieve that. Also there was some specifics in terms of looking at data by age, which I also think is something, according to my team that we can do. I'm noting the Mental Health Integration Council, I fully agree that that is a great area and aspect for them to focus on. And then the accountability around the completed action steps was also a significant part of the memo. I fully support that the Department of Mental Health has a bit of a track record and this kind of accountability. It reminds me a bit of the work that we did. We're implementing an action plan for sustainability for the bottom of our retreat, which where there is a lot of reporting back to the legislature to document progress towards those action areas. So I think we are well poised to be responsive to that, and to provide the kind of reporting back to the legislature that you are looking for. So that's just, I think a quick highlight and review of what was articulated in the memo, in addition to just the specific work that can be done directly with the EDs in collaboration with VOS to make immediate improvements to the environment of care. And that was one of the outcomes of the previous convening that I noted, where families really let us know the department that coming into the emergency department with a child or youth, whose experience of significant mental health crisis is completely overwhelming. And it's hard to know where to begin who to talk to, what are your options. So we actually created a great brochure in collaboration with the Vermont Federation for families that we distributed to all of the EDs. We will be moving forward with reprinting that and ensuring that there is adequate supply of that in the EDs. Again, that's just one example of, you know, some of the ways that we can immediately improve the environment of care and also ensure that families in particular have the supports that they need, and the understanding that they need of the system because it is completely overwhelming and very complex to navigate. I also just wanted to note that, of course, we have made incredible efforts to support our community mental health system of care, and our largest inpatient provider. I would just note that over the past year, given that the broader borough retreat is the only provider of child and youth inpatient. We have successfully implemented that sustainability plan. Also just wanted to note that we were able to implement an alternative payment model with the broader borough retreat that was actually implemented in April. That is a huge accomplishment on behalf of the agency of human services and the retreat, creating significant fiscal stability for them, thus allowing them to maintain the essential capacity that we need. I just wanted to note that for the committee. I don't know that we have specifically testified on that in the committee, but I wanted you to be aware that that was a big part of the sustainability plan that we were able to execute and implement successfully. In terms of our action plan, I see a lot of alignment between some of the areas that we put forward, in addition to the benchmarking and data pieces and other pieces that were noted in your memo. I would also just note in addition to that. One of the things that Massachusetts is doing is looking at for children and youth who are boarding, if you will, that if it's appropriate, they could be admitted on to a pediatric unit to receive psychiatric consultation. I am very happy to report that UVMMC will be starting to do that effective Monday. They are planning to have capacity for up to two child or youth patients who would be appropriate to be placed on their general pediatric floor, and then they can receive appropriate psychiatric consultation from the child psychiatry team there at UVM while they're awaiting placement. So again, just another demonstration of the systematic efforts that are being made and a great thanks to UVMMC for their work on that. I won't rehash all of the solutions that we put forward, but I do just want to remind the committee and note that we will have an incredible opportunity, not only to implement but scale up mobile response efforts across the state with the increased F map that will go into direct in April of 2022. That's an 85% F map so that is huge for us as a state system. As we move forward. Of course it will support, not only the short term implementation of mobile response, but if we really again want to make the kind of systemic change that we want to see our ability to scale that up in a meaningful way will be significant. And we also heard from Diva and Dale and some of the work that they are doing Dale in particular who is putting out or has out an RFP for intensive transition supports, specifically for children and youth. I will note that some of our most complex cases in the system are those youth who have both complex mental health needs and developmental disability needs. So that is something that we also need to continue to look at. And I guess, finally, the agency of education, grateful to have them join us here today. I just wanted to talk about some of the collaboration and work that has been happening to date. First and foremost, I would just note that last gosh, March or April when we were grappling with the immediate throws of the pandemic and the crisis. We have worked side by side with Secretary French and Deputy Secretary Boucher to ensure that the provision of school based mental health services could continue, even if delivered in a different format, more remotely. There was quite a bit of work to ensure that our funding mechanisms would still align at the local LEAs would be supportive and continuing to support these contracts. And just to underscore that that collaboration is ongoing and has been really essential particularly for the continued implementation of school based mental health supports. Also the agency of education's recovery plan. They worked very closely with the Department of Mental Health to articulate and underscore that now more than ever the fundamental building blocks of social and emotional competency and well being are so critical. And one of the three legs of the stool of their recovery plan is solely focused on emotional functioning mental health and well being and their work to work with their local education agencies, and really ensuring that there are significant targeted efforts that are focused in this area. And really the recovery plan that the agency of education has put forward. I think clearly articulates that as children and youth return to school. Attention needs to be paid to safety structure and reestablishing those strong and secure relationships. So I just want to thank Heather and Dan for their leadership and partnership with us as they have moved that forward. And one piece I would just note in thinking about, you know, the table that set the size of the tent of the partners that need to come together to support this issue. I would just note that ADAP is another partner that I think we also need to include in this conversation. One of the factors that we are beginning to recognize that is driving some of the mental health challenges particularly for youth and young adults is substance use, which is a significant increase in the rate of cannabis. So again, I just note that is something that we need to keep our eye on. After years of stability, we saw the first statistically significant increase in rates of Vermont youth cannabis use as part of the youth risk behavior survey in 2019. It's not clear that we have truly systemic data on this, but we are starting to recognize that a high proportion of involuntary hospitalization of adolescents and young adults are occurring among individuals with significant cannabis use. And we are all aware of the data and research related to how harmful cannabis use can be to developing brains, and how it can convey increased risk of psychosis, suicide, anxiety and aggression. So again, I think it's just another area that we need to continue to focus on, and to turn some attention to as we look to address this issue. Those are my comments for the committee. Again, I just want to thank you all for the thoughtfulness of the memo. We are looking forward to implementing it and to working side by side with us particularly on the data pieces. Thank you. I think what may make sense is for us to entertain some questions now and then hear from others and take questions again later is that agreeable. So I think was it representative boroughs. Representative Goldman. I'm last, put me last. I think it was art. I mean, people take turns. So art go ahead. Okay, thank you, chair. Commissioner squirrel I want to thank you very much for mentioning a cannabis is a real issue with our kids. I fought against the legalization of that drug for a long time now, and it's very, very important people realize the real problem it could be in our kids. I just want to make that statement I do have a couple questions. You talked about the Brattleboro retreat and I want to be clear and we've heard a lot about it and and I'm not familiar with the place so my question might be very elementary. It's not a place where children can be placed. I know represents Donahue I brought it up before and it's for adults but I wonder what you said regarding the Brattleboro retreat that might have a component with with children. Yeah, thank you representative Peterson. The Brattleboro retreat is our largest inpatient hospital in the state of Vermont. It's also the only inpatient hospital we have in the state of Vermont for children and youth. So they have a total of 30 beds, they have a child unit and an adolescent unit. So I made that note, simply that the sustain the sustainability and the stability of the retreat are critical to the system of care, which is why we have been working so hard to ensure that they are fiscally stable, because without the retreat then we actually don't have any child and youth inpatient capacity in the state. Just to jump in just just to say just to be clear, we're talking about inpatient mental health treatment here when you the commissioner says the only inpatient mental the only inpatient unit for children the largest hospital inpatient services. So just for represent Peterson that we're not talking to general hospital here we're talking. Oh no I understand. Be sure that we're not. Yeah. I don't know that I appreciate that. So, so if a child goes into the emergency room in Rutland with a problem with it and needs to be sent to a place can they be sent to the Brattleboro retreat that hospital as an inpatient. Yes, if they are found to meet hospital level of care then yes, they would be admitted to the Brattleboro retreat. How many beds are occupied there right now can you tell me that roughly I mean you maybe you don't know. I can look it up in just a second. They have again they have capacity for 30. I know that they've on the adolescent unit in particular which is an 18 bed unit. They've been operating at a capacity of about 14 or 15 but I can pull that up in a minute and take a peek and see what it is today. I'm only asking because one of the things we've, I think I've heard is that the backlog here is that a child goes into the emergency department gets seen, determined that he needs to be he or she needs to be in the emergency department. I forget the word but in an environment where he has to he or she has to stay in a place committed. And that there's no place to send them. And I'm wondering if that facility at Brattleboro retreat has bed space. I mean, why aren't we sending them there I guess. Yes, so it's a great question. There are a couple pieces there. There are factors that influence the capacity of any inpatient unit and any given time. So the Brattleboro retreat has 18 adolescent beds, let's say, on any given day, three to four of those beds may be closed. That could be due to staffing issues, we certainly know that across our healthcare workforce, we are experiencing significant staffing issues. So running an 18 bed adolescent unit at full capacity. That's, that's an intensive unit. So there are times where the Brattleboro retreat given the acuity of the unit and the youth that might be on it might also need to make adjustments to capacity so that they can ensure that they can keep all of the youth safe. Just a little bit just in terms of how capacity on that unit might fluctuate, and that really applies to any inpatient unit across the state child youth or adult. Those are factors that are at play. I think what's really important for us to keep our eye on, which is this continuum of care. So what's really critical is that for those children and youth who are ready to discharge from