 Okay, welcome folks. This is a joint hearing with the House Committee on Corrections and Institutions as well as the House Committee on Healthcare. Representative Houghton and I will be running the committee managing. This is going to be meeting in terms of receiving some real high-level information about how healthcare services are delivered within our incarcerated facilities and for our incarcerated folks. It's to really have an understanding of how the systems work within corrections, which is a little different than how it works in the community that we access our healthcare. So at the table here we have the committee that really understands corrections and then we have the committee that really understands healthcare and we've got to meld that. We don't understand corrections. We don't understand corrections and we don't understand how it works in the community that we access. Yes, the House Committee. We do, we do. That's how we get paid for. It doesn't make any light of it. So I think one thing we should do is start by just introducing ourselves because this is the first time our committees have met together. So I am Representative Alice Ammons. Representative Lori Houghton. Representative Toppo McFly. Representative Bobby Farley's Rubio. Representative Michelle Bosler. Representative Eric Maguire. Rep Troy Hedrick. Rep John Harrison. Rep Wayne Rush. Representative Bob Peterson. Representative Alan DeBarn. Representative Mary Morrissey. Rep Connor Casey. Rep Leslie Goldman. Representative Alyssa Black. Representative Tristan Roberts. Representative Chip Toriano. So I think as we were going around, folks, ask questions. Please raise your hand. Depending on who you are, you can call on your committee members and I'll call on mine. Absolutely. And I think what we'll do, we'll get started with DOC. We have Annie and Annie. I'm not even going to try your last name. We're Missiano. And I think the best way to do this is, Annie, if you're fine with this, if actually we are overview, if there are questions, maybe people could ask at that point in time. After we hear from DOC and have a dialogue and questions, we have with us as well, Stephanie Ruckman, who is on our screen. She is Vice President of Operations of WellPath. WellPath is the company that we contract the DOC contracts with to provide our health and mental health services within our facilities. It is not provided by state employees. DOC has a contract. It's about a 30, $33 million contract per year. It's a three year contract that they have just negotiated with WellPath. And the contract started in July of 23. So we do have the Vice President of Operations for WellPath and we also have the Deputy Commissioner of the Vermont Department of Health, Kelly Dogarty, who's also on screen. So we will start with Annie. So Annie, if you could introduce yourself for the record. Certainly. And then it's all yours. Hey, my name is Annie Ramnessiano and I am the Director of Addiction and Mental Health Unit for the Department of Corrections. And I'm very happy to be here today with you and start this journey of joint exploration together. I will level set by saying a little bit about the structure of the Department of Corrections facilities, because I know some of you may not know that. We have six facilities in state, five male facilities, and one female facility. The female facility is terrible. The female facility is in Chimpton, and we call it the Chimpton Regional Practical Facility. And the other five male facilities are sprinkled around the state. One is in Swanton, one is in Springfield, one is in Rutland, one is in St. Johnsbury, one is in Newport. I'm currently, we have about 1350 unique individuals who are in our custody and currently housed in one of those facilities. We also, as some of you know, have a contract for an out of state correctional system as well. And, but I know that that's not the topic of our conversation here today, but just for completeness of information. As Chair Emmons discussed, we deliver all of the health care services, a comprehensive health care system through our contractor well path. This is inclusive of all health care up to the point of specialty care and hospital admissions. So everything else is delivered within the walls, either by contract by the contractor or by services that well path contracts with. So if somebody needs a higher level of care or specialty service, we use the regular consumer based Vermont citizen based health care system, just like everybody else. We also experience the same wait lists that you guys do because we're all using the same system. And so what timeliness, acuity of care, etc. is something that we pay very close attention to because we're bumping up to that scarcity of resource that really is national, not just here in Vermont for certain care. Having said that, and correctional, our correctional facilities have infirmaries where if somebody needs infirmary level of care, they can be housed within that infirmary, which is obviously staffed. Sorry, I can you for those of us in health care, can you explain what you mean by infirmary versus. Yes, so just remember that we don't know the language, right? There's a lot of language. There's a lot of language and I was going to counter with it, you know, who understands corrections by who really does understand. So an infirmary is a different unit in the correctional facility that is staffed differently and is obviously geared towards supporting medical needs. So there are cells and then there are medical staff, as I started to say, nurses staff that 247 people obviously need that level of care for monitoring chronic conditions. They might need that level of care as a as a holding place while we secure hospital level of care. But it's typically a higher intensive, higher monitoring place in the institution. That said, there are also differences in the types of infirmaries and the robust nature of those infirmaries. So as you would imagine, our facility in Brotland, Oracle Valley Regional Correctional Facility and our other regional northeast are much smaller. They house about 100, 120 people and everything is scaled differently because it is a smaller facility and does not have as robust of an infirmary, for instance, as a larger facility like northern in Newport or southern state in Springfield. So Annie, let me interrupt because I don't want people to think when you said the 100 or 110. You were talking about the population of the whole facility, not the population of the infirmary. So of the infirmary, like it's in the St. Jay facility and the Rutland facility, how many beds do you have there versus how many beds do you have in the Springfield or Newport facility? I need to answer that question. But it's fair to say that there are less beds in Brotland and Newport. We certainly got that information for you. I'm just less familiar with that since it's more in the healthcare arena and my focus as my title states is addiction and health. So but it's about three to five beds. So just stepping back a little bit when you spoke of bumping up care level for a condition that is untreatable within the confines of the medical system you have working now. So my question is who makes the decision to send that person that individual to special care and who pays for it? Is it part of the contract and how does that work? Can you tell us that? So the providers sometimes obviously it's a complex situation. Somebody might have many comorbidities. The providers in that facility would make the decision that a higher level of care is needed. These people are obviously all licensed in the state of Vermont. Obviously they're a medical provider. They're licensed by the medical board of Vermont. And then other people who have other types of licenses might be licensed by our Office of Professional Regulation. But they all hold their own licenses and operate within their scope of practice and then operate as per the contract and the state laws and regulations that this body has created for us to follow. In terms of the level of comprehensiveness of the healthcare that's provided. When somebody gets to the hospital, as many of you know, we've probably all been to the hospital, you may be actually admitted for your condition and you may not be admitted for your condition. There is sometimes a little bit of an advance there while the screening and the assessment is done. Because then while they are in TALA, which is a federal law, people in the health community actually know it means you can't be refused admission to a hospital or at least be seen at a hospital level. Everybody must be seen. Your