 All right, good morning. This is Senate Health and Welfare and it is January 26th. Today, we're looking at some bills related to our mental health crisis and trying to understand how we might improve what's going on out there with children, with families, with hospitals, with clinics, with providers, with mental health care workers generally. We've seen such an escalation in need for support services, counseling services, mental health beds. Our schools are in crisis around mental health. So today we're beginning that discussion. We have three bills. The first bill that we'll be looking at is a fairly benign workforce bill, working group bill. But I'm very interested in listening to folks today and our goal today, committee is really to take testimony and to hear what people have to say about the issues related to our mental health crisis and then the solutions that might be possible. This is the first day on these bills and there will be other days that we can take testimony. We will also be deciding how to deal with the issue, whether we integrate some of these ideas into a single bill or two bills or keep it as three. So we have a long way to go on this and we have some very informed and experienced folks with us this morning. And I look forward to that testimony very much. So we're going to begin with S197. As introduced, the committee's been through it and we have a number of people here to testify. So we're going to begin the morning. I'm not going to introduce a committee at this time. I think some of you are new to the committee but our names are all posted with our pictures and we'll just move ahead. So Ashley Miller is here, a pediatrician from South Royalton. So Ashley, welcome. I understand you're on a time crunch. Please introduce yourself for the committee and then we welcome your testimony. Thank you for having me everyone. So as Senator Lyons said, I'm a pediatrician and owner of the South Royalton Health Center in South Royalton, Vermont. I've been practicing in the Upper Valley for about 15 years. We also operate Health Hub, which is a school-based health center as our nonprofit bar. We serve 10 towns in Orange and Windsor County providing medical, dental and mental health services. In my clinic in South Royalton, I'm lucky to have co-located mental health. I have a counselor as well as a care manager. So, and I have a psychiatrist who comes in two hours every month to consult with me about medication management. So overall, I feel very well supported and lucky compared to a lot of my colleagues. But I'm here today to tell you story about five patients and the impact they've had on me in the last six weeks. As Senator Lyons said, since the pandemic, our mental health crises has really come to a boiling. I used to do maybe 25% mental health in my clinic because I really enjoyed mental health. And since the pandemic, it's been 50 to 60% of my daily practice. So starting about six weeks ago, I had five patients with fairly lethal suicide attempts. The first patient I'm gonna tell you about presented to the ER before Christmas and boarded for two weeks in the ER awaiting a bed at the NFI hospital, which is a diversion program to help prevent serious mental health consequences. He didn't get a bed. And in those two weeks, his deans were able to return home. His family no longer wanted him waiting in the ER room, literally empty. Nothing that he could hurt himself with. A sitter, meaning an untrained person, trained to keep him safe, but no mental health training, sitting in his room, watching him 24 hours a day, not receiving counseling, not receiving psychiatric care, not even receiving healthcare care for me. So they went home after two weeks. And unfortunately, that same patient is back in the hospital again today after another serious lethal suicide attempt. When he was discharged, there was no follow-up with the psychiatrist or counselor. He followed up with me. I voiced my concerns. We worked hard to get him into urgent psychiatric care. Luckily, his attempt was non-lethal this time, but it's very concerning to me that this is where we're at. That was patient one. Patient two was seen in the ER, probably spent 12, maybe 15 hours there. After, again, another very serious attempt that could have been lethal. They were determined to be safe to return home with their family who assured the ER that they could keep them safe. And they were sent home with follow-up with PCP. Again, no psychiatrist, no counselor, just me. And I'm lucky. I can get my patients in the same day. I own my own practice. I make my own hours. My staff loves me. They'll stay for me so I can get them in. Other PCPs aren't so lucky. They don't have the flexibility in their schedule. So it might be several days after this ER visit that patient would be waiting to be seen by anyone. Patient number three was again seen in the ER. Unfortunately, this patient at only 13 needed chemical restraints because of serious attempts that continued in the ER. Because she needed chemical restraint, she was lucky enough to get admitted to the medical floor. Because she was on the medical floor, she could be seen by the child psychiatry doctors who came in and did a full diagnostic evaluation, diagnosed her with autism, and started her on the correct meds. She had been on a waiting list to see psychiatry for over 12 months. I had been managing her as her PCP, doing the best I could. And now she finally has the right medication and hopefully will do better. She will be discharged with follow-up with both the psychiatrist and myself and the plan for counseling at our local mental health center. This is where things get bad again. We have a wonderful system in Vermont. We have the infrastructure to provide excellent mental health care. We don't have the staff. The staff that we do have is often under qualified and they are all overwhelmed at two times capacity. So our local community mental health centers also known as designated agencies, things like Clara Martin Center, HCRS, Howard Center. The plan there is that they have wraparound intensive services that they can provide individual, family, group counseling, summer programs, respite care, intensive in-home behavioral therapies for parenting support, parenting interventions, as well as case management that they can go into the schools and provide counseling, that they can do behavioral assessments in the schools and provide behavioral health care as well. Unfortunately right now, one of my local community mental health centers has a six month waiting period for counseling. Six months. The other local community mental health center doesn't have a psychiatrist and they haven't in almost a year. So again, these patients end up back in our PCP care. We do the best we can, but we worry for them as we go. The fourth patient was seen and admitted to brow-to-brow retreat. Again, another lucky patient they're gonna get the care they need. Well, brow-to-brow is so overwhelmed. They spent about 48 hours there. They saw a psychiatrist. They wrote in their discharge summary some question diagnoses that they thought maybe this patient would have, but they didn't spend enough time with them to feel comfortable in their diagnoses. They made