This is the House Healthcare Committee. It's Tuesday, May 4th, and we are here in our afternoon session, starting later than had been planned because House caucuses went ran long. And so we are going to continue with our scheduled agenda this afternoon, but we'll come back, we're skipping what we had scheduled at 1.15, which was review of a particular budget section. But if we have time, we'll come back to that at the end of the afternoon. But right now we are returning again to the issue of children's mental health, children and mental health, and in particular the pressures that are happening with children waiting for far too long in emergency departments, waiting for inpatient services or other services as they're needed. And this morning we spent between nine and 10 o'clock hearing from the commissioner of mental health along with some of her colleagues and colleagues from Dale, from DCF, and from Diva each briefly. But this afternoon we have several other folks with us about the same issue. And first we have Devin Green with us from the Vermont Association of Hospitals and Health Systems. And I must say that the part of what was referenced in the morning session, and Devin I'm not sure if you were able to tune into that session or not, because we haven't spoken between because other things happening for both of us. But reference was made to the collection of data that the hospital systems have begun doing or to give us, to give everyone involved a sense of the state, the number of children waiting in emergency departments and other related information. So I just, I wanna acknowledge that and say that there were some questions this morning as to whether the data that we heard from the Department of Mental Health corresponds with the data that the hospital association has. So I'm sure you will get to that but I wanna mention that upfront and invite you and I see your colleague, Emma Harrigan is with you to speak to that issue but also to other related issues because I know you've also provided a memorandum to our committee previously. So with that, I'll turn it over to Devin and then we will, and we have Jack McCullough here as well from the Mental Health Law Project and Vermont Legal Aid. We'll look forward to hearing from you, Jack, as well and Sandy Endow, as she is able to join us. So first turn this over to Devin Green. Great, thank you, Chair Lipper. My name is Devin Green. I'm with the Vermont Association of Hospitals and Health Systems and Emma, I'll go ahead and let you introduce yourself. Hi, for the record, Emma Harrigan also with the Vermont Association of Hospitals and Health Systems. And I'll go ahead and dive right into the data piece. I know there were some questions from this morning about the disparity of our data and DMH data and how we had 19 children and adolescents waiting in emergency departments at one point while they had nine. And I would just say that our data is a point in time. So it's every Thursday at noon, we go to our emergency departments and all of our emergency departments. And we say, who is in your emergency department for mental health treatment, children, adults? How long have they been waiting? Is it a day? Is it zero to five days? Is it above six days? And so we are collecting the data for everyone and we're doing this because there's been no great way to look at the emergency department data. And that would encompass everyone. We've had this dialogue back and forth with DMH where they say, we are seeing so many people in the emergency departments and then our emergency departments are saying, well, we are seeing this other amount of people in our emergency departments. And I think a lot of that stems from the fact that DMH is, we are looking at everyone, essentially who comes in. So whether it's commercial pay or voluntary or involuntary, so that's the data that we're trying to capture here. Do you have the most recent data that you have collected? So we don't have data for this week yet, but we will have a new collection point at Thursday at noon, but last week's data we saw, let me just pull it up real quick. Yeah, I was thinking last week's data would be the most recent collected data. That's correct. So last week we saw six children waiting in emergency departments for inpatient placement as of Thursday at noon. Okay, and I'm just ask a few more questions about that. When you collect your data and I've seen it, but I don't recall, do you break it down by voluntary involuntary or by payer type at all? No, we just do a point in time. So the only elements we collect are how many people by age group? So whether they're under the age of 18 or over and then by the time that they were waiting. So less than 24 hours, one day to six days or seven days or more. So we do not break it out by legal status or payer, but we are very clear with emergency department directors that we want every person waiting regardless of their legal status or their insurance type. Right, and of those who were waiting last Thursday, you say there were six based on your review of all the hospital emergency rooms. Can you give us any information as to how long they had been waiting? Sure, so for children, we had one child who was waiting less than one day, three children who had been waiting between one and six days and two children who had been waiting seven or more days. And seven or more is pretty open-ended. So I'm just wondering what that, if there's a, I'm just gonna ask because I think we really are trying to understand what we're facing because if seven or two, I'm sorry, two were waiting more than seven or more days. Yes. So they would have been in the previous week's data. Yes. And can you remind us how many children were waiting based on your data the prior Thursday? I believe the prior Thursday was 19 children. And our data brief, which I can send again so that it can be reflected in the record. We do collect anecdotal notes from emergency departments as they're willing to share. So some of that does give a little more detail. For example, one critical access hospital reported they had an adolescent who had been waiting four days before being discharged on Wednesday. Another critical access hospital reported an adolescent left after eight days waiting for an inpatient bed and ultimately was never admitted. One acute care hospital reported that the adolescent who was currently waiting, so one of those two children, or I'm sorry, no, one hospital reported that the adolescent currently waiting in their emergency department had also waited a total of 13 days over the course of two prior visits to the emergency department. And then another hospital reported that they had no patients waiting as of the point in time count, but as of that Friday morning, they had another youth patient waiting who had arrived overnight. So sometimes we do get a little more detail, but we are trying to create a data collection process that can be collected quickly and efficiently to just give a sense of the numbers as quickly as possible for each week. And I will say that Bos does eventually get the data on every visit that comes through an emergency department. It just runs about three months behind. And so those visits do give us more information on how many days each case waited, but we felt just being able to provide quick data and actionable data that that was the level of detail that emergency departments could provide quickly enough. Okay. And you are at this point collecting this each Thursday as of a point in time. Can you remind us how, when that Thursday point in time measurement started? It started three weeks ago. Okay. So we'll be able to, you will be able to, and we will be able to see that tracked over time. Not knowing if there's fluctuations up or down in between the points in time, but at least at the points in time. Let me have one more question. If you are, so is there any process underway for Bos and the Department of Mental Health to compare your data from your point in time data with what they are collecting to see if there is any, to see, there may not be a discrepancy. It could be that, you know, if you collect, you collect on a Thursday and if they report something from say a Tuesday or a Monday, their numbers will likely be different or it could be different, but it seems that it's important for us to not operate with a discrepancy with numbers. And so on. Oh, apologies. Yes, we are looking forward to working with the Department of Mental Health on making sure that our data are as comparable as possible. And I think part of that will also be highlighting how our data collection processes are different. So while most of the volume coming in through emergency rooms for children does appear to be Medicaid visits, there are children who are private pay who DMH might not have information on. So I think highlighting the differences in the total populations that each organization is able to collect information on will be important and also the process in which it's collected. So our data comes directly from the emergency department directors or the emergency department nurse managers every Thursday where DMH's process sounds like a combination of direct phone calls to designated hospitals and also designated agency emergency services directors, which depending on the hospital may not be involved in every placement for admission, depending on whether the child is not affiliated with the designated agency or maybe is waiting on a voluntary status. So I think understanding those differences will be important and also, yes, looking for opportunities to align. Yes, and it just to my mind goes without saying that it's imperative that the Department of Mental Health's data includes not just Medicaid children who are eligible for Medicaid or are being reimbursed through Medicaid, their care is being reimbursed through Medicaid, but all children who may be waiting, whether they're private pay, whether they're voluntary, involuntary, et cetera. So I think it's certainly my hope and my intention as the chair of this committee to continue for us to pursue this on an active basis until we are all satisfied that we are collecting comparable comparable data and that we watch not just the trend line, but that we watch the actual data as best we can and that we know as was not available today from the Department that we know not just the number of children waiting, but in some ways an age range of the children waiting, but also the number of the length of time, and not just an average, but the range so that we're aware of