inpatient, that we have the appropriate community based services to discharge them to, which would be residential programs, hospital diversion programs. And then on the other side, we really want to put our energy and emphasis into diversion, because ideally we don't want children and youth to need to access this highly restrictive level of care. Which is why our work with our community mental health agencies is so critical. Why are we are looking at initiatives such as mobile response which will allow us to respond more proactively to children and youth and their families in their homes before they need to go to an emergency department and other alternatives to emergency departments, such as the puck program, which is an alternative to an ED for children and youth. I had one thing, this is David Ritu, the medical director for the child division of DMH representative Peterson use the word committed. And I just wanted to be clear that the retreat, most of the people who get hospitalized at the retreat are there on a voluntary basis. So they're not, they're not being committed there. But both youth who are there on an involuntary and voluntary basis, share the same space. That was a wrong choice of words by me. I struggled with it was impatient that I was looking for. Thank you. I think we'll move on to questions. So I can't tell on my screen so those committee members who think they're in next in line just go for it. All right, I'll go for it. I'm really grateful for all of your work, and particularly to hear that you've been focusing on systemic issues, while while also solving solving the problem that's that's right in front of us caused by systemic issues and situational issues. Also really glad to hear of your integrative work. And that I know that you all talk with one another on a regular basis anyway but that you're really you have to use your words. Commissioner you set the table, got the people there in a formal way to address this. I have a couple questions. I'm going to ask them both at the same time. Commissioner, can you. I'm interested about the alternative payment model for the retreat. Can do you have a two or three word phrase that you can describe what that is. Or if it's similar to other payment models that we've been working with in the healthcare reform in Vermont so that's one what's the alternative payment model. The next one is in with regard to UVM Medical Center, opening up beds in their pediatric unit, which I think is a great move. And I'm concerned I don't recall that UVM Medical Center has pediatric psychiatry nurses. So our psychiatry nurses floating to the pediatric floor where they typically the nurses they are care for with cancer, RSV various surgical issues, cystic fibrosis, or our psychiatry nurses that care for adults being floated to inpatient pediatrics to take care of those kids. Great. Thank you. I will take the first question and then I'll let Dr to answer the second question. So the alternative payment model of the battle for retreat. Probably what is most similar is the alternative payment model that we have with our community mental health and designated agencies, where we essentially have determined you know what the breadth of scope and services that they're providing at any given time, what are the utilization components around that how many people are they serving etc. And then we pay them prospectively for providing those services so all of our designated agencies and specialized service agencies receive perspective payments and then there's a reconciliation process by which we look at utilization volume all of those things that are required for accountability of an alternative payment model. With the battle for retreat, we recognized that some of the challenges that we're contributing to their fiscal instability with some of the fluctuation in demand and then of course coded created a significant fluctuation in demand, and to continue to operate in a completely fee for service model was not going to be sustainable to them. So what we did was we developed an alternative payment model by which we looked at the breadth of their services and you know bed availability essentially and said, you know, we will assume that this will be the utilization for all of these units across the street. Here is that number and the cost and the rate, and then we bundled that into a monthly perspective payment that they received so that creates stability for them it doesn't necessarily need more money, but it creates stability in terms of their cash flow, which is essential for them as they are trying to you know regroup around workforce development and etc. And then again there's a reconciliation process very similar to what we do with our community mental health agencies. I'm happy to provide more detailed follow up information as well but that's kind of a synopsis of the alternative payment model of the retreat. And as I noted we were able to implement that in April, and just thank you for the great work of diva that was a pretty significant lift to implement an alternative payment model in about three months. And I will turn it to Dr were to who can probably best speak to your questions related to the UVMMC pediatric unit. Thank you Commissioner. Yeah, I'll do my best. It's a great question and I think it speaks to why it's not as easy as it may sound to just bring people up to a general pediatric floor because there are some really important things to be considering. Especially in the time of coven and the training of the nurses is one of them. Their UVM does have a 24 seven psychiatry consult service, and also now has a child psychiatry consultation service during the week. And while the nurses on pediatric floors as you may know are pretty well experienced and trained with helping kids who are upset and dysregulated. They're not psychiatric nurses and I actually I'm afraid I don't know the answer about whether there's going to be any switching over that maybe someone else on the call does and we can certainly find out through UVM about that. Yeah, I mean I would be fine with a follow up email it's a concern I've mentioned before and that a nurses spend very much appreciate the work of the physicians and nurse practitioners that provide the consultation services and the bedside nurses are with patients 24 hours a day. It's definitely an issue and I'd be happy to have an email follow up. And just to. I'm glad to know that you're hearing my concern. And if you could carry that forward. Absolutely. Thank you. I think I'm next. Where you go. Okay. Commissioner squirrel. Thank you so much for being with us this morning. My question is, can you please tell us more about the community mental health system of care and what specific measures have been taken to bolster sustainability. That's a great question. I mean I think what I can say. When the pandemic hit, we all had to shift and pivot fairly quickly. I think you saw DMH and AHS move very quickly to ensure that our community mental health agencies are stable, which is why we move so quickly to get approval for a tranche of CRF funds to be deployed to the community mental health agencies and all in all I think the total amount of CRF funds that we provided to the DA's and SSAs over the past year was about 19.7 million dollars. We also worked very quickly to ensure that their school based mental health services, which is still a fee for service. Part of their service delivery was also stable and I noted some of the work that we had done there as well. I think we will have to continue to evaluate what the needs of our community mental health agencies are, where we need to target resources specifically. As I noted, our great and incredible network of community mental health agencies across the state are readjusting to more in person service delivery. We talked a little bit about that at our last testimony. We have provided additional guidance in collaboration with VDH, making it very clear what sector, if you will, the DA and SSA workforce is thus allowing them to move into more in person services. I do think that the workforce development piece, our ability to recruit and retain individuals in our community mental health agencies is absolutely critical, which is why we brought that forward as one of our recommendations. Our task force here at DMH, which is I think co-chaired by members of our community mental health agencies are working on a strategic plan related to workforce. I believe there is also an opportunity as we look at different federal funding or opportunities for the state. We absolutely need to prioritize our community mental health workforce. And in addition, as I noted before, we have been in receipt of just over $8 million in federal funds, enhancements to our mental health block grant, all of those funds go to our community mental health agencies. So we are working closely with them to determine how do we target those funds to ensure that where there are gaps or needs or increased demand in specific areas that we can be responsive to that. In addition to I think work and planning related to the provision of school-based mental health services. I do think that as schools reopen, we will be able to better assess and identify where there are need areas. And I also think there is going to be significant need identified and we need to be prepared for that. Thank you. And just to say that that's such a broad and involved area of trying to continue to sustain our community-based system that there's so much more that can and will need to be understood as we all move forward. So I'm looking to representative Page and representative Black and have either of you, Trevor, whoever wishes to go first. Representative Page, did you take your hand down or was that in anticipation of being called? No, I did take it down but since I've been asked, I'll just ask a couple of questions. As we wind down here in the legislature, how can we ensure that the work and this letter that was sent to you, how can we ensure that things will improve during the summer until we get back regarding our children in emergency rooms? And then I thought I'd just, Commissioner Squirrel, give you the opportunity as you prepare to depart. Do you have any words of wisdom as you look into the crystal ball? Advice to your agency or this committee on issues that may be coming up in the future that we should prepare ourselves for. I'll listen to your answer off the screen. Thank you. Yes, thanks representative Page. What was your first question again? I apologize. Oh, you'll have to repeat it again. As we wind down here in the legislature. Oh, thank you. Yes. Yes, so the accountability is critical and that's why I noted there was also a lot of accountability related to the action plan for the sustainability of the Brattleboro retreat. I think we will follow our monthly reports that we were required to provide legislature. I think we will follow a similar model as is outlined in your memo that we will create, we will translate all of these action area solutions if you will into an action plan. We will convert that into a monthly monitoring report that we can send to the committee on a monthly basis. And of course, you know, should specific legislators or legislative leaders be interested in meeting with the department, you know, during those summer months to kind of monitor our progress towards implementation of these action areas. And we welcome that. So I think you see us, you know, really taking that charge seriously. And I think the reporting accountability on a monthly basis will provide you with the transparency that you need and the insight into where we're going as a system. Can I just excuse me. I just want to say, is there a point person that we can anticipate looking to or can you identify at some point, if not today, who the who the point person given your own transition but who the point person would be at the department that we could turn to in the interim period when we're not in session around. I think we would, I would say that that would be Shayla Livingston for now our director of policy, and then we will determine who the appropriate point person will be for this work going forward. Okay, thank you. Yes. And to your second question, representative page, I guess maybe three things come to mind. First and foremost that I think one of our strengths as a system, and in Vermont is our value of collaboration and partnership, we are incredibly fortunate in Vermont that we are a small state. We can get our arms around issues in a way that no other state can, we can implement things and bring them to scale much more quickly and comprehensively. And I also think that continuing to maintain collaborative