some medication recommendations to me. Again, sent the patient home with follow-up only with me, no counselor, no psychiatrist, follow-up with your local community mental health center. And unfortunately, these discharge summaries because the psychiatrists are so overworked in inpatient take six to 10 days to get to me. So I've seen the patient. I don't know what the diagnosis was. I don't have a medication plan, but I'm doing my best to help keep them safe as an outpatient. So the fifth patient was seen and again, lucky was admitted to NFI. So they spent five days there. They saw a psychiatrist. They had a diagnosis. They did some counseling, some group therapy. They developed a thorough safety plan that they went home with from there to use with their family. But again, no counselor, no psychiatrist, just me to provide follow-up. So again, this patient, I didn't have the discharge summary when I saw them. And then fortunately, I saw them, they were discharged on a Friday and I saw them on a Monday. Luckily, this patient felt comfortable enough with me to disclose over the weekend it had returned to their binging disorder. They had binged and purged five times on Saturday and were again contemplating lethal suicidal thoughts. Their parents didn't know. If I had known from their discharge that this was a concern, we would have gotten them in Friday. We would have put supports in place not just around their physical safety but their mental health over the weekend as well. So I don't say any of this to begrudge my colleagues who are working so hard in mental health to try and see all of these children and who are supporting us in every way possible, creating emergency consult clinics that we can call into his PCP trying to see our patients for one visit to help us with a diagnosis or a medication problem. But I tell you about these stories because I really think Vermont can do better. We have an amazing infrastructure, as I said. We just really need to put the time and effort into recruiting these providers, training these providers, providing accurate and reasonable payment for the services. I talked to a psychiatric nurse practitioner who had been practicing in pediatrics for 10 years out on the West Coast and who was looking to come back to the East Coast. I thought, ah, finally, I can have a psychiatrist in my office full-time. This will be amazing. She took one look at what our insurers were paying for her time and her efforts and said she couldn't work in Vermont. So I feel like this is where we need to do better. We can be set up for success. I really appreciate all of you taking the time today to listen to my stories and I hope we can do better. Thank you very much, Dr. Miller. I have one question for you, and that is you're talking about pediatric patients, all five are pediatric patients of varying ages. Yeah, from 13 to 18. And I've had one as young as eight who's had to go through these services as well. So I hope that we can turn to a preventative model instead of putting out fires and use these community mental health services at the beginning and not the end. Thank you. Thank you. Yes. Before I let you go, it would be extremely helpful if you could get us a one-pager of your testimony and particular your recommendations for moving forward. That would be very helpful. I'm happy to. Thank you, everyone. Have a wonderful day. Okay. And Senator Hardy has a question. It has to be quick because Dr. Miller is in this place. Sorry, I've been to the office. Oh, I'm sorry. We can discuss it as a committee. Thank you so much for your testimony. And I hear you on all of the requests that you're making. My question is more that the bill that we're considering wouldn't solve any of the problems that you're laying out. So I'm wondering. Senator. We're solving the right problem with the right bill. So Senator, that is exactly why we're taking testimony so that we can take this bill and modify it so that it does begin to solve some problems. I completely understand what you're saying. It may be that there's a working group in it. It may be that there's not. And we will be working on finding solutions for the mental health crisis. So as I have said before, this bill becomes a vehicle and it may be one bill. It may be integrated with others. So we'll just continue to listen and figure out. Thank you, Dr. Miller, for your testimony. No problem. And feel free to reach out to me if you have other questions in the future. I'm happy to be a resource. Thank you. We will. All right. So next, Erin, help me next on the list. Do we are moving past Emily Hawes and Allison Crumpf at this time and moving on to Stephanie Winters of the Vermont Medical Society? That's correct. Thank you. Stephanie, welcome. Great. Thank you so much. Stephanie Winters, I am here today. I represent a number of groups, but I'm here today on behalf of the American Academy of Pediatrics Vermont chapter, the Vermont Academy of Family Physicians. Stephanie, your audio is in a tunnel and it's echoing. Is there a way that you can- Is this better? Yes, it is. Thank you. I had to turn off my space heater so that you could hear me. It's a little cool in my house today. Oh, okay. So Stephanie Winters, I'm here on behalf of the American Academy of Pediatrics Vermont chapter, the Vermont Academy of Family Physicians, the Vermont Medical Society and the Vermont Psychiatric Association on S197. And I'm here to speak in support of that. I, as you all know, and as you just heard from Dr. Miller, our mental health system is in crisis. Vermont is not alone, but as Dr. Miller said, we can and should do better. There are many organizations and individuals doing amazing work to come up with solutions to improve mental health for and of Vermonters, but we cannot do this in silos. We must work together to leverage existing resources and come up with innovative solutions. Any sustainable improvements must happen in a coordinated effort with the right voices at the table. So if we do move forward with this work group, we would urge that the representatives include a primary care physician and a psychiatrist whom we would be happy to name. Our comprehensive and multifaceted approach must include short-term strategies to alleviate the current acute boarding crisis, as well as longer-term interventions designed to support the growing need for mental health services, both inside and outside the hospital setting. We're pleased to see that the governor's recommended budget includes a proposal to expand mobile response units and urge the legislature to appropriate funding to do so, as well as to support more statewide alternatives to emergency departments, such as pediatric urgent care for kids and past minutes. In speaking about coordinated mental health crisis response, I'd be remiss if I didn't include a few actionable things we could do in the short-term that could make a large difference in the lives of room owners. So as you heard from Dr. Miller, much like mental health, primary care is in crisis and you're gonna hear more about primary care, hopefully in the days and weeks to come, but they are the backbone of our healthcare system and patients trust their primary care office and we know that a high percentage