 I'm Michelle Singer, I'm the Adult Programs Coordinator for the Helen Hubbard Library. We're very happy to have you here tonight. Welcome to the library. We're pleased to be partnering with the leaders from the voters once again this year for their speaker series. We're glad to have them here. We're glad to have the panel. If you need anything, please let me know. The restrooms are, the restroom is in the back of the room. Good time to shut off your cell phones now. I'm gonna check the other mic. I'm gonna head to the room now. Okay. Okay, here's a tester for this mic. All so good? Okay. So, welcome. Thank you for coming out on such a cold fall night for this discussion of prison health care. It's part of the League of Women Voters annual series, annual library series this year, 2019 and 2020. It's on criminal justice. I'm Madeline Mangan, a member of the League of Women Voters. Before we begin, I wanna quickly thank our partners. First of all, the fellow-covered library and Michelle Singer, who support these discussions and give them a home. And also the ACLU, Disability Rights Vermont. We have two speakers from Disability Rights Vermont here today. The Peace and Justice Center and the Vermont Women's Commission. Our partners help us get the word out about these talks and contribute to them in many ways. The League of Women Voters is a nonpartisan organization that was founded about 100 years ago at a time of women's suffrage. So, but to men and women, sometimes people get confused about that. And this mission is to empower voters and defend democracy. We have nonpartisan volunteer projects to register voters at Heikebets College as prisons, swearing-in ceremonies for new Americans and other events. We advocate for evidence-based positions at the State House. And this year, we're leading a statewide year-long commemoration of 100 years of women's suffrage. Sign up if you're interested in any of these, joining us in any of these projects. Tonight, we are very fortunate to have an outstanding moderator for our panel. Susan Clark is a League of Women Voters member for SWALF. She's a writer and educator focusing on community sustainability and engagement. She's co-author of Slow Democracy, freeing decision-making back home, all those in favor, a book about Vermont town meetings. Susan consults with communities across the Northeast on how to build inclusive, deliberative, and empowered public engagement. If you're curious about public engagement, Slow Democracy has examples of public engagement and deliberative decision-making in action. Susan serves as the town moderator of Middlesex, Vermont, so I'm going to turn it over to her and we'll begin. Thank you again. Thank you. Thanks so much for that wonderful introduction. You have a fantastic panel with us. So much wisdom up here. It's going to be really great and my only hard job is going to be to somehow funnel it all in because I know there's so much to do here. Maybe you can just wave when I say your name. Emily Tridot is the supervising attorney at the Prisoner's Rights Office of the Defender General. Dr. Dolores Burrows-Fyron, who I understand goes by D, former health director for Vermont's Department of Corrections. Tina Hagan is the senior investigator with Disability Rights Vermont and Ed Paikwin is executive director of Disability Rights Vermont. And last but not least, Judy Jenkins, W. Hinkin. Hinkin, no doubt. Hinkin, thank you. Hinkin. Oh, and Alias is always good in crowds sometimes. Deputy commissioner of the Vermont Department of Corrections. So we have a handful of questions that the league has asked us to cover, which you guys all know about. And we were discussing beforehand that maybe the best way to start before we dive into some of the meat here is to just take maybe two minutes each to set the stage because those were tiny little introductions of who you are and what you do. If there were one or two pieces of wisdom that each of you could impart to us that would really help us lay the foundation of this discussion, help us understand, you know, our topic more fully. What would it be? And really, you can go in any order, but you might want to sort of feed up each other in a way. But just a couple of minutes each to set the stage for us. I'll volunteer. Good man. And the reason I would volunteer... Oops, here we go. Okay, the reason I would volunteer is that what I had thought I would do rather than talk about what disability rights would do and does in our role in monitoring conditions and working with inmates and prisoners, because Tina does more of that directly than I do. What I want to just point out is a few of the basics of where the rights of a prisoner to what we feel is the standard of health care that they are due by right. And from the federal level, Article 8 of the Constitution says that excessive bail shall not be required nor excessive fines imposed nor accrual and unusual punishments inflicted. And those... That's an expansion of some of the previous amendments and that's the amendment from which the basic interpretation that a convict who has... that person who has been convicted of a crime and is incarcerated by the state or the federal government, they have a right to freedom from accrual and unusual punishment and withholding of health care has been shown over the years of jurisprudence to be accrual and unusual punishment. For detainees in Vermont, our prison system is very different than many and we have a mix in our sick prisons of people that are convicted of a crime and people who are presumptively innocent until proven and they are detained and for them, Article 14's protection of nor shall any state deprive any person of life, liberty, or property without due process of law nor denied to any person within its jurisdiction the equal protection of the law. That's the clause from which is interpreted the right of a detainee to health care, to reasonable treatment, to due process and a number of other things but health care in prisons are there by right and it comes from our constitution at the federal level. On the state level, you'll hear me and other advocates talk about what is it that a prisoner is entitled to and you'll see, I use the term prisoners. They're in prison and when I say prisoner, I'm including convicts and detainees both so just so you know what I mean when I use the term. So there, the department shall provide health care for inmates and courtiers with prevailing medical standards. Now, the way we interpret that that means medical care should reach the community standard. So in other words, if a person has a diagnosis of an illness whether it be a mental illness or a physical illness and the prevailing standard in the community is acts that should be what they are entitled to as a prisoner. Not necessarily acts minus something. So that's the standpoint from which we come. There's some other important statutes that deal with people who have serious function of impairments which are people who have very serious mental illnesses serious traumatic brain injuries or serious developmental disabilities. There are other aspects or there are other situations that require the state to look at their situation a little bit differently that come from Vermont statute and there are a few statutes regarding segregation of inmates that look a little differently at the category of someone who has a functional impairment there's supposed to be only held in segregation no longer but then 15 days if they have a disciplinary report or 30 days if they have an administrative segregation. So those are just I just wanted to convey some of the basics where does the law protect the individual's right to medical care at what we would interpret as a community standard? Very natural. Can I? I'd be happy to just give a little background on what our system is like what the correctional system is like I'm Judy Henke and I'm now deputy commissioner and just for a very short period of time really for about eight months now and I had a background in healthcare regulation working for the Green Mountain Care Board and I think that's one reason maybe that I was selected for this job or offered this job is because healthcare is a big concern in the facilities there was a report about a year ago about how much is spent some people were outraged on how much is spent some people were outraged on how it's spent some people were saying it's too much some too little there's a lot of complexities there's about let's say I should know the head count today how many people there are but we have six facilities here and about 250 people in Mississippi right now it's about 1761 I think today something like that altogether and it is absolutely right on what the law is and what people are entitled to we have to take care of the people in our custody it's done through a contractor right now and it will be for the foreseeable future because it's been that way for 30 years A. and having the setup that Vermont has having these geographically scattered facilities it's not easy when you have competition with hospitals also for medical people in nursing this is the model that's been used although there's going to be a new contract entered into for the fiscal year next year and that's not been selected more negotiated quite yet but it's scheduled to be done this year and that will become public once that's done but as you might think just out of common sense a lot of people that come into correctional facilities and come into the custody of the department have more serious health concerns a lot of them come from a background where they have not taken care of themselves had not had access to healthcare have not had access to dental care a high incidence of use of psychotropic medications a lot of the opioid crisis is reflected in our communities yes but it comes to light very much in the correctional centers where I think today there were over 700 people that are getting medically based treatment so it's not an easy thing and I'm hoping we can always improve it there's a lot of pressures from our bad infrastructure it's not conducive to good health to have people in these types