trusting relationships between the legislature and the agency of human services and the respective departments is also very important. There is shared dialogue there is shared accountability, and also trust that those individuals who work in state government at the agency of human services are incredibly dedicated and work so hard every single day to continue to advance the system of care. And to that, I would have to underscore our efforts as a state to lean in and prioritize early intervention and primary prevention as another strategy and area that we need to focus on. We all know that children are setting their long term health trajectories in their earliest years, and the more that we can move upstream the better the outcomes. The more that we can continue to enhance and scale up our collaboration with pediatricians in those first zero to six years, I think is absolutely essential and I think Vermont has an opportunity to really focus our energy and efforts there. And then on the other end of the continuum, we need to come back to the mental health needs of our older Vermonters geriatric psychiatry it is still a significant gap in our system of care that we need to be able to address. So, I think those are some of the, the things that come front of mind to me right now. Thank you. Good turn to represent black and then represent hoten and represent court is and then I'm going to suggest that we hear from our other witness guests this morning and then open up to questions again. Thank you. So I have two questions one for Commissioner squirrel and one for dr to please. So the first one is, and this is more of a long term, long range plan. I'm, has there been any contemplation of diversifying inpatient locations. You had talked about that Brattleboro often will have to close beds because the population of adolescents or children there might be more dysregulated at that time so you know when you have that many children all together. It seems like we've put an awful lot of our inpatient eggs in Brattleboro's basket. And, you know, and I'm also thinking about obviously the needs of families, if I mean, as I'm in Chittenden County. I have to be honest with you after learning all the things that we have learned if I was familiar with the system of care right now, and my child was in a psychiatric crisis. I'm not sure I'd make that call. That that concerns me, because I'm not sure which is worse. Having my child sent to Brattleboro, or not getting the help that my child needs. So I'm just wondering if there's a if there's a long range plan of, you know, making possibly making smaller units more spread across the state. Rather than just concentrating on Brattleboro. Representative black, all great points, and a great question. And I think what we have articulated as part of our vision for Vermont is that over time, as we invest in understand implement more efforts around integration that we would see our reliance on more restrictive higher levels of care decrease. That's a very long term vision. At the same time, specifically I think for children and youth, stepping back and assessing what capacity we have, and what we think we need as a state, and is there value in diversifying some of that capacity. So considering that one of the main solutions to this issue is not necessarily more beds, but more enhanced community based services. So I think that is some of the tension that Vermont will have to grapple with over the next few years. There are additional assessments of child and youth inpatient capacity. I think many would agree with all of your points in terms of, you know, having one large unit in a very southern area of the state becomes limiting. If you are from the northern part of the state that amount of travel for parents, I've heard from families how stressful that is to have to travel three hours to try to visit your loved one. I think that will be a question. I don't think suggesting more beds. I'm suggesting less beds in more places. Again, I think that's something that the state in collaboration with the legislature and with the Brattleboro retreat will need to consider, and also of course, taking into consideration that the retreat is one of our largest inpatient providers so you also have to attend to the fact that we don't want to destabilize them as well. So that's the balance. And I think this is why we have worked so hard to try to clear whatever barriers we can in terms of access to CVPH which is in Platsburg which is closer. There are still challenges there. It's not ideal. So I think your question is a good one and I think it's something that will need to continue to be evaluated. Thank you. And my question for Dr to only because we've discussed this before and I think it's a really important point to make, particularly with some other things in the legislature right now. I was wondering if you could talk specifically to issues around cannabis and what we're seeing at this time and any concerns around that. Sure. Yeah, and I'm so glad Commissioner Squirrel brought this up because, you know, while we don't have good systematic data yet. I think many healthcare professionals are becoming very, very concerned about this. I also work at UVM I spent last weekend on call for UVM psychiatry so I was actually in the emergency department, talking to kids talking to adults. And, you know, I've, I've observed over my times on call that a significant proportion of, of young people who are hospitalized psychiatrically or come to the Eds are heavy cannabis users and we also know that the cannabis that is being used today which can be 2030 40% THC is nowhere near, you know what was used back in the 60s. And the research that this is a significant psychiatric risk for a whole host of problems, most notably psychosis but I think also suicide and aggression is becoming increasingly recognized at the same time that the public perception is in fact opposite way. And so I'm really hoping that, you know, as sort of the cannabis advisory board, and that people will really be paying attention to this and that will have the data to monitor that this because I think it could really impose a really large burden on our, our mental health and substance of use treatment system moving forward. Very concerned about this. Thanks for elaborating. So I'm going to, again, let's turn to represent Houghton, and then I'm going to ask a representative courtesan that represent down he might be able to hold their questions so we can be sure to hear from others first, and then we'll open up to more questions. Mine is very brief. It's not a question. Okay, hold it represent home. And mine is actually my comments are directed more towards agency of education and Heather so Heather, if you have testimony I will wait until that point. I'm assuming we'll perhaps get to hear from others who have come from the agency of education as well. Representative Curtis. Commissioner I don't know if I will get another chance to say this but I just wanted to tell you how much I've appreciated working with you in the last over the last two terms and I'm very grateful for your work and I think that you've taken the department in a good direction. And I think many of us will will miss you I wish you nothing but the best. Thank you. I greatly appreciate that. Thank you. Thank you. So, let me turn back to the commissioner and because I know there's still some further questions and but let's let's give have the opportunity to hear both from the agency of education, who has had to be here with us today, and then from boss. Is that. Is that appropriate. Yes, I think that makes sense. Okay, so let's let's turn first the agency of education and then we'll hear from boss. Chair Lippert. Good morning, everyone. I wanted to also thank the committee for the opportunity to come in and share a bit about what's going on in the education space that's relevant to this issue. And then also certainly make myself available for any questions can be members might have. It's a little bit daunting to kind of try to figure out where to jump in. So I think what I will do, perhaps is first state that we stand in strong support with the Department of Mental Health and are very eager to partner with them as needed as required or asked for in the letter to assist as we can with this critical critical challenge that is also very concerning to us in education as well. You've heard a bit about our partnership with mental mental health Department of Mental Health and designated agencies and I thought I might expand a little bit on that. This, this work between our two agencies has been actually going on. I, this is my sixth year in the agency of education as the deputy and we started this work. I was a commissioner's ago I believe for the mental health department so we have long been really understanding and really wanting to address the systemic issues that interface between education and mental health and well being. So this is a very interesting and really critical topic for me, a lot of folks don't know but I actually am a psychologist I'm actually a developmental psychologist and so my entire career has been in the interstitial spaces of education and psychology. So it's a really critical, really critical arena of focus of support and interest, and I am grateful that under the past to the current and the prior secretary of education that value, they have also valued this integrative work. We have as just some evidence of that work together. We have successfully launched SAMHSA grant project aware grant in several three of our districts and several of our schools within those districts, where we are focused on not only providing clinicians in those schools but are also providing significant professional development and supports to the existing educators to really bolster those local systems. This is a pilot program. We certainly intend that that the pearls of wisdom from from this project will actually certainly be scaled up as we move forward. So I'm stating this because I think it's important to know that our partnership is not solely due to the COVID pandemic the emergency that we've actually been working together prior to this certainly help emergency, and it's only gotten more critical and stronger as a result of the emergency. So we're very happy to continue our partnership with mental health. I thought it might be useful. I'm not really sure how much folks on this committee have sort of followed what's happening in schools. I'm just, this is a new committee for me to testify before so I thought I might just give a very high level of sort of what's what's been happening in terms of the orientation of schools because of the pandemic. So back in March as you probably certainly remember everything was shut down as a result of the governor's executive order so that means schools were literally overnight shut down for about three weeks. We rapidly, we meaning both the agency but certainly also folks at the local level worked really hard to come up with what education would look like in the immediate future at that time so we actually were focused on the continuity of learning, which was, okay kids are actually home school is not happening how do we ensure that they get the services to the extent that they can in this in this health emergency, and have some semblance of continuity. So, we required that districts actually provide what were then called continuity of learning plans where they had to really think through these issues, again in an emergency capacity. We always knew that we were doing the best we could both at the state and a local level but that there would be challenges, and as we saw there certainly were so we saw. And again I'm talking from last year March to the end of the school year that there were certainly students whose needs were not being met, who, you know because of the restrictions on in person gatherings were were, you know not going to get the services that they needed. So, moving from that space into what the next school year would look like which we focused as sort of our reopening phase of the pandemic. You know, it was really front and center focused on safe operations of schools and making sure that schools could sustain safe operations because again, the health aspects of the pandemic. So, we were taking front front and center, which I think we all think made a lot of sense, but we also knew that the social emotional learning and implications for mental health psychosocial adjustment student engagement, we're also going to be just as critical. We worked together on some guidance that went out in the summer for social emotional learning and how to and we worked with mental health on this, and, and really