where the outliers are and when we say outliers, that really what that means is a child and their family have been waiting sometimes an extraordinary amount of time in an emergency setting. We 100% agree and I think there are certainly opportunities through the process that we've established with DMH, but also I think a long-term goal of the electronic bed board and being able to collect this information so that we have a sense of the numbers, but also that it can be more actionable so that designated agencies or others who can help with finding placement for children have data as timely as possible and also at the level of detail they need to to help move children out of emergency departments as quickly as possible. Yes. Are you reporting your data to the Department of Mental Health on a weekly basis? Yes. So our Friday or Monday morning email goes out to hospital affinity groups and the Department of Mental Health and I believe Ms. McGovern. Yes. I would ask to be half of the house health care team. Yes. Great. Who then in turn should be forwarding it to all of us. Great. So we have a number of questions. I think we'll take some questions and then we'll, I think there may be other things you wish to comment on but let's take some questions initially and then in addition to my questions and then we'll hear further. Representative Goldman and then Representative Donahue, Representative Page. Thank you, Chair Lippert. I was just curious, I just want to clarify. So you started collecting data on April 13th if you're saying it was three weeks back, is that correct? Three weeks of data, am I understanding that right? Yes, that's correct. So on April 13th, can you tell us the data for that day? Maybe not, I'm just looking, we did talk about trends. But we could provide, we have data briefs for each one of those weeks so we could provide data briefs to the committee. That's great, thank you. And I also, are you collecting data on adults too? Yes, we are. So I would be interested in seeing both if that's possible. That would be helpful, so thank you. Great, Representative Donahue and Representative Peterson, did you have your hand up earlier? No, okay, Representative Peterson, I mean Representative Donahue and then Representative Page. That was a perfect segue from Representative Goldman. We required a few years ago and just extended the end date for getting emergency department volume and wait times. The report says individuals, I know you're very familiar with them because you produce a lot of the data for DMH for them. Does that include children and adults that are not separated out or is that solely providing adult information? So the data that we provide to the Department of Mental Health for Act 200 is adults and children. I will point out that the level of measurement is actually technically visits. So there could be a difference between the number of visits that happen each year and the number of people that visit each year because people can have more than one visit. But the point in time information because it's a slice at a point in time is individuals. So we probably really ought to be requesting that that information be divided into adults and children if we wanna follow those trends. I think we can definitely work with the department to make sure that we have the right level of detail in the Act 200 report. Can you remind me of the frequency of those reports? Those are annual reports that cover a year by year comparisons that we receive. Thank you. Representative Donahue, other questions right now? Nope. Representative Page? Yes, I'm kind of interested in the big picture. Regarding the collection of data for children with mental health issues, how did you start collecting it? Were you asked to collect it by the Department of Health or the Agency of Human Services? Or did you just based upon some of our committee hearings that you decided to simply do it on your own? So the data that we provide year over year in the Act 200 report was driven by the request of this committee or the request of the legislature. The data that we provide the Thursday point in time really was generated from a need coming from our emergency department directors. And it just so happened to coincide with the timing of these hearings and this discussion. So it was generated by our emergency department affinity group with really just expressing a desire to have a data point that showed the entire picture of people waiting for inpatient care, both kids and adults, regardless of legal status and regardless of insurance type. It also came from our pediatric surge group too. It was sort of a confluence of our ED director from our pediatric surge group, talking with the other ED directors and making it happen. So if we hadn't received letters from constituents, we probably would have heard about this issue through your organization. Is that correct? Yes, that's correct. Okay, and for other issues besides mental health related to pandemics or flu-like issues or whatever type of health issues that come about throughout Vermont. Are you the frontline that sees data from our emergency rooms that would throw up a red flag to various departments and agencies and say, hey folks, there's something wrong here. We need to do something. Is there somebody else or is there some other organization? Well, in terms of the emergency departments, yes. So we have, through COVID, it was weekly and bi-weekly meeting of all the emergency department directors across the state. Typically it's quarterly, but it's actually worked out really well to have one hour bi-weekly meetings of our emergency department directors via Zoom. And so we will continue to have those frequent check-ins with them, but yes, they bring those issues to us. We have brought the issue of wait times in emergency departments to the legislature in the past. We've worked with the legislature in the past on that issue. So this is definitely not a new issue to us. It appears to be getting worse and the children in waiting emergency departments, especially really has a big impact on folks. I mean, no one wants to see adults in the emergency departments waiting for a long periods of time either, but it creates quite a strain to see a child waiting for that long. And I guess, besides contacting the legislature, there is a process that you go through to bring issues up before the agency of human services or Department of Mental Health or what happens. Is that correct? Yes, we do meet with the Department of Mental Health monthly and discuss issues. And who sits on that? Who is there from those agencies? Is it of anybody? Not that, is it somebody that can take action if there's an issue that comes up? Yes, I'm Commissioner Squirrel and Deputy Commissioner Fox are on those calls. Okay. And we appreciate the collaboration. Thank you. Representative Peterson. Yes, Chair. I'd like to ask questions that get into the how and why of emergency departments, but I don't want to do it if we're concentrating on data alone. Sorry for the phone. I don't know if that was the time. I don't know what the testimony is going to be like. I don't want to get into something because I have a number of questions about what is an emergency room visit? Why are they there? How it works and all that. Well, let me suggest this. Let me first, before we go to asking and answering some of those questions, which could actually be useful for all of us to understand how this is thought about by the hospital system. Let me suggest that we first, because we're wanting here to focus, particularly on children and children's mental health, waiting and children's issues as related to our emergency departments in the hospitals. Let me first turn to Devin Green to provide other information, including perhaps some review of the memorandum that you sent, because one of the things we were looking for was what kind of immediate steps can be taken to address the situation with children, numbers of children, as many at one point apparently as 19 on any given day. And now perhaps as few as either three or six, depending on the numbers. But this is a fluctuating number. What are some of the immediate steps that can be taken? And I'd like to give Voss and Devin Green a chance to share that information with our committee. Thank you. So when I approached this issue, I did approach it with the lens of this being sort of a public health emergency. And so I put this into the buckets of regulatory flexibility, resources, and data and statewide coordination. And I think right now for this body, some of the most actionable steps can be taken in the regulatory flexibility piece, realizing that providing resources and talking about building and new services takes some amount of planning. So last week I mentioned the emergency certificate of need for emergency departments or a streamlined process for certificate of needs for emergency departments. I did wanna correct the record. I said that Northeastern Vermont Regional Hospital had been waiting for a long time with their certificate of need. They have not filed their certificate of need yet. They wanted to file it as an emergency process and that was denied. So they are still in the process of getting to file it. So they have not filed it yet. What we're asking for is a process that would be streamlined while taking into account stakeholder input. Just to take away those barriers to creating therapeutic spaces in emergency departments. Again, with the understanding that an emergency department is never going to be completely therapeutic. It is not a place that we want people to stay long-term, but how can we get them to be more therapeutic? And that often takes building and that building creates a certificate of need process which takes time. So to the point that we can minimize that time a little bit, I think that would help with some hospitals. Can I ask a question about that just to help understand it? Isn't there a threshold beyond which, I mean, if there's certificate of need, there are things that can be done absent a certificate of need. Yes, but a lot of times- I believe so, there's a financial threshold I believe that has to be before you have to file for a certificate of need. Or am I wrong on that? Like three million or? Yeah, it's about three million, I believe. And a lot of- Seems like a lot can be done absent three million dollars without needing an emergency certificate of need exception. I think it's hard when you talk about emergency departments and when you're talking about creating spaces for people who