condition may not be at that level of care. So that's for the hospital to determine. And again, we use the entire hospital system of the state of Vermont just like everybody else does. There's no separate forensic healthcare in the state. Sorry. So when I finished this, yes, I wasn't sure if you were done yet. So the financial piece is that if somebody is actually admitted to the hospital. Then their health, their health care is activated. And that is what pays for that service. This happened in the past that well, most of our incarcerated individuals have Medicaid or Medicare. Sometimes a family does hold Blue Cross Blue Shield insurance and covers the whole family. And then sometimes I do get letters from incarcerated individuals saying Annie, I'm so concerned. I just got a bill for $500. I don't understand why. I'll have a discussion and their diabetes got out of control because they didn't take their medication. They didn't get admitted. And then when we do the deep dig, it's discovered that they do have Blue Cross Blue Shield. And that was actually their hospital on payments. Thank you. So we have, we actually have a health care member that's on screen that we don't see her on screen. So, Mari, if you can hear me, you can ask your question. Thank you very much. Can you hear me? Yes. Thank you. So I have two questions. One is for continuity of care for the individual. Does any health care provided within the correctional system? Does that that person's case get and any events and treatment get communicated to the person's own primary care provider. So that's the first question. And the second one is, can you, it would help me to have more specifics about treatment within the infirmary. And using an example, someone has COVID or someone has pneumonia. They would come to the infirmary and they would be evaluated and assessed by someone, a licensed independent practitioner who holds either a nurse practitioner or a physician or a PA. Someone that can assess and prescribe within the infirmary and can they also can the infirmary and provide intravenous infusions. Ori is a nurse. Thank you so much for your question. So the first one again was about continuity of care. And has questions and institutions will work together. And then that was during act 176. So that was 2018. We created legislature like legislation and I believe the numbers act 135. I don't know. I don't know. We lived there specifically to your to your question. So continuity of care happens at intake. And somebody's booked into a correctional facility and then it also happens if the individual a sense to it at any point in time. And that's basically the essence of what that law says. So that happens in a variety of ways just to flesh out my answer with a couple of examples. So upon booking, we have a very robust interview called a receiving screening. This receiving screening has even been by Dr. Levine. And it's the typical set of questions that you would get if you are going to see your doctor in the community. It's incredibly long. It takes about an hour if you're able to have a rapid recall and answering of questions covers a lot of different bases. Part of the initial questions is about medications, conditions, previous hospitalizations, including psychiatric hospitalizations of the life that we can get. Also allergies because obviously these are all top issues to make sure that we know the answers to to ensure that person's safety is as close as coming into the door. Part of that is asking about medications, active medications in the in the community. And then providers also can access VPMS, which is our PDMP, our prescription drug monitoring system. And so we can look at that. We also get releases immediately for all of the providers that they can recall they're receiving care from in the community. And those releases then allow us to talk to their providers. We can also call their pharmacy if they say I can't remember who my doctor is. This is the pharmacy I go to. We can also call the pharmacy. So we have, you know, a wide variety of avenues to gather as much information about this person as possible. And then sometimes there are special designations. One is called SFI. Again, this is entitled 28 statute definition is serious functional impairment. It's seriously functionally impaired and we will learn about this typically as continuously with their booking as possible, usually within the first 24 hours. And these individuals are people who have been just diagnosed with a serious mental illness in the community, and who have been receiving a waiver, a Medicaid based waiver, CRT, TBI, treatment or traumatic brain injury choices for care, which is another Dale based type of waiver. We have built a very intricate system connecting many, many databases in the agency of human services. One of my team members who runs on a regular basis. Against all of the new names coming into bookings that we can discover whether somebody has one of these waivers as obviously that then gives us a whole nother set of partnerships to learn about the person's conditions, care and coordinate health care. Another example I'll give is also at release. Well, actually, anytime any medications change, I'll give you an interim example of care coordination. Somebody's medication can only be changed after and this was Act 135 only after a face to face interview with that individual. And if an alternative treatment plan is indicated. And that's discussed with the patient and at the same time, the patient can also ask for this information to be coordinated and communicated back to their community provider. Obviously, another release is required to provide that information. We've tried to build it as porously, but obviously, complying with HIPAA and 42 CFR2 as possible. But because we are such an enclosed system, it takes a lot of coordination and sometimes waiting for releases and so. So just to clarify bookings. That's a terminology when someone is brought into the facility before they're admitted into the general population area of a facility. They go through a section of the facility that's called booking. They fill out forms also. So those medical questions and medical connections. Those are done by correctional staff. Or is there anyone from WELPAD present as well? Or is it just our correctional staff? And the information that is given to whomever is taken is voluntarily given. It's a voluntary basis from the person who is being booked. So they don't have to answer. Correct. So chair, this is correct. They are held in booking. Directional officers are first laid eyes. This is pretty after they're brought into the Sally port, which is the transport area of the prison. Then they're brought into the booking area, which has holding cells. And there is a set of questions that correctional officers, booking officers ask people. There are some mental health questions in that. It's called the booking wizard. And some of those quite pertaining to suicidality and the presence of any suicidal ideation or behavior. Plan allocation as a plan. Any report from the transport team for all the sheriffs and other people. So that begins the process. Then all of the other questions that I. That I call the receiving screen and those are actually all done by medical professionals, not by walking on. There's redundancy built in the system. So while we use the Columbia screening tool for corrections. Which comes out of the house school of public policy and Columbia University. They actually reviewed our. Directive on suicide prevention. Those questions are again asked by the health care professionals. And if there's a discrepancy, obviously there's more of a dialogue. But that's a very multidisciplinary process. If somebody says that they are suicidal or there's some evidence of that from the sheriffs or whoever walk into in booking. That is an immediate red flag and full spot and a verbal and physical. Given to the medical staff for time to go and to start intervening at that point in time. It should person safety. I didn't get to answer the second. I was going to say we were just talking about that if you can do that and then we have some more. Yeah. So the infirmary, yes, is that by medical professionals who can diagnose and treat again up to the point of hospitalization. We provide all immunizations inside of the facilities. We get all the immunizations through a coordinate coordination with the health department. We have we have we call them like vaccine drives or something like that where we have vaccine vaccines offer a regular basis. Many of the facilities offer these vaccines as part of the initial receiving