focused on like what districts should be thinking about and putting in place so that they could actually attend to students social emotional learning needs their well being their mental health functioning. Then, yeah, can I apologize, I totally apologize for interrupting you, Deputy Commissioner. And I think now your screen froze as well no no you're there okay. Let me let me apologize to you and to the committee, I understand that Commissioner squirrel and Dr to our, I'd forgotten, I've been told that they're needing to leave in just a minute or two. And if that's the case, still, I wanted to at least have a moment to interact with Commissioner squirrel before, before she leaves the screen this morning. And again, my apologies for interrupting you so abruptly and not usefully. And because I because I this may be mean, so I appreciate that representative court is also expressed her appreciation to Commissioner squirrel but as the as the chair of this committee and on behalf of the committee. I really want to express my deep appreciation to you, Commissioner squirrel for the work that you have done in the period of time that we have had the chance to work together. And for your deep commitment and the values that you bring and have brought to this work. And this may be a given because we're coming to a close it's not clear when we will have that opportunity to thank you directly again. I personally want to express my deep appreciation for you and my best wishes for you. And say we look forward to working with your successor. But we want, but we would be very remiss not to acknowledge the work together that you have so so ably led the department so thank you. Thank you. And I just want to say and thank the committee, you know, we have done a lot of great work together. And I deeply appreciate each and every one of you and your dedication to serve in state government and to really focus on ensuring that we have the strongest mental health system. It's possible, you know, I started my work back when I was about 22 years old working in a adolescent residential program, and have never looked back. This is my passion. This is my work. It is so personally meaningful to me. And to be able to sit in this seat in this position for the past two and a half years has absolutely been the greatest honor that I could have ever had. And I just want to thank you all. It has been nothing but a pleasure to work with all of you. And I am sure I will find my way back to this work. Once we make our family move, and we'll be able to contribute hopefully in the way that I've been able to contribute in Vermont so thank you all. Thank you. Thank you. Thank you again. Okay, and as awkward it was to interrupt you, I had never the less it just felt like I had not anticipated the timing and was intending to speak to before she left with us today. So let's turn our attention again to continue to understand the agency of education's involvement and I understand that Shayla Livingston will stay with us from the department as the commissioner and Dr. Ritu are needing to go to other commitments this morning. Should I continue? I think you should and you know I'm going to be I'm just going to say it's important for us to, I mean, high level is great. And I think we're actually interested in, you know, kind of on the ground how things are what's happening. So I think I think that'd be useful to if we could focus there as well. And then I do want to hear from boss because we have some very, we in our letter with some very specific request suggestions and I know they've sent us some information that subsequently so it's that we need to keep room for both. And let me before we before I really interrupt someone else. Let me just check in terms of timing Devin are you what is your, are you, you're good for time. And okay, and Emma. Okay, well then, yes, let's let's hear further from you, Heather. And then we'll entertain some questions or perhaps here from boss and then we're entertaining questions. So, thank you. Great, and I think I forgot to say for the record, Heather Boucher, Deputy Secretary for for education earlier. I think I will focus primarily for the rest of my comments on the current phase that we're in. So we, and I believe this had been referenced earlier by Commissioner squirrel. We required significant recovery planning efforts. So when we talk about education recovery we're talking about what the LEAs, which are local education agencies which basically as lingo for school districts and schools are doing in terms of mitigating the impact of COVID on students. And we have identified three different areas or buckets that we're requiring LEAs to actually do a needs assessment within and they've actually completed those they were due April 15. So, those are social emotional learning mental health and well being student engagement and truancy reduction, and then of course academics. And the reason why it's really critical to highlight this is because we actually were very adamant about the fact that all three of these areas need to be equivalently attended to for a robust education recovery effort for our state. We actually were a little bit ahead of the national curve if you will on this because we had done so well as a state in terms of in terms of what's happening with the virus but other states have taken a cue from us and certainly have also focused on social emotional learning and mental health. What are preliminary, very preliminary scan of that needs assessment looks like is that yes there there is an increase in mental health needs in mental health referrals in the needs for student and family supports. We're also one of the things I wanted to identify is that we're also working on implementing on an implementation plan as part of recovery for our districts and that is in deep partnership with the Department of Mental Health and Education of Children and Families and so each of our districts has its own individually tailored based on their needs assessment state team that is comprised of the Agency of Education staff and then supplemented with folks from mental health and children and families, depending on what their needs were identified as a result of the needs assessment. Laurel Omland who I believe still might be on or perhaps not has been a real critical partner in that work. She attends weekly sessions that we have with our districts where they bring problems of practice to bear. So, we are actually as a state, the state agencies are have one eye toward working towards state infrastructural solutions around funding and some of those issues that Commissioner Squirrel talked about, but we're also doing some more hands on the ground really sort of like holding the hands of our districts as we move forward to really support them where they need it. So, I just wanted to clarify to clarify a bit about what's happening from the state's perspective in in that arena. I'm very happy to take questions I'm very happy to, you know, clarify any information that committee members might need. I'm sure I've forgotten something to mention so I hope it comes up in questions. Sure it will. So why don't why don't we turn to represent hope and I think you had it earlier at a question that you said was more involved in the area around the Agency of Education and so represent hope and why don't you Thank you and Heather thank you for being part of this important conversation. I serve as extension so the comments I'm about to make are relative to what I've heard from families within the USD school district and just so you know I have a seven year old seven seventh grader, seven year old seventh grader in the school as well. And the efforts, the agency and the local school districts have made have just been outstanding to ensure continuity over the past year so I appreciate that. And I guess, you know we're all excited to go back to school many kids are excited the parents and the teachers are excited to go back to school but as we go back and focus on social emotional learning and assessing the needs of our kids I'm hoping we don't forget what we've learned the positives that we've learned through this and a couple things I've heard from families is one that the class been in EWSD for everyone it has been been hybrid this year, as well as a remote Academy that some people have attended. So, for the hybrid kids, I've heard directly from kids that they like the smaller class sizes, they have one on one connections with their teachers they did not have before, and a lot of the behavioral problems teachers have seen in classrooms has gone away for that from the kids and and then I think the other important thing to remember is that it's hard to be hybrid it's hard to be remote on families I get that but for some kids, they've been able to find the time to focus on or or become interested in more things that are important to them, whether it's something in nature, you know, doing a science project that maybe they wouldn't have had time to do in school, and that getting outside has been really really helpful for some of these kids and I think that's important as part of social emotional learning and academic assessments as we move forward. And I guess my final this isn't related for a question but my final final comment would be that as we go back into the box of the school that I hope we continue to to think outside of the box. And there's a structure that has to happen in the school, but there's been lack of structure that has happened in hybrid learning that I think has been very beneficial for some kids that will help in their social emotional learning as they continue. So, thank you. Sure. Thank you representative Houghton. If I may respond. I think that the points you brought forth are great points and there's something that we're definitely in agreement with. So we have always been trying to think about what are some of the ways that we have had to because of the emergency, pretty rapidly change the way we're doing education that we actually want to hold on to. And that's always been something that we have had an eye toward as we sort of worked through these different dispositions in terms of what our education system looked like. We meet the agency of education myself and the secretary meet pretty meet weekly with an advisory group from folks who represent principals who represent superintendents who represent teachers who represent pretty much all different entities that are related to education systems and their strong agreement within that group as well. So I don't want to give the I would want to make sure that I can relate publicly that I do believe most of our districts have that frame as well. They're really interested in looking at what what has really worked for us that we want to actually continue moving forward. Preliminary scan of these needs assessment data actually indicate that what you've noticed in Essex is certainly not only happening in Essex with respect to behavioral referrals. Again, the data are not fully revised yet but it does appear that in many districts, the smaller class sizes, the not mixing things up in the hallway with students and so keeping them in a pod structure has really worked in a lot of ways. And so we will certainly be looking at what can we do as we move forward to perhaps think about what we can move forward with in in the box as you called it. I do want to point out though an issue that is very important for us as well which is equity in the agency of education and so one of the things we have to keep in mind. Particularly when we think about a state perspective is not all students have equitable access to the hybrid opportunities and so we do you know we really focus on in person learning because we know that that is. It is the still the best way to actually have an education that's equitable and accessible for all students. So I do think that's something that will also be part of our contemplation as we move forward is how do we. How do we make sure that if we're going to have a continued hybrid footprint in terms of our education system that it's actually equitable and so it isn't just all the students who have privilege and are able to get access to those hybrid opportunities that are experiencing that and all the students who can't are in the brick and mortar and that's a really critical issue that we've all got to come to grip to grips with I think as a state. Thank you Heather I would absolutely agree with that and I appreciate you bringing that up it's it's very important and I'm not suggesting that hybrid, you know should be extended but just the learnings would fund the hybrid system I think are really important and it sounds like the agency is