of environments it's not conducive to good mental health there's a lot of budgetary pressures it's not a priority to a lot of people to put money into this type of activity in fact corrections has been level funded for seven years and it's all general fund money so it's not necessarily a popular thing it is what not only the law is but I believe that what the leadership department of corrections is trying to do is to make wellness more of a focus and I could talk more about that later so I'd like to say it's not for lack of trying or bad policy but things have changed over years and I hope that the way they're changing is pushing it towards better mental health better opioid treatment a lot of things that have really played out and get carried back out into the community it comes in from the community and goes back out so I am Emily Trito I just wanted to get a sense of your familiarity as an audience with some of the issues we're talking about because this could turn into very inside baseball with the five of us because this is what we do or used to do or sometimes we do for our living so who knows what does everyone know what a detainee is anyone? that's someone where you go to court the judge says bail is $5,000 you don't have $5,000 so you're being detained so it could be anyone today you're walking down the street tomorrow you've been accused of a crime so it's someone who's not been convicted of anything who's had some contact and this could be professionally or as an advocate or as a family member or personally no one's going to ask you which one of these it is who's had any kind of contact with the correctional system? okay most people here but not everybody I'm asking that because there's Judy sort of alluded to a reaction every time there's an article about healthcare in prison or sometimes when there is a death in prison that could have been or could have been prevented all of the people sort of talking back and forth in the article and quoted in my office prisoner's rights being quoted or disability and then a lot of the comments are just don't do the crime if you can't do the time and you might not be here tonight if that's how you see it but you might be and that's part of the context that this is all happening so just one nugget of wisdom since that's our assignment is but I'd like to convey the law that Ed was talking about that says there's a prevailing medical standard that has to be followed that's very very different from the bare minimum that's required by federal law the federal law requires that it not be cruel and unusual punishment which is defined as anything if it's not deliberate indifference that's the legal term if you're not deliberately indifferent to someone suffering you just miss it or if it's not very serious suffering then the Constitution of the United States is taken care of that's much much much lower bar than treating someone the way they would be treated if they went to their doctor's office and that makes a material difference in Vermont you know my office I wouldn't reduce it to nibbling around edges but we're looking case by case we represent prisoners and litigation in court we identify cases where we think that the standard hasn't quite been met or sometimes isn't met by a lot or sometimes it's met by a little we fight that out but across the board it's exceeds what's required by the 8th amendment when you compare with states where that is all that's required and we see this from Vermont prisoners when they're in Mississippi in prison there the contract with Mississippi is everyone familiar with that that we send about you know 20% of our mill prisoners out of state the contract with the private company CCA not with Mississippi I'm just using Mississippi colloquially not with the state of Mississippi well it used to be CCA what is it now is it a court? they're using a county facility some are using the state of Mississippi isn't a player now it is part of the contract that they are supposed to be following the Vermont Medical Standard DOC didn't neglect to put that in the contract it's there but enforcing it is a whole other question because you're asking medical professionals who are treating thousands of other inmates in that facility to one level and saying but Vermonters is a different level and live out over the shoulder scrutiny or someone from Vermont saying this is what we require how do you ensure that that's happening and we haven't figured out from my perspective we haven't figured out how to make that happen yet but the law makes a big difference and we're also seeing that so a lot of you might be familiar with the law that passed this summer to this past earlier to effect this summer requiring DOC to provide medication assisted treatment to people who have substance abuse disorder so that's methadone or suboxone or naltrexone and reduce the effect of them so that you don't get high which is when taking opiate so that it's a means of recovering from opiate addiction and right up until the law took effect the medical contractor was discontinuing people there are people who were going to be detoxed, discontinued from this treatment on June 15 knowing full well that they were going to have to put them back on on July 1st and it was grand and ugly and they took them to court and sometimes sometimes didn't and what the point I want you all to know is that the law made a difference and so the legislature choosing to pass that law your representatives passing that law made a material difference in the quality of the health care so these changes can happen and the legislature can make a difference it's not just intractable I mean some problems are intractable but things can be accomplished I am the former medical director for the Department of Corrections and I haven't served since about 2015 I think and I'm currently in primary care I will say though and adding on to what Emily said and what Ed said regarding the standards the 8th amendment, the 14th is that the contract generally calls for what is medically necessary and that's a term that follows from Medicaid and other publicly funded services that was often used and I think probably still is in terms of what your insurance company or your insurance provider needs to give you or what that level is and sometimes the term is medically necessary and I think that's what's been followed for the most part and the contracts that the Department of Corrections has had with companies in the past and going back to that briefly Vermont has been involved with a privatized system has had a privatized system since at least about 1996 and the first was EMSA why the department or not the department actually it was the state the legislature decided to go with the private contractor I'm really not sure but I suspect it had something to do or I'm minimally sure with the fact that all state employees were being used at that point to serve the to provide nursing care and other types of care the majority of the people were employed by the state and the oversight from the state the doctorate level individual at that point I think Tom Powell around the time that the contract came into being that privatization came along there I think there were some events that had transpired negative events and I think when states are looking at states or municipalities are looking at should we go with the private contractor or not should we use our own people or not there's also a sense of what's the cost going to be will it be cheaper sometimes they think it is they find out probably it isn't the second part is the liability who gets that hit when something happens that contractor will get the hit if you have a contract that says that private company or profit company will hold the state harmless and they will indemnify them in a court of law so I think there are a number of different reasons for choosing private contractors and I'm not saying that Vermont definitely made the decision because of anything that I've said at this point but I suspect it was a combination of that and after a while it also got harder to hire nurses and physicians and other people and the community physicians had reminded me of this actually used to come into the correctional facility to see the individuals after a while that got to be a little bit harder and harder so just a little bit of background and I'll jump in off and on and we all will if there's some nugget nugget that we want to add or if someone has a question that we can answer more specifically excellent more nuggets to come now Hi I'm Tina Hagan with disability rights Vermont so our role is we're the protection and advocacy system for the state of Vermont so there's a P&A protection and advocacy in every state and our work in the prisons we've been doing prison outreach for 18 years which I started when I started working for disability rights and our job going into the prisons is to make sure that there's no abuse, neglect or serious rights violations for prisoners with disabilities so our focus is specific to prisoners who have disabilities and we do outreach in the prisons we're in there routinely throughout the year and during the outreach what we do is talk with prisoners about what their rights are. Prisoners again with disabilities about what their rights are how to access services while they're incarcerated if they have a disability what rights they have or accommodations etc. things like that so I think my words of wisdom just having done this so long in Vermont being such a small state that it is is that I approach the prison outreach of I never know who I'm going to be meeting with it's not uncommon that I sit down and meet with somebody I actually know or have met at some point just because that's the nature of Vermont and we just go in for us whether incarcerated doesn't matter so we never ask about what the crime is because that has no bearing on making sure that their rights are protected as a prisoner with a disability and a lot of the work we do is under the Americans with Disabilities Act when it comes to accommodations and care etc. Great, alright that's a very nice treasure test to begin with and I