Good morning, everyone. This is the House Healthcare Committee. It's Thursday, April 22nd at 9 a.m. And this morning we're going to spend the entire morning putting attention on the issue of children, children and youth mental health and particularly prompting our attention this morning is what we understand is the significant number of young people, children continuing to wait in emergency departments of hospitals seeking mental health treatment. So I'm just going to say a couple of brief words and that is that we need to understand, we need to understand the situation, we need to understand what's happening. We also need to look for solutions. We need to look both in the short term and in the long term and I welcome any and all of our witnesses to engage with us in both understanding the situation and looking for a resolution. I would just say personally, earlier in the session, one of the hopes that I had wanted to put forward was to pose this question. What is it that we would need to do to never have another child or young person wait in an emergency room for mental health treatment? And I think that that is not just aspirational but it should be really our goal. It should be our goal for all Vermonters but particularly for young people. So we have a very full agenda and I know that I would first start by thanking Representative Donahue for helping to organize the witness list this morning. And I understand that witnesses have been given timeframe within which to speak and hopefully allow for some questions. And I'm gonna need to ask committee members also participate in helping us as we listen and ask questions to help us manage our time because we wanna hear from all the witnesses. And if you look on the, I think it's posted on the agenda so you should be able to, you should be able to see who all is in line to be heard. We will do our best to take a short break mid morning because we all need that. But with that, I'd like to again get started and we first invited three folks who are working with the Department of Mental Health. I'm going to start by introducing Deputy Commissioner Morning Fox and Fox, I'll have you introduce the other colleagues who are with you here this morning. Take it away. Thank you very much for the record. Morning Fox, Deputy Commissioner Department of Mental Health and two-year point chair Lippert since there are a significant number of witnesses today and a fairly limited amount of time and a lot of information to discuss will not take up too much time. I would like to introduce with me today that we'll be doing the bulk of our presentation this morning but also here to be able to answer questions and provide additional information is Laurel Omland, our Director of the Children and Family Unit at DMH as well as Dr. David Ratou, the Medical Director of our Children and Family Unit. So I will actually at this time turn it over to Laurel to take over for our presentation. Thank you, Commissioner, Deputy Commissioner Fox. Good morning, I'm Laurel Omland, Director of the Child and Family Unit at the Department of Mental Health. I do have a PowerPoint to share. So if you bear with me one moment, I will start that. Thank you for the permission to do so. Can you all now see my screen? Yes. Okay. So we have been worried about the rising needs of children and youth for several years and the pressures on the system including, sorry, if that's interfering. I'm just trying to move things around here. Can you still see the screen? Okay. Yes. Okay, thank you. So we've been concerned about the rising needs for children for several years, including the increased pressures on our whole system and the increased use of emergency departments to meet their mental health needs. We've been seeing increases in depression, anxiety, suicidal concerns, especially among our LGBTQ youth and Black, Indigenous and youth of color. These concerns have increased as youth have been struggling with the social isolation following the health and as they're following the health precautions in response to the pandemic. Unfortunately, emergency departments have become a point of contact for children and youth having mental health crises. The increased use of emergency departments has been primarily among youth who are waiting on voluntary status as opposed to involuntary status. And we'll show some data related to that in a little bit. But we also know emergency departments are not the appropriate setting to be treating youth psychiatric needs. Yet youth may board for hours or even days in emergency departments until viable plans can be enacted. We know this is difficult for the youth, it's difficult for their families and it's difficult for the providers. This isn't in line with our systems values and it's been an area that we've been working to address with our system partners. But it hadn't reached the level of the immediate urgency that we're seeing currently. We're aware that even during a pandemic when overall emergency department visits have declined, children and youth are going to emergency departments for mental health concerns and they're going at higher numbers than we've seen before. And again, we'll show some of that data. So this is the pre-pandemic rates that we were seeing. This shows the rates of pediatric mental health diagnoses, diagnostic codes and emergency department claims and it's shown by sex and year. And so you can see a bit of the trajectory. We know that female youth, children and youth have higher rates of claims with the mental health diagnosis per 1,000 emergency department claims compared to males. And we also understand that about 86% of all of these youth had public insurance and about 14% had commercial insurance. We also understand that while individual children ages 11 to 17 years old comprise about 40% of the overall child population in Vermont, they account for about 80% of the emergency department use for mental health related concerns. And those concerns have to do with things around suicidal ideation attempts or intentional self-injury, anxiety disorders, depressive disorders, trauma and stress related disorders and other disruptive or impulsive control and conduct disorders. And then this shows the context both pre and during the pandemic and you can see the higher numbers of children who are waiting were those who were waiting on voluntary status as seen in the orange line compared to the children who were on involuntary or emergency exam EE status, which is the blue line. And this is from fiscal year, 19 through April of 2021. This slide the total number of each month ends the average wait time. So as I said, even during a pandemic when overall use of emergency departments had declined they're still going, youth are still going there for mental health concerns. And you can see that in the green line and the dotted trend line. And the wait times here have also been on the rise which you can see in the blue line and the dotted line. That with the blue line, that's the average wait time and we know that with an average sometimes those can be driven up by a few individuals who have significantly longer wait times but the numbers and the in general the weights are still of concern to us. This is David. If I could just chime in one point on this graph you'll see that in 2019, there are seasonal variations to the number of kids you tend to come into emergency departments. And you can see that there was a similar spike in 2019 where I almost exactly the same point of the year right now. So I think we share Representative Lippert in your sentiment that we don't want any kids with extended weights in the ED but I just wanted to point out what will be a hopeful sign which is that there is a surge that happens around this time of year and it tends to diminish and as school starts to wind down. Any idea what happens next, sir? Excuse me. I'm wondering if either of you have any particular? Yeah, it's a great question. Why the surge? I think people talk about two things. One, it being related to school people just kids sort of feeling like the school is a long year and they kind of run out of gas. Secondly, there may be actually some seasonal variation in terms of mood and depression. There are actually some, I don't want to go into it but there's some interesting studies from Australia that kind of show the flip of this graph. So there may be a seasonal component as well. As spring hits. We also see it in other requests for other higher levels of care as well. So it is something that we have noted over time and we see it in the inpatient trends over the years, even pre-pandemic. But it's still of concern for us. Yes. Can I ask one question? And this is based on contact that several of us had over the past year with staff at Spectrum Youth and Family Services. So we're talking here, I think the numbers here are children 11 through 17. Is that right? At least that was the