screen so that we're addressing it right when somebody comes into the facility. Pax lovid all of those medications are available to the incarcerated people. So again, it would be a medical person's decision whether or not it will go forward. Yes, I know. When I go to the facilities one week every month, I spend the entire week on the road driving to all the facilities. This is part of my duties in recovery without with an incarcerated individual based coaching program that I developed and then help supervise monitor. And one of the first questions I ask these men and women every month I go is I would like you to tell me about your experience and all of the units, including segregation or the infirmary because they do tours and all of the units, including booking. And I say, I would I'm ready to take down a list of names of people that you personally as a citizen of this correctional community have concerns about. Tell me why just give me the name and I promise I will look into it. So through that system, I come in contact with a whole range of issues that I then report back to my team back to back to well path our contractor, and we drill Drant down on these cases. The recent case was coaches at Southern who were providing coaching and supportive compassion at listening to people who are very sick in the infirmary at Southern. They were very concerned with an annual at a very, very visible and visibly disturbing illness, chronic illness, and they were very, very upset by what they were seeing. And so, obviously, we had a discussion about this with well pass. I looked at the electronic health record. This is out of my scope, but I was able to see and confirm yes this was concerning. It's a very complicated situation that is being co managed by the hospital in Springfield also Dartmouth, as well as our well pass contracted medical staff. Everything was known to all the providers and again, the care was being coordinated across all of these systems. And this individual is just ours. So we have a lot more questions. Okay. So. Wayne. Yeah, write it down. We got Wayne. We have art. We have Tristan. We have John. We have John. And we have Connor. So you can write them all. I got him. And then we have Topper. Topper. I got him. That's okay. Thank you very much. That was very, very thorough. I appreciate it. You're welcome. You mentioned that there might be instances where. And then may. May go to a hospital and not be with you. Tell us what. Kind of things would result in that. And also. On the flip side. But there's somebody be returning from. Hospital and not be. Re-admitted back into the facility. Great questions. So. Thank you for a minute. Sometimes people are sent to the hospital. The one that I see. So. Well path provides us a. Daily. Overview of the system. That is a multi-layered. Recreation. That is a multi-layered. Report. Of emergency department. Admissions. Inpatient hospitalization. And specialty. Appointments. These are longitudinal lists. So we can also track patients activities. Through this portal. I look at it because I'm a curious person. And our contract in my role also is to provide whole health. So I'm not just looking at mental health. They know that there are many home morbidities. People with heart disease. And having people with heart issues. Are almost 100% likely to have some degree of depression. And I want to make sure that all of that is being monitored. And taken care of. So I bring that up specifically because sometimes. People experienced chest pain. Or let's say shortness of breath. So this is a symptom. It's not a diagnosis. And so. To be very careful and sure that we are not missing anything. The team at that facility, the well path team. Will often take vitals and say. We're not really sure what's going on here. This is a rapid onset. This person's never had anything like this before. And maybe they have. So the picture looks slightly different. But nevertheless, we are uncomfortable. Maintaining this person in the facility called the ambulance. So they take them to the ambulance. They may go to the hospital. Intake may be done and intake interview. Vitals may be taken. They may be put in a little room someplace. And then they stabilize. And. Hospital at least to their gone. We want to get back there. The hospital determines that they are cleared. To come back. Does what does well path out to clear them to get back in. No, it is the hospital's decision. It is the hospital's decision. So I think that's a really good point. Thank you for putting. I put, I, I call a size in that because. We have our scope of work under all licenses and the contract. We rely on community based care. The same care you all are getting. I think that's a really good point. I think that's a really good point. I think that's a really good point. These independent doctors who are licensed and. And. You know. Providers in a hospital then make the determination. They order the test. We do not have any authority over that. It's independent. Medical autonomy in the hospital. And then they decide that they're cleared. And then they are transported back to our facility. Or vice versa. Or vice versa. So then the medical center. So then our care managers are well-path care managers. Follow that person stay in the hospital. To find out what's going on. We work very hard to gain access to different hospitals, portals. So that we can see in real time without having to have verbal. Conversations necessarily, but obviously if verbal conversations are that's that obviously happens then the key there is the care coordination of time released from the hospital this is also very difficult and I just want to make sure we are all citizens of the state we've all experienced this I've experienced this personally when you're discharged from the hospital you were hoping that that information has gone into your electronic health record or has been communicated to your primary care provider I can't tell you how many times I personally have gone back to my doctor and said well you know I had my hip replaced and they're like really it's not in your record you know so I mean this this no you didn't exactly it's like yeah so you know and so it's very difficult and then it's a tightness issue because when they decide that the person no longer needs hospital level of care they're on the phone with the sheriffs or with the with the correctional facility to say take this person out of here right now and we don't necessarily get the discharge plan before they come back we're calling you know there's all that usual melee that happens in every single situation whether we were a correctional facility or not we have to make sure that the medications the person was given in the hospital are actually in stock or we need to order them specifically for the person because medications are ordered by person is it formulary is it non formulary there are many different layers that the medical staffs have to negotiate to make sure that all of this happens safely timely and continuously for the individual but that there's not a break in the action and an offset of that is the transportation either sheriff department have to transport the person from the medical facility back to the incarcerated facility and you have correctional officers when someone's admitted to a hospital you have two correctional officers there around the clock so and that's out of the general fund that's what I was just going to ask so that's that's covered by the contract with well path or that's a separate it's paying for correctional officers salary that's out of DOC's project okay to address that we actually the commissioner really looked at the data and issues with ensuring that we have the best coverage at our facilities and so we've just instituted a new special team that individuals can apply for and we've tried to create like a SWAT team of experts who then go they could be from the field they could be from the facility to provide that hospital coverage so there's less of an impact on each facility because it can be a real hardship we've had people placed in out-of-state hospitals because the complexity of their care and the lack of the hospital Vermont system to provide them a bed an appropriate bed and they've been at state for like a month and we've had to have multiple teams obviously of correctional officers 24-7 for 30 days and housing them in hotels etc to provide that coverage so you have the rules on that part yeah yeah thank you trying to understand who pays for the services they get in other words someone who's under the infirmary for something and needs care and that's as far as I