think that the first question that the leak would link you to focus on I mean in general our discussion is going to focus on how healthcare in prison compares with healthcare in the community the first question is about healthcare and medication in corrections so can you tell us a little about how access to and quality of healthcare and medication compares to community healthcare and this may be for all five of you or maybe MLA, UGDD what we feel like we're done gives it the weight I'll give it a start if you want I'll start with this one so the short answer is it depends medical care in prison sometimes especially in some types of medical treatment is right up there with the community standard things where we it's very black and white we can measure easily what someone's issue is and what their needs are an example I would think of is hypertension I don't want to simplify the treatment of hypertension because I'm sure there are people in this room who would say it's not that simple not only the medical doctor on my left but people who might have experienced it but I almost never hear complaints about prisoners who are trying to get their statins to control hypertension cholesterol well here you go cholesterol but in all areas there's delay that you wouldn't necessarily experience in the community and something you would we've always wanted to see a specialist for some thing but for basic stuff there can be layers of delay and not because someone's deliberately trying to withhold available treatment but because there's a scarcity that exceeds even the scarcity of medical care in the community and you have to I got sick tomorrow and said I have this really you know a couple days ago I used the chainsaw for the first time and it was really fun this is true but I think I gave myself a back spasm from using muzzle that I wasn't used to using and if I still felt that way the next day I could have called my doctor and probably seen a nurse practitioner someone the same day or the next day to say like I'm your patient I'm in acute pain help me out you know what do I do how do I feel better and if you're a prisoner it's a little more of a crapshoot there's a system where you submit a six slip and people are triaging just like they are in the community there's not a nurse sitting around saying you know I can see that someone's in danger for their life but I'm just going to not do this but they have a triage system they can be very imperfect when you have people who don't necessarily have a lot of medical education prisoners trying to articulate what their needs are in writing in a six slip that there can be delay and it can be especially difficult if you have an unusual or chronic issue chronic pain I realize that we have a separate question for chronic pain but to me these all kind of go together medical care and pain treatment and no opiates are available in prison at all which might be a good thing but if so anyone who has experienced relief from Vicodin or Opsicontin that is not available to anyone in prison in Vermont as a matter of policy with the contractor there nor is the drug Naurantin which is used for a lot of neuropathic pain you get your teeth cleaned every two years not every six months and the thumb is a little more heavily on the scale for extracting teeth rather than filling them it's not that people don't get fillings but a tooth might not get saved that would get saved in the community which is not to say the community to enter for dental care is that high if you don't have coverage this isn't a problem limited to prison it can be difficult to get a hearing aid in prison because sometimes the need for it is looked at contextually you need to be able to hear everything in prison you're not going to work a woman who is a former prisoner's rights client worked with the Human Rights Board in one large settlement because she had been denied a hearing aid for some time and she's a very able self-advocate not everybody is and speaking of advocates in prison not outside of prison if I had an elderly relative or close friend who I knew would have trouble articulating their needs when they go to the doctor or remembering what the doctor said you can go with your family member if they consent to you going with them if they want your help and be a medical advocate for them there are some hospitals have formal patient advocates a patient advocate an independent patient advocate would be a terrific addition to the correctional medical system we have prisoners rights and Tina I'm just going to add to that I just wanted to finish this but at least my office we get to interact with DOC medical staff at their pleasure and when Dr. D was the medical director she was always very available including for the 429 p.m. on a Friday proverbial call which we always seem to be sending to her but our advocates on the ground in the prisons get to speak to medical staff as their schedule and inclination permits which sometimes it seems like the more rigorous we advocate the less we're actually afforded that opportunity to advocate so I've been telling you a lot of the ways that it differs there's a lot of positive and a lot that's perfectly fine but there are in my view pretty big goals thank you we're talking about advocates in the prison and how that would be a good thing and Dr. D might remember this but actually one of the former contractors did have their own patient advocate I think specifically she was stationed in the Springfield prison but she worked for the contractor and we worked closely with her and it was a really great partnership as far as advocacy roles go and she was really able to help a lot and it was a great resource for prisoners and she just vanished one day I'm not sure what happened to the position that stopped so I would just put that out but actually I think is something that would be really helpful if they came back and beneficial for everyone just an example I'll be very fast one of the things that we're looking at now because there has been a new request for proposal because the contract is ending the contract that's there now has been in effect for about five years I think Dr. D was there and implemented it was one of the drafters of it things have changed quite a bit in five years on what has to be provided for example we didn't have any provisions in the contract for medication based treatment we didn't have provisions for the hep C stuff I have some budget stuff that I received from our budget person who's wonderful to provide it but right now that contracts a lot of money and if you looked at what the average expense is what is paid per inmate and the care provided it's not inexpensive there's a lot of stuff there and the pieces that are kind of missing out of it are perhaps the advocacy piece we can't release information medically as Emily knows without a release of information if it's not within a certain if it does not allow you to freely share medical data having someone inside of the contractor's medical area that might be able to work as an advocate makes a lot of sense so as things change one thing we're looking towards is a new contract entered into has to have some better protections for the patient and also for communications to be between patient and doctor like you do get on the outside to get some of that clearer because the number of six slips that come in I pulled this because I'm sorry that I didn't pull too much information but there is yearly last year there were well over 11,000 provider encounters the money paid for dental dental in the community is poor also if you don't have insurance it is more than the Medicaid amount that goes on the average because that's pretty low also walk in visits there were about 2,570 70,500 prescriptions dispensed there's a lot of healthcare that goes in here and looking to a new a new contract we want to make sure that money is allocated wisely and things have changed in five years they've changed quite a bit let me correct you Judy the MAT was put into the contract when I think I negotiated the contract we also put in the fact that prisoners needed to be either transported to the site where Bart for instance if they did not have the ability on site to be provided the medication if they had to go to the clinic they would if not the medication came back in a locked box from the Bart clinic or whatever the other clinic was to the prison so that individuals would be able to continue their M&T their medication assisted treatment there was a lot of time and effort spent into creating those protocols and getting the department of correctional staff and the commissioner working everyone working together to make sure that transportation would be available for those people we worked with Howard we worked with a number of other places so that people could be seen in a timely fashion so that they were not out all day to get their MAT but it's been there while it's been there for several years actually and we can look back on the contract on that or it was written as an amendment because the legislature required the department to do that we did a considerable amount of work and a number of studies in order to demonstrate to the legislature that yes we were in fact putting that into place how much of it was being done at that point and the data was there and then we were going to explore and explode more in the future and I think that's what happened it was we were given an opportunity to graduate to gradually bring that on board and that is what has happened as it should within a system when you're exploring and trying to get the best system possible so MAT's been around a while highlighted in 2017 I believe because we just had to study back no it was before that I've been gone for a while it's been really patient but I want to add just I think we were on some of those committees together about medication system treatment and so it's it's new that it is in every facility and that it's indefinite there used to be first there was a 30 day cutoff and then a 90 day cutoff which does not reflect the community practice with these medications depending on how long you were