data. These are all children, but excuse me, sorry. These are all children, but about 80% are the 11 to 17. Okay, so what is the upper age range that this data includes? Because I think one of the questions as well is transitional, what some people refer to as transitioning youth, who actually are in their late teens, very late teens and that don't necessarily, or the question is, do they get captured in this data because there's been concern about emergency room response to youth, runaway youth, homeless youth, who in this instance, Spectrum Youth and Family Services has referred to emergency services. I'm wondering if those are captured in this data. Yes. I believe that this data is for children, meaning under the age of 18, the 18 and over data, I believe are captured with our adult tracking and the EDUs. But we've also had conversations with Spectrum and share those concerns for the transition age youth. So it is a population that I think across our department, we are aware of and are looking to see how we can continue to address those concerns as well. Because psychiatric units kind of have an 18 cutoff. So there may be a lot of transition age youth coming into the ED, but they have more options in terms of where they can go for if they need a hospital, then do kids under 18. The one other thing I would note with this data is that it is only for, with the voluntary youth, it only includes those youth who are Medicaid enrolled. So we don't necessarily have data for all youth in Vermont. I think we've been, some hospitals may report youth who are on voluntary status, but many do not. And so we need to, who are not Medicaid enrolled, but they are all required to submit data for involuntary youth regardless of coverage. So what that indicates to me is that, as you can see, there's a spike or an increase happening from January forward. But in general, these numbers are of concern and it might be somewhat underrepresented. And again, if I may, I'm sorry, I caution our members from asking questions, but I'm looking at this and I'm having to translate in my head, the wait time in hours to days. I'm going, oh, well, day is 24 hours. And if it kind of start my way up the side here, we're talking the average is days. Yes. So that's, and that doesn't account for the outliers. So that's a pretty significant wait time. So we started to get into this a little bit, but why the upward trend? We know that as David talked about, there are some seasonal demands. We also know that again, given that highest age group of the 12 to 17 year olds, they've largely been in either remote or hybrid school and the social isolation is really, I believe impacting their mental health. And so we know also that they've been struggling with increased anxiety, with mood disorders, as I talked about, suicidal concerns pre COVID. And so the pandemic has exacerbated what existing mental health concerns there may have been. And also we understand is leading to some new concerns in other youth. The other aspect of this is that provision of community mental health service in this past year hasn't been business as usual because of the pandemic. It has certainly our providers have done a tremendous job in switching very rapidly to telehealth and ensuring that they're still connecting with youth, but we just need to acknowledge that it is different. The workforce has been impacted. And so that is also a contributing component. And I think lastly, just to say that it's unclear if this level of urgency is any trend or if it's temporary, given where we are currently with the pandemic. And that's something that we just need to continue to keep an eye on. And I know the analogy gets a little worn out, but in some ways the term perfect storm, I think may apply here when you put these three different things together. So the other components to that perfect storm as I was noting is the impact on our capacity in general. And so this slide shows some of the current bed closures and we've been seeing these numbers. They fluctuated somewhat, but we've been running at about 70% capacity with our inpatient units and our hospital diversion and crisis stabilization programs. So I can say that the closures at Routteborg Treat have fluctuated slightly over the past four months. And these are due primarily to staffing vacancies. They're also trying to manage acuity on each unit. As you know, the Routteborg Treat is the only inpatient facility in Vermont for children to access, especially if they're on involuntary status. And so they don't have other options for shifting groupings within Emilia U. So they're trying to manage both reduced staffing and vacancies as well as acuity. We know with NFI North, their closures are due to space limitations in order to follow COVID precautions. They're very much interested in being able to reopen their beds. And that's something we'll talk about a little bit later. With NFI South, their closures are primarily due to staff vacancies. They've been, as everyone in our system has been trying to recruit to fill those. And just as a reminder of that program in the Routteborg region of NFI hospital diversion just came online a couple of years ago. And it came online as an attempt to help alleviate some of our system's needs. And then the Howard Center Crisis Stabilization Program has remained at full capacity during this period. They have not had bed closures. The other thing to note is that we've been working closely with CVPH, Champlain Valley Physicians Hospital in New York. And we've connected with them and with our dozen agency emergency services teams to talk about how their inpatient hospital could serve Vermont youth. Of course, they could only serve youth who are on voluntary status because we can't have youth on involuntary status traveling out of state. But we've really appreciated that partnership with them and with their medical director. And we have been seeing some increase in their ability to serve Vermont youth. So we wanna continue to maintain that. And of course, there are some other inpatient hospitals that are Vermont youth access in some of the other states as well, but not at the level that we are doing with CVPH. So really, if we could get these closed beds back online that would reduce some of the pressures within our system. And that's an area that we want to continue to be focused on. So this was a visual of our system flow and it also I wanna show where some of the pressure points are that we're talking about as well as areas for potential planned projects and interventions. So I think, we've certainly acknowledged that there are significant workforce challenges across our system and at different levels of care within our system. So this is impacting the broader borough inpatient units, it's impacting our hospital diversion program and it's also impacting our community-based system and their ability to truly meet the need locally as well. I think you've heard from our community providers about the number of vacancies that they are experiencing as well as the increased demand for their services. So when that system experiences capacity pressures it puts pressure on some of the further downstream more intensive levels of care. So it can put pressure towards the residential programming towards crisis beds and towards our inpatient. And now we're seeing also significant more increased pressure in our emergency departments. It can also tend to pull resources from upstream promotion prevention activities when we have pressures within that community-based system and that's really a concern for our longer-term system. We also have some residential pressures. We've had some closures of residential programs in Vermont as well as over the past decade. So that we have more limitations there. There is also reduced bed capacity due to COVID in some of our Vermont programs as well as programs that AHS uses across New England. And again, this isn't just an experience that DMH is challenged by, it's also challenging our sister departments at Department for Children and Family Services and Development Disability Services. I like this graph because, you know, I think when you hear about kids being stuck in the ED, you immediately go to the ED, you go to admissions to hospitals, but we really try to take a broad view of the entire flow. And it's just to remember that, for instance, if you don't have hospital discharges, you don't have hospital admissions. And so there are a lot of different places where you can get bottlenecks that affect the entire system. That's absolutely true. We've had youth also ready to transition from a higher level of care to something else and had to have that delayed because the next phase was also delayed. It is a bit of a domino effect. So there is a system flow concern here where COVID is playing a role in it and our workforce is playing a role in it as well. So some of the things that