on top of that in the school district so thank you very much. You're welcome. Hey I'm going to turn to represent Burroughs and and then then I think I do want to hear from boss because I'm just concerned that we not be able to have time to hear from them as well represent Burroughs. Thank you. One broader educational question. Following back with what what you just said. Do you think the agency of education will reconsider its recommended class sizes as a result of what you've, what you've taken from this experience that's my first question and my second question is, is the agency of education doing anything to accommodate students who have been homeschooled this year who have faced really extreme isolation as they return to school next year, or if they return to school next year. Sure, I think I'll take your second question first so yes so part of our focus on ensuring that all districts have a very strong plan for how to address all students social emotional learning would capture that group of students who were primarily home and who are coming back and you know that's very likely to be a very unique transition for students who are in that that learning disposition, you know we know from, you know we're hearing about that just in the media about adults actually moving back into what in person the in person world looks like as a result so and that again will be part of this teaming process that we have with mental health and with division of children and families to actually make sure that as districts identify particular needs that they're seeing so for some districts. There was a very strong footprint of home study and overall we know that home study families actually more than doubled as well corresponding with the pandemic. There are some where that's actually not going to be a big issue because for a variety of reasons, they didn't see a big increase. So I think that it's a great question and I think it's built into the system that we've actually set up because they're going to be actually measuring and looking at what those look what what that adjustment looks like for their students and so them will be able to actually tailor supports for them. It's interesting because I don't know if there are. I don't know if that's a question that has been sufficiently addressed. Part of the thing is that the, you know, normally I think in Vermont has a very strong homeschool community, and but which fell apart during the, the this past year. So it's, it's been a different experience I think a lot for a lot of families and anecdotally, I can say the homes, I'm on the school board but I can say that the homeschooling families I know of are really reaching a crisis level at the moment because their, their kids are feeling extremely isolated. I just wondered how, how to pick up those pieces. I think, yeah, I think it's a good question. I mean, I think the way I framed the way I interpret your question was, how do we actually help students who are transitioning back into the public school system. I would say including ours don't have a very strong regulatory context for home study. It's, it's kind of, if parents have chosen to kind of opt out of the public system. There are some things we can do. But I do think it's really critical that it's a good question and I think it's really critical we obviously care about all of our students in Vermont and so I think that's an important piece that will, you know it's good to hear that as a question and I'll attend to that moving forward. Regarding the issue of class size. I do think that's something that we will continue to look at. We certainly haven't made any decisions on what we would recommend to the State Board of Education on current education quality standards. It is something that is certainly, you know, something that we're, we're going to spend some time reflecting on particularly given the data showing, you know, a reduction in behavioral referrals. So, I do think that's a good point and it's something that we had intended to be thinking about already and will continue to. There's a lot of factors obviously that go into how class sizes calculated. A lot of those, a lot of the recommendations from both within our state and also nationally come from a non pandemic situation and so we're kind of, you know, we're kind of working with a completely blank slate in some sense so we'll be trying to actually figure out what makes sense in terms of, we're moving obviously and want to move towards whatever sort of a stable system looks like after the pandemic but also we anticipate there's you know we anticipate recovery being a three to five year prospect and so you know we don't, we don't have a disposition where we're immediately snapping back into okay everything is exactly the way it was. We don't think that's actually going to be very helpful for students or families and it needs to be a very thoughtful and gradual recovery process. So I think that also fits in that particular perspective of one of the features we would look at is like what does the classroom actually look like as a result of what we've learned in the pandemic. If I may just as a quick and then I'll probably be quiet because I know you have other folks need to hear from one of the. One of the interesting lessons we learned and I think this is also something that has been discussed and sort of replicated in other states experiences. When we first were figuring out how do we do this kind of emergency overnight on the fly system and then also focus on our reentry. I think many of us thought okay so a big part of that is going to be virtual learning is going to be some kind of hybrid system. And I think many of us and you know I'm a little chagrined at myself because my area is adolescent development, but we had kind of thought okay this will be, we're really focused on our younger students and getting them back to in person because you know those interactions are so critical they really need to be, you know, back in school because they can't really learn effectively online. And so what we realized though is that who has actually struggled more in this pandemic are actually our older, our older kids are middle school students and our high school students. And I say that not in a way that I think we did something wrong I think we were using like the best thinking at the time and like I said we're not we're not different than what other states had done. It's more one of those unanticipated like oh and the social needs were so critical for middle school and high school that you know in a perfect world, we might have thought about this differently. And so, although we were also dealing with requirements health requirements based on the virus and so you know we knew at the time that adolescents and high school for instance we're much more like we're much more biologically like adults and and could not be in small, you know could not be in social proximity to each other. And I guess why I'm saying that is that we're all we've all learned some important lessons and we're very committed to moving forward with that. That lens in mind, and certainly what we've learned about existing challenges with the mental health system and what we're taking forward would relate to that system just as well. Thank you. And I think there, I think there's, as you say there's much for us to learn still from our experience. I would just mention in passing that I received today a an email from persons work working with what's called the what the expert program, which does screening and talking and I'm going to forward this whole committee and not try to represent it here right now but really talking about some of the issues of identifying like one in five youth are struggling with mental health, one in four with substance use and one in 10 with self harm that that the impact is is very real during this period of the pandemic. And so we'll continue, we'll continue to want to learn about that and the implications for the education system which is where as well as families and communities were children are spending much of their time. I think at this point I would like to turn our attention I would like to hear from Devin green. So, representative down here I see your frustrated look at me when I say that. So let's let's, but let's, I'm, frankly need to balance all this so let's let's hear from representative Donahue and representative Tina and then I do want to hear from boss. I understand I had a question for the Department of Mental Health. I was asked to hold off, but then they left and I didn't realize the commissioners need to leave. So I understand so that I know I understand but that's why I'm asking to raise it now because it is a carry over question for for context, as vast and maybe not to answer up front but to consider as part of that and then answer at the end. And that is when, when the commissioner responded to the question about geographic access for it for inpatient children's care. The commissioner said yes that was an issue. She was aware that the state and the retreat needed to, to look to and address and the state was conscious of that. And I want to point out again that, you know, if cardiac care was only available in Brattleboro. We would not be looking to the state to solve that problem. We would be looking to the hospital system and our healthcare system to solve that problem. And there's a history of mental health segregation. And that created the need to have state intervention, and we're still, we're still in that phase, trying to work out of it but I would hope that in looking at this issue. We would be making that transition to the hospital systems responsibilities for ensuring all care is accessible where people need it. And that is of course the focus of the integration council. But as you respond to these issues, I hope that it's starting to come from that place of responsibility and not not a state responsibility to ensure adequate care. So thank you. Thank you and represent she knew. Would you like to be heard at this point. I'll just comment, because I don't know who's coming and going that because what we have someone here from the agency of education, which is unusual for our committee. And I appreciate the update and I guess I just all I would want to say is that if we can, if school districts can use Medicaid money to pay for police, which we found out has been happening. I think it would be creative and find ways to do more in the schools to do preventive work, and maybe even to do more to support kids in crisis, because right now when when kids are in crisis that you know, schools call for support outside the school. And a lot of times that escalates to kids ending up in emergency rooms and there just might be more we can do for kids in the school so it was good to hear an update from you. I was concerned to hear that school districts are using Medicaid money for police and hopefully and that does kind of intersect with the work of this committee so while we had some education here. I wanted to just throw that out there so thank you. And that something that's recently come to my attention and as I understand it is not in fact an authorized use of Medicaid funds and something that needs to be addressed. I would just to add to that I would just say we are looking into into that and looking into what the actual use was so we're will be more happy to report back on what we find when we actually dig deeper into that. Great. I think we'd all appreciate hearing about that. So, with that, I'd like to turn to Devin Green and Emma Harrigan from Voss and give them the opportunity to respond both to our letter and to some of the comments that have been made subsequent to in the course of the morning. So, Devin. Great. Thank you for the record Devin Green from the Vermont Association of hospitals and health systems and I have here with me today. Emma Harrigan, you can go ahead and introduce yourself, Emma. Good morning, Emma Harrigan with the Vermont Association of hospitals and health systems. Thank you for your time and attention to the issue of children waiting for mental health treatment and emergency departments. We realized that this came up late in the session and we really really appreciate the work that you've done in this area and the letter that you sent to Voss and AHS and the Department of Education, or the Agency of Education. We think that letter provides a good framework for AHS and Voss going into the summer and keeps the momentum going through the change in leadership at DMH. As you thanked Commissioner Squirrel today, we would also like to thank Commissioner Squirrel and DMH. They have been great partners, especially throughout the COVID