going to be in or was kicked in and then which has no bearing on your medical needs and it also started out I think in the Rutland facility and then in the St. Albans facility I might have that backwards but it meant that Springfield has the most skilled most advanced medical facility Newport has the most advanced jobs training these are all locations of different prisons for those who aren't familiar Chittenden has women so if you have one of these needs and you needed medication assisted treatment you couldn't have both so this is where we've really made a big improvement yeah I I was going to make a short comment on that there's very recent I remember the argument or that I shouldn't say the argument the discussion in the House committee that I intend attended really did my perception was how was the argument for a specific number of days limited as a protocol when there's not an analogy in the community in the community it's a medical necessity up to the point where it's judged not to be a medical necessity and so a person in some cases might maintain for some years on Suboxone or some other form of treatment whereas they had initially tried it as it was said was 30 days 90 days and then I think they proposed to the committee well yes you're right let's go to 120 days and we argued against that saying no why don't you go to the medical necessity as being the standard which is what I think has been adopted and you know hopefully for the better we've got you know the 700 people that were there I wanted to point out something that has been moving to us at disability rights Vermont and I think points up one of the greatest differences of what you see in the community and what you see here mental health treatment in the community has a long way to go in our opinion and in my opinion there is so much in community mental health that is lacking and but in the community if an individual is in a serious mental health crisis they're going to end up at an emergency department and eventually they're going to get a bed if they can't be released safely to home they're going to get a psychiatric bed in corrections very often what our experience has been individuals will be segregated and the main fact of that is that there is a physical protection from them harming themselves or others their clothes may be taken away they may be in a suicide smock there may be any number of different interventions and the main goal seems to be and I'm speaking for the experience of the clients we work with that we will isolate this individual and we will protect them from harming another client or physically committing suicide and to us that does not meet the community standard and very often what we see in cases like that which admittedly are very difficult cases medication is certainly offered but the level of therapeutics that a person is available just to me does not meet the community standard and now I on the plus side of things there used to be a unit that was very often full of a unit that has no longer is no longer used as an isolation unit for people in psychiatric crisis and I think there is progress being made but I think there is a long way to go and in most in most systems that are the size a population that we have first off there is almost no system that is as small as ours where is small state on the other hand if you have a system that is serving the medical needs of 1800 people there should be something that is really equivalent to a hospital level of care and that lacks in the system sometimes an inmate will be sent out to a community hospital but that does not happen as often as we believe it should happen so I just wanted to put that on the table as one of the differences between community standards and the standards let me just charge in here at for a moment this is a consideration this is a conversation that went on for a long time when Susan Weary back in the 2000 was the medical director then when I came on board in 2007 and fast forward to 2015 as I was leaving the state of Vermont has not invested in mental health facilities for anyone or really good community psychiatric or mental health care the department of corrections as is true and a number of other states since the de-institutionalization occurred is still in that place the department of corrections along with the advocates have asked in the past on a number of occasions to please do something about this there were opportunities to put a forensic unit in at southern state correctional facility an actual forensic psychiatric unit outside of southern state the facility itself but still within a call shall we say we also ask when the state was after tropical storm Irene when the psychiatric facility was no more because of that storm when we all started looking at what the needs were it was taken to the legislature very clearly that there was a need for a forensic facility forensic meaning to house individuals who might be to having been charged with some sort of crime and needing care psychiatric care the other part of that is the department of corrections for a long time and I'm not sure if it still does received individuals who were in acute psychiatric crises they were brought in by the local constabulary by the police the state's or whomever some of those people never received an intake through an emergency department to have their psychiatric needs addressed we also during the time that I was there were receiving individuals who were called DPs delayed placement persons because there was no room within this current system or the system then to accommodate these people they were languishing in the emergency rooms there still are some of them so I guess I really get a little bit warm under my turtleneck when we talk about mental health services in the state of Vermont there have been multiple missed opportunities and it is not just the department of corrections that has been involved this is a community issue and it needs to be addressed as such corrections it's only a part of it so let me just say we have moved on to question number two I'm not even asking it they were so well arranged they just slowed together and to Dr. D's point here this is still an ongoing discussion just two years ago then Secretary LeBae had discussed this when I was at a meeting with the legislature this is really a problem for not just corrections but corrections is where certain people land now there are requirements to get a screen within the four hours but what do you do where do people go once you screen them if you have no hospital or they came from an emergency room they're not going back there if they're released for any reason and they end up back there they're right back with you it is a struggle there's not a huge number but just having a few people coming through the system that shouldn't everybody knows that's not the right place everyone knows where do they go for mental health well what can we do there is not a very clear path for certain people and they are in the not right place when they come in with us and when someone with a judge or a court send somebody in on a sentence it's not up to the department of corrections often to release someone so we can't just make that decision on our own and there's lots of partners in this and I hope that discussion continues and not just through corrections and the people we see here that are involved there's other parts of the justice system that have to really get involved and communities have to be willing to accept you know speak to your legislators that these are needs that aren't being met by the systems we have now so I just wanted to expand a little bit on what Ed was talking about when prisoners are having mental health crises within the facilities it's not uncommon that I sit and meet with someone who sometimes could just sit there and start crying and we start talking and I'm like well you know I always encourage people having to reach out to mental health have you spoken to anybody and the response more so than not is I don't want to do that because I'm going to be humiliated I will be stripped I'll be given this mock to put on and I've seen this mocks and we all understand that there are safety issues around this and then I'll be put in segregation and I just that's not going to help me that's just going to traumatize me so it's really hard to sit and have those discussions and debates with somebody who's feeling like they really need to talk with somebody but they know what's going to happen as soon as they say I'm having these thoughts of you know self-harm that's what's going to happen and the other important part to understand about mental health in corrections is that again they have the difference between corrections and the community they don't have a choice of who they get to meet with they get to meet with the providers at the facilities if they don't develop a good relationship with a provider that's still going to be their provider and so a lot of times people will stop seeing mental health they don't for whatever reason it doesn't work for them like we can go out and choose if you know we need somebody and decide oh this person's not for me I'm going to try another one they don't necessarily have those options and then to be seen by mental health again it's the same as for medical you put in a six slip and you are maybe seen within three days sometimes it's much much longer one basic challenge that a medical staff in prisons face that medical providers everywhere face is time pressure we've all had the experience of going to see a medical provider in the community where you think well they didn't really get to explain what was going on or they weren't really listening to me or you're left with a bad feeling like you haven't really been heard and maybe you're therefore your medical treatment isn't necessarily going to be what you really need and then we've also hopefully most of us have had their adverse experience of like oh thank god they finally listened to me and they actually didn't seem like they were thinking about their next patient and pressed for time even though they must be pressed for time I don't know