of visits include mental health. One way to improve access to mental health care and support primary care is the integration of mental health services into primary care. There are a number of ways to do this and Dr. Ashley described her model and we would hope that this was expanded throughout the state, but a model that has shown great promise and utilizes existing workforce, which is really important when we hear about the inability to get more workforce in the state. But a model utilizing existing workforce is a collaborative care model or child psychiatry access program. The collaborative care team in this model is led by the patient's existing primary care provider and gives the primary care office and patients access to support from behavioral healthcare managers, psychiatrists, and frequently other mental health professionals and allows patients to receive high quality psychiatric care in their medical home, their primary care office. A pediatric collaborative care model has received HRSA grant funding to launch in Vermont. Unfortunately, ongoing reimbursement for this model is not paid for by Vermont insurers and there are a group of codes that would provide payment for these services. So we would propose that all of Vermont health insurers, payers, including the Department of Vermont Health Access and commercial insurers turn on and provide payment for these codes. And I've provided in my testimony a list of those codes. And really what we see is this would be a support to Dr. Ashley, who's doing a lot of these things on her own. It would also relieve some of the burdens from a lot of the other mental health agencies. Again, we support the creation of the coordinated mental health crisis response working group and we look forward to participating. Okay, thank you very much. As I look at your testimony, I see that you have a distinction between the insurance codes for providers and the codes that are utilized at FQHCs. What is their monetary difference between? No, okay. No, it's just their different codes for FQHCs because of their reimbursement model. Got it, yeah, the PPS. All right, thank you. That's helpful. Any questions of clarification, committee? All right, thank you for that. You've given us a lot of things to think about going forward. Senator Hooker. Thank you. Thank you, Madam Chair. And thank you for being here and testifying. My question has to do with availability of providers and how that, you know, I certainly understand the need for the collaboration. Do we have enough providers and how can we address that in the short term? Well, I think that's a great question. We always need more. We always need more providers, practitioners. We need more psychiatrists. We need more primary care. What I will say is there's already people interested in doing this and actually very timely, I got an email from a pediatric office this morning who said, we're trying the collaborative care model with Dr. Strokoff, who's a psychiatrist who's working on this model in the state. It's been useful, except we need him more. We can only really see him once a month, so it's not as helpful as it would be and we really can't even cover that because we're not reimbursed. We're not paid for his time for our time and so it's, they're a small independent practice, they can't afford that. So I think there are already existing practitioners who want to do this, who would love to be able to do this and they can't. So do we need more? Yes, but can we implement something now that would really make a big difference? I believe we can. Okay. I have one other question. As you're talking about access once a month, how much of this access, is it your understanding that there is telemedicine involved and would that in any way improve access? Are you talking specifically in a collaborative care model? Yes. Yes. So yeah, I think there's different models. I think there's phone consultation, there's video consultation. Sometimes the psychiatrist is brought in with the patient. There's a behavioral healthcare manager. I have a great graphic. I can send you, it kind of shows this flow chart of people and how they interact. And again, there's lots of different models. This is one that, I think this is one of the more generalized ones. Yes. I think telemedicine is certainly phone call, video. Sometimes in person if it needs to be referral, certainly. So there's lots of different ways to do that, but yes. Okay. Thank you. Any other questions? Okay. We're beginning to get a picture. So we'll move on to Devin Green. Devin, thank you for being here. Thank you for having me. Devin Green from the Vermont association of hospitals and health systems. And I do have written testimony that I will be providing to you right after this. We just needed to get the latest statistics. So I wasn't able to get it to you beforehand. But what I can tell you is that this Monday on January 24th, we had 37 people waiting in Vermont emergency departments, for mental health placement. Over 70% were waiting more than 24 hours and 10 people have been waiting for more than a week. In a system where we strive to move people in hours, we consistently have people waiting days for placement. And this is not the right care at the right time or place. Over the last several months, we typically have 30 to 40 patients waiting for mental health placement. Total hours waiting for mental health placement have increased since we started measuring in May 2021. Over half on any given day have been waiting more than 24 hours. Most are waiting for inpatient admission. While COVID has severely limited inpatient and community capacity in Vermont, wait times for mental health placement are not unique to COVID. The volume and wait times for people seeking care through Vermont's emergency departments have continually increased in the years since Tropical Storm Irene. And I'll say that one of the things that I learned in the COVID crisis, I was talking to some of the ethicists during COVID to talk about crisis standards of care and how to allocate resources to individuals when we have scarce resources. And one of the ethicists mentioned, you know, now that I think of it, I think we've been in crisis standards of care in Vermont for mental health for a long time now for many years, just because we have people waiting in the emergency departments for these long times in these extreme circumstances. So VAW supports all efforts to improve initial response to individuals in mental health crisis and more therapeutic alternatives to the emergency department and peer supports for patients. As well as statewide telepsych, I didn't know we'd be looking at all the options today. Basically we support all of them. I think statewide telepsych would also help in terms of getting that care in the emergency department that we heard was not happening necessarily right now. So that's another thing that we support. In terms of S197, we think this work group is a good idea and it's good timing right now with the 988 National Suicide Prevention Lifeline going live on July 16th, 2022. We think that there's a lot that can be done in terms of coordinating that initial response to a crisis and making sure that the default is not to just automatically