pandemic. I know that they face a lot of challenges that we face. They align closely with us and it's difficult to come out of one emergency that we're actually still in and pivot to another one and we really appreciate the short term and medium term goals that they've set up in such a quick amount of time. So much appreciate their work in that area. Going to the memo, we did have a couple of items we wanted to flag. One was the data on DCF custody status. We think I've sent this request to our ED directors about whether they can collect this data. They are very enthusiastic about providing data. So I think it will be fine. We did have one person who had some concerns, but we think that that will be possible and we will work with our ED directors to make sure that happens. The other piece in the memo asks that the data be broken out by hospital. We are fine with breaking it out by hospital and submitting it to DMH. We think that that will give DMH an opportunity to see the system as a whole and address issues. We worry a little bit about providing this data to the public. Because if you have one person awaiting an emergency department for a certain length of days, you can really get into issues of HIPAA and privacy issues. And so we would ask that this information go to DMH. They can act upon it and they will have it. And then in terms of submitting it widely, we'd ask that we provide statewide aggregated data for that. And then one of the things that this committee was looking to understand a little bit further is how emergency departments work on the ground and what all of this looks like. And we think going into this and in partnership with the state, we would love to be able to actually bring you to the emergency departments so that you can get a sense of, you know, the differences between our critical access hospital emergency departments and our designated hospital emergency departments and our academic medical center and just create a baseline understanding of how these work and what is possible in all these areas and what they might look like. I know we've been working super hard and haven't had much of downtime or vacation but I would ask that you consider that perhaps over the fall as we go into the session so that you have an opportunity to learn some more about those areas in our hospitals. And in terms of what Representative Donahue was saying about our hospitals taking this on, we are with you, we are looking at this, we, you know, we are coming here in partnership, we are not saying that this is a state's problem, we realize it's a hospital problem also. And so we are looking at all of this, but just as I mentioned at the beginning of this session, it's really hard to balance quality and access and affordability in a rural hospital system. So we will be looking at all of this with that lens and certainly hope to expand access going forward. I think Commissioner Squirrel's point on prevention, being a focus and trying to ensure that people do not end up here in the first place just as we don't want to end, we want to change people's diet so that they don't have heart attacks and don't end up in a cath lab. We also want to look at those interventions and emergency department diversions as well. Emma, do you have anything you'd like to add? No, thank you. Okay, well, let me say that I think, so I think that you've done, you've taken an important step previously around identifying data that we find very helpful. I think that with some of the data requests that we've made in this letter, it, I guess what I'm hearing is, and I'm saying that Shayla, Liz and you're here with us from Department of Mental Health and Devin and Emma from VAS, that it sounds like the specific data and ongoing reports seems agreeable to and achievable. Is that what I'm hearing from the Department of Mental Health as well as VAS? That's terrific. We will not be in session, but we as a committee are committed to trying to follow this and so we will arrange for that working with DMH and VAS to make sure that information continues to flow to our committee members as we continue to individually monitor this and as a committee. We think that's critical because we don't want to lose the momentum, frankly, we don't want to lose the sense of what happens because we're here part of the year and you're here year round and we appreciate your ongoing work and commitment. But we feel it's important for us to stay connected to this as the department and VAS continue to address this critical issue. I'm a little perplexed, but I'm able to talk more offline, but I'm a little perplexed as to the HIPAA issue because I don't think anyone's identifying any particular child in an emergency room. And so I'm just a little perplexed as to why length of time waiting there in any particular hospital would be identified any more than it would in any other situation. Perhaps that's something I can understand more fully. Is that Emma, do you want to comment on that? Yes. Um, so we're dealing with, I mean, we're in Vermont, the numbers are very small and we do lead, we do borrow examples from other parts of state government that use was called suppression on low numbers. So for example, if you're grabbing data from the all payer claims database. The numbers are less than five. You're just supposed to indicate that it's less than five. And so, for example, when we're working with smaller emergency departments who may only report one or two children waiting knowing the location in which a child is waiting. And how long they're waiting can be identifiable to people outside of this committee people in the public who are reading the report. I really want to be sensitive about when we call out the location of one specific individual or two specific individuals who are waiting a particular amount of time so we're committed to providing that level of detail to DMH so they can be part of the process for identifying services for the individual but at a public level there is a risk of of accidentally identifying an individual who's seeking services. We don't want to do that for sure for sure. So we want to be sensitive that we just maybe we can all understand it as as this moves forward and you provide that information to DMH. Perhaps there's a way for some just even suggest that some particular committee members might be able to sit down with the image to review some of that and not make it a public document that goes well beyond what any one of us would want to pay any consequences because that's certainly not we all want to be very sensitive to that. So I want to raise one other issue if I may and and this is again Shayla I know that you're here from the department and I know we don't have anyone from Dale with us this morning but it but it comes partly and it's touched on in terms of our request that for children who are in the custody of the Commissioner Dale I mean DCF I'm not I'm sorry I miss speaking DCF where one of the questions that came. I mean I think one of the suggestions was that there were numbers of children in the emergency room settings who in fact were already who were in the custody of the state through DCF. And that we don't have any we don't get any picture of that. Based on the data this is I understand the data that we're collecting, but I think that is important data to understand. And so am I am just am I to understand that that is something that we can try to provide to DMH at least and if not to the committee. Is that going to turn to Emma. Yes. Yes. Yeah, we will try to provide it. You know a lot of our hospitals are collecting that data by hand right now and so they can. We can add that data piece in for them there are a couple that are trying to automate this realizing that this might be a process going forward and but they're all very motivated to do it so we will do our best to get that data to you. And thank you that's great. And I'm just going to flag something which, again, we always have to look at what are the unexpected consequences of an initiative in one part of state government versus another and, of course, I think many of us are pleased to hear that again we don't have DCF with us so I'll mention it here because there's there is collaboration. But we, I least to receive and I think all of us have received a memo from the commissioner of DCF talking about the intention of the administration to work hard to bring more children back into the state rather than having out of state placements. And I think the numbers are there's significant number of children who are now state placements and one has to conclude or one has to assume that if they're in our state placements because there was not sufficient setting for them to be for their needs to be addressed in the state so bringing them home and I think I don't have the. I'm missing the, it's a type of more intensive support setting in a foster care type setting where they're going to be working to recruit additional family settings and add additional support, etc. Sounds like a terrific initiative, one has challenges but terrific initiative. That should do good things for children and families. I find myself thinking at the same time, will that potentially lead to additional pressures on our emergency psychiatric needs. I don't know that, but I'm just, I just flagged that and I would ask Shayla to particularly be thinking about the work between the DMH and DCF to anticipate whether we will inadvertently be adding pressure within our children's mental health system in the state where for for some perhaps high needs children who are now placed out of state. I'm not saying it's wrong to bring them home. I think that's a good thing, but we need to anticipate some of the potential, or at least at least be thinking about what what that collateral impact might be not just for DCF, but for our entire system of care here in Vermont, which which reaches into emergency settings and into the mental health community settings as well. So that's, you know, something for another time to and perhaps there's, I'm very open to hearing about what is being planned and maybe misapprehending with any concern that there might be there. But I wanted to flag that given our chance to mention it today. We can include maybe an update on that in one of our summer reports back to you. I think that's some, some juncture. I would, I would appreciate that. Okay, now I know that. So I represent Cordis you had texted me that you had an update on some information you received. But before we go there I wanted to check in with representative Donahue if there was a particular question for us follow up. So I think we'll go to representative Donahue and then represent course will still come back in here for me. Thank you. Yes, this is just a direct follow up to what the chair was just saying because I think it was a news media version of that update regarding foster care and I think that part of what it said was that they were hoping that this initiative would also be addressing children who currently show up in the emergency room who are in foster care and that it might help reduce that and quite frankly when our sub work group was developing ideas for what we should do in the letter. That was the specific reason that we added tracking foster care because we, we are response to seeing that was, we didn't even realize that a significant some significant portion of those children are in fact in foster care so there's two ends of that and I think that's important to track the question I had and it may, I don't know may connect with representative Cordis update but just I appreciated the update on UVMMC. We simply provided some examples brainstorming of current environment of care, and I'm just wondering if you have any response about what kind of other things, whether they be suggestions that we had made or things from the hospital and are there any specific updates that you can provide on things responding to what we've heard from parents about, you know the current environment for children who are waiting. Yeah, I think I think our plan going forward is to take all of your suggestions into consideration I know that there's been immediate responses to the specific areas that were raised by parents which I think is helpful but we are as a hospital system we are going to look internally to see what is possible to change those spaces and make them more therapeutic for children. That being said, there is a potential limit on what we can do there and we're also going to figure out what those limits are and why they're happening and and if or how we can change them which again is why I think it's important for this committee to come visit some of our emergency departments to get a