the numbers other people at this table might have them but the nursing staff in the prisons do deal with a large volume of people I mean Judy quoted some of the numbers about the number of six slips and they are perennially understaffed and I think perhaps mostly with newer speculating because people I've known worked in the prisons for a longer time eventually stopped going this way but there can be some discomfort with the prison population no one goes into the nursing to say I want to do this so that I can be hostile to my patients or you know or mistrust them they all still have the desire to help people and heal people but if you think of what can be accomplished when someone has the time to listen so anecdotally we had a patient in prisoner's rights who a patient client who complained of a food allergy this particular food tomato was made him ill and he said I'm allergic to tomatoes and if anyone here has heartburn tomatoes are a heartburn trigger and if someone listened if you said that to your primary hopefully they say well why do you think you're allergic to tomatoes and you describe your symptoms you realize the guy has heartburn you treat heartburn you explain how to treat it but in this case you know you're allergic to tomatoes let's do an arm prick test you're not allergic to tomatoes too bad keep beating spaghetti on spaghetti night because you might not actually be able to avoid tomatoes that much in prison unless it's recognized that you can't eat them so that's just it's relatively minor because he's experiencing heartburn he's not dying of untreated cancer but it was just an example of a case where it turned into this full litigation where it was about communication where if he hadn't had the vocabulary to know what it really was to describe what was bothering him then something could have been done about it and I think it would have been done about it they do treat people for heartburn in prison through diet and medication but he used the wrong term and it wasn't until we'd been litigating for you know grieving and grieving it and litigation that we figured out this is what's actually happening with the guy and hopefully in the community everyone should have access to a medical provider who could have that the time, the luxury of time to perceive what their patients really saying to them not just the words that their patients using this is another just aside to this one of the ways that the department has kind of dealt with some of these in a little bit forward thinking we do have an open years program these are not professionals they're peers there's a peer program that's in part to help recognize some mental health issues that may be appearing and allowing people to deal with it by speaking to peers rather than speaking to professionals because peers may have a better maybe empathy and understanding of their situation right now I think in December there'll be about 35 coaches some in all of the facilities they're trained on principles such as suicide risk recognition they do go through a training they also have a hold on their stay so they won't get trained to do this and make relationships with people and get transferred this is something that was instituted through our director of mental health and substance use disorder and we found that as just an aside this is not remedying anything to any full amount but it is some way that the department has been able to institute a positive low cost and good outcome program and I think that type of innovation sometimes is needed in our situation and talking about advocates and you know there's no one through the health through the health care contractor but we are trying to at least work with some of the people who come in there was a story I think on the news just recently about it you could probably still get it and I didn't see it I was away but I think it's available online and Stuart led better to the little story about this open years program so that's been one way to help supplement some of those stressors and catalysts for mental health crisis which because as I said it's not a natural environment for people to live in and hopefully in the state as there's some discussion of changing some of the types of beds that are available for people to make housing for people instead of beds to make things have a community that can develop outside of concrete walls there's wooden structures places with natural light and looking forward that's kind of the push that I know that our commissioners now trying to make as far as when they're talking about well these failing buildings in these horrible places well then where should people live are there places that can be more like homes are there and that's the discussion that's been going on so recognizing and that there's not probably a way to just say everyone gets to live in the community without a lock on their door at night I don't know if that's what's going to happen I don't see that but I do see that there's going to be changes in how people house and how they live and I think that a lot of it has got to be related to what we see also as the effects on people's mental health of living in a type of institutions we have now let me just say this also I think we all sit here although we don't always agree in the past we have and we won't always agree in the future but I think what happens sometimes is is the getting stuck on what exactly is normal within a prison setting there's nothing normal about a prison setting and I think if we all start there the next question then that comes to my mind is how do we make it how do we optimize what is there and not increase the trauma of being there for people but there is never going to be as we know it now a prison that is a normal kind of place because we keep saying well they don't have this they don't have that they should have this they should have that some things just are very difficult to provide it's not difficult to provide respect it's not difficult to provide time it's not difficult to provide advocacy but there are things about the prison and being in a prison or a jail that are inherently abnormal and no matter what we do that's not going to change so I think having a conversation about what are the things that we can change what are the things that we can make mean incarcerated doesn't mean that every moment of your life you need to be punished in some way shape or form so I think it's kind of sometimes difficult to push past that someone says one thing I say another you say something different and then we never go anywhere with the conversation so I think listening and hearing from Judy about the positive changes that are taking place is very comforting for me and reassuring I think one thing that the department could do more of is to advertise and self promote a little bit better I've been on the website and I will say this it's awful it's horrifying if I had the time that's what I would rather be doing right now there are no statistics there I'm apologizing to everyone and that really needs to change it's gloomy it's like looking at a prison cell or something and for a while it wasn't like that and we used to be a little bit more self promotional about what medical was doing I just think informational and transparency we don't have it right I look back and I said why is there a document right on the front page for 2017 that's not even that relevant the RFP just never changed either sorry so I just wanted to a little more follow up on the mental health piece that I didn't get to say was when prisoners do have the mental health time with providers typically that time is no more than 15 minutes so it's anywhere and that's depending on what's going on and what kind of day it is and what the person's issues are but from the amount of records that I've read over the years and just recently because now the time spent with a prisoner is actually documented in the records so you can see how much face to face time there is those mental health visits typically are no more than 15 minutes and one positive plug that I want to give for corrections is in the Springfield prison they have a Bravo unit and the Bravo unit is a mental health unit and that Bravo unit I don't know how much it's changed but it has some specific programs and group activities that go on for and prisoners have to meet certain levels of diagnosis and treatment to be in that unit but when we do outreach at the prison we don't get complaints about that unit so that tells us a lot as opposed to the Alpha unit that Ed had talked about earlier which was a closed segregated mental health unit where you went when you had disciplinary or really bad behavior issues so the Bravo unit to me is a really positive example of how a treatment unit can look and that it would be really great to have one of those units in each facility or one for women I think that could be a constitutional issue we've actually brought that case for a client who had acute mental illness who would a female client who would do well and you know she I think did better than some severely mentally ill women because when she was in any sort of control of her faculties she was a lovely person and everyone loved her and it was not for a lack of compassion by the prison staff that she was suffering because they were in out of their depth and they knew it and they wanted her to be in the hospital and other inmates who was really touching would look after her and could tell when she was starting to decompensate and would alert people and she was just boomeranging back and forth from the hospital when she would finally become so acutely ill that she would be hospitalized and as soon as she was stabilized enough there that she didn't physically have to be there in that moment she'd be back to jail and it was this cycle of women hospitalized this women or make the Bravo unit in Springfield available to women or open up the old Alpha unit as a Bravo unit for women she originally completed her prison sentence before we had any sort of a ruling so the case ended but it is a constitutional issue there's this level of care available to men and not women