send people to the emergency department, but to ensure that they get the right care at the right time and the right place. In addition to the important goals of this group, VAWs would ask that the committee have the group consider a rare but devastating situation, which is when a patient assaults one or more healthcare workers and are taken to court, but then they're ordered by the judge to return to the same emergency department while waiting for inpatient treatment. So this is not to say that mental health patients are inherently violent. They are not inherently violent. In fact, they are more likely to have violence enacted against them, but anyone who's been waiting in an emergency department for a long time is in an emotionally volatile situation. And so there are times where assaults happen. And sometimes those people are taken away and put in front of the judge, and the judge says that they need inpatient treatment and they are brought back to that same emergency department with the same staff. And that staff needs to care for someone who has just assaulted them or their colleague. Now that's not helpful to the patient. It's too much to ask for that staff. And it's just because we have a gap in the system in terms of resources for these types of situations. And so we would ask that the work group consider that situation as well and consider a solution for it because it's completely unacceptable for both patient staff. And so we support S197. I can also speak to the other bills, but at this point in time, we definitely support the work group and greater coordination to ensure right care at right place in right time. Okay. Thank you. So what I'm hearing you say, and it sort of resonates with what Dr. Miller said earlier is we have an infrastructure, but it isn't coordinated and we don't have the people to fill the slots. This is the frustration, I think, that's driving the conversation completely. Yeah. I mean, I think, you know, I think everything needs to be bolstered infrastructure coordination. Like I said, I think we need more resources across the mental health care continuum. We've been in crisis for a long time at this point. Yes. Yes, I was, I've been on the, the board for a heck. And I remember years and years ago when we were talking about trying to find additional child psychiatrist for the states, not, it's a never ending problem. If you have your testimony in writing, that would be great. And then, and for each person who does testify highlighting your suggestions for moving forward, if there's some direction that could be given to a workforce task force working group, or some concrete solutions that we can put into statute, that would be helpful. So thank you. And you just want me to speak to S197 right now, right? At this point, and we will, I'm going to put you at the top of the list when we get to 195, I know you're also on a time crunch. Great. Thanks. Yeah. Okay. So morning Fox is here morning. Thank you for being here. You, we are familiar with you in your, in your old position, but maybe you could introduce yourself for the record and then we'll listen to your testimony. Thank you, madam chair for the record. Morning Fox director of mental health programs for the department of public safety. So I've, I've been intrigued listening to some of the testimony earlier today. And none of it comes as a surprise to me, you know, as you mentioned, Senator Lyons, due to my prior role with the department of mental health, as the deputy commissioner there for the last four and a half years. It's, it's very apparent that the Devin Green said that the system needs resources in multiple places throughout the system. I think Dr. Miller examples of the cases that Dr. Miller presented as well as some of the information from Stephanie Winters in talking about access to psychiatry. In essence workforce development issues. As well as tele telehealth was brought up. And, and the idea and the concepts of expanding psychiatry and mental health services integration and primary care offices are all extremely important pieces. As well as the ongoing devastating information that you hear from, from vase with the number of people waiting and the wait times and such. And I'm well aware as the committee knows of, of, of how how strenuous that is on the individuals who are stuck in those situations, as well as for the providers and the system as a whole. And speaking specifically about S one 97 and how it was brought to my attention in looking at developing a coordinated response, if you will, to people in crisis. I think what we're looking at here in some of the conversations, if I may be, may be so bold is that we're looking at several kind of tendrils, if you will, from, from a single piece here. As you know now that my work is with the department of public safety. So my, I was kind of given two charges when the commissioner brought me on to the department of public safety. So before I get to those two charges, the one thing I just want to point out as well is that for the department of public safety, this is an extremely important area. The Vermont state police and department of public safety have been working on modern, modern, modernizing law enforcement and how Vermont state police respond to individuals who are having a crisis. I tend to try to stay away from describing folks as having a mental health crisis per se. I prefer just the term that people are having a crisis because we could be talking about addictions. We could be talking about age related issues to mention Alzheimer's traumatic brain injuries, et cetera. And so really what we're talking about is people who are having a crisis because of something going on in their life that they don't have kind of the, the ability and, and what not from a cognitive perspective to manage that stress in kind of societally accepted ways and in safe, safe ways. And so the department of public safety is extremely committed to continuing this work. One, the example is they created my position in order to do it. I am the first position within the department of public safety to be a mental health professional, to be really overseeing all the mental health. It seems weird to say this. The mental health work in state police and in the department of public safety. But as you have heard over the years, people will talk about how law enforcement is the first front line responders for people in mental, you know, who are having a crisis. And you have heard for, for a long time that law enforcement will kind of look around going, we're not social workers. We didn't go to school for social work or for psychiatry or psychology. And yet we rely on law enforcement to do much of the work at times with, when it comes to someone having a crisis out in the community. Law enforcement is frequently asked to go to people's homes to do welfare checks and determine if people are safe and things of this sort. And that we're expecting these, these to happen with law enforcement that have, you know, really minimal training. That's not the bulk of their training is to do mental health assessments. And such. And so really looking at how we in the department of public safety and how law enforcement in general respond to people