better sense of that as well. Thank you that may have been part of my concern and asking the question because you were referencing fall and I think we were hoping that some of the ideas were like you could institute next week. I was saying visit. I wanted to give you a little bit of a summer break before before demanding field trips but you're welcome to come out whenever. Okay. Thank you and I think I think related to that I think I think this is representative Cordis indicated she had some further information that had been communicated her actually in the course of our hearing. Representative Cordis. Thank you. Yes, I heard from one of my colleagues who works on the pediatric unit at University of Vermont Medical Center which I'll just also add is a fairly therapeutic milieu they've done a really wonderful job in creating a healing environment for for kids. What I heard from my colleague is that they are the hospital is actively including nurses on a committee. Planning how to address this and make sure that the staff are skilled and prepared to take care of patients in these two beds. And also to make sure that they have very clear criteria about what kids kids with what mental health issues are being placed on that unit. So my concerns are laid. Everybody's working together and that's great. And I would just add that I think knowing what I know about therapeutic milieu and the pediatric environment and what UVM Medical Center has done in the past. Knowing that having heard from parents who have had to travel to Brattleboro and with their kids or don't feel that the, they're not happy with the situation across the lake that if we could create capacity in patient capacity. In the northern part of the state that that would be really fantastic. Thank you appreciate your sharing that update in particular. So I'm, I'm thinking we're getting to the point where we're going to bring this to a close but I wanted to also just say that I think boss you had. We had had a communication from boss about an upcoming training around children in emergency departments that you might want to also just bring everyone's attention. I think I have the specifics in front of me and if you do that's great. If not, you could again, make sure everyone knows about it, because it seems like it's another piece of the larger initiative that we're all working together. Sure, so I can give an update and I hope we're talking about the same thing I think we are so we've partnered with the Vermont program for quality and health care. So I wanted to bring Dr Scott Zeller, who is an emergency psychiatrist, who was part of the group that created what's called the Alameda model in California, and has moved into a more national framework called an empath unit. And what it is is it's psychiatric urgent care or the intersection between emergency room services and psychiatric services or inpatient services so provides provides a more supportive environment for people who are experiencing a mental health crisis and has shown some really promising results in terms of 75% of people who come into these units are able to be diverted back into the community so it reduces pressure on inpatient care and provides more opportunity for people to be served in the community. So I think some aspects of this were kind of being considered in part of CVMC's planning before the pandemic with their with their design on the campus and increasing inpatient capacity and redesigning the emergency room so we're just bringing the expert here to Vermont and it's open to pretty much everybody. It's an open medium so that's why we sent it to you and we can certainly send the flyer again to reflect in the record. But we're really hoping to have a very good conversation and possibly bring Dr Zeller back to have more discussions about what could be done in emergency rooms to support patients who are experiencing a mental health crisis. And that would be open to members of this committee and other legislators who might have a particular interest in this and again I'm not trying to, I mean, I appreciate I appreciate the initiative of trying to look at new and are different models and not trying to sell. I just wanted to just say that we had the attention of our committee members about this. California model that you're referencing. So, but it's evolved. I know there have been concerns about the California model and this was discussed several years ago but I think the movement and the lessons that have been learned from the initial pilot or the initial design in California has really translated into some really good work and other parts of the of the country. So, and definitely whatever is discussed by Dr Zeller I think there's always. I think everything always needs to be right sized and and approach in a different way to work for Vermont so we're just, we're starting the conversation with the national expert and we hope to continue it from there. Great. Okay representative Peterson. Thank you. And I'm a thank you for your testimony here. My question though about that was the personnel who who the first face people see when they come into an emergency department. Is that person be trained or is that person trained now to deal with these types of of mental health issues that occur in an emergency department. I mean, they must see a variety of things I see everything from, you know, horrible, you know, health medical problems to to now more more mental health problems I wonder how those personnel are trained to to maybe diffuse a situation calm down a patient, be a smiling friendly face so that somebody feels like they're welcome or in the emergency department. I mean how are those people trained and are they trained or will they be trained more in not so much the doctors or psychiatrists and psychologists but the the clerical help that man the desk there. Yeah, so I'll jump in and say the emergency department folks are trained for anything right like they need to be there and ready for anything that shows up. And they are a place of triage and stabilizing and then transferring or discharging and so because they need to be trained for anything they I think a lot of them do receive training in this area that being said I, I think there's more work to be done there. They can't go as in depth, necessarily, you don't have your baby in emergency department. There's, there's there is training that can be done. But I don't think people are going to be experts in this area necessarily just because they do have to be ready for anything to come in that door. And it really isn't a place for treatment it is a place to get the person to where they need to be going forward whether it's just to stabilize and send them home or send them to an inpatient unit so but again we're looking into it we think that there's more training that can be can be done in this area and so we'll continue working on that. Thank you. One other thing we've been looking into is getting more peer support into the emergency department we've had this conversation with our ED directors and just in terms of the, you know the smiling faces and the people who do have the training. You know regulations do not allow peer support to take on any hospital services, but they can certainly be there to enhance the experience and we think the fact that there's movement in certifying peer support for mental health will really help give a framework that will be easier for emergency departments to work under and to sort of bring this support system into their EDs. Thank you. Representative Goldman. Thank you for a Devon for bringing up that idea of peer support because you also talked about having a baby and it reminded me about the doula model, which is a really important model for supporting women in labor so yeah the model exists so yeah let's just spread it. So that's great. Thank you for allowing your invitation to visit emergency rooms but maybe in July will take a visit children etc but yeah I think that that would be really an interesting field trip so thank you for the offer. I'm tempted I'm just gonna say it. To be in emergency rooms over the past few years and each time I said I'm actually doing research as the chair of the health. And in fact, at times it has been very revealing to be an anonymous patient in an emergency room observing what's taking place. And not a special guest. But I but also I hope I hope we will take you up on that opportunity because I think there are times as well that I thought it would be very useful to be able to be there and ask questions or to hear from people as well. That's an invitation I hope will some of us will be able to take advantage of. Okay, I think with that I'm going to bring this part of our morning which is now gone a good period of time but I'm going to bring this to a close. And thank you Emma and Shayla and Shayla there you are just I have to search the screen to see where everyone is. And thank you Shayla and we will and as Commissioner squirrel indicated as this issue will continue and be important in her in the transition and leadership in the department that I was looking for a point person she indicated that you would be the person, at least that we would be directly in contact with as the committee in order and there may be another point person identified around the specifics, but we will look forward to staying in touch with you Shayla. In the course in the course of this through the, as we come to adjournment and move into our other lives but also we do it's this isn't this is such an important issue. I think our goal has, I think been a well achieved and I want to thank again I want to thank the subcommittee of our committee, representative Donahue, representative Goldman represent China for helping to craft the letter, which I think, as we've followed up on that I think has in my view has met many of our goals in terms of setting some timelines, some goals in motion for this issue to be continued to get continued attention, even as we move into out of session ourselves, but to keep us informed. So again, thank you, thank you, each of you and and also the Department of Education or Agents of Education, I would appreciate thank you for being with us as well. So there's one other thing that we're going to switch to that is a different, different issue or you're, you're welcome to stay with us if you like, but I don't think you need to. So that is that we had a number of student interns with different members of the committee in the course this and while I haven't done this in any organized way. There had been a specific request and I think we have one of the interns with us this morning I'm going to turn to represent Cordis who's had the opportunity to have Olivia Churchill interning with her, and had requested the opportunity to say a few words to introduce her again, which we had done earlier I believe, but also give just a few words of feedback about what it's been like and thoughts they have as having been an intern with us, and then we're going to close for the morning. So, let's turn to represent Cordis. Chair Lippert, I was initially a little concerned that about my capacity to keep an intern from UVM busy enough during our legislative session. And because of who Olivia Cook Churchill is that was not a problem. She had a wonderful experience working with her. She's very interested in, in health care in health equity, and in climate and health that that intersection. She also reached out to one of our committee members representative China about H 210. I just wanted to thank her publicly for all of her great ideas are very good work. And for her commitment to these really important issues and wanted to give her a moment to say hi and share a few comments about her experience now that we're at the end of the semester and she's wrapping up her, her finals. Hi, Olivia. Welcome to the zoom, zoom room of the house healthcare committee. I know you've been following us on YouTube. Yes, thank you so much for having me. It's interesting to actually be on the zoom call now. I just wanted to take a moment to thank you all for all the work that you do for our communities and just generally improving the health of her monitors. It has been such a treat to end my time at UVM interning for representative Cordis and watching you all engage in the community discussions. I've learned so much about just general processes and legislator and as a public health student interested in health disparities. It's been awesome to see you all acknowledge the equities and take action in Vermont to make health more equitable. I'm excited to see H 210 introduced the session and kind of follow along with that. And then also most recently in this internship