because we just don't have the physical facility so it sounds like we could talk pretty much all night about mental health and I'm sure there's way more to say I want to make sure we touch on a few other issues obviously the opioid crisis plays into this discussion and if any of you would like to comment on medication-assisted treatment for opioid addiction and pain medication just tell us about how that access and quality of these accommodations compares to those in the community we've touched on it to some degree already I would say that with the passage of legislation we are seeing the state of care and facilities approaching that in the community certainly compared to what it was before the legislation passed and before even before that that Dr. D was a part of getting some medication-assisted treatment there used to be none there's still stigma at the rank and file staff level in some facilities we still have incidents where there are nursing staff or correctional staff who are hostile to the idea and we care about that from our clients of people receiving at the donors suboxone and so forth in prison and there's one big difference in prison if you're on medication assisted treatment than if you're in jail which is that in jail if you are there signs that you're continuing to abuse drugs so if you come up positive for something on a urine test that's not prescribed or otherwise mishandling medication you might be taken out of this program which is not to say you can never be removed from a suboxone clinic or a methadone clinic but the idea of relapse being part of recovery is practically speaking a lot more in practice in the community compared to within prison people can get on it if they qualify now but they can get kicked off of the program and for a variety of reasons that are not what would happen in the community and on that note we have deferred to providers we do have an issue that we're hoping will become much more minimal over time the medications being diverted and they're worth money and it's unfortunate because what happens is we do leave these decisions to the providers but if someone has diverted a number of times they might say well then you might not really need it so you gotta do counseling and come back to us in 30 days or whatever and we'll reassess you so we do have that issue and it's one that's very difficult and we have as I said it's not really a security issue for us it's more a medical issue that we want the providers to decide that whether someone is going to be continued or not and that's how we left it and I also want to say that this is something that as far as community standards a lot of it does track what's happened in the community because I just know from my last work when people did have to get on the long wait lists to get any type of treatment and that has changed drastically too so I think that maybe they're running sort of parallel in my mind and that now when the needs being recognized also in the community people aren't having necessarily to drive from Bennington to Rutland every day to get their treatment and there's not a huge wait list where you're not going to be able to even do it for the next six weeks easy I think that that's also what has gone on inside that there's a recognition that there's a much more immediacy to this whole problem of opioid use and recognizing that and being yes pushed along by the legislature and that's a really good thing wakes people up makes people do things I think that it holds the department accountable for making sure this happens also and I think at least as far as I know from our leadership everyone's pretty committed to making this work we've seen some we've experienced some positive results rank and file always an issue but that's an issue with the public too just like the people that say they deserve to be locked up why would we help them make sure that from the public too is why are they getting treatment when they're in so it is a culture that we have to really work hard on changing and I've seen that change for some people which is encouraging so it can happen and that's what we push for if the leadership believes it and if we work with our contract and make sure that people understand this that this is something that's it's the comparison's always if you had diabetes and you ate a cookie it doesn't mean you take the medicine away so that type of thinking has started to permeate not just amongst people in corrections but in our society that people understand this has been a very serious issue and there is a response to it that's a medical response that is appropriate I wanted to ask Emily I think you made a statement earlier about the fact that there are no opioids in prison for anything not for pain. I should clarify if you are receiving hospice care this is a change that happened in 2016 I think this was after your time Dr.D. that there was a policy at the centurion level saying no more opiate based medication unless you are terminally ill and that is how it has played out there we have brought cases about that about pain management and the response from the department has been like well there are all these alternative ways that are much safer in terms of risk of addiction for treating pain mindfulness meditation yoga stretching which are you know those do have pain but they're not being provided so if you're not providing the alternatives then I did see that mentioned in the new contract and we've mentioned it in ours before that those should be those alternative treatments for pain should be available but I am surprised to hear you say that there are no pain relief remedies there are there are pain medications there should be propane and Tylenol right and there should be propane and Tylenol and I don't know if that's totally correct I think there's other things because I know we've had questions and I've looked at grievances about what people want but I'm not being a medical doctor I can't I don't know if there's a policy necessarily that says there's a written policy saying about the opioid based I'd like to see that because there is a statute that came about maybe 2013 or 14 one that stated if an individual comes into the Department of Corrections on a medication that is verified by his or her provider that they were receiving prior to that that medication unless there's a very good reason for not continuing it should be continued I helped write that so I'm surprised to hear that and I'm sure Judy's going to take a look to see what's going on I'm not sure if they take for those but if you're on a high dose of Vicodin or something they might rapidly take for you but they are not prescribing and they are not continuing that opioid based medication unless if someone has metastatic cancer and is dying and is receiving full hospice care then they might give you opioids I will say as a primary care provider it's a thorny issue in the community as well and I think the step therapy is very much supported and being done by just about all providers unless you've had surgery and then your surgeon is going to say I'm going to supply you with seven days a prescription for seven days after that you go back to see your primary care your primary care provider sees you and says well how are you doing maybe three more days so no one's doing extensive extended there are some of us who still have patients who have been on these medications for years and are not being cold turkeyed and removed or even changed having them changed at all but I think there are situations in which narcotic medications are beneficial for a short term generally speaking for longer terms not so much so but there are certainly instances where they are needed and for longer than just a week or two weeks then for a little longer periods but I think that's a community standard that has changed pretty dramatically over the past five or six years but I would have to question you know the none whatsoever the law I have the law that you helped with here about there are steps for discontinuing someone on medication that they come in with and they are entitled to continue if it's a verified through the registry entitled to continue and any discontinuance has to have a certain process for doing so and then I think in the community the benefit if you want to call it that in corrections is you get the benefit the ability to observe the individual in there at that point natural environment if I'm telling you that I need five oxycontin per day because I'm in so much pain you you're not in my house I'm not in your house when you're in a correctional facility you're in my house I'm in your house I see you the correctional staff sees you you're lifting weights in the gym you're pumping lots of iron you're not in pain you're doing fine so to continue to someone under those circumstances absolutely would make no sense but I think that every case is needs to be looked at individually so I think sometimes blanket policies don't work well yeah I certainly don't disagree that in a population where addiction is a huge driver of why they're there in the first place that opiates don't have a huge danger in a downside and that a lot of people should be beyond them but Centurion did publish this blanket bright line policy that they use and it is the I agree with the statute as quoted but number two in that same statute says notwithstanding subdivision one of this subsection the department may defer provision of availability prescribed medication in accordance with this subsection if in the clinical judgment of a licensed physician physician assistant or advanced practice registered nurse it is not medically necessary to continue the medication at that time and I think in the discussion in the committee the point of view about having narcotics in the prison was brought up very clearly that the idea was we can't have this commodity was described really was a commodity and so they included this section that if the medical provider they can in their judgment if they believe a substitute can be done and so I think that's what they do they take them off the narcotic as fast as they can and put on to other