we think can help address this, we wanna continue to focus around our school mental health as an essential component of education's recovery planning. We wanna ensure that there are supports in place for children, youth and their families as well as educators as they prepare to transition back to in-person learning. And then we also believe that enhancing mobile response and stabilization services in the community level can help address some of this. And that's the next piece that we'll talk about. So I know from talking with my counterparts in other states that we're not alone in all these challenges that I've just been discussing, they're definitely felt around our country. And I know that also doesn't ease our particular burden and challenge. It just puts it in context. The workforce challenges, the children waiting in emergency departments, the need to strengthen our community-based approaches and system are shared across our country. And I think one of the main areas of focus right now that I'm seeing again in other states and with some of our national technical assistance folks is really talking about what does make up an effective crisis continuum of care and one that can address upstream as well as immediate diversion options. So that's described a crisis continuum of care can be described as having that strong community-based system of care including community wraparound services. It should include a crisis call center and we know we're working towards the 988 in our country and in our state. It also includes a mobile response and stabilization service such as what we're proposing for the Rutland pilot. It includes emergency services crisis screeners. It can include urgent care centers for mental health like what you might hear later around the UCS PUC program, the Psychiatric Urgent Care for Kids. And it can include crisis stabilization, hospital diversion programs as well as inpatient care. So ideally, you didn't hear me mention that this includes emergency departments or police response. So we want to not have those be a part of our intentional crisis response for mental health needs. For these to really be last resort or not even part of the picture, we need a more robust and high quality continuum of crisis services. And for kids, we need one that's tailored for the developmental needs of children and their families and distinct from systems that might be designed for adults. So we do believe Vermont could benefit from developing, enhancing a mobile response stabilization service. And that's why we've been looking to test that out in a pilot in Rutland. We anticipate that it could have impacts on outcomes such as those listed here. And we recognize that COVID is having an impact on children and youth such that mental health concerns and the need for supports are on the increase. So we might not reduce prior use or spending, but our hope is that we would at least bend the curve on what the alternative trajectory might have been and avert unnecessary out of home intervention or going to emergency departments or use of higher levels of care. And these outcomes have been demonstrated in similar programs in other states. It's not just something where aspirin, not just aspirational threats. Thank you, David. Yes, and here are some examples. I'm not going to walk through these, but you have them for reference in what other states have seen as they've implemented mobile response and stabilization services. So some of the short-term responses that we've been looking at to address the concern around children boarding and emergency departments, we have been meeting the needs of the state we have been meeting every other week with emergency department directors with FOS, the retreat has joined us. And it is a problem solving, discussing what are the challenges? What are the potential solutions? We've been talking about how to get those closed beds open. It's clearly a systemic workforce issue, but there might be some adjustments to guidance that I'll talk about in a minute that we're hoping might alleviate some of those that are closed just due to COVID. We know that UVM Medical Center added a child psychiatric consultation within their emergency department. This happened not because of these meetings, but they've been able to share that experience with other emergency departments across our state to talk about what that impact has been. And then there's been some discussion about accepting youth who are waiting in a mental health crisis, accepting them onto general pediatric floors. And it sounds like a couple of hospitals are considering that as well. And that's been an approach that other states, David had understood other states have used that approach as well. It doesn't resolve the issue. It is just a change of seeing away from the emergency department environment into a setting that is more pediatric oriented. We've also been continuing to have conversations with our community health agencies, understanding what their workforce challenges are and what the limitations are related to COVID precautions and working with the health department to understand when can some of those approaches be adjusted. We have had some continued focus around workforce development to ensure that those practices within communities are grounded in good evidence-based practices that can address anxiety, depression, societal concerns. Certainly some of our other projects have been helpful with that.  We had a community think tank. We pulled together a multidisciplinary team with AHS and community partners to look at what's possible there and focusing in on the mobile response and stabilization services. We had some opportunities to learn from other states and put together the proposal that has been discussed elsewhere. So we also know, I've been in conversation with the NFI executive director about the possible diversion beds and closures and what's contributing to that. These programs want to open the beds that are currently closed. I think particularly for the NFI North program with their closures due to space issues related to COVID precautions, that's an area where we want to continue to work with Department of Health to understand how can we shift that as vaccinations increase and the governor's Vermont forward plan is enacted. So that could help eliminate some of those within hospital diversion as well as potentially in residential programs that have had reduced capacity due to those, that guidance. And that can help with some of that system flow that we talked about. I mentioned already the collaboration with CVPH in New York where we really do value that partnership and we're continuing to communicate with them about what are some of the barriers or challenges that our designated agency emergency services teams have experienced in trying to get youth accepted into that program. And they've been great. CVPH has been great in thinking through and making some adjustments to help with that. But again, it's a more limited population that is able to go there. And then there has been extensive AHS interagency work. We have care managers or similar roles across family services, DMH and developmental disability services working every day around these situations where youth are waiting in emergency departments or ready to transition from another level of care and trying to work through the complicated components to what are those barriers and trying to address those. So that is ongoing daily work of our teams across DMH and the other AHS departments. And then for midterm responses, we really do want to partner closely with agency of education on their recovery planning. We know that it needs to include supports to address social emotional and mental health needs of students as well as of educators as they prepare to reemerge and open up or get back into in-person learning more full-time, especially for the older kids. We also know summer is an important component of this. It can be a helpful transition to work in towards some of those reemerging and getting back into some routines and connecting with friends in a fun, accessible way. And that can help prepare students and families for their return into school as well. We also have the opportunity to consider additional capacity across our continuum and especially within our community mental health agencies. Again, our proposal around mobile response is one component of that. We have an opportunity under ARPA with some of the enhanced FMAP options for new programs for mobile crisis services that we want to continue to explore. And we're committed to ensuring the other federal funding that's directed to DMH for community mental health services is implemented in a targeted and strategic manner. And then lastly, we will be focusing on workforce recruitment efforts. We'll be pulling together task force to look at a five year strategy to strengthen the workforce, hoping