are in mental health crisis, because once we get into that, you may recall this from Rutland Regional Medical Center needing to overhaul their emergency department a couple of years ago, because regulatory authorities came in and said that there were ligature risks there. So there's, it ends up adding up quickly when you have to take into account mental health needs and the ligature risks and the special equipment that you need and the special type of building that you need to address all of the issues there. So two rooms ends up costing a fair amount of money for most hospitals and does trigger that certificate of need process. Well, I don't expect us to sort that out right here, but my first reaction frankly was that not remembering the threshold, but I would still think there's something we can explore there without a certificate of need. But let me, the audience representative, Don, who you had a question or comment, your own mute. Yeah, just very briefly to say, I think that there are some low cost emergency changes and revisions that can be made that way before you need to do a major or pending a more significant change and it would be really good to see those done, acted upon several years ago, but now it would be good. Yeah, no, and I think that's right. I mean, we are looking internally at what our hospitals can do. We are having our emergency department directors meet with the designated hospitals to talk about the transfer process and medical clearance. We are looking at things that we can do. What I'm bringing- I'm talking about environment- No, no, no. In the interim, not just, I mean, move much of this important, but yeah. Yeah, I think the environment of care is the same piece. What I brought here today are things, actionable items for this group. I'm happy to get into what we are looking to do also, but my understanding was this group was looking for actionable items that you could do, which is what I brought here. Okay, well, let me just be clear, we're interested in actionable items that you could do as well. Okay, great. Frankly, I think we're looking for actionable items for all stakeholders and not just things that require legislative action. No, seriously, and that's not meant as a criticism, but we are very interested in, because I think, frankly, this is, we're trying to put a spotlight on an issue that is requiring each stakeholder to see what can they do in the immediate term to help resolve this, and even it's not to change in numbers, to change in the quality of experience. And coloring books this morning. Well, yeah. That may be an exaggeration, but when even that is not done, you kind of... Yeah, yeah, so again, let's complete this, but I'd like to hear, I would like to hear from the hospitals about what are actionable items that either are already underway or that could be taken in the very near term. Great. So, okay, so I'll continue with this piece and then I'll move on to what the hospitals are doing if that works. Sure, yeah, that's great. Okay, great. The other piece in the regulatory flexibility, I think is already in process, just looking at licensing so that we can use telehealth. To support a statewide telehealth program, there's been some success in places like North Carolina on this. And as you'll see later, we have a real workforce issue that is preventing us from providing care. And so that is sort of happening right now in terms of you extending the regulatory flexibilities, which we appreciate. And that will give us the time to look at this issue in H104, which you also passed. So thank you for that. And then also transportation. We do hear a lot about transportation needs. And if we are going to look into alternatives to emergency departments, then we need to be able to have transportation to those alternatives as well. So any regulatory barriers to that, which maybe at the federal level, I know a lot of ambulances get paid only if they bring someone to an emergency department. And that is changing at the federal level, but any state barriers to that would be needed to be knocked down as well. We do think that there are resources needed at every level of care. We appreciate DMH's willing or Diva's willingness to talk to us about a different payment model for emergency departments that would take an account to need for more resources because people are staying longer and we look forward to working with them on that. We really want to be at the table and dive in with advocates, with all of you, with DMH to look at alternatives to emergency departments and programs that are partial hospitalizations and really strengthen that every level of care. So that instead of just community services and just inpatient, we need more of a spectrum of care for youth. And we also need the community services and all the levels of care strengthened as well. So we would be happy to work on that. And we've brought up the psychiatric urgent care for kids in the South and the idea of having one in the North and really any resources in the North especially the Northeast Kingdom would be helpful. And I mentioned statewide telepsychiatry services but really we want to continue to work. We think this is an issue among hospitals. We think it's a statewide issues and we want to continue to work on it going forward. We hope that there's further statewide coordination. We talked about enhancing the bed board as a way to give us both data and then allow us to have actionable information to see where beds are open, to see what the supply and to see what the sort of how many people are coming in, what is the demand, what's available to give us a more detailed picture of what that looks like. And then using ED wait times as a measurement in these, as we go forward, make sure that the ED wait times go down in response to the initiatives that we're taking. And we realize it's not the only measurement but we do want it to be taken into consideration going forward. And then finally workforce development. This is a problem throughout the healthcare provider world in all different areas, not just mental health. I don't have an easy solution for it but I do have to highlight it because it's particularly difficult in the world of mental health right now. And so we are open to discussing workforce initiatives as well. And so those are the items that we are hoping to work with statewide and at the legislature and with advocates. We internally as hospitals are doing a couple of different initiatives. I think I mentioned that we are going to look at our medical clearance protocol in terms of what needs to be done in the emergency department to clear that person and say that they're physically able to go to an inpatient unit because places like the retreat don't have the capacity to deal with the heart attack or other health complications that might also be there while that person is at the hospital and so they need to get cleared first. And sometimes that process can take a long time and so we need to minimize that process. We need to do the coloring books and the crayons for kids. We need to do the little things. We need to provide comfort for children who are waiting in the emergency departments. I think our healthcare providers try to do that to the best of their abilities but as you heard last week, the emergency department is a very difficult place and not necessarily a place for children to be for a long length of time. Emma, I know you have some experts that we're bringing in to talk to our hospitals in this area. I don't know if you could go into more detail on that. Sure, and I believe we included some basic details in the brief that we provided but nationally there are models called empath units that see rates as high as 70 to 80% diversion so that and that these places in some states do accept involuntary patients as well as voluntary ones. They really are a place for anybody who's experiencing an acute psychiatric emergency can go and that they do intensive services and warm handoff to community resources so that they can divert the majority of their visits back into the community. So we're looking at that as a potential opportunity. We've also highlighted there's been proposals by a collaboration or a network of peer organizations of Vermont, Vermont Psychiatric Survivors, Alyssa another way and I am blanking on the fourth group but I think there's been some proposals from the peer community on peer drop-in centers and two-bed folks who need inpatient care to give them an alternative to emergency department. I think that's... I think you might have frozen when you, I think you were saying two-bed crisis respite or something to that degree is that what we didn't hear? Yes, yeah. So I think there's some and then psychiatric urgent care for kids the model that's in Bennington. So I think there's a lot of interesting ideas that are available in Vermont and outside of Vermont that look at making a continuum of care so that we have something that works in between or is a combination of both inpatient and outpatient services. So that we can look for opportunities for diversion to prevent children from arriving in an emergency room and ultimately needing inpatient care. So I think being able to serve children and families and better but also hopefully reduce the need for hospitalization. Okay, thank you. So let's take some, thank you. And let's take some questions. Representative Donahue, Goldman and Peterson. I'm just wondering if the hospitals are receptive now to considering having peer support folks come into the emergency rooms to be with somebody who's waiting and provide support. Has there been any change in that? Yeah, I think there has been change in that. I can't speak for every hospital. I think it varies hospital to hospital but I've seen a lot of progress forward with that. And we endorsed the certification of peer support which I think will also help hospitals accept peer support coming in and helping out providing a little bit of that certification and framework around it will help also. So yeah, I think there is movement in that direction. Is there anything that you, I mean, is that in order to move forward on such an initiative is there, is that something that the hospitals could do unilaterally or on their own without any action taken by other other than that obviously you need access to folks who are peers and interested in being part of that. Yeah, I think so. I don't think there's any, I'm gonna let Anne speak to it because she's more of the expert but I don't see how we would need a legislative, we