painkillers and they do in fact the number three which I won't torment you by reading you does say that they have to record that that's essentially what they have to do what that did the decision they made and why they made it the purpose of that was to eliminate when someone comes in you're on this you're off of this so you have to have that face to face you have to have a the individual needs to have a chance and to read their history typically we don't have community records that quickly within a correctional facility sometimes they are available and in that case you would know why the individual's been using the medication for what period of time but there should be some time so that that documentation is legitimate and that assessment has some legitimacy to it we've been doing it long enough so that there was a time when a person upon incarcerated they basically said okay we're going to baseline this guy and see what he's then reassess and see what they need and that hurt a lot of people which isn't to say that there weren't a lot of people who came into the facility on all kinds of chemicals and getting them out of their system was probably the best thing that could have happened for them I would grant that but the medical assessment will come a long way okay so given where we are in terms of our time I'm going to see whether you're willing to combine the last two questions that we have especially if there are any questions from the audience I can use which have to do with privatization really just kind of asking you whether the healthcare has it affected access or quality to care what kind of accountability for these contractors in terms of privatization and our final question is about cost so the degree to which you feel that that's related or not related that's fine too whether there may be some questions about the cost of healthcare related to in relation to the community versus in prison so privatization and cost privatization has been as I said earlier the department of corrections in Vermont since 1996 and it has continued forward so about 23 years or so privatization for profit companies have been in the state each time the contract is rewritten bids go out people have an opportunity companies to bid on those it's a very lengthy painful process in many ways because you're taking all the statutes you're combining those the national commission of correctional health is included in those contracts if I way of accountability whether or not the contractor has the ability to provide certain things is looked at before they come in before they are selected if you've never been on and the department can open this up it won't be for a while again I think but unfortunately I don't know how this went this time but I think in the past we did try to include as many of the advocates and other people as could attend so the people have a sense of what it actually takes what goes into an RFP what goes into contract negotiations it's really very eye-opening and how much of a very difficult and challenging process it is in a very in-depth process so privatization the use of contracts has been around for 20 something years it is not a decision that the department made it was a decision that the legislature made at some point and continues to make because every few years there's a study that's called for by the legislature to look at whether or not we're getting the most bang for our buck with these contracts or not to look at the cost to see whether or not the most recent one was done in 2018 two years prior to that possibly four years there was a half a million dollars spent on doing a study that lasted two years and led to the last contract that we had that study was done by we use correctional oriented community health services coaches to come into the state and they were with us for two years and it cost $250,000 per year they did a very extensive analysis of what the system was like our end point for that was for the purpose of trying to figure out whether or not there were other models we could use rather than the for-profit model we spent a lot of time looking analyzing questioning all of you all of the advocates were called upon to for input what ended up happening is that we decided along with the our consultant that wouldn't it be great if we could get our community health centers the federally qualified health centers to come on board with us because many of them do in other states to help provide these services it would have been a seamless transition in and out unfortunately we got one bid and I literally went out and tried to walk people through that process of what it would take unfortunately again they had to drop out because they couldn't meet one of the conditions and we were really sad about that but we had to march through this process ended up again with a for-profit company it's not for lack of trying and the legislature supported that $500,000 effort I think the problem is we keep calling for these studies but we haven't changed anything we're still a unified system we're still six small facilities we still are spread out over great distances we still have people who have severe mental illness who are housed within correctional facilities we have lots of challenges within the state and trying to meet those challenges under a contract is difficult and you do the best that you can do we're now in the process of choosing the next contractor for the state but I think the point I'm getting at is this is not a corrections issue it is a community issue if you have an interest in seeing something different happen then you need to talk to the legislature and say gee I have an idea or why don't we do X, Y and Z or why can't we get a little bit better infrastructure for our facilities and that was something that was looked at not long ago as well so and another thing I want to point out is it will be a new contract it's not necessarily a new contractor but some of the lessons learned from the things that the doctor was telling us about that trying to do we're still trying to do we still discussed having the FQHC involved some states have their academic medical center involved that's a wonderful idea trying to have UVM the health network party over us they have they're not it's not something that corrections can just decide to do alone unfortunately we need legislative backing we need support from the hospitals if we are going to utilize that type of input but in some states it works beautifully a lot of states have several contractors so they might have all the different pieces mental health pharmacy and physical health separated out some states say that's very confusing even though that's how it's ended up there's lots of hybrid systems it's not like this is what we necessarily have to do and just keep chugging along especially if it's not working I think the way that the department is hoping to make this better now is that the next contract will be different that the negotiations will end up with something better and less subject to constant change and I know that medicine changes and situations change but things have changed a lot in five years so I think that's something we're hoping to be able to implement some of those changes through the contract to really have that enforcement and then have a nice strict oversight over it we do have a CQI program we do have oversight but it's not it is a difficult thing we have these separated facilities we don't have a unified healthcare team in one place oversight in one place we have differences amongst the facilities and that's something that is a real challenge and we are hoping that we move towards a better contract and a more consistent application of the standards of care everywhere and with the healthcare workforce shortages it doesn't make things any easier but being able to hold your contractor accountable for those instead of suffering from those that should really in my mind be something that we have a pay for performance well what if you don't perform and you can't get all your employees to do that you know that should not be the state that we should that should be something we should be able to protect ourselves with in a contract so there is some sort of some sort of I won't say a penalty but there's some sort of repercussion of not trying to have making sure there's a fully staffed facility and making sure that everyone's you know we know everyone's license I don't think so because it's a really tough system I can just the silver bullet to my mind of controlling the cost of prison healthcare which I think we have the highest person in the country not quite maybe after California it depends on if you're we're apples to apples apples are hard especially with our MAT that no one has and things like that it is wicked high and we also have the oldest prison population in Vermont the silver bullet is to let people out of jail is to shorten prison sentences there was a bill last year for compassionate relief that would allow people to petition in court people who had not yet reached their minimum sentences but because of illness a combination of illness and age we're no longer a threat to the community for them to be released $18 people can't the department does not receive $18 unless they're hospitalized over a certain amount of time I guess that bill must have come around again because I did that bill for so long I went out to nursing homes and beg them to try to take our people yes so we still have that problem we still have that problem nursing homes don't want them either and so when in the mid-2000s every life maximum sentences were passed as legislation for a number of crimes through well-meaning legislators just wanting to keep us safe but the natural consequence of having people with a life maximum is an aging prison population and a very sick and expensive prison population and I just wanted to add in about accountability issues with the contractors it's been our experience so right now as far as I know there's DOC in central office does not have a medical director we do not have a we have no director for the health service division at this time and have not