in crisis is one of the charges that the commissioner tasked me with. Getting back to those two tasks that the commissioner asked me to take on when developing this position and bringing me into the department of public safety. That the state police. With collaboration with department of mental health and the DA system. Designate agency system. Have started embedding mental health workers within all the state police barracks. When I took over. In the beginning of September here. We had about four. Mental health crisis specialists in the barracks. As of last week, we were up to nine. And we're finishing up some interviews and hopefully we will be having mental health crisis specialists in each barrack. And in short notice. The other piece of my charge was to help leave the department of public safety and envisioning an alternative response to people who are experiencing a crisis in the community. That has come to the attention of law enforcement. Generally through a call to 911 or something of that sort. And how we can develop an alternative response. That doesn't necessarily include an armed law enforcement response to people who are in crisis. And so. To that end, I have already started. Engaging with stakeholders around the state. To begin the conversation of envisioning. What it is. How do we want this to look for our state? There are. As many. As many people on this call or watching, there are that many models and 10 times more across the country as to how law enforcement works with mental health providers. And peers. And EMTs. To respond to people in crisis. And so what we need to figure out and what the commissioners charge me with doing is helping to lead the department of public safety. In figuring out what can that look like from a statewide model. For the, for, you know, the department of public safety. There are models as this committee may be aware of. The community outreach program in Burlington through the Howard center. Is a tremendous model. That has national recognition. And I think it's a tremendous model. And I think it's a tremendous model. And growing numbers that show incredible support for its work. There are individual embedded workers and. A number of places and local law enforcement. There are CIT models. Crisis intervention team. Models that. A few law enforcement agencies have taken on as their model. For training their officers. And working with community providers. I think it's a tremendous model out of Eugene, Oregon. Called cahoots that I know that the folks in Burlington and DMH are looking at. And what we need to do is really take a look at what's going to work for our state. I think the cahoots model is a great model. However, I don't think that model is necessarily something that's going to work well in our extremely rural areas. It will work much better in kind of our more populous. In our rural areas. And we have a lot of different models that are going to work best within Vermont. But we really need to look at. Of all these different models, what's going to work best? And it may not be that there's one model that covers the state. Because I think Vermont is, is unique in that sense. Similar to, to some other states. But we have pockets of. Metropolitan. Ask. Areas. And very rural areas that have very different needs. Very different resources available to them. And so, I think we need to look at what's going to work for our state. And so when I began doing this work, I started with individual conversations with. Many of the various stakeholders. And so I have already had. And begun conversations with. Individuals from NAMI, Vermont, psychiatric survivors, disability rights, Vermont, mad freedom. Green Mountain self-advocacy, Vermont Federation for families with children with mental health needs. And so I have now been working with. The Canadian independent living. A DAP. I've talked with Monica Hut, the chief prevention officer. Vermont center for independent living and I can continue. And these are all the individuals that I have started to have these conversations. Because I feel and we feel that these are folks who are. Stakeholders who. needs are of our communities and to help us guide where we go forward as to what what a statewide system now looks looks at. Now I know that my responsibilities in the Department of Public Safety are with fire EMS and the state police. I do not have purview over and the Department of Public Safety does not have purview over local law enforcement sheriffs you know university police things of that sort nor do we have oversight of the the police academy and so my work is focusing on how will fire EMS and the state police interact together going forward and so in relation to S197 while I am in full agreement of the need of this work and and such plainly because it's the job that was created and that I I took on because this is such important work and you know for those of you who who know any of my history I have you know an extensive history of working at that intersection of mental health and and criminal justice systems and so this is a passionate piece of work for me to continue doing this. I think that S197 the the intent behind it is exemplary and we need more focus on our mental health system and how we respond to people in crisis. I'll be honest I'm not sure if we need a study group per se that's legislatively mandated partly because I've already started that process and you know I've I've already started to engage with these individuals. I do not necessarily intend to have a two dozen member work group I've done enough work groups working for the state that I know that a 24 member work group will come back to the legislature with a report of absolutely nothing but this needs to start with this large of a group to get all that information and bring all that stakeholder input in while then we pair down to a smaller subgroup from this group to really do a deeper dive into what's going to work for our state and so I think that if there was something that I would be coming out for and ask for to help with my work in doing this especially on on how Department of Public Safety can respond to people in crisis would be that if there was the availability of a national consultant or someone else who was you know maybe helped set up the Kahootz program or the Denver Star program or programs in Albuquerque and I could you know the list goes on you know the Bureau of Justice has technical assistance and just other other folks that there's there's just such a there's a lot of work in this area right now going on across the country and across the globe and I think it would be unfortunate if we don't take the opportunity to access some of that other work I consider myself a real good person in this area consider myself somewhat of a subject matter expert however I would never consider myself to be I haven't set up these programs before there are others who have I've researched them I know how they look I know how they work but I haven't done the actual work there are others who have and to be able to access and and work with someone that can work with our stakeholders to be able to report back to the legislature and the governor as to what we feel would work for Vermont would be the