would need legislative action to take advantage of peer services. I'm trying to think of like the current visitation guidance. If folks are vaccinated then they are fine to come in and I know we said peer services for substance use disorder. I think I'm not sure if mental health was in there. No, it's excluded from that. And peer agencies have been trying for more than 10 years to offer voluntary peer support and have in most hospitals not been accepted. Substance use disorder folks are admitted as peer support people. I will say that the emergency department directors have been more motivated than I've ever seen to work with peer support and their community providers and try to figure out solutions to this and we'll continue to do that. Thank you. Representative Goldman, Representative Peterson. Well, actually before we go on, let me just say I would be interested if there, if you, I'd be interested in understanding what is experienced by the hospitals from your end is to what are the barriers to implementing peer support around mental health issues, whether there's perceived changes that are needed in order to make that more possible. Cause we've again been hearing about it for a long time and it seems like it's something which perhaps whose time has come or maybe, maybe it should have come earlier but it's at least should be happening now. And if there's perception as to what that, what the barriers are, I would be interested in having you share that with us as one of the stakeholders, even if it doesn't require action on our part. Yeah, and what I'd like to do is consult with our ED directors. We have a meeting on Friday and I can get that or I could email them out but I'd want to hear more from them before making some guesses. No, of course, of course, but I think it's an important issue. Representative Peterson or Representative Goldman, whoever was first in the queue. I don't know, but I'll go, mine's quick. Emma, I think I heard you say something about an issue brief that you provided to us and I was wondering about that because I'm not sure I've seen it or if I did, I don't remember it. Anne, you mean. I just forwarded them to everyone so you have them in your email. Oh, thank you. The ones that we have received thus far. I think we're talking past each other. There's the emergency point in time briefs but I think what Emma, I believe what you were referring to is I have a printed copy is the Memorandum which actually doesn't have a date, I don't think, but it's around testimony for children and adolescents in mental health crisis and emergency departments from VAS. That's not what you're referring to, Emma. And I think all members of the committee should have that document is posted also on our website but if you don't- Do you have a date of that? Well, I don't know, there's not a date on it but it was distributed, I think, in the last week. Okay. You look under documents on the website and you look under VAS. Okay. Where the report came from. I'm sure Colleen can help locate it. Thank you, Representative Peterson. Yes, thank you. I have just a fundamental question, a number of them really, but I'll limit it to a couple of three here about what happens in an emergency room and children with mental health issues. And I'm wondering why they're in the emergency room. I'm trying to make sense of emergency room used for this purpose. If a child is, unless they're chronic, but if somebody had a chronic mental health issue, wouldn't they have a provider that they would go to in the event of something? If it's not that, if this is a first-time event, a child is, I don't know, really has an episode of a problem, say a 10-year-old and a parent brings them to the emergency room. Is the holdup in not having a care provider, a psychiatrist, psychologist work with that child? Is that where the holdup is? The manpower needed to see the child or is it somewhere else? And I'll take a first attempt at this and I'll look to Devin, but I would say we have a healthcare system that by and large says if you're experiencing an emergency, call 911. And when 911 is called, usually the next stop is an emergency room. And so we also have a narrative beyond just healthcare, but just a narrative that we all have that says when we're experiencing an emergency and we can't contact our provider because it's after hours or we don't have a provider in this area, we go to the emergency room. Other conditions have urgent care. So I make an assessment as an individual whether I need to stop at my urgent care or whether I need to go to my emergency room. We don't always have that level for mental health. So I would say sometimes it's families who maybe are experiencing a crisis for the very first time and don't know how to access the system. So they lean on what is most familiar, which is what we use for almost everything else in healthcare. And other times, and I think the testimony we heard from families two weeks ago, we have children who have a really acute need. And they may not have the resources in the community or those resources may not be available at off hours to support families. And so families are told if they need a place where someone can stay, that is safe, and staff 24-7, that's an emergency department. So I think we have a cultural narrative that tells us emergency departments are where we take emergencies. But there are really creative ideas that I think we've presented today that other states have looked at and things that we could use in Vermont to create alternatives other than emergency rooms. And I also think the advent of 988, the suicide hotline or the 911 equivalent for mental health crisis could help us create different networks or different pathways for referral when people are experiencing a mental health crisis. So I think that's my perspective. I'd be curious and I think we could take it back to our emergency department directors from a little more of a clinical perspective. But I think it's cultural as well as resource related. Okay, so I see what you're saying. So one way to get to help that would be to have another avenue to send that family to that child, to a call, oh, it's a mental health issue, you would go here to the PUC, like they have down in Bennington. That type of thing that would clear out or keep the ED from being overfilled with folks. And I do want to emphasize that I think PUC is really promising because it's an extra resource for the community, but it's also very promising because it takes the typical referral networks for children and it turns them upside down and it says to the whole Bennington community, if you have a child who's experiencing a mental health crisis or an issue in schools, do not call law enforcement, do not send them to the emergency department, call us first. So that partnership and that collaboration and that effort to change the narrative and change the referral pattern, I think is as important as creating the extra resource for families and children. Yes, I was very impressed with the testimony we heard on that. Now, the other question I have is, do your hospital emergency rooms have an on-call mental health clinician, person, doctor? Do you have someone, a child comes in, he's there, got a problem, got to be handled, you call this person in and they take care of it? Is that how it works? So I think it's different from emergency department to emergency department. So larger hospitals that have outpatient psychiatry programs or have inpatient psychiatric units upstairs have better access to mental health resources. Hospitals and designated agencies have different ways that they work together that varies from hospital to the hospital. So that's another resource that can be brought in. So I think it truly does depend. So the smaller hospitals may not have, definitely do not have the same level of access to mental health specialty and psychiatry as our larger hospitals. And that's a function of, that's just a function of a rural hospital system. So our rural hospitals don't have a pediatric wing that they send children up to if they can't, if they need special pediatric surgery and it's more than just giving a child IV and releasing them. There's, we, because we are a rural state and due to workforce, we can't have every service at every hospital. And so we have this system of emergency departments that then triage and transfer to appropriate places. Okay, are we finding that there are more children waiting at small hospitals in large for mental health issues or no? No, okay. We only have three weeks worth of data. So we don't have anything to indicate a trend, but I would say by and large, most children, most visits that we are seeing waiting are at our larger hospitals and smaller towns. It's also where our populations are. Right. Now that being said, we do see, and again, more weeks of data will help us tell this story a little bit better. But when we see children and adults waiting in smaller hospitals, it creates more, it's more likely that a smaller hospital will have a higher percentage of their overall beds occupied by folks waiting for mental health care than larger hospitals. So even though the numbers can be smaller at smaller EDs, it's a greater proportion of their overall beds. So it can create a strain. I mean, we have some emergency departments that are five beds, others that are 10, and our larger hospitals, it's anywhere from 25 to 40. So there's a lot of variation in just the resources overall that emergency departments have. Okay, thank you. So I'm gonna suggest that we hear from Jack McCullough next and hopefully Devin and Emma will be able to stay with us and we'll turn to Jack to hear some of your perspective from your years of work with the mental health system in here in Vermont. Okay, thank you. I'll leave you to introduce yourself, Jack. Yes, thank you. Good afternoon, Mr. Chair and members of the committee. I'm Jack McCullough. I'm an attorney at Vermont Legal Aid and for about the last 26 years or so, I've been the director of our mental health law project. And the function of the mental health law project is to defend the legal rights of patients in the involuntary mental health system. So by contract, we are automatically appointed by the court to represent anyone in any involuntary mental health proceeding in the entire state. And so we represent people in every hospital in Vermont in which people are receiving involuntary psychiatric care. We represent people in every county who are getting care in community settings. We represent adults and we represent