need to go to the hospital that care that person receives if they say they have their own private it does it impact their insurance while they're at the facility or is that covered by the contract Thank you for the question so this is federal law we medicated Medicare Act of 1965 excluded anybody who is military custody of state correctional facility for the federal Bureau of Prisons from accessing health care insurance for the provision of health care for the payment and provision of health care so Annie does that also include their private if they have private insurance that is negated there's no insurance coverage when someone's incarcerated it stops when yes it's on our nickel because not a state law so but I just want to clarify if they are admitted if they go to a hospital then if they have private insurance that that would cover that they obviously don't have Medicaid or Medicare correct I mean so it is or would they have Medicare Medicaid if they are at a hospital so almost everyone who it because we have worked on this so all in the state everyone has Medicare okay so that so I need you to explain how that works because you just said the federal law says it negates so I was trying to explain was almost everybody has that as their foundational insurance coverage but when they're incarcerated so when they are hospitalized that is turned back on and the hospital submits their claims through those health care systems or Medicaid Medicare okay not while you're not while you're incarcerated so the answer to your question I just wanted to give that as the foundation because it's not a state law it's not something department creches can control this is all part of another conversation that you'll be having in the future how states negotiate with the federal government about how they use the Medicaid and Medicare dollars and we negotiate this with the federal government through something called the 1115 waiver negotiation and we'll be having that conversation happen yeah but I think what's really important when someone is incarcerated they lose all insurance so all the health care that is provided within our correctional facilities is on the state's nickel it comes out of the general fund because for the Department of Corrections is really no ability to match federal dollars so our DOC budget is about 180 million for years no no I mean our yearly our yearly budget for DOC out of our appropriations bill general fund is about 180 million for that and of that about 33 million is for the contract for well path but there could be some other health issues there correct so no all of you are probably familiar with coding and coding per intervention so you were seen by whoever whatever medical care provider to have a diabetes check and they're all these CPT codes to do that and as you may know there are people who literally are part of medical practices hospital services etc I mean this is a job who do coding and workflows are built around making sure that the coding aligns with what's asked the patient to maximize the potential coding and reimbursement and charges to the health insurance and then those costs and how the health and first are all negotiated like you get your EOB from your crossbow shield and it says the charge for this service is $750 and you're like what for a bandit and then it says if a blue crossbow shield is negotiated this they're only $50 and the payment you pay that time so we don't have that in our system because we have this one annual rate of 35 million times rates or the whole contract and then what we do is we have a per inmate per month cost that that contract extract is extrapolated from okay the contractor well correct so the 33 35 million dollars is an extrapolated cost based on a negotiated per inmate per month cost which actually is not that dissimilar from like the platinum plan a blue cross blue shield it's like two thousand one hundred dollars a month it varies a little bit across each year of the contract I can't remember the numbers exactly but we can certainly provide those for you but it's like twenty one hundred dollars or whatever but when you then average in like your other exposures of like a hospital co-pay or specialty co-pay so whatever depending on what your use of services are it could potentially mirror close to what that top plan is for blue cross blue shield now having said that we're not billing individually so people just put in six lips unlike you have us you have to wait like we'll have to call our provider and say you know I am I am starting to get tickling my throat I'm earache or something like that or my child's getting sick depending on the severity of the symptoms that you present on the phone they're going to triage you and say well your provider can see you at eight days in a correctional system we have a much tire bar we have to have a nurse see that person once the request is made within 24 hours so there is a face-to-face visit with that individual with a nurse who then triages it to the right level of provider sometimes people say I'm putting in a mental health slip but when you talk to them they actually say I want my medication adjusted I'm having symptoms or I want to come off this medication or something like that which is not necessarily obviously I mean that I'm a mental health provider that's not my scope of practice to do medications so the nurse would triage that to then to a provider who was having who did have that scope of practice but nobody's getting charged we have no co-pays so correctional systems states charge people co-pays a lot abolished that a long time ago we didn't want to be barriers to accessing health care because of financial ability to pay so they can put in a six lip they get seen triage within 24 hours and sent to the right provider we also have for individuals which is like this is like 98 percent of the individuals product care visits so every 90 days you are automatically seen by the provider who's prescribing your medications now that doesn't mean you have to wait for 90 days as I just said you can ask for a provider to be you can ask to be seen by a provider and you most can see a provider within the 90 day period that's kind of the cycle of how so I think I'm going to end this here because we have a lot more questions but I do just want to say for the committee and those of us not for those not on health care a person can always be seen in the community as well so they can go to urgent care or they can go to emergency room they don't have to wait for a provider to call them back and just want to be clear about that Tristan is this talking about all health care right now with Annie or your job is more substance oriented so I'm just checking I have a general question all health care within our correctional facilities okay for inmates so I have a essentially a cultural question having you know over the off-session spent number of hours in different correctional facilities in New England and speaking with incarcerated individuals and families enough questions arose about this but I think I wanted to put it in cultural terms because you know all health care can be delivered by the book and yet when it's bureaucratic or even oppositional or even punitive and health care is not well experienced incarcerated individuals sometimes report that the doctor is not going to see them and I'm saying this of course it's a general state that this can happen that can be reported and it has been reported you know I've spoken with folks working in correctional facilities where I asked them about this and I'll say including in Vermont this is I'm not throwing mud here from up because I've spoken to really dedicated health care professionals inside Vermont but I asked well how would you characterize this knowing that sometimes what you hear from inmates is a lot of grievances so how would you distinguish what's really important about health care in this facility and I think one individual suit really summed it up well they said you know we just don't have issues where it's sort of a trust issue or a punitive issue because I need to speak to the doctor I'm just out there I'm interacting with with inmates I know what's going on we know there's an understanding and I was just wondering if you could sort of characterize a described culture the users and I also as I said you know speak to many incarcerated individuals every month so I have a lot of contact and I would say that one thing I don't think either the chair or myself have mentioned is that all health care is voluntary you touched on this when you said people can refuse so participating in any any activity