that that would include partnerships with higher ed, looking at licensure reciprocity and other strategies to recruit and retain a quality mental health workforce for our state. We need to be able to continue to respond to the lingering effects of the pandemic and that workforce is essential in helping us meet that goal. We want to be able to provide the right service at the right time for kids. And so we know that that's a component of it as well. And I'll invite Fox or David to add any other aspects to that. I don't have anything to add, Laurel. I think that was really well done and comprehensive. So I think we're, I'm just available here for help answer any questions. Why don't we take, thank you for going off screen so people can, so let's, we have about 10 minutes available for committee questions or further comments. Representative Houghton. Thank you. It's more just a comment. One of the things I've talked about the last couple of years in this committee is the success beyond six. So I was glad to see that in the medium term and then seeing the data about the seasonality and how it seems to spike during the school year. I have felt quite frankly that there has not been an emphasis on the connection between what can happen with department of mental health and the schools. You know, I think this is a key place we should be spending a lot of time focused on what more do we need to do in these schools to prevent the downstream effects? And then the other question I have is on the bed capacity being offline, is that simply a COVID workforce issue or did we have those capacity issues or the bed closures prior to COVID? Thank you. So I can start with the, go ahead, David. I think COVID has made it worse, but there have been bed closures and difficulties with capacity even before COVID. There can be a lot of reasons why, you know, a kid won't be accepted to Brattleboro based on acuity, based on the fact that they may know somebody on the unit. And so there are other barriers, including the workforce has been a tough one for a long time. And I would just add that, you know, as around the bed capacity, I think, you know, Dr. Ritu is accurate that it existed pre-pandemic, but it really was more based, you know, one bed here, another bed here, based on acuity of a unit or some potential conflicts as Dr. Ritu mentioned, we didn't see pre-pandemic kind of the consistent bed closures of three, four beds on the adolescent unit. I think, you know, right now we're looking at four of the 18 beds on the adolescent, older adolescent unit at the retreat have been fairly consistently closed. And that is COVID-related staffing-related issues. So, and that's not just a retreat issue, that's everywhere. We have, you know, beds offline throughout our entire system, pretty much every hospital, including the Vermont Psychiatric Care Hospital. Staffing has just, it's been just a really very difficult time right now, you know, in all places. So, I just want to be clear, that's not just a retreat issue, that it's a systemic, you know, the staffing issues and the impact on bed capacity. Thank you. And I, if I can just make one last comment, I would urge you to have that school connection with it in the short-term responses, if at all possible. Thank you. Representative Black, and Representative Peterson and Burroughs, and we have 10 minutes, Max, so we can hear from our other presenters. I'm just wondering what our capacity is in the state for non-acute care, sort of psychiatric child, psychiatric care, psychiatric nurse practitioner. I'm wondering if a lot of the people we're talking about here, the kids we're talking about have been unable to access in an outpatient setting and then it gets to the crisis point. I'm wondering if we have a shortage also in that. I do believe that is a contributor. We have a number of vacancies across our community mental health system for providing that outreach and in-home and even school-based. We have providers who are doing it, but between vacancies and then the increased demand that there is a pressure there. And then we do have some gaps also in child psychiatry, although we have partnership with UVM in a fellowship program to try to have child psychiatrists trained under that. And we hope that they will stay in Vermont. Some years we are successful in that. In other years, they have other plans elsewhere, but it's an important component to our system to ensure that we do have effective child psychiatry. Another way that we've been trying to address that gap if there isn't a child psychiatrist in a particular region is to have that region be able to access for child psychiatric consultation through UVM and through some other folks that we are trying to support to provide that consultation as well as for primary care physicians and for child welfare social workers so that there can be access to really getting questions answered around what's going on for youth. What is the best approach to care? Thank you. Thank you. Representative Peterson, representative Bruce? Yes, thank you, chair. And thank you for your presentation. And please excuse my ignorance on some of this because I'm in the water here. The statue show for kids coming in for care, correct? Children 11 to 17 coming in for care. Ignore the ring in the background, we'll get to that later. I'm wondering how many of those children actually have a problem versus some that might, with kids, there could be things where it isn't really that big of a deal. Please go home and you'll be all right. Does every child that comes in for a mental health issue actually have a mental health issue? I'm just trying to get to that. So I think mental health is a continuum, right? And I think for all of us, we can have increased mental health needs and then increased mental wellness. I think what part of the way I can answer your question is for children who are coming to emergency departments with a mental health need, are they all going and waiting for an inpatient stay? The answer to that is no. That's why we have crisis beds so that children who might not have as acute of a crisis need could go to a lower level of care, if you will, a less intensive setting. And then we have some youth who go to emergency departments and wait and then the crisis abates. We know for kids that sometimes crisis can get really intense and then it can be reduced. And so with that, there is our, again, our designated emergency emergency services teams are really trying to evaluate the youth and determine what is the best plan. And if they can put together a crisis plan that can support them back in the community, that's their first goal. If they need a more intensive level of service then they're pursuing that. And unfortunately that's where there tend to be longer waits. I would add that if there's a kid who's being listed as someone who is waiting for an extended time and an ED, it's a big deal. That means that there's a safety concern, that there is a real concern that this child or youth is in danger to themself or other. It's not a kid just having a temper tantrum. Okay, and along with that, Dr, when you say waiting an ED, are they physically waiting there all those hours? They are. They are. So if somebody could, I mean, be there for, just wait there for a couple of days or they sleep in the room, I mean. It's in regular, you know, some of the emergency departments have now tailored rooms to be different than your typical ED rooms. So there's not all, you know, the tubes and equipment that may be in there, but it's one of the rooms in the ED and the parent is there as much as they can.  All right, thank you. Representative Burroughs and then there's a moment I'd like to add one thing, but Representative Burroughs. Thank you. Thank you for your testimony this morning and thank you for taking my question. I wondered what whole family measures are being put in place to support children as well as their families? So I think that's a great question because we're talking about children waiting but we know that their whole family is impacted when there's a mental health crisis and especially if they're waiting in an emergency department.  