children. And so we have a lot of experience with the kinds of issues we've been talking about. I've observed over many years in this committee that the mental health system seems to be determined or maybe I should say faded to instill in Vermonters with psychiatric illnesses. The perception that the mental health system is not here to help them but to do things to them. And this is another example of that observation. It seemed to get really bad at the beginning of this year. In the last several years, we've certainly seen people being stuck in emergency departments this year, especially for children it seemed to get really bad with children being held for days, sometimes even weeks in emergency departments. And when I say children, we do definitely find ourselves representing children under 10 years of age, sometimes significantly under 10 years of age. But a lot of the children that we represent are adolescents and you tend to, we all know teenagers and we know how we interact with teenagers and we sometimes find even the teenagers we're representing who are being held in voluntarily to be crying, fearful, really desperate because of the situation they're in, they're being held, they don't know what's going to happen. And it sort of seems like, you know, it's hard to know, but when we have children in the hospital and being held in voluntarily, they don't necessarily seem to have the same orientation that adults have to the idea that I have rights, I have the ability to speak up for my rights and I have the ability to have somebody help me stand up for my rights. And so they often tend to just sort of accept whatever's being done to them. And it really, if anything, it really makes them even more desperate in the where they find themselves. And it also makes us, we hear from children and parents that they're less willing to ask for help when they do need it because of the terrible experience they had the last time they went through it. Not every hospital's the same, but you go there and it's been a long time since I've had the chance to visit a client in a hospital, but you go there into the emergency departments and you see a person in a tiny windowless room not free to move around or interact with other people or to go outside. There's a staff person sitting on the outside the room at a computer terminal, watching the person not necessarily interacting with them in any way. And it really is far from what any of us would think of as a humane or compassionate way to treat someone in a psychiatric crisis. I know it's hard in these times to arrange something like this, but I would really urge the committee to get out and visit one or two of these emergency departments to really witness what conditions are like there. And so to give you an overview of the legal structures we work in, the law does allow people, either adults or minors to be taken into custody if the person is found to be mentally ill and a danger to him or herself or others. And when I say found to be, I mean observed to be by a mental health clinician, not necessarily found by court at this point. The purpose of the involuntary custody, you probably heard this referred to as the 72-hour-hold process, the purpose of this involuntary custody is not only to contain the person, to prevent them from doing something dangerous, but also provide psychiatric care. And it can only be justified really in my view if the person is provided with the treatment needed to address the psychiatric crisis that they're facing. The child who's locked in this tiny windowless room with no real therapeutic care is not receiving meaningful psychiatric care. And so we question how the state can justify involuntarily detaining that person. And in our cases, what we've been doing, you know, I'm sure you've heard the term psychiatric boarding. Well, hospitals aren't there to provide room and board for people, they're there to provide care for people. And in cases like this, where someone is simply locked up in an emergency department, we've begun filing motions to dismiss the application for involuntary treatment, arguing to the court that the state can only justify keeping the person if they're gonna provide treatment for them and keeping them locked up in an emergency department is not the treatment. We talk about parity in the mental health system. It's been the policy of the Vermont law for many years to have parity between psychiatric and physical conditions. Would we tolerate the state of affairs in which someone's admitted to the emergency department with a heart attack or other medical crisis? And they're told, we're gonna keep you in the emergency department for several days until there's a cardiac bed that opens up to treating. Obviously that would be intolerable for any other type of care. It should be intolerable for psychiatric care as well. There are a couple of issues that I think are immediate issues that we could talk about. One problem we've noticed is that in our cases for both children and adults, even after an application for involuntary treatment is filed and the person is transferred to a psychiatric hospital, there can be a considerable delay between the time the person gets to the new hospital and the time the attorney general's office files a motion for change of venue. The case will have been filed in Orleans or Chittenden or whatever county the person is initially admitted to, but then when they're transferred to the retreat, the case needs to be transferred to Wyndham County. The judiciary has now has created this electronic file system where the official case file in any case is the electronic file, not a paper file, but still the receiving court can't do anything with the case until a change of venue is filed and the case is now officially located in the receiving court. So one thing that could be done immediately is the attorney general's office could be filing the motion for change of venue as soon as the patient is transferred from the emergency department to whatever the new county is. We've brought that up with them. They may be getting better, but I can't see any justification that there's any delay at all in filing those motions. Another thing that we've noticed, and this is something that's more of a question than a factual assertion because I'm not certain that it's true, but we've repeatedly had clients, children who've been admitted to emergency departments being held for a period of time and they wind up being transferred to the Brattleborough Retreat and immediately or almost immediately being discharged. And it seems that some of the general hospitals, either in the emergency departments or the general hospitals have the impression that they don't have the authority to discharge an involuntary patient before they're transferred to the retreat to have the aviciciatrist at the retreat to evaluate the patient and make the decision to discharge. Before I came here today, I've been emailing with Devin, Green and Emma Harrigan to see if they know the answer to the question. They're gonna help me find the answer to that because if a child's being held just for the purpose of having a psychiatrist retreat, say they're okay to go home, there's no justification for that. And so if that continues to be a problem, that seems like another thing that we can, whether it's a miscommunication between the hospitals and the department of mental health or what, that seems like something that can be addressed immediately. And I think that is pretty much it for me. I think what we've found is that the situation is intolerable. It doesn't seem to be getting better, although I should say after this morning's hearings, hearing I discussed the testimony I heard with my staff and it does seem that the department's figure of only three children in emergency departments as of today, that does appear to be correct based on the number of cases that we have open, so that's good. But I think that's it for me. I'd be happy to answer any questions. So, Jack, I'm gonna jump in here. Thank you. Just to be clear, you deal only with involuntary patients. Is that correct? Exactly, we get up.  They may not be seeking it themselves. And then that's the group that you deal with. Just knowing that, can you, because I think one of the questions that's been raised before is, what are the numbers? And I don't know who's tracking this. Maybe the department actually is because they deal with, they've been tracking the environment. The department actually is because they deal with, they've been tracking the involuntary patients and not always the voluntary patients. And what are the numbers of children? And I'll say you can define it by under 18 or whatever. What are the numbers, what is the proportionality or numbers of children who are in a part of the involuntary mental health treatment system that you deal with? Do you have any numbers that can shed light on that? We do, I'd like to confirm it before giving you a fixed number, but I think the number that I got from my secretary the other day was 42 in 2021. 