this is all patient report except for the information we can get from a PDM P etc but they can also say I don't want you talking to my doctor at all so and sometimes it does happen people's infuse they can answer any questions and it's very complicated I have a case that I'm sort of doing a root cause analysis on right now that was this type of situation a detainer who came in with detainer is somebody who has not been sentenced so they're being held on condition report with us on the average length of stay for detainers in Vermont is about three to five days and during that time period just bases typically somebody's Medicaid or Medicare would be removed or paused because they're interested in period of time the systems don't know that yet so a detainee is a person who has not been convicted and has not been sentenced they have just been arrested right so and they're waiting for the rain is determined that they should be held in our was detainee and a detainer is same thing sorry but they haven't been sentenced that's it may be held on bail if they haven't met or another status hearing etc so they may be on the traffic board so in the case that I'm thinking about this person refused to answer any questions but they actually were seriously mentally ill I've come to find out but since they would not participate and wouldn't sign any releases to talk to anybody we have no one what was happening to them and that's the same in the same in the general population so so in terms of culture I think it's important to know that because I think sometimes we have ideas because people are in our care and custody that means that things can be forced on them and so that that actually is a myth the only thing being forced on them is their care and custody and the commissioners care and custody that everything else is not forced can I follow up I mean I sort of I heard in your response an issue with sometimes someone doesn't comply but some doesn't want to work with the writer and some things can't be forced if that really doesn't cover a lot of cases that I've heard from individuals about they say you know I had an injury and it just wasn't seen it wasn't taken care of I got worse so and I did see treatment and so is there's there's some things being left out here so our system as you mentioned before of grievances is something that we obviously pay very close attention to and I actually oversee ones that are addiction and mental health related the mental health chief Colleen Nelson and operationalized the responses but I review all the cases and everything is happening I just need to know that in my school and then we can't we have reports every month by every facility where we look at every single category and we actually can go back and look at the trends and the grievances to try to assess what I think you're you're asking about I would say that most of the time so I would say a little over 50% and people can run to see so put in multiple grievances so sometimes he will see the same thing says time to day that stays all the local level I only see it when it comes to the official level to the medical and their self report is not always accurate in the grievance system we have different ways of reconcile in the grievance I would say of the ones that I oversee health ones 99% are rejected it is a disagreement that the incarcerated individual has with a provider and we since the provider has medical autonomy well I can ask evidence-based questions site research probe and prod and question the medical team making the decisions I don't have any authority over them to direct the care because they are the provider so we always say continue to work with the provider our jobs to oversee if they are not getting getting the care that they want just because we asked for something doesn't mean we get it that an alternative treatment plan that makes sense in terms of medication or frequency and service etc. are being met there are other categories of grievance response to other ones there for decent part or meritorious and whole sometimes I do see and agree that the grievance should be meritorious and whole because there is not been full communication with the patient and an alternative treatment plan has not been provided to them in a manner and then that's obviously a continuous quality improvement issue to go back to well past and then sometimes it's meritorious in part so all I can say is that there are a lot of there's there can be a lot of discontents I see that about dentures or dental care sometimes I see that about eye care sometimes I see that about other types of care but when we drill into those and look at the content of the medical record they've been provided the standard of care to the state all right I'm gonna keep moving us along here John thank Connor thank Connor my medical professional interviews the term nursing could you elaborate expand on what the contract would well path requires so we absolutely so sorry if I was confusing you know first of all and so we have different levels of providers we have RNs we have L&A's we have LPNs we have doctors we have advanced practice registered nurses APRNs we have psychiatrists we have an addictionologist so we have a different array of professionals with different scopes of practice and the workflows to address not only the patient's path through our internal health care systems is staffed at each point with that scope of practice as they move along their diagnostic and care continuum so a medical provider is a typically what we when I use that language it's somebody who can prescribe and there are there are many different levels of medical professionals who can prescribe versus just assess so assessment is done by a nurse so they can do one level of assessment and an L&A level of assessment so each each person's scope of practice level of information gathering and seeds into their medical record and then is continued to be triage so that the right person can be seen the individual to make a diagnostic conceptualization and then ultimately the nurse would in consultation put in the order for whatever medications are needed because the prescriber has authorized it John it's just like you would have if you go to your doctor but let me be a little more clear let's say right now one of your facilities there's just an RM there I shouldn't be just an RM RM is there how do you access the next level of care I mean you don't have to be all these levels at every facility 24-7 no we don't and then we also use telemedicine like the community does as well so you know there's not a psychiatrist at every facility there's one psychiatrist so good yeah and so it's the provider's determination it's there it's their license that they would rely on their training that they would rely on that the symptomatology the vital signs they're collecting etc would need to be escalated to another provider in this in the system well path access to these higher levels all available yes 24-7 and I and I just want to follow up with that point all of these people you're talking about when you say provider if they're not in the hospital the provider is a well path employee okay thank you or else a specialty care just remember that was the other daily report I get specialty care in the community so that's another area that again correctional officers staff those transports and they go out for specialty care not just hospitalizations okay so then the error would be fed in to buy determinations from that community based specialty care provider right so it's across the systems inside of the system great we're gonna go to Connor sorry I'm just making sure we get to lunch and then topper and then topper and then Alyssa and then toy and then Daisy good job all right so Annie I'm gonna admit like every year that goes by I become a bit more skeptical that privatizing these services is the way to go and like for a number of reasons right like company continuity of care I think of like a prison health services correct care solutions vital core well path it seems like every three years there's like somebody different doing it so a couple that was like okay like transparency could I submit a public records request to the head of well path for all their emails I don't think so and then like you know accountability and I think we need to talk about it just a few weeks ago on the paper it came out that the head of services for well path at Springfield you know had been lost their license or been suspended in three different states you know somebody came out and disclosed this and they said the whistleblower was in fire to me so I don't know if she's