So we've developed some brochures for families who when you're in distress and in an emergency department to help them understand what they might be able to anticipate, who they could be talking with, just some informational, we had our Vermont Federation of Families Organization help us design something that was oriented for families to understand the process and to be able to capture some information as they were there. We know that ensuring that we have again that quality approach within communities is essential so that perhaps families feel like their needs are being met in a community setting, they don't need to go to emergency department and that's where the pressures within our system are challenged, we believe something like a mobile response approach could enhance that. We also think that there are other practices around wrap around and enhancing some of our family-based interventions is an essential component as well. David or Fox, if you wanna add. What happens when there's a family member who's in crisis, which causes an adolescent to be in crisis? What happens to the whole family? Are they treated separately? Are they treated together? What kind of wraparound services are there? Typically the emergency services team at a designated agency would be contacted and they would evaluate what the situation is and then respond accordingly. If they have the capacity, they might be able to go out and intervene where the family's distress is happening. I think because there's been increased demands on those emergency services teams, it has become, I think, efficient to meet at the emergency department and do that evaluation there. And I would just add to that, that's definitely not a preference that the recommendation and the way to engage with services is to go to the emergency department to connect with folks. I think there's some research that also supports that. When evaluations, assessments and supports are provided in the emergency department, there's a higher outcome of resulting in needs for higher levels of care as opposed to those services being provided in the home. And I think as Laura was talking about, the emergency services teams, when the capacity does exist to go out, they're assessing who in the family is actually in crisis and then who's having kind of a secondary crisis as a result of that. And so it may be a coordination of efforts between child and family services and adult services depending on how that situation kind of is teased out. I think that's one of the roles of the mobile response system where you really have a team that's focused on a family-defined emergency and addressing the family as a whole with one cohesive, coordinated team of professionals to go out. And so that's one of the big impacts of that mobile response type system as well. But you're saying that the mobile response system is stressed at the moment. Is there potential for two family members, an adult in crisis, a child in crisis, to both go to the emergency room, the adult be treated or dealt with within a few hours and the child remaining there for 60 or more hours? I think it depends on the outcome of those assessments. In your example, if the adult is assessed and is able to receive the necessary supports that will help them remain safe in the community, then that's what will happen. But if the youth remains unsafe and needs a higher level of care, then unless that bed is readily available, then yes, you're right that youth may end up now waiting in the emergency department while the adult or the parent may be staying there as a support but not waiting for placement. So I'm gonna suggest we move on because I think this issue is, perhaps can also be addressed by our next witness, which is Christian, is it Polchini? I'm not sure if I'm saying your name properly, welcome. You are saying my name correctly. Thank you. I'm looking for you on the screen.  So let me welcome you, ask you to introduce yourself. I understand that you are at UVMMC in the pediatric emergency medicine and perhaps you can help us understand what role you and others may play. And I'm just gonna pose a question to the outset that I find myself thinking about when we've heard from the others that have just been talking that, I'm concerned that I've spent time in emergency rooms for myself and with family and it's not a place you wanna spend a lot of time. And I'm concerned that the length of time that some young people are spending in fairly sterile environments, in fact environments that are not set up for mental health care, actually could exacerbate the situation rather than lend itself to it resolving. But let me welcome you to comment broadly and then if you were able to comment on that particular question, I'd welcome it as well. Yeah, thank you Chairman Lippert. You actually just stole the thunder of exactly what I was planning on saying. So I appreciate it. I think we're kind of on the same page, but for the record, my name's Christian Bolcini. I'm a board certified pediatrician and pediatric emergency medicine physician at UVMMC and UVM Children's Hospital. I'm also a former middle school science teacher with a master's of education and secondary education and a formal public health professional with a master's in public health with a concentration on maternal and child health. I recently moved from Pennsylvania where I can go ahead. Thank you for being in Vermont and now you tell me you're moved from Pennsylvania. I recently moved, yeah, I recently moved from Pennsylvania where I did pediatrics residency at Children's Hospital at Pittsburgh and pediatric emergency medicine fellowship, which is actually a new specialty for the most part in available to kids in Vermont. And I did that fellowship at the Children's Hospital of Philadelphia. But I have some written testimony. I completely intend on providing you at the end of this as well as some data out of UVMMC. And I think it actually will address some of the issues you bring up Chairman Lippert. I wanna sincerely thank you all for allowing me to provide testimony today as well as for recognizing the importance of understanding the current state of our children's acute mental health care needs. I sincerely applaud your solution oriented approach to address this issue with a sense of urgency because as someone representing Vermont pediatricians through the American Academy of Pediatrics, Vermont chapter, my emergency medicine colleagues at the UVMMC and Children's Hospital and as a father of three and community member, I think a sense of urgency is needed for this issue. You've already been presented with quite a bit of data and I'll just say when I went to my UVMMC shift yesterday at the ED, I should add to some of that data that there were five children waiting at least five days in the emergency department for an inpatient mental health placement. One of those children have been waiting two weeks. This is unfortunately becoming the norm in our emergency department on my arrival. Our shift is always 2 p.m. to midnight. I did want to emphasize, however, that this issue seemed to be, and I'm again, a new person in Vermont looking back on some data, not really a new issue as Laurel was highlighting some of the trends, but at least the trends that I've seen from UVMMC data from 2010 to 2019, there was a threefold increase in the visits for ED visits for children and youth for primary mental health complaints. I will add as an emergency medicine provider, I think this should be said, we can't account and none of this data can account for the number of children, especially in that transition age you're talking about who present the emergency room with abdominal pain, chest pain and what ends up happening is that we have a strong, we always think of in pediatrics and in medicine in general, there's a strong mind-body component and some of those visits are certainly related to mental health during this pandemic and we won't be able to capture them. Those to answer Representative Peterson's question are usually not on the magnitude of the children waiting five days or more, like Dr. Ritu pointed out, those are usually very serious issues, but I don't think we're fully capturing the extent of what is going on certainly during the pandemic and probably even before. In that time from 2010 to 2019, the maximum length of stay in those years increased from 12 hours to 62 hours for mental health complaints. So this data suggests that even pre-pandemic that an intervention for our youth was inevitably needed. So beyond these statistics and I'm glad you brought it up Chairman Lippert, and what's particularly challenging in my setting is that we are extraordinarily fortunate at UVMMC to have a trained child psychiatrist who assesses these children every single day. This is not a resource that is shared around the state or even around the country, notably at the critical access hospitals where a lot of these children end up boarding. We also have a host of social workers, case managers, nurses, physician assistants, ED technicians, child life colleagues and parents and family who are doing their best every day to provide any sort of environment that's therapeutic for these children. And speaking with my emergency medicine colleagues and pediatrics colleagues around Vermont, they are experiencing the same even at critical access hospitals, like a well-intentioned group of people who care about children, witnessing children and adolescents being boarded for days, waiting for a more appropriate setting to address children's mental health needs. And I think the reality is and you guys have already, several have already