I had the awesome chance to speak with Dan Quinlan. He's the director of the Vermont Climate Health Alliance, and he really opened my eyes to how drastic climate change affects our health, which is something I didn't really think about previously. There's been a lot about policy efforts that are being made to promote environmental justice. And also more specifically he talked about how there is a need to look at recent rises and heat waves in Vermont that are affecting the health of our population. So I know you're all busy but thank you so much for letting me come on and say goodbye and thank you all for the work that you do. Thank you, Olivia and I think I shared with the committee we were talking about the Lincoln gap. Recently and I shared that I drove you. I took a risk and started to drive up the Lincoln gap with you not knowing whether it was open or not. That field trip was initiated by Olivia with her idea to get my campaign team together and other friends from the Lincoln area to just get out there on green up day and join the community so I loved having that opportunity to meet you in person Olivia and and work in the in the community and take a risky trip up the partway at the Lincoln gap and thank you for everything. Of course it was so beautiful to drive up there and so nice to actually meet you in person finally to. Yeah, good well thank you congratulations and best wishes in your next adventures in your studies in life. Thank you. And it's a good reminder to just this is embarrassing but it's like it's a good reminder that there are numbers of us who have not yet met in person we've been doing incredible amounts of work together. And as a committee and I would like I'm just going to say this I would like for us to carve out some time. And it doesn't, we'll need as a committee just to just reflect on our, our work together this, this half of the biennium, both informal and maybe a little formal reflection, but we'll try to carve that out it as we enter into this new session new part of the session which I'm just going to say that there are there are still some issues in front of us and some opportunities maybe to put some more information in front of us, where we're there as the speakers said on a number of occasions we're in a period where there's this kind of hurry up and wait type of activity but there may be some discrete pieces of healthcare information that we can bring before the committee in the course of this as our time our committee times are going to change next week as well, because it's the final week of the session and that is that we'll be on the floor far far more. If that can be imagined at times that to bring the session to a close. So I'm thinking some about that and so anyway. Thank you. You had a I see your hand. Yes, thank you. I just wanted to also thank on the on record, although she's not here today. I also had a UVM intern, Rachel best and she also was able to sort of plunge into an area and as the committee knows we spent a fair amount of time looking at how to identify response to the needs in our forensic healthcare response system and she she did a great deal of research and turned up various other models that other states are using, which will be a value to the work group itself, you'll hear me reference on the floor when we when I present our section of that bill, but if anybody's interested in a copy of it it's it's a list of links and resources regarding some other examples of what other states are doing so I thank her for her work as well. Great. And I think there may be other committee members who had interns we didn't this is we didn't organize this as a plan thing but if there are other acknowledgments that people wish to make right now that that would be fine. And if not we can do that another time. Great. Okay, represent Goldman. Well I'll just take this opportunity to acknowledge my intern Alexis drown. She got me through the session technologically. I really grateful. I've been doing zoom meetings monthly with my constituents I couldn't have done it without her. She really is the total infrastructure of that. And I asked her also to write a position paper on the middle sex facility and she did a fabulous job on that and really helping me understand where I wanted to land on that so I am grateful for her work. And I hope we have an ongoing relationship I hope that she's just a freshman so we might be able to continue on so I'm happy about that. So thank you Alexis. Great. Thank you represent Goldman. Don't want to skip over anybody but there's nothing that has to be done here. Okay, so I'm going to suggest that we bring this to a close for the morning. Then, and stay in touch as we need to be flexible in responding to the appropriations committee's work. And, oh, I know there's two other two other issues. And again, I haven't said anything ahead of time but I'll just mention that s3 is still an issue that is being looked at by the Judiciary Committee and we did. We had a, you know, we took some significant time and had input into that. I don't know if representative Donnie is anything that you wish that you are able to share wish to share and then I also mentioned that just suddenly comes to mind. Again, impromptu if you wished it if there's something to add if not that's fine representative boroughs and representative courtes are being representing our committee on the emergency housing subgroup and if there's maybe just a matter of letting us know that it's continuing or when it's of its work but if there's anything you wish to add that would be, we could do that quickly as well. But first represent down here. Yes, my apologies for not having initiated the need to just to provide an update so the committee's aware. The s3 had been referred to appropriations and they did voted out yesterday unanimously with the, both the 25,000 for the expert analysis support, and also with the additional resources for the per diems for committee members who were in their positions. There's also a significant amount of money that had nothing to do with our part of the bill, but in order to implement the changes in legal supports in the system. There was a need for an appropriation there as well but it didn't really involve our part. So, it is on notice today. So it will be on the floor Friday and Tuesday. Just as a reminder to committee members because of the extensive work that we did on sections, I think it's five, six and seven. Representative Donahue will be the judiciary committee has requested that those sections be reported by our committee and represent Donahue will be reporting those sections on the floor. Yes, there's there's a technical, technical change in terms of procedural things from from past years. We saw it with I forget which bill previously but because I'm not a member of the committee. I cannot report on those sections at the time the bill is being reported. So representative LaLonde who's presenting the bill will very briefly reference them and report that I will be reporting later, it will then go to the appropriations committee amendment which has to be voted on. And then when it's time for, you know, member questions statements and so forth. I will be recognized first just as a member of the assembly, but we'll get up at that point to lay out and explain the sections that we worked on. I don't get up. But doing that on behalf of the committee. Yes, on behalf of the committee but don't be surprised when I don't get up at the time the bill is being reported it's a procedural piece so I'll be reporting on our vote and so forth on on that. Okay. I realize I did not give you any advance notice representative boroughs representative court is if there's anything that you that they is appropriate to add at this point in time if not that's fine to turn to thank you chair. I just forwarded an email to the House health care committee and I will take advice about the best way to. Create a document instead of an email that that perhaps we could upload to our committee website so others can see it. But we did meet once and have some email communication before that and came up with a fairly comprehensive list of things that we would want to be sure were addressed. The plan was that as far as moving forward formally with this list we will. It would be better to wait till age 439. The appropriations bill has been signed into law. I think we have a lot on some of the issues were one just a correction actually the first bullet talks about grappling with substance abuse disorder it should be substance use disorder. Also in making sure that the funding silos between housing and services. The silos are removed that there's a direct connection between housing and the services that go with them and that that was something that our communities brought up as a in our community providers and housing providers brought up as a as a major issue. And then might the 1115 waiver negotiations consider investments related to the provision of shelter. And a lot more so I'll let you look at the list in the email I sent you and chair do you think that would be acceptable for me to create a PDF of the bullet list. Let's check in. Let's check in offline when we get chance. Okay. Before we take too much further. We're doing what is consistent with the appropriations committees. Next steps. Sounds good. I don't know if there's anything that. Well, just to just to take a step back. What this was was a. There's a work, a work group that is tasked with coming up with a plan for what to do with people who are the 1900 people who are housed in hotels, and we were committee members who were assigned to discuss. From the committee perspective. What from from each from our own. Subject area perspective, what. Bring suggestions to. What the plan should actually wind up being so. Yeah. And this is a follow up to the joint testimony with the human services committee. That's right. I think one, one thing that is listed in the list that I want to highlight is that we did talk specifically about using the pathways model. As one of the ways to, to provide wraparound services. Great. Good. Okay. Thank you. Representative Goldman. Yeah, I just have a question. I'm not sure if the committee thinks thinking about this and I just need help understanding it from my understanding. A lot of times shelters are only open at night, like people can come for dinner and sleep and then they have to leave. And don't have, don't have a place to be during the day. That sounds horrible. So I'm just wondering if the committee is thinking about that particular issue when they think about shelters. I don't, it did not come up. So I don't recall it. I'm just, just been glancing through my notes about it. And I don't recall it coming up. During the discussion we had on Monday. Can I suggest that you engage further with represent courtes and represent boroughs offline as well. And this, I don't believe this is the last opportunity for some input along these and, and I think the pathways model is also one of the ways to respond to some of those issues as well. Which of course our committee has been supportive of and as, as one of the models to it to pursue. So, so again, thank you, representatives, courtes represent boroughs for representing our committee on that. So with that, let's, let's conclude for the morning and we'll see you on the floor and stay in touch. Please do stay in touch in terms of texts or emails from Colleen as we have the need to reconvene to address issues along the way. And I will try to stay in touch actively throughout this process. So thank you. And I guess I just lastly want to say how much I appreciate the initiative that this committee took and has is continuing to take around children and the emergency service and the wait times in emergency rooms. And that is an example of initiative that came from particular areas but that then was taken a hold of by this committee in a really significant way and I think is a as is an important piece of the work of our committee in this half of the biennium. So, let's, let's keep that this. So bill number to say yes we passed bill so and so, but that's there are times when some of the most important work we do not to demean our bills we pass, but end up being something that's reflected in an appropriation we advocated for in the budget, or in work that we're doing that's ongoing in collaborative relationships, or the letter that I think actually achieved some significant impact here, at least from my point of view at this point. Okay, it's the sun is shining where I am I hope it's shining where you are. That's all get a break go outside get something good for our the sunshine is always good for my mental health.