covered under whistleblower protection like a state employee would be but it feels like information we should know and then it was like you know reporters call no comment no comment from well path and it just doesn't feel like you know that coupled with the increasing number of deaths which I believe are unrelated you know I do believe that it just doesn't necessarily inspire confidence so I'm hoping you could maybe just go over the rationale like is it money is it cheaper well path is it staffing you know because I probably even that if you could get a state pension you know for some of these jobs when that be more attractive so I'm hoping you could just give me a bit more confidence in why we're going this direction so I in my tenure this is my 10th year working at the Department of Corrections I worked in the community before this role and that tenure period I personally have been part of three or four legislative analyses of your question and and almost every one of those reports they were conducted not by the department I mean with the Department of Corrections but typically with another governmental entity and then independent body and the findings typically found that our correctional system because of its smallness because of its uniqueness one of six correctional systems in the country to be integrated which means we have everybody we have incapacitated people we have detainers we have sentenced people we're the smallest and only one of six that are like that the scalability the complexity and then also that we have to pass our system again lack of scalability to the degree that it needs to at each of the facilities that ends up being a very very expensive proposition and so all the reports have basically shown that the intersection of all of these staffing issues facility operations issues etc that this is the least expensive modality we always come up number one or number two and to research evaluations of correctional health care systems is being either the first most expensive in the country of the second most expensive and I hear everything you're saying and a lot would need to change for us to endure this into the state health care system and some of the assessments and I'm happy to send some of those over to the committee for review time I have estimated that it would be the money we were expensive this was delivered health care was delivered by employees because of the very okay topper we've been talking about people in the present when a person's getting ready to leave can you just what would that just tell us what you do for that person to make sure that that transition works that's my first question the second question is a veteran who has tricare treated any differently than the Medicaid do they lose tricare when they're in there they do we have so let me start there we have we have released on at facilities with the VA so I've worked with that many of those individuals and they come in and you can reach the veterans and we try to blade and blend to take advantage of that system as much as possible but it doesn't cover any of the costs of health care it's simply for preparation for release and to make sure that they know that the VA is still there for them and to create more of a community for them and you know support okay you do that that happens currently but it doesn't pay for any of the health care right okay so when the person comes out of the present you have a plan and you've made the appointments so that was question number two okay so then this goes back to understanding the correctional system which is very complicated so as we discussed earlier there are some definitions and a lot of this can be found on the Department of Corrections website we give all of the legal definitions of all of the different legal statuses that people can have inside of our facilities I'm sorry if I'm getting detailed but this you do need to sort of know this to understand my answer we have the detainers the detainees three to five days average not charged not sentenced and we have the sentenced population they're about 50 50 half of the facility 45 40 to 50% are detainers coming and going very very rapidly we don't know when the sheriffs are going to come literally to the Sally port and say I want to take this person out and they get released from court leaving causing a lot of stress then we have sentenced people they don't get any case planning detainers no case planning because they're in and out we have no idea what's happening they really are their house with us but they're going for a court process we ensure that they get the receiving screening all the health care they need a long time line it's the same typically as the community and then they're gone so there's not a lot of discharge medical discharge planning possible with them because they get released a court then the sentenced population they do get case planning and medical knows the window that they're going to be released we have good time to consider etc those calculations but generally speaking as it gets closer and closer and closer we basically know and we tee up who knows who who's going to be released her the contract with the department of corrections well path providers are supposed to provide comprehensive medical discharge which includes medications and appointments for all of the active problems active diagnoses that they're currently receiving treatment for so that they have that when they get out now they are provided rich prescriptions individuals are provided rich prescriptions for their medication and it's called into the pharmacy of their choosing they have to go and pick it up well path is also responsible for reactivating their Medicaid insurance or Medicare insurance so that it's active for when they go they pick it up lots can fall apart with all of that obviously from fax machines now working to all kinds of action against the other populations that we have they may not know we have about as annual basis this happens most way the Chittenden at Northwest we are part of the public health system so people who are inebriated publicly inebriated and determined to be a suit risk to themselves and who are not admitted to the hospital for detoxification are brought to the department of corrections we call them public inebriates their legal status is called protective custody so they actually aren't charged with anything they're not under done or court order it's a separate statute and we have to hold them for up to 24 hours to make sure that they have their symptoms are reduced their risk to themselves is reduced we provide health care to them as best we can as you can imagine they're not including the state sometimes it's been determined by a hospital that they are not has to a level of care but then whatever they adjusted has become that you know that it has become exaggerated and or amplified with the mixing of them at again whatever they're on and we have to then send them back to the hospital but they get released for 24 hours that's up to like 1400 unique individuals here facilities allow so that's another of the people then at Northwest we have people who are called or under the U.S. Marshall service custody care I think that contract goes up to almost a hundred potential beds across the system and we do not we have to negotiate with the federal system for their health care so we don't have full autonomy over them so that comes up equally in my role with MIT if your presence is still expanding their medication is treatment programming and sometimes they will refuse to allow somebody to become inducted or continue or switch medication because they don't approve it and there's nothing the department corrections I can do about that so I just wanted everybody to understand that when you hear my team and the department is works tirelessly to ensure that people are getting what they need we don't want them coming back it is not in anybody's interest to happen to come back but it is so difficult when 40 to 45 percent of the population is released a court and then this is often what happens that then we are looked to as having failed and we can't ever disclose anything to the press about any of this but we know that they were detainer and they were released from court and there was not really anything we could do so that's great I'm going to put a question out there I don't want to answer it right now but I would love at some point to connect with you on it because I want to get to everyone else who's been here is that what is the relationship between DOC well path and diva to make sure that as these people are being released they get access to