42 in 2021. And can you put that in some perspective as to the total number of persons that you would have dealt with in that same period so that there's some proportionality? It's a small percentage. We tend to get in the neighborhood of 1500 or probably more cases per year of all of our cases. So 42, if you expand that over the year, it might be 120 or so. So it's a small percentage of the cases that we do. And... So that's 42 to this point in 2021. Is that what you're saying? Yes. So that's not an annual number. Correct. An annual number would be more than that three or four times that. I'm not sure exactly what the cutoff date was. I will get you that exact number. I think that would be useful because I think it becomes... And those are, I mean, proportionally, that's a small number. That's not a small number really when you think about it in Vermont. It's a lot of kids who are in crisis. Yeah. That's a lot of children who are in a situation that is not just a crisis, but is also a crisis where there's considered a danger to themselves or others and there's a mental illness. And another thing I can say is that it's the cases we have in which we're representing children tend to be much less likely to go to hearing than cases where we were representing adults. Typically, once they get hospitalized, they work with the treatment team at the hospital. They work on developing a placement. And not many of them wind up going through the whole commitment process. They eventually get discharged without being committed. Which is probably a good thing all the way around for everyone. Oh, I agree. Yeah. So you don't have this stigma that, I mean, there's stigma, but there's not the same stigma perhaps. Right. Okay. Questions for Jack McCullough. Representative Black. Hi, thank you. I'm not even really sure this is a question. And anyone can address it or not address it, but all day long today, as we've been going through this, I and Mr. McCullough, you sort of reminded me when you said something that you thought might anecdotally be happening. I just keep thinking, how did we go from 19 kids to three kids in two weeks? Did we, are we doing things that we should have been doing all along? Or are we making space for some at the expense of others? And I'm not sure. Or is it just a coincidence that this has been, you know, on the radar for the last two weeks and it's gotten better? Yeah. It's being cynical. And like I said, it's not really a question, but... An observation. It's an observation. May I dive in a little bit to that thinking? Please, welcome you too. Devin Green, Vermont Association of Hospitals and Health Systems. I would just say, I wouldn't hang my hat on it yet. I think you see that the data fluctuates from what the M.H. showed you. We only have three data points, so we can't say what is happening right now or whether there was an intervention that helped. I think it's just a matter of... And again, it matters in our point in time, right? Which is why we try to include the anecdotes that say, someone who was waiting here for eight days just left 30 minutes ago to create a larger picture. But I don't think we can say what made that change at this point. And I don't know if you have anything to add. Thank you, Devin. I think you covered it. We only have three data points, so we can't really say for sure what the trend is. But we can say when we look at emergency department visits over time at on a yearly basis versus week by week, we have seen increases with each year in the number of visits and the number of days that those patients are waiting. And that number does include kids and adults, so I don't have a good sense of how the children's picture has specifically changed over time. And I will also say the kids number that we've provided has gone from six to 19 to six again, but the adult number has been much more static at, I don't wanna say off the top of my head, but in the teens to the 20s with each of the past three weeks that we've reported. So we are hoping that more weeks of data will help us understand more of a trend. And when you put this on top of the data that we've provided going a little bit further back, this is at the top of a very long increase of overall visits and days to emergency departments in Vermont. It's also, yeah, I think representative Black's question is one that's crossed other minds as well. And I wanna just put out there, you know, in some ways I regret that I didn't make it more of an issue earlier in this legislative session, but at one point I raised with some of my colleagues here that I wanted to see us try to establish a goal of what, I mean, to challenge all of us as stakeholders to say what would it take for there to be no child waiting in any emergency department for mental health services period. And I still think that's the goal that we should establish. I think that that's the measure that we should have and that when we deviate from that, we need to understand why we're not accomplishing that. Because we, I mean, I'm just gonna get on my own soapbox, but I think, you know, we've heard enough testimony and I think we know enough to know that there's nothing therapeutic about being kept in a non-therapeutic setting in an emergency department, despite the best intentions and best efforts of those who are operating in difficult situations. And I don't attribute motive, personally I don't attribute motive to anyone working in our emergency departments, but I think we need to collectively, and I think that's part of our role as the legislature quite honestly. I don't think our role is not always just to pass statutes or to, there are times when the role of our work is to shine a light on an issue and to use that to convene or mobilize stakeholders other than ourselves and in addition to ourselves around an issue. And I think that's how I see this situation at this point in time. I think there are numbers of specific suggestions and some mid-term suggestions that we will as a committee try to collect from different stakeholders who have testified and identify. And to work with the department, one of the things that I wanna take from this is that I wanna work, I wanna have the department work to identify timelines and goals and measures for implementing and tracking whether we're successful in implementing some of the issues that we've identified as achievable. Some of the most immediate ones, including some that Jack mentioned, which are less, I mean, frankly, I think most people couldn't begin to come up with the specifics that were articulated there because they're very much in the legal world weeds, but when you do, when you put a number of small pieces in place, it can begin to make a difference. And we know that there's some things that need to be done in the medium-term that need to be set in motion now. But I personally would just, I think collectively, we should challenge ourselves to have a goal of no child waiting in an emergency department for mental health treatment. And we should air in the direction of having the resource that allows that to be the measure, the successful measure, that there may be times when we don't actually use every resource because, in fact, we're successful. So let me, so we have a number of questions still. I'm gonna suggest that we continue to take questions and then we, I think, well, let's do that and then we'll see what we do next. Okay. Representative Goldman, I think I see in the hands just Representative Goldman, Jack McCullough and Representative Peterson, is your hand still up or is that a new hand? In any case, Representative Goldman, go right ahead. Well, I was last. So I think- Okay, it's hard for me to tell on the screen, sorry. Okay, I'll go. Go for it. Yeah. Yeah. Take your turns. Yeah, I think that was the first one, but it doesn't matter. I'm still, I'm trying to get to, and Mr. McCullough raised the painted a picture of kids in a windowless room sitting there and I'm trying to figure out where the holdup is. And Devin, you've talked about workforce issue. Are we saying we don't have enough mental health workers to take care of kids that come in? Is that where the rubber meets the road? Okay. A child comes in with a parent. You know, with a real problem. It would seem someone would, in any kind of hospital, somehow, somewhere would get a hold of someone that could on call or not come in and take care of that child's need.  If they have to stay, then that's another issue I guess we have to address is, is room or place or where or how that individual would get there. But it sounds like it's straight manpower issue. We just don't have people. Have I got that right or am I way off base? I'm trying to understand it. Can I jump in here and say, I don't think you're completely off base because there are 500 vacancies across the community mental health system generally. And so we're trying to address that through workforce issues. I mean, we've been coming at this issue, not just for children, but generally for a period of years now. And there is a mental health workforce shortage. That's not, but I don't think that's the key issue in this instance. That's not the only key issue. It's also, as I think Representative Peterson, and I think what we're hearing and what we know from testimony is that there's also a shortage of alternative settings from emergency rooms. So someone who comes through an emergency room, in fact, may not be able, based on evaluation, and Representative China can probably speak to this because he's actually one of the people that participates at some level of evaluation. But based on an evaluation that it's not appropriate for the child and the family to have the child go home with the family at that time. The question is where can they go and not sit in an emergency room, which is a very highly technical, highly skilled, very expensive setting to really respond to physical healthcare emergencies primarily. But if we don't have an opening in a respite bed or in an alternative setting where there are staff already there working with children and families, then there's no place to quote, transfer them to. So they sit in the emergency room until the bed opens up in this alternative setting. That's part of what we've been pushing for as a committee and the department is committing to as well to try to create more settings in the community for children and families. But not just at the front end, like the puck is a prior to getting to keep people from going to the emergency room, but we also need settings for children to go to once they've been in the emergency room or once they've been at puck and they're identified, they need more than can be provided there. They need someplace other than an emergency room. So I think we have, and I think we heard the commissioner say there are resources that can be put to those. We're fortunate there are some substantial federal resources that can be used and that is underway and in the process. So it's a combination, it's a system and just as the commissioner said, it is a systemic issue, but it requires movement in different parts of the system simultaneously and we're trying to move that system and the department is trying to move that system. But it's not strictly just like there's literally not manpower in the emergency room. Although there is a shortage of psychiatrists, there's a shortage, so we need to have telepsychiatry. There's a shortage of staffing in the community system generally because we have chronically underfunded the system. So anyway, it goes, so it's all these different pieces that fit together. And in some ways, I think someone said at one point, I think it's maybe not a completely accurate analogy or metaphor, but in some ways, children waiting long times in an emergency room setting is a little bit like the canary in the coal mine. It's like, it's a symptom. It says there's something not working in this whole system when children end up waiting in non-therapeutic settings in an emergency department for failure to be able to get to an