the position of the direction that I'd like to see this this work going now we'll pause there terrific thank you morning and if you could please get some testimony in writing we'd greatly appreciate it I know that you and I have talked about this previously and obviously the public safety issue is just one piece of the whole mental health concerns that we have in the state and it and but every time one one piece of the state starts working with the da's and the ssa's or the primary care forks for care folks it might detract from another section so as public safety is building a number of mental health counselors within the barracks what does that mean for the availability of mental health counselors in schools or other organizations so the need for coordination this as I said in our first meeting on this bill my experience with what happened to the EMT in the northeast kingdom and the response and the lack of coordinated response was is is key so the I have no qualms about the great work that you are doing it's just outstanding and we need to have that work continue within public safety I think our goal here is to sort out how to bring all the little all the silos together and across medical and social response and public safety response so we'll we'll continue thinking about this and if there are specific recommendations that you can make that we might include legislatively that would be helpful now we want our goal certainly is to go beyond the working group but we're hearing that working group might be also helpful oh thank you senator hardy thank you um thank you morning uh or mr box um doctor doc are you a doctor I wish I was I could pay a lot more I hear you um well thank you for your testimony and um I appreciated that you your comments about how uh working group was probably not necessary actually um and the but I think we need to we're in crisis right now and we need to find solutions that are going to help right now getting 24 people around a table is not going to help right now um I'm also somewhat skeptical of of consultants however they can be helpful if you're talking about a specific area so I was intrigued by your suggestion of a consultant who might be able to help you implement some kind of national best practices model for integrating mental health into law enforcement and if you could flesh that out a little bit more I would I would really appreciate that um that seems like a more immediate solution to a problem that you're already working on and coordinating across a lot of people my I have a question though which um I'm sure I'm not unique in that I'm hearing from people on the ground in my community um who are local mental health providers and local law enforcement so not state police not people at not state mental health workers but the da's and my local police departments are having a really hard time coordinating and staffing and responding in a collaborative and helpful way to a crisis like you uh described at the beginning of your testimony and I'm wondering how your work can or if your work can help with those kinds of situations at the very local level or what do you recommend to us to help with that situation well thank you thank you for the question senator um you know I think I think you're not alone in in hearing the that that kind of response that there's been maybe an increase in difficulty in coordination between law enforcement local law enforcement and mental health agencies particularly when we're talking about you know coordination around a crisis uh type work uh you know I think with the um implementation of the statewide use of force policy um at the end of last calendar year um I think what we're witnessing is uh kind of the ripple effects of people responding to that um you know I think you know yes it's true that all law enforcement agencies both municipal local as well as state police have all adopted the the statewide use of force policy um but I think some of the interpretation uh is different each department has you know different attorneys and different attorneys interpret things differently and so we're getting there's much different responses in different areas I have been pulled into some conversations when some of that coordination issues relate to with state police and been involved in those conversations and I've had some conversations with some of the partners at the designate agencies and emergency services just around the use of force policy and and its impacts one of the things we've done is we had some of the folks who did the training for law enforcement across the state on the use of force policy present that information to the emergency services directors and the executive directors of the designate agencies and also had them do that same training for the mental health crisis specialists who are now embedded in the state police barracks the goal of that is to try and help everyone to understand this is the information that everyone's being provided with here's kind of what some of the concerns are from the mental health side here's some of the concerns from the law enforcement side and how do we kind of bridge that gap in the middle and I think what we're experiencing now are the growing pains so so what is the limit you know it used to be clear I feel unsafe you I call you you go now it's not so clear anymore and you know there's I feel safe so I call you to go and it's like well but they're not endangered anyone else and so how does that you know should law enforcement even be involved in this and you know things of that sort and so I think you know I think what we're experiencing in in in your community and others is the growing pains of that but I think the way we get through that is that these types of conversations that I've been involved in with the local agencies and the local law enforcement or the barracks to have a better understanding and in each place where I've been involved with that it seems to improve as we start to have those conversations more I thank you that that's pretty comprehensive if you could just add perhaps something to your testimony and this is exactly why we're sitting here today we have felt stressed out about a lack of coordination and leadership and it isn't about your leadership for public safety it's about the overall system so we are looking at a more holistic vision and how to improve our mental health infrastructure and response so the we're going to have to move on but thank you morning for being here and I know thank you also for the work that you're doing yeah thank you yeah it's it's terrific yeah so we're going to move on to Lynn Coda who is here and Lynn why don't you introduce yourself for the record and I will share with folks that Lynn has appeared in the education committee unfortunately we were unable to hear all of her testimony and her slides but I think what she has to say about schools is significant to our conversation in health and welfare so Lynn welcome please introduce yourself and we'll listen to your testimony my name is Lynn Coda I'm the superintendent of schools for the Franklin Northeast Supervisor Union so I appreciate having the opportunity to speak with you today I am wondering if I could possibly share my screen