Medicaid or Medicare or whatever they need something else so that's that's for another time it's for another time so I wondered what's a couple of questions but very quick what's the per inmate per year cost to provide health care I think I know there was three different costs that for each year I think per inmate per month I think you started at $2,100 specific to health care could you send that to us yeah thank you that's a lot of money and I'm sorry I'm having a hard time wrapping my brain around the concept that their insurance particularly Medicare I'm referring to that it would stop and start right I mean Medicare requires a premium be paid so how do you stop it and then all of a sudden the person ends up in the hospital and you start their Medicare how does it work and I'm wondering how it works for medications if a person is on a particular range of meds I'm sure that you're stuck some of them but not all of them who's paying for these medications if they don't have any insurance at the time that they're we are we are we are we pay for everything per month so I know that you were saying that seems very high meditations are very expensive yeah yeah I mean the poly subscribe prescribing is enormous our people are well I think what I'd like to do and I'll talk to Alice about this but I know we'll have a debrief in our committee and I already have a list of questions of data we would like to see from you before we come back to the table so we'll gather that at that point we'll work with Allison her committee and then send you a list and then continue so I think one thing that's really important is when folks are coming into an incarcerated setting they're very sick a lot of them have not had medical care they don't have a provider they don't have a primary provider their medications may be so outdated and I mean that's what DOC is seeing is folks who are coming in they could be 30 years old 40 years old but they have the health issues of a 70 year old that's what's happening that's what people need to understand that folks that are coming in are not coming in they're not healthy for the most part some are but the bulk of folks who are coming in have some real sickness they haven't been to a dentist they don't have a primary care provider they don't have medications or the medications are totally out of date they haven't had the money to pay for them I haven't had the money they're not on any insurance they're not on Medicaid I mean that's and then corrections has to pick all this up they were disconnected before they even get into this okay we have Troy and we have Daisy I'm a springboard nicely off representative last question I want to stay on that per in May per month rate for just a moment now curious to know what happens to quality of care as we approach that limit right as we start realizing we're close to either surpassing or arriving to that to that rate limit we don't approach it I'm curious to know is there any sort of clause in the contracts that refunds the balance back to the state either way I'm really I'm worried about the motivation to maximize profits for well path here and the impact that's having on quality of care and then vicious cycle that would create right when quality of care goes down we can probably anticipate a likely added care more care required right so when healthcare goes the quality goes down because it's profit motivated that just leads to chronic illness so instead so what who's tracking that per rate and how quickly we're approaching it and what happens when we do surpass it what happens when we don't surpass so you are on point with your concerns but the contract that we have developed doesn't address those concerns and shares the liability that's your passing those costs so it's not a cap per se that if they're not calculating the costs and there's a there's a cap on how much well path and profit so they don't profit by withholding care that's not the way the contract is developed and I'm happy that we can also follow up by sending sending the specific because I think it's best if you see the language of how we've constructed this because a tremendous amount of work went into this over gosh seven years of us cropping these contracts that this amount of legal advice for the ag's our own legal counsel and everything correct me if I have this regardless of a cap being on profit profit impacts quality of care right they're motivated to deliver their care based on the fact that they still want to make money even it even if it's even if it's capped right does that feel accurate and it is but the devil's and the details and I really would like to share that information very specifically because it's all in the legal language of how we track this on the end the other broad answers I can give to your question without being premature and having you look at all of this and then having follow-up conversation about it is that it Dan big answer is yes if there's money on the table it comes back to the state okay there are a lot of financial controls every month and every quarter on all aspects of the contract there are whole facts and all sections of the contract we track all of this very carefully and Max Titus who is my who is the director of our team and who's my boss that is one of their primary responsibilities in concert with the other team members so we have a very robust system to to track this and to make sure that quality of care is not getting impacted by any financial constraints and then we have no barriers to access a care as long as the person sense to it and it is medically necessary and those are our those are you know lifehouses thank you easy thank you so much for being here today I've learned a lot and it's a pleasure to see you and I know if your work I'm a member of the print executive committee and having come from the Department of Mental Health I'm very familiar with your somewhat unique role to kind of have one foot in mental health and another in corrections and just have an appreciation for your awareness of the some of the struggles that individuals who are being incarcerated have have dealt with and I'm looking at some of our print surveys from 2021 and almost 40% of incarcerated people had experienced seven to ten on the ace category of the ace categories and Daisy maybe does everyone know what ACE is adverse childhood experiences so these are things like witnessing domestic violence or experiencing violence themselves or child abuse and things like that so we know that they're coming from difficult places the the print surveys have a wealth of information they were done at the Southern facility there was a really high response rate that the work of the print committee is excellent but it's ending it'd be curious to hear and I have a couple questions one is I'd be really curious to hear you know what are your personal hopes for carrying forward the input which was both you know came from inmates as well as staff and there's some really shocking data and in in those surveys I think around some of the points and themes that have come up in here especially on discharge 89% of inmates said that they disagree that the prison did a good job preparing them for release so print is ending the funding for that projects ending and this terrifies me that people feel so not prepared but I'm also deeply appreciative that we asked them so this data is there I'm curious what we're going to do next and I'm happy that that you're part of what's to come next that's my first question my next is how can we be involved in helping to improve or be aware of the mental health grievances that come up it sounds like there's a lot of them I remember that and I know some of them are repetitive or due to you know the own individuals experience and unique needs how can we see those two big questions the first and you know really the prison research innovation innovative prison research innovative network for those of you don't know was a federal grant that six states about four years ago it's right in the middle of the moment yeah mr. Baker was taking over to shut and southern state was chosen to be the facility where these activities took place and it was a case and learning collaborative high-level learning collaborative prisons who were involved in this focus on how to improve the culture and it was a very iterative process almost like a prescient of inquiry we incarcerated level on up to the leadership of the facility having said that it really are our initial thinking even applying for that grant was because we had already been moving in that direction philosophically at the department and as you may