appropriate setting. And it's not just a matter of changing the emergency room settings to have them be more amenable, et cetera. That's part of it, but that's a symptom rather than a solution, long-term solution. That's my... Well, let me just say that that is, thank you for that because that helps a novice like myself in this environment I'm trying to learn, understand where the problem is because I haven't heard that expressed quite that way and that registered me, so thank you. And I would just say, I appreciate your questions as a novice to this because in fact, it actually asks some of the questions that people would be asking who are not immersed in this system. So I represent Pearson, I actually appreciate and value your asking some of the questions which need to be asked. And I wanna follow up with one other thing and then I wanna hear it from the other members who have questions. I think it would be useful at some point in time given everything else we've gotta do, but it may not happen immediately, but somewhere along the way, I think it would be very illuminating to have our committee hear from folks who are actually working in emergency room settings to talk about, to answer the question you have. I mean, I have a picture in my head but it may not be current or most complete to hear like, what is it that's bringing children to the emergency room settings and what are you seeing, what are you doing? What are you not able to do? To actually hear from the frontline people, I think that would be illuminating for us whether it leads to a specific intervention or not. I think the information would be useful from your perspective, represent Pearson. I think it would be actually useful to all of us. And I'm gonna turn to Representative Chiena who actually has feet in multiple worlds here and actually has some of the more direct experience than many of us. So, Representative Chiena, I'm welcoming you to this. Can you hear me okay right now because I'm using a different sound system than usual. It actually can hear you very well. Okay, good. So yeah, I am a part-time crisis clinician at the Howard Centers and I've been one since 2004. So that's 17 years. So I've seen like a lot of changes and I've seen a lot of things stay the same. And I will say that what the chair just said about, there's nowhere safe for someone to go is often the barrier. Like there's not, the bed's not open yet that they need. They're unsafe to go home and there's nowhere to go other than staying where you are but it's not a therapeutic environment and people languish. And I think part of the problem is I'm gonna say something and then I do have actually have questions, but it seems like people are sharing thoughts too. So I will, and you literally just said we should hear from frontline workers and the emergency women and so. And I say this with all due respect, but like part of the problem is the infrastructure and part of the problem is like the culture. And like people get inconsistent treatment. Like what a person's gonna get from me may not be the same thing they're gonna get from another crisis worker. And sometimes people get, like I sit in the back room and hear how people are talked about by providers and it's concerning to me. And in that position, I'll advocate for clients and I'll speak up and then sometimes I just have to be quiet and do my work because I'm not gonna change someone else's mind for the judgment they made about a person and how they're gonna treat them. So I think one thing we could do is look at how to address burnout and staff and look at having more consistent training and like standards between people. And part of that's probably within a program. Part of that's, it's not like when I say providers like there's so many different providers in the emergency room working together. Like there's mental health crisis workers like myself there's like the peer substance abuse support people. There's nurses, there's doctors, there's residents, there's the sitters and depending what sitter you get you're gonna get a different experience. Like it's just inconsistent treatment. And so a few questions I have is, have we ever, I'm just gonna say them and then be quiet and listen and continue to digest because I'm trying to listen and reflect too in this moment, have we ever considered we meaning like our society or whatever, have we ever considered having UVM create an inpatient unit for adolescents because I keep hearing they can go to Plattsburg but that doesn't really work well for people. And when there's like nine kids in the emergency room at UVM, it just doesn't make sense that we can't move some of them into the hospital if they really need that level of care. The second thing is, could there be some kind of mobile therapy program that begins therapy in the emergency room or in some adjacent unit kind of like a like a like more intensive than just giving them puzzles and books and like juices and putting a video on, like having like similar to like how on the inpatient unit there's the activity staff, people who could be like a little more interactive. And then the last question is, have we ever considered like sending them home with a sitter, like a person goes to the home and stays at the family's home and stays awake and sits with that child in their own home and helps the family kind of like a visiting nurse or visiting social worker and sits with the family at home until the bed opens, you know, because I'm just trying to be creative about like how do we address this? And that's a question that I thought of while you were just talking. Thank you. I don't know there's answers to your questions but I think the questions need to be out there and I think the kind of things that you're asking about are the kinds of things that I would hope and want both the hospitals and the department to be participating in as key stakeholders to think creatively. Because in fact, we have a history in Vermont of thinking outside the box and thinking creatively about how to keep people in their home settings. And this is another instance where and anyway, I could go on over the years, I watched us take initial efforts in one part of the state and then try to find a way to move those successful efforts into other parts of the, everything from parent child centers. We didn't used to have a system of parent child centers and we now do. We, I mean, intensive family-based services were an innovative model at one point in time and now they're in intensive family-based services is something that we think of as an essential piece of intervention with social workers. So I think that's a great question. Intervention with certain levels of need. And I think some of the things you've talked about, I think there's things we can learn. And I would, I don't, we're not here to do that today, but I think we're here to identify who can best be the crucible for thinking about new, to continue to think about, because give credit where credit is due. The department has been thinking about and working on numbers of these issues. This is not like they have not been part of this, but I think we need to add to that and add our sense of external urgency around this. So with that, so Brian, I'm not trying to, I don't know if others want to respond to your particular suggestions or questions. Yeah, thanks. I don't expect answers right now. There's sort of things that I've been like as I'm listening to the discussion that came up and I just thought I'll put it out there and if people can't answer it today, at least it's out there and people we can maybe be thinking a little more creatively. Not that we haven't, because I do wanna say that in the 17 years I've worked, there's all kinds of improvements and all kinds of things that have gotten better, but there also are some things that just aren't changing and it's not okay. I'm gonna turn to Representative Donahue and then Representative Goldman or whatever order. Just a quick comment, because if it were adult mental health, I would have remembered to say this a whole lot earlier, but I'm hearing about meetings, vast DMH, emergency directors and all that and I strongly encourage involving pure voices at every table and in this case, that means parents. There is a, the head of the Family Federation couldn't make it today to testify here, but I know Digger talked with her, she was talking about opportunities and ideas and that voice needs to be at the table from day one, not with here's our plan, what do you think of it?  Great, thank you and I'm aware that Sandy and I was not able to join us today, but I'm calling your listening here as well. I'm wondering if reaching out to her and seeing if she's available to join us when we have some further discussion tomorrow afternoon, whether that's a possibility. Okay, Representative Goldman, and then let me stop and think about how we proceed from here. I wanna thank you, Chair Lippert because you said something really important that got my attention, which was you wanted to set a goal of no child in the ER for mental health issue. I think that's a really important goal, but I think it needs a timeframe. So, this is a big system, but I would want somehow to say by one year from today or by somehow we put the pressure on to say, and I don't know if we do this as a committee and of course, I don't have this whole system works about this mental health. You just said a mental health group that already exists. How do we fix it in a timeframe that we can live with because it's not gonna be next week. And obviously it's been going on for years. I like to see goals that have a timeframe so that we can know whether we're reaching that goal. So, I wanna thank you for that. I'd like to put a timeframe on it. I'd like to say, you know, tomorrow can't do that. I'd like to say by the end of the summer, can we do that? Hopefully COVID will be over, the school supports will be back in place. Can we really look and say in six months because schools will be back in session and kids will get the support that there won't be kids in the ER. If there are, we then have backups that we need already, you know, ready to go. So, I would like to see a timeframe. Thank you. So, I'm aware of the time and I'm also aware. So, I think there's been very fruitful testimony and conversation here this afternoon. I think a next step from my point of view picks up on what, not just what Representative Goldman said and what I suggested, but from, I think there's, I think one of the roles in addition to shining a light, bringing