for several months so the previous person who was in that position was not a licensed medical provider and didn't have as far as I know a medical background and then that there used to be also I think a mental health director equivalent position for the mental health so as far as overseeing the contractor whoever it may be we had those two positions in central office who kind of were the gatekeepers of what was going on with the medical and mental health services because there are parts in the contract as they stand now where there are penalties for if the contractor doesn't meet certain requirements they can be penalized but that's only if somebody says you're not meeting these so I think that's a concern overall just about having those positions filled with people who are qualified to be in them let me just say that we can bemoan the issues of resources and things but at the core of it I think you have to realize that when an individual is incarcerated they do not have the freedom that an individual outside has and if the state does not take the responsibility to either provide health care or ensure that the persons with whom they are contracting to provide the health care then that individual doesn't get the health care and that's not right and that's not something we should tolerate and the standard should be met and the standard you know good people are trying to do good things I'm not arguing with that but we but I do believe that we would not have as many clients over the years as we have if those standards were well met and then the other thing I was going to suggest should we let people ask questions that's way through the year yes that's exactly right so who brought a burning question that hasn't been addressed by this panel yes I don't know whether we characterize it as a burning it's a very focused question since I moved to my about six years ago I followed CUD one of the local community justice centers doing about restoring programing and COSA and I've made an observation that when people come out of parole by the way I love the idea of parole as different from parole they often come out woefully unprepared to live in the community they don't have the life skills and primarily they haven't been helped to get hooked up with medical care and services except those that have mandated counseling that the DOC might mandate but they come out and they haven't got their license signed up they haven't got to hook up with a medical clinic or anything like that they come out and they're lost and we at COSA are a very weak read trying to help them trying to get them hooked up and I wish that more could be done before their release to get them hooked up I think it could make a big difference in their lives I also think it could reduce rescinders quite a bit absolutely and there should be in 2013 or 2014 when the state was going through its changes in bringing in and health insurance for all and all of those things were going on I actually arranged to have a lot of the individuals trained as advocates and the as what was the term we were using health navigators so we did a huge training for I don't know how many of our DOC folks as well as the contractor staff so that in each facility there were at least two navigators two people trained who could do that who had access to the system who could get people in for to make sure that they had Medicaid for instance before they left or whatever the health insurance was that they were able to qualify for it seems we keep repeating things you know something happens it's a very positive thing then we go along and that falls behind what happened to that I do not know but that is an absolutely essential Massachusetts where I was also a medical director for the state of 9,000 inmates one of the associate medical directors it's been forever that we have had or that state has had the ability to immediately sign you up for Medicaid before you left you went with your Medicaid card and you went with your next doctor's appointment I'd love to see that here I have no idea what happened and coming from the world of healthcare we've had a lot of problems with our computer systems with our Vermont Health Connect and other things that have made this a more painful process for many people I think we're working right now with the department of Vermont Health Access on making that transition for those eligible for Medicaid and people are much more seamless and I think that's a work that's going on right now and hopefully that will happen but it has been an ongoing struggle in getting people the knowledge of where to go and the whole issue of furlough to me is something else that is kind of a web there's many kinds of furlough and depending on where people come in whether they're put automatically on furlough from the court or something else they may not even step foot into the facility so sometimes it's very hard capturing where you insert that information but working with case workers and others we have some better electronic capabilities now too utilizing those to make sure that if we're all part of the agency human services we should be able to say you step from here to here and you're still covered you have this coverage now and you're in the community and you can go to your doctor so getting that together it is yes I think it's been going on for a long time but I hope we're getting a lot closer on and it's all very doable as a matter of fact the system was set up in that way and Vermont in fact has the ability to do that to make that seamless connection and it should have been written into the whatever that old program was that they use for Medicaid eligibility there was actually a little kind of turn on place that you could fix that for the Department of Corrections and it was never done and I sat on a number of committees for endless amounts of time saying yes but you can do this you can really do it it doesn't take a lot and finally got a little closer from a lot of ground perspective I would love if somebody coming out joining a COSA group has in his or her hand medical card and a first primary care appointment also we put into place care coordinators who are supposed to be doing that too but I won't belabor the point I'm just getting myself a little and even the whole thing of people having identification now you know people have to be provided with an identification which I understand my work phone number appeared on the back of by error so I have people but but even that is another step towards helping people access other community services once you're out I want folks to know that this is the second of a five part series so there are three more panels that are going to be coming and one on January 22nd is about implicit bias on February 12th racial bias and criminal justice in Vermont and to your point on March 11th transitioning back to the community after so there will be additional times to talk about it's 8 30 8 30 close if they need to I think it's okay if individuals want to say and talk a little bit more but I think we need to make sure that if there's one more question maybe we can take the last question one last question in prison there was one God and that God is security and that permeates at every kind of interaction that occurs between an inmate and staff including medical staff and it's responsible for all kinds of problems you can always find an excuse not to allow somebody to do something for a security region the worst aspect I can remember was somebody read a story about a grain elevator exploding from dust and after that a foot powder which is talented which I don't think can explode was banned and it took about a year and a half to get it back okay security the other another issue is I've been doing advocacy work since I think 1994 or 96 and it's very rare that I come across medical staff in prison treating patients they treat prisoners that's the language that appears on the medical records almost exclusively is the prisoner said rather than the patient and here's a question for those of you that work within the system how much freedom is there really to use your best medical judgment as opposed to unofficial policy that's indicted I know how to work within the system but how much freedom I'm sorry medical judgment you would use in the humanity as opposed to saying we don't do it that way I think it depends on the circumstances the situation the diagnosis if you will as far as how much one might push I would hope that that is the underpinning of everything we do specifically part of the oath that I took was to do that was to put my patient person first so that should it should not be it can be a question absolutely but I think if you really feel that this individual needs something then you push for that on behalf of them as their medical provider exactly I want to just comment on that too is that I see in records that I review where the positions the contract positions at the facilities are doing that they are suggesting and making suggestions for things that prisoners need for their health care needs but the problem is that that gets squashed at the head medical director for the contract they made these big decisions and a lot of times their turn they're denied I think this reflects the difference between your experience doctor as the medical director for the department and let's say you're the most recently hired nurse in the facility we've spoken with whistleblowers I agreed not to name who said that they felt they were being pressured by the contractor not to provide the care that they thought they needed to provide their patients because of costs so it's certainly not the goal of DOC for that to happen it's happening I think we need to respect people's time and allow folks who need to go at 8.30 to go and if you have follow-up questions I think maybe we can just approach the panel I'm one of those people that really has to go can we have a budget clause for on time through the department of fractions I was stating their address and my name is on that horrible lift page and it's on the sign here so you're welcome to contact me directly thank you approach the bench