or may not know many of the individuals who you worked with who were incarcerated were actually part of the group of coaches that I started the program back in 2017 called open ears and so you know we've been trying to leverage their voices and to create a more civil society within the constraints of the correctional environment for quite a while so I totally appreciate the work that did and I my hope is that there's enough of a flame lit inside of the department where this continues this movement continues this focus in trauma informed of hearing the voices of the people that we're serving because ultimately in the customer service business where we're protecting the public we're doing the job of the courts we also have to serve these individuals and the better we serve them my argument would be that that is the best rehabilitation how you were treated inside of a correctional facility is ultimately how you will learn to behave when you leave and if we're treating them not with civility and what's not not not with respect we're not enhancing the rehabilitation for their return to the to us so I have been looking at I'm actually many people at DMH and an AHS and across the state in the opening of training that happens anyway this is a group of incarcerated individuals who provide mental health substance use and just recovery from life peer-to-peer coaching we actually have a segment it's most of a day on the science of trauma we don't focus so much on ACEs because that's kind of a punitive not strength-based approach but we focus on resilience so with Dave on this who is the direct clinical director family to he is a statewide expert on this area and so we have a big part of the training is on on toxic stress which certainly a correctional environment is that their lives they were incarcerated were probably toxic stress and we talk about the behavior continuum of being completely overloaded on toxic stress but how stress is also necessary to motivate people to do things to take action and ultimately it's about leadership and humanity so I'm hoping through that education they are now trained to talk about this with other incarcerated individuals pre-covid for instance in northern there were over 1500 individual coaching sessions in one year so they really do impact a large part of the system but I'm sorry to interrupt but that's not happening with the staff from what I am aware of I understand and I hear you loudly clearly there is peer support with the staff and you know I think there's been a lot of awareness raised through print as you said the results on the answer about asking about suicidality etc in print were very impactful and what we know about any system any organization I don't care if it's IBM or it's a correctional facility organizations are organized around trauma and they're they are parallel processes especially in a residential setting and what I mean by that is if you have a psychiatric hospital setting the staff work typically doing that work are almost just as traumatized as the people who are inside of the system so it's nothing that we can ever lose sight of and correctional officers are just people too and they have the same types of health issues people have probably if not more and we know that they also have a higher suicide rate so you know in addition to print I don't know if you are aware of but I want to Commissioner Demos first acts when he assumed his role was to immediately organize a suicide task force and an initial report was developed that report was done in concert with a lead researcher the only researcher in the United States who has done this work who is at Northeastern University she developed her scope of work because of the extreme level of there were eight in one year of suicides in the Department of Crimes in Massachusetts and so she had been working in concert with that system to take a look at this and build some kind of a bench because there's so little research about this so that group continues to meet and is continuing to try to address the needs of staff have a very appreciative employees where there are staff who are feeding in working work groups who then generate ideas and then that's brought to the to the higher leadership and people are the commissioners desire is to empower people to have a voice and to take action to tell them tell leadership what they need and so very much mirroring what you could have one last question then I think we'll be done Brian hi you still work together a long time so you talked about how a lot of people are arriving in the correction system sick and that's not surprising to me because the social determinants of health are intertwined with the social determinants of crime and so I'm guessing that the same factors that are making people come to the facilities unwell or the same factors that that drove them to commit criminal behavior or if they even did because some people are innocent and get convicted but that being said I'm curious how you see health conditions worse and for people due to the fact that they're simply incarcerated because even though you talked a lot about the services that are being provided research shows that incarceration itself is bad for health so I'm just curious and we saw like with the Springfield survey I believe it was called that was done at Southern State Correctional Facility that you were referring to Daisy that people reported that their health worse and I'm curious if you could say more about how you see people's health worse and just due to being incarcerated I mean that is absolutely correct and there is and I did this search for Isaac I can't remember the citation but there has been some national research on that issue Brian and I mean it's literally something on the level of for every year a year in the outside and this is again like a healthy year right for somebody who's not suffering from social determinants like people who may be likely to be incarcerated or have high A scores as we know that's part of the ace outcomes as well one year equals like seven so they're like cat lives so you know I know that it's again it's a public safety issue to contain someone who was not willing to address their behaviors that are creating a public safety threat for the rest of us and yet you are also correct that that certainly does not make them well and that's what I've testified many times to HCI before is that what people are seriously mentally ill it is a serious decision to incarcerate them but right now it is the only institution that is longitudinal that has the containment that might be necessary at least initially for that person and we don't have another institution to place them in so this you may not be able to answer this question today this is a common thing as you know when you come talk to the legislature but I see this is the beginning of a discussion of our committees working together is is there any data or research that you're aware of that shows different outcomes for people who are living in a secure recovery residential facility which Vermont has won versus people living in a correctional facility yeah so that's maybe something for us to flag in there we're gonna process this later so I'm gonna save my thoughts about what I want to hear next so that we don't take up any so you can see it's really really I want to say complicated but not so much complicated is layers and I've often said about corrections it's like an onion you peel off the first layer and it's gonna expose more layers and more layers and more layers so this is the first approach that we've had we also had with us electronically well path and we also had the Department of Health and we didn't get to those folks so what's gonna happen next we're not quite sure Laurie and I will sit down maybe we do another joint meeting and pick up well path and we just have to figure out what's next what's next it's gonna be so valuable to corrections and institutions committee to have the health care view to help us it's gonna be really valuable and I hope for you folks on health care information we have on corrections and institutions will be just as valuable to help understand how the delivery of health care services within our correctional facility operates which is similar but different yes definitely so we'll figure out how we're gonna go forward next I don't think we know no I don't think we do but this is very good and you obviously are know your work and so I appreciate that and I appreciate all your time with us this morning thank you thank you so YouTube I think we're done for now yep and this discussion will be continued so thank you folks