spoken to this, is that even in a resource rich environment such as we have at UVMMC, the ED is not an appropriate setting for children to get comprehensive acute mental health services. We have contributed a host of human resources to optimize what we have, going far beyond expectations and many instances like in our ED. We have done this because watching children, quote unquote, board in the ED day after day confined to their room, which is an additional thing, Chairman Lippert, they actually cannot leave their room physically because it's not safe during the pandemic is extraordinarily disheartening to all the individuals who witness this day by day. I should just point out as a pediatrician and father, that children should be in school learning, children should be at home developing and when needed, children should receive appropriate mental health services in the right setting at the right time to get back to the learning and developing that's so important for their lives. So this data that I've given and Laurel actually did a fantastic job giving to this group is really important in arriving at solutions to avert the crisis. My colleagues at the Department of Health, Department of Mental Health and VAWS can certainly testify and provide the big picture data as expert. I feel it's my duty, however, as a physician specializing in pediatric emergency medicine advocate for kids to mention these unmeasurable consequences of ED boarding of children with acute mental health issues. For example, we can't measure the trauma that we are inflicting on children who already have a history of trauma by holding them in an inappropriate therapeutic environment such as the ED. We can't measure the developmental consequences of boarding an elementary school-aged aggressive child for days in the ED.  And I think that's something that we need to think about. Absolutely. As we know from a recent surge in high profile media stories as well as some data presented earlier across the nation, there's a lot of focus on acute children's mental health issues. These tragedies are happening daily and will only increase in the wake of the isolation and lack of socialization with peers that most of the children have experienced during the pandemic, especially those who can attend school, as Laurel mentioned, and those participating in things like sports that are strength-building supportive activities that didn't happen over this past year. I'm proud to live here. I think Vermont, from what I've seen, it does a fantastic job of prioritizing kids and understands the needs for hearings like this to avert further harm to kids, notably those with mental health care conditions. It's been well known in the pediatric community that 20% of kids in the US have been diagnosed with a behavioral mental health condition. That was in 2019 pre-pandemic, which is exponentially growing due to the COVID pandemic. It seems now is the time to assessing a comprehensive and multifaceted approach to children's mental health in Vermont that includes both short-term measures to alleviate the current boarding crisis, as well as longer-term interventions. And I won't go more into that because I think Laurel did a fantastic job and I agree with basically everything she said in terms of some of the interventional work that is there, as well as a former teacher, I certainly support any interaction with schools that Representative Holden also spoke to. So I know this situation will require investment, but the cost of not trying to provide these services to youth will certainly lead to greater economic challenges, which I'm sure you all understand. And most importantly, it's just devastating on a human level. These children are our next generation and having them experience the mental health stress that I see so many experiencing will affect the wellbeing of our children long after this pandemic for sure. So thank you for allowing me to speak today on behalf of kids. And I hope some of this was helpful and didn't add to just what was already been said. And I look forward to any questions or concerns. And again, I'm happy to send these words that I spoke today, as well as some additional data that I have. Well, I want to thank you very much for adding to this conversation this morning, adding your knowledge and for your personal willingness to move into this work with the background that you're bringing. I'm just going to name one thing I see Representative Holden has a question. And I say this with appreciation for everyone we've heard from so far. But I'm thinking of the families. I'm thinking of the children. I'm thinking of people who are like, for whom it's no relief to hear that we're thinking about this at the legislature. They're in the emergency room with a child or a family situation and actually horrified that they're having to be there for days and days and days. And so the question I would pose and I'm not looking for an immediate answer necessarily, but it's like, if we truly consider this, if we consider this truly an emergency situation broadly that children are waiting for days in our emergency rooms, what would we do? What would it take for us to respond? And I'm not suggesting that anyone's not taking this seriously, but it does seem to me when we have children waiting literally on average three and four days for some type of real service, it leaves me still with the question, like what would we mobilize? What could we mobilize that goes beyond what we're doing now? And I would just, again, I say that with appreciation, not criticism for what it is that you all are doing on the front lines. It's, but it's, yeah, thank you. I'm gonna turn to Representative Goldman and welcome others to respond along the way. And again, thank you so much for being here, Dr. Pochini. Representative Goldman. Thank you, Representative Lippert. I think your question is essential. My question is I'm trying to understand in a way what the denominator might be, which is how many children actually come into the ED with mental health issues that can be cared for, refer, and I wanna understand what happens to the group that doesn't require admission and how many of those children are there compared to those that do require that level of care? Is there data sort of a, what the whole denominator of children coming into EDs with mental health problems and their disposition? That's a great question. I believe that I have that. Acute mental health needs are rising. And some of this, I have the rates in terms of percentage of visits, hours of care as well as length of stay with acute. So okay, it appears as in from at least 2019, again, these are not updated to 2020 data that there were around 2200 kids coming to the UVMMC ED alone. So I can't speak to other hospitals with that data. Obviously we are probably the largest health system and largest hospital where the most kids in the state present to, but 2200 kids. And for those being admitted, I actually do not have that data, but that is an easy thing honestly for us to obtain. I don't know if anybody else on the call has that specific data sitting in front of them, but that would be something that I can follow up on and certainly send to this group as part of the data that I'm happy to send. And again, that's just UVMMC data. The denominator, I will tell you that what Laurel alluded to as well, just from a clinical standpoint, and this doesn't provide the statistic that you specifically asked for, is that the number of presentations that go home who are assessed by our crisis team, who are fantastic and we love to work with them, it appears even in my first seven months here that the number of children who go home is less and less than the number of children who stay due to the acuity being higher. And I think the data of the length of stay in general speaks to the fact that the acuity has gotten higher in the last five years especially, you'll see in the data and that reflects in the length of stay. As Dr. Ritu said, the kids who stay for a lot of days are assessed by mental health professionals in the ED. And I would say it usually happens within 10 to 12 hours at the most that they're timed to a mental health professional. And so they are deeming that it is serious enough for them to remain in the ED to either be assessed by the child psychiatrist who is in in the morning perhaps or during the day who also follows up and sees these kids every day. So I would just say that in our particular setting with the five kids who are waiting for greater than several days, they're assessed by a child psychiatrist every day and deemed to be unsafe to leave the emergency room in a need of inpatient placement. So that's the highest level of care that we could provide somebody in the emergency room and we're already providing it. And we're still seeing these outcomes. Thank you. Thank you. I'm gonna turn to my committee members. The queue is not always clear on my screen. I think maybe represent Peterson and represent Donahue and then represent Page. I think I was next, but I'll jump ahead of the other two. Thank you. And Dr. Thank you for your testimony. You certainly have a very well-rounded background to say the very least. And I would recommend that you leave Burlington and come down to the Rutland area. Person in the Rutland area, but seriously, in my opinion, we get no, not that we get nowhere, but we can find ways to fix the current problem. I think when we put our heads together, we'll find ways to reduce the wait times and emergency rooms will take care of kids. My concern is the root cause of all this. Take COVID out of it, put COVID aside. What do you think?  