not in chair yep let Aaron can you um yep you can there you go okay do you see the slide yes okay perfect um so I want to speak with the committee today around the about the mental health crisis that we're seeing in Vermont schools and I'd also like to speak in favor of uh S197 so today I'm going to be giving you the perspective of the public school system that is supporting the youth you've been hearing about this morning for seven to ten hours each day so we're on the ground really able to give you insights about what this looks like within our school systems so in having conversations with colleagues around the state in the Champlain Valley we were seeing an increased need for mental health services prior to the pandemic and after the pandemic we started to see more significant needs more students having mental health challenges um and then what was even more concerning to us than the number it was the magnitude and the complexity of what those needs were and the resulting behavioral manifestations of those needs we're feeling like some of those some of those needs are starting to overwhelm our capacity and our expertise within the school system to be able to provide that level of support that these children need within public schools so it definitely you'll hear some things from me today that will mirror some of the things you've heard from from other people who have spoken with you today I'm going to give you some of the details that we see from the education perspective so in reflecting on some of the challenges that we've faced like I said not just in Franklin Northeast but across the state some patterns have emerged in terms of some of the things we're seeing with students we're seeing more violent outbursts in episodes of vandalism with our students we're seeing more sexualized behaviors in students in pre-k through 12th grade we're seeing more significant disruption more defiance we're seeing eloping students running away from schools and we're seeing the increased threats of harm to self and others which I think you also heard about today the complexity of these behaviors and of these for these students is really putting tremendous pressure on our capacity to serve them well in our schools so right at the moment when we have a need for more intensive services and more therapeutic interventions more than ever the resources that are available to support these students and families are inadequate as you've heard today not by anyone else's fault it's just the increase in demand is outpacing the level of resources that we have within the state so schools are really right now serving children in the general education system who are exhibiting behaviors and mental health challenges that far exceed anything that we would have previously considered manageable well within the context of the least restrictive general education environment so one of the things that we've noticed is this this higher demand for the mental health services throughout the state has resulted in wait lists which you I will spend a lot of time on some of these pieces because you've already heard about it we're experiencing lengthy wait lists for our youth and we're seeing families experience lengthy wait lists for for family-based services as well we're hearing from our mental health partners that they're really struggling with staffing shortages and they have vacancies in some programs that are up to up to 50% staffing shortages in some programs and the school-based programs that we typically partner with them on our local DA communicated that they had about 37% of their positions that were unfilled at the moment we also are seeing patterns since we've returned to more in-person learning after the pandemic of an increase in DCF referrals around the state and also reports from our local Human Services Department of Children and Families that their workforce shortage has been substantial as well at one point in time when we had more restrictions about being in person than we do right now their their staffing shortage was around 49% of the positions were not filled at one point so we know that through the pandemic Department of Children and Families had barriers to being able to support families and students and children in their homes and there was a period of time where students were really unseen by educators because they were experiencing going through the pandemic and not having access to in-person learning so as a result what we're seeing is that some children have experienced more trauma as a result of that they have they're experiencing the effects of deteriorating mental health in adults that they're they're connected with and increases in domestic violence and substance use are also having an impact on our students one of the things that we're also seeing is that when our students get to the point where they need more intensive services and we start to look outside of our school systems for support the wait lists are incredible you heard about this from Dr. Ashley earlier today we had an example of an 11 year old spending 11 days in an emergency department waiting for a bed to open up at the Bridalboro retreat and so it definitely can relate to everything that that she shared with you about that today we're also seeing you know when children need placements in alternative schools that can provide more therapeutic and intensive interventions we have wait lists for those programs that are a year or more to get children into those programs and then sometimes when we do get to the place where we're ready to enroll a student in that program we sometimes are hearing their needs exceed what that alternative placement can provide so that presents additional challenges for us because then when we're faced with those situations where there are no more intensive services that are available for our students our school teams then are left to develop programming to to meet those intensive means without the expertise and the resources to do so and Senator Lyons I heard you ask a question earlier about the impact of us building capacity within each of our silos and I've been really interacting that with that in my mind because in the absence of outside resources school systems are really forced at this point to build their internal capacity so I think if you were to study how much mental health services are being provided in schools we're doing our best to create what we can internally because we don't feel like we have a choice in terms of the response but I think about that the silo analogy we're doing that and then that's having a direct negative impact on our da's because we're all pulling from the same staffing pool so I think that I'm really interested in the coordinated effort idea because everyone's working as hard as they can but within their own silo so I think that there's there's definitely a need for us to to work together better because I don't think it's it's humanly possible for any of us to work any harder than we're working so I'm interested in the coordination of these efforts just a little I've already stated this just these are three of the big challenges we're seeing in terms of our experiences of our students and our families adult mental health substance use and domestic violence and one of the things that mazlo has taught us about hierarchy of need is that students are much less likely to excel academically if they're based on human needs are not being met so I just want to acknowledge that I feel like Vermont is really on the right track with some of the state-level priorities that are in place creating more equitable access to basic needs for Vermont families around affordable housing, food insecurity, high-quality childcare, broadband access, etc so I think that's really important to not lose sight of how important those efforts are so I think one of the things I would really like this committee to hear is that the the pandemic has really rocked the foundation that supports students in our public schools and we rely upon our partners in those outside agencies the DA's the mental health services the primary care we rely on the Department of Children and Families and when there are limited resources in any of those areas our students are going without getting their their needs met and that is having an impact on their experiences in our schools and so foundationally there's work that we need to do in order to be able to better support our students so some of the things just thinking through how could we improve and approve improve this and improve outcomes for our students is really allow schools the opportunity the time and the space to focus on the priorities they have right in front of them without adding any new initiatives right now and in my mind the best way to support our public schools is to really focus on supporting the very systems that our schools rely upon to support children and families in crisis to help human services, local mental health, and intensive therapeutic programs both residential and day treatment so in conclusion I just want to say that I I do support S197 and the development of that coordinated mental health crisis working group I would encourage you to to consider if there is an opportunity or should there be an opportunity for education to be at the table when talking through the coordinated effort part of this work and I would also ask that the legislature consider prioritizing providing financial resources to address the staffing shortages and the salary inequities that exist in human services and mental health fields I heard one of the people who spoke earlier this morning about you know really having a hard time recruiting people to Vermont because of the pay inequities I would ask that you continue to prioritize investments intended to address those basic needs of our Vermont children and families provide targeted and increased funding support for mental health services to address those intense fine complexity of needs for children and families and really work to expand access to the day in the inpatient therapeutic programs for Vermont young families in crisis so I just I think I've already said I don't think that any of any of the silos any of the parts of our system can work harder I hope that the coordinated effort that you're you're talking about could really help us all to be working smarter so I appreciate the opportunity to speak with you today and I welcome any questions or comments that you might have all right Lynn thank you we're very appreciative of the time you've taken to bring us this information and I'll hope that you and maybe some of your colleagues will be available as we go forward with the discussion so at this point we're simply gathering data information and thinking through what steps come next I will say just one comment because I know we don't want comments today but it's really a question I think for us to think about and that is the salary comparison between the DA's public safety mental health counselors primary care nurse practitioners who've been invited in as as practice mental health practitioners and then folks who are in school so obviously salary has continues to be a big barrier along the way so I'm glad you brought that up senator Cummings question I'm muted um just one question we hear schools got a whole lot of esser funds uh we hear but we don't know and we don't know where they're going I'm just wondering what's the department of education doing for you if anything in could you be a little more specific in the area of we know as kids come back in everything that you laid out it was bad before the pandemic now we've got kids that had you know relatively supportive home lives who have had their whole education disrupted plus we have kids who had some challenging home lives have been closed up with those challenging home lives and we know there's going to be support and treatment necessary to help those students succeed and I'm just wondering has the state offered you anything acknowledged the problem I mean what are you hearing from us I definitely think there's an acknowledgement of the problem and there are it isn't that we don't have the financial resources to be able to to pull some of these things into our system and that's exactly what we're doing with some of the pandemic response money I think the challenges we have been still working on navigating the pandemic in real time so that shift to moving us into a pandemic recovery mode has been delayed because we're still responding in real time so they definitely know that that is one of our big priorities on the ground is the mental health needs of our our students within the system and you know we've talked about that becoming a real priority throughout the state I don't think that we have seen enough yet in terms of of support and I and I think I just want to caution because I I think it's more than the department the agency of education I think it is all of us as we talked today because we could work really hard and we could build those systems of supports within our school but then they're disconnected from all of those other parts of the system so when students are in crisis at home and they get seen in the ER by the primary care positions it's pretty likely that they're in crisis at school so if education isn't working with all of those other agencies we're really not going to impact change on that child because we're the ones that we have them seven to ten hours every single day so I think there is to answer your question I think there's more work we could do as a system in the state and I'm hopeful that that that work will become a priority as we get out of the responding to pandemic mode it sounds like everybody would like to coordinate and we can coordinate as far as getting people into the emergency rooms but we don't have the resources to get them out we don't have the resources to intervene on a regular enough basis to prevent emergency rooms and so the challenge is to figure out how to do that I see you grinning senator lions I know but they won't let me raise taxes no well we're we're we're going to work on this and we I'm sorry to say we we need to move on I know everyone wants to make a comment and have a discussion and that means we're we're headed in a direction that's important to each of us so Lynn thank you again and please stay available as we go forward your information is always very helpful appreciate it very much thank you all right so we