What do you see as some of the root causes of these issues with our children? It's very concerning. I'm a grandparent of 12 kids and it's very concerning to me that kids are having these issues. And I wanna get your perspective because you're very well-rounded. Thank you.  So, I would say the things that I have seen in general is, it's hard. I find that the stressors that kids are presented with in modern times, I don't wanna just point to social media because some social media and some technology can be healthy for kids in their interaction with it. But I would say that the overwhelming stressors of just their regular environment has increased probably in the last few years. I think that there's plenty of people in the last 20 years who care about kids and are doing the trying to do the right thing by kids and are also trying to adapt to the environment that their own kids are in, such as me at home. I remember putting COVID back into it. I'm not sure I was the best father during that stretch of time where I was home with my kids all the time, also trying to work full-time on things like research and activities such as this that I feel passionate about. And I think that things that support families in the best possible way probably will be helpful. So I mentioned things, what I did in childhood was sports. I just signed my child up for a musical theater summer camp. Like these things are very rich in Vermont. Child care is a huge issue. And we're talking about upstream solutions that are a much larger conversation, I think. And I'm not sure I'm exactly the best person to speak to this directly, but I do know some colleagues that are, and I probably would call on their help if I'm going to try and answer that question holistically. Thank you. Thank you. Representative Page or Donna Hugh, either go forward. Representative Page? Yes, these questions probably apply to everybody. But do we know what our success rate is for treatment? What is the treatment for these children? What does that look like? And once these children reach age 18, what happens to them if their treatment continues on? I guess we'd open this up to any of the witnesses who we've heard from to this point. So from the department as well as Dr. Puccini. Does anyone want to step into this? Dr. Ritu or Laurel? I can take a stab at it. So if you're asking about like, what happens when they get to the hospital or when they get to 18? Well, when they get to 18, I thought- I'm sorry, Representative Page, to speak for yourself. Yeah, please. That's quite all right, Chair. What is our success rate in treating these children for one item? And what, I guess, how do you treat them? Do we medicate them? Is that what we call success in the treatment? And then also, if their treatment continues on, what happens after some of these children reach 18? What then? So treatment, we generally really advocate for a very comprehensive model of treatment. Medicines may or may not be part of it. Certainly individual psychotherapy can be a big part of it for a lot of youth. Working with the families to help them often cope with very challenging behavior we think is really important. Encouraging activities for kids that we know build healthy brains. So getting them exercising, getting them off eight hours of screens a day, all those kinds of things. That's what we sort of call comprehensive treatment. And you can't always accomplish that in a short hospital stay, but we try to get the ball rolling when kids go in. Regarding your question at 18, it really depends on sort of where they are in the system, but like a child psychiatrist like me, we don't kick kids out at 18 and say, sorry, I can't see you anymore. So there can be continuity, we'll see people. I have a whole bunch of patients now in their 20s because I've got no place to send them and they don't want to go anywhere. In terms of the DA system, the community mental health system, there will sometimes be a transition from who's taking the lead on their services, who's their case manager, who was there so that there can be some transition that I think, frankly, we can probably do a better job making more smoothly. And Laurel, do you want to add to that? Yeah, I was just going to say, our children's mental health system does serve children up to the age of 22. So there is an overlap for that transition age period from 18 to 22, where it really depends on what they evaluate. What are the needs of the youth and is that need most effectively, effectively met through the children's system or is it met through the adult mental health system? So there are some intentional decisions that are made with the youth, with their family if still connected about where to receive that care. And if they're still involved in school, that's another component of it where they might continue to receive school as mental health. Representative Black. I'm in trouble, I'm muting, thanks. I know this is a really simplistic question and it's not a long-term solution. I recognize that the problem is a lot deeper. I'm really struggling to understand how like particularly the largest healthcare provider in the state, why we can't find at least some temporary beds for these kids so that they're not sitting in emergency departments. I mean, I've spent a day in emergency department and by four hours I was ready to pull my hair out.  I'm not sure why these kids can't be moved to at least a slightly less traumatizing area of a hospital. Like I said, it may be simplistic, but that seems like something that we could do in the short term. I think the only way that I can comment to that and that is, yeah, it's not a simple issue. I think it's a very complex issue that many people are working on. I would say that the amount of staff that it takes to keep somebody safe because that is often what I tell the kids or the goal when they come to the emergency room.  It's not like the environment or milieu that you wanna stay in for longer than four hours, but this is kind of what we have. The amount of staff that it takes because you have to have 24 seven monitoring of somebody who's actively suicidal, as well as the nursing staff that it's taking. And I will tell you just so you are aware, I didn't wanna highlight this because this is really focused on children's mental health. I think that's important, but it's not like the children with other medical complaints are stopping coming into the emergency room. And so we have a situation right now in our ED where sometimes children, and I say this like the most respectfully, we do what we're doing our best. Children with a broken arm are waiting five hours in the waiting room because we physically don't have beds because we are boarding so many patients. And so the other day it was a baby that was four weeks old that was waiting in the waiting room who you optimally do not want in a waiting room due to infection risks and such other things. So I think it has to do with the number of staff it takes to adequately care for them and make sure they're safe and that that staff is difficult to one come by and multiple settings as Laurel highlighted, especially on our inpatient, but also certainly outside of the emergency department, which again, we're well-resourced and set up to help do this, but we're supposed to be a transition point. And I agree with you. It is a complex issue that I don't fully understand, but I do understand at least what it takes from an emergency department to keep somebody safe. Oh, but it seems like we're already staffing them. In the emergency department? Emergency department. And I guess you'd have to mirror that staff to then go upstairs in the downstream. I know it's a, it just seems like, you know, I guess I'll leave it at that. I know it's complex, but this seems to be an emergency. Yeah. I think there are those of us who share that point of view. Representative Cortis, who actually works in the healthcare setting, let me turn to you. And then we're going to need to stop in just a few minutes in order to take a break, in order to then hear from our other witnesses, but Representative Cortis. So I think you're definitely raising a really good point, Representative Black. And I'll just add to the question about staffing. It's not just numbers, but what the skills and qualifications are of the staff. We might have empty beds in patient cardiology, but I'm a cardiology nurse. I'm not a pediatric nurse. I'm not a psychiatry nurse. And we don't otherwise have the resources we would need to take care of those kids. So you're right. It's definitely a complex issue, but I think definitely one worth looking at in the context of our hospital system statewide. Okay. Thank you. Representative Donahue, do I see your hand? I'll just quickly mention another background, informational piece. I know that UVMMC has been working on a redesign of the whole emergency department, which would include a whole separate pediatric area, which would then also address mental health, because right now they don't have a separate pediatric emergency room. That of course got delayed some, I think with COVID, because they were close to putting in their application and it's been deferred. So, but the emergency room itself needs more physical capacity to be able to create that new design included a separate adult mental health specific area and a separate pediatric emergency area. But they don't have- And Southwestern is too, Southwestern Vermont? They already have their CON, they're moving ahead on it, but UVMMC has drafts, but not movement yet. Yeah, and I can't pretend that I understand all this. I do know in 2019 when I was in Philadelphia, the local crisis center closed down and we anticipated that was going to happen and we got emergency authorization to build to expand our medical behavioral unit upstairs, which we don't currently have one at UVMMC, a medical behavioral unit for kids, but that would make sense according to our past volume. I can't comment on that, but the ED actually was able to expand to six specific acute mental health beds within six months from start to finish with an emergency authorization knowing that that crisis center was going to close. And thankfully we did because from what I hear from them now, even that six bed space is now overwhelmed and their entire inpatient unit that's a medical behavioral unit is also currently full. Well, I think we need to stop here right at the moment. We have further witnesses to hear from which we look forward to hearing from, I wanna express appreciation to folks who've testified so far this morning. And I don't know, I think some of the folks from the department perhaps will be available throughout part of the morning at least or through the morning, someone from the department will be. And Dr. Polcini, I wanna say thank you particularly for bringing your perspective to our deliberations this morning. You're certainly also welcome to stay. I also understand that that's not likely given all the pressures on your work in your time. But we're gonna stop here. Okay, folks from Dr. Ritu is gonna stay. I look around, thank you. And Laurel, again, thank you. I think it's as a small attempt to address some of our own health and wellness needs as legislators who spend really far too much time on Zoom and not enough time standing and doing other things. We are going to take, I'm gonna suggest that we take a break from the screen and that we come back and start promptly at 10.30. I think, Dr, is it Kepadia? I apologize for mispronouncing names. We've met before, but- Kepadia. Kepadia, thank you. Yeah, all the A's make the same sound. It is here to join us right at 10.30. So let's take a screen break and be back a few minutes before 10.30 and then promptly we'll start at 10.30 again because this is very important.


This thing is breaking my balls.  Why I can't do this Try this again. I guess we're just gonna have to keep drawing. I know it won't let anybody comment because it's not processed It won't let anybody comment because it's not processed So, I guess we keep drawing. Yeah, I know. Yeah, comments aren't working on it Guess we're gonna have to go back to square one back to the rolls Copy this one Go to my comment picker Okay, we're gonna do it again Yep rolling it It's better be somebody in here better be David Monroe Is there a David Monroe? David Monroe. I'm trying to keep track of there's some people in here. I know there's 52 people in here right now David Monroe 10 9 8 7 6 5 4 3 2 1 Yes, I know you can't comment on the last one. I'm not drawing that off that one I'm drawing it off of the original sp video and You know, we're redrawing it.  So it's on The original video the the one where I did the review on this gun That's that's the one you have to hit enter me on the video where I reviewed that gun Roll it again Mike Arsenault Mike Arsenault Mike Arsenault 10 9 8 7 6 the live stream accepts comments now it does Hold on We're gonna see this one Just a second. Let me see if it does allow. I'll pull this one. We're gonna try to get this done the right way It does it does All right, so what you have to do you have to get out of this live stream And you have to go to the other live stream and put enter me All right, can we can we do those directions?  It's funny how many people are dropping out It works it worked Good, and then everybody get back over here. I don't write I'll give people a couple more minutes to go through just in case of the slow interwebs 410 I'm just here for the suspense. It is it's killing me. It's killing me This is supposed to be easy Just here for the comments, that's all we're here for. Yep, just here for the comments pull up See how many we got 81 comments in there Okay, so I think we're good you have another 10 15 seconds just to make sure everybody's on there Funny thing is There is somebody in here who won the first time around And now they're in here, but they weren't in here when the original drawing happened. So Sorry That's the funny stuff Because we're drawing again All right refresh this Pulling comments. We got 82 comments right now Here we go guys Someone is gonna win this time It's gonna happen enter me. We got that in there drawing Picking it picking it picking it picking it that name Jose Luis Carbajal I got it. I got it here. I got to see a There he is There he is.  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Thank you, ma'am Big thank you to all of my subscribers And that's the kind of stuff we're doing and there is going to be a couple of little you know a little bit of a Torx kind of to that one So there is going to be a video on that one and it's going to be for all of my I'll I'll let you know the rules in in that initial video But for the og people who have been there and who have been assisting me all the way and who have been supporting me through not only youtube but other You know things that i've been doing over you know other You know versions of the automotive industry of what i'm doing You'll you guys will get it then but for everybody who supported me You're going to have better chances at winning this one the the people who you know one time in one video came in It's not going to happen. We're not going to have to be doing all these redrawls and stuff And it's going to be something where you're going to have to put your name and email address in Where that person will win it. We're not going to be doing this You know crazy amount of drawing and everything like that. So that giveaway We're going to be doing coming up. I'm going to be making a video. So that's going to happen this coming saturday Big thank you to you guys again. Congratulations to jose who louise who wins these sp tools half inch Mini impact rules allow. I don't really care. That's one of those things where this is my giveaway and for all of my Subscribers who i'm wanting to say thank you to This is going to be apparent in that so It's going to be a thank you to those people some people are going to get kind of butthurt about this giveaway because it's not going to be available for absolutely everyone so the rules will be On there on saturday and hopefully you know we can enjoy it I'm not sure exactly what time on saturday. It depends on what time i'll be able to make it I don't think i've got any work going on But i'm hoping saturday morning the video will drop It's it's i'm not giving it away on saturday the video will drop with all the rules on saturday But i'm not giving it away on saturday Yeah My deal my rules that's what's happening and you know, it's going to be a big thank you to the people who support me the most You're going to get more entries for the more support that was given in certain areas. So I think that's all about all I got for tonight. Thank you again everybody i'm going to go rock out some more videos and everything And hopefully get some more tool head stuff done because our tool heads great stuff has got to roll out this week So I got a lot to do to catch up on that one Got to get cracking. Thanks for tuning in guys You guys stay awesome