this issue to the forefront again and not saying, oh, it's now six. So, we can back off. It's not 19 anymore. I think what I've learned over time in this process is it also requires persistence and commitment over time regardless of the issue. This happens to be an issue I think which engages many of us. It doesn't mean we're not committed to other issues, even related mental health issues including adults in the mental health world. But I want to suggest that my sense, I'm trying to do the committee now for this, but I'm thinking that rather than trying to turn our attention to trying to bring together specific recommendations at this point in time, that we might step back. We have scheduled some time tomorrow afternoon on our agenda. I think the floor may be such that we can actually achieve that and that we come back and have some committee discussion based on what we've heard, based on some of the ideas that move it forward and try to then see if there's, what our role is in terms of, what our role is as a committee in terms of taking next steps. Because as I say, it's not always statutory. It's sometimes, there's different ways for us to influence change. My sense is that while there's good energy, there's also it's late in the day to begin that process right now. So I'm going to suggest that we not try to do that right now, not to try to avoid it, but because I think we'll be more able to with maybe a little more fresh energy. And I think I'd like to take a five minute break before, and so I'm, Jack, are you, is that your hand raised? Yeah, go ahead Jack. Yes, thank you. I just wanted to, because I'm on the verge of bringing this to a close for the afternoon in terms of this topic. So I just wanted to open up and say is there any last comments? Great, thank you. I know the focus of today has been on, and this week has been on children and emergency departments. I just want to say, Mr. Chairman, I agree with exactly with what you said that there should be, we should be in a situation where there are no children waiting for psychiatric care in emergency departments, but we should also bring about an outcome in which there are no adults waiting in emergency departments for psychiatric care. I'm sure you, I know you agree with that. I completely agree. But I also think strategically, we need to put attention in a particular place. And my experience also is, if you move part of the system forward, you may very well move the entire system forward simultaneously, but you'll be more effective. I think we will be more effective if we continue to focus attention and energy on this. I will add one other thing, because I'm struggling as I'm listening. Some of us I think represent Donahue and myself and maybe others, I apologize for forgetting. We were approached by Spectrum Youth and Family Services some many months ago around them because they work with youth, but they work with transitional youth who are sometimes older than 18, but younger than 21. I don't know what the official denotation is. And I'm wondering, I find myself wondering in terms of the data and understanding who we're talking about, that there's particularly unique, I think there may be unique needs of transitional youth or they might be transitional young adults. However you think about it, and I'm wondering whether we're capturing really the magnitude of what we're talking about in terms of what is happening in our emergency departments when we just say youth. And Emma, in terms of your numbers, it's under 18 or 18 and under, but that means someone who's 19 or 18 years and are 19 in a day or something like that. You could, there are many young people who are particularly if they're homeless, if they have no housing, if they have no family supports, they are really not in the adult world in the same way as someone who's like, even 25 or 30 and has a whole different world around them or may, I mean, not everybody does. But I guess I'm wanting to also acknowledge that there's a transitional youth segment of the population that I think maybe doesn't get captured as we talk about youth as 18 and under. Right, they're all counted as adults and that includes treatment settings as well. So inpatient hospitalization. It's probably a broader issue. They all, at 18, it's all the adult system and numbers. Yeah. Okay, so I represent page, I see your hand. Welcome you to show me. I'll just be quick, but I just wanna remind everyone that so long ago this morning, we did have a presentation by commissioner Squirrel and she did have some immediate solution midterm and longterm. And I don't know whether Devin or the others were listening in what they think of those solutions, whether we think they're gonna work, whether there should be more work done on them. And I guess I'm putting you on the spot and I don't wanna do that, but I'm just, I just wanna remind the committee. We did hear some thoughts from the commissioner and I'm not so certain that they're the right ones. And I will also add, and maybe I'm sticking my neck out on this, but our secretary of human services made some comments and maybe he was misquoted about how we shouldn't react to perhaps a spike or a seasonal fluctuation, but I don't think that's the case here. And I don't know as if he has actually retracted or rethought those comments that were made previously. So I'll just leave it at that and just perhaps take a break maybe. Okay, Emma. So I would say we were really encouraged by the agency's presentation this morning and we are at the ready to work on any solutions that the state has proposed and also work on the solutions that we brought forward in our memorandum and that we are ready to collect data and use data to measure whether the initiatives that the state wants to implement are being successful. And I think the addition of some sort of timeline or time period so that we can measure and assess whether we've achieved this in a year from now or at the end of the summer is also something we should add but we need to look at them in more detail but we were encouraged by what we saw this morning. So one thought I have and I'll just throw it out here and then it's part of what I was perhaps gonna say tomorrow afternoon, when we get to it is that I would like to ask, I would like to not have us necessarily be in the position of evaluating which are the best proposals or not the best proposals. I don't think that's our job particularly as the legislature and except unless there's a major initiative that requires significant funding or authorization, et cetera. But I would like to ask the department and the hospital association as two of the major stakeholders to take their suggestions and put them into actionable time measures and metrics to measure the successful implementation of those which are deemed as immediate and some of the medium term goals. I think to ask the department and the hospital association to come back and say some great ideas here, let's put them into a timeframe and some metrics to measure whether we've gotten there. And I think that would take us and that with a broader what I would call an aspirational goal but an actually achievable goal of no child waiting in an emergency room for mental health services would be would give us something to look to collectively and measure ourselves against not criticize each other but measure ourselves. What did we do? What has been successful in moving this forward and in fact, over time that trend line if it gets to where we hope it will be how do we keep it there? So that's the kind of thing and that's not gonna happen by tomorrow and I don't expect it down by tomorrow but that's kind of one of the things I would hope to that we might that might come out of our testimony. Representative Houghton. Thank you. I am encouraged by all the meetings we've had on this in the path forward. I guess I just wanna say that and I'm confused a bit by the numbers that we've heard in both presentations but if I'm remembering correctly we may have one or two children still waiting in an emergency room department for potentially seven or more days right now and I think we need to find a way to help those children so quickly. So I'm just, I just have to bring it back to that or I'm thrilled about this path forward we have. Thank you. Thank you. I feel like I've been trying to bring this to closure and I keep opening it up but I feel like I need to add one more issue to the table that has actually been in the back of my mind for every time we've talked about children and waiting in emergency departments. Especially when we hear Jack McCullough say that part of why some children wait is because they're deemed a danger to themselves or others. We need to require ourselves to look at the painful really painful data of the children who were a danger to themselves. And who we lost. And that's not attributing any kind of anything other than the fact that, well, where we collectively have not been successful in finding a way to help those children and their families in a very difficult time that's led to a death. And so I think that that's a very hard thing to look at and a very painful thing to talk about. But I think that that has to be part of the picture that we look at as well. So, and I know that there's a lot of resource being mobilized by the department and others. And it's a very, very important issue. But I'll just add it to the table of things if we're thinking about what's happening with children and mental health and or the challenges that children and young people face. It has to be part of the conversation as well. So, and we need the data around that as well. Representative Donahue. I just can't help but then add in as we try to wind up that part of that balance and consideration has to be that death that results is often from the sense of terrible hopelessness. And if when you've tried to get help you wait for days in an emergency room that contributes rather than helping prevent. It can be a trauma that makes it higher risk for you rather than saying, well, we're keeping you safe. You are for that those eight days, but then maybe things are worse afterwards. Yeah, I appreciate that. And I think that's part of why it's been in the back of my mind as we're talking about this that we want to find ways to mitigate additional trauma in an already difficult situation for a young person. Okay, Representative Coleman. I can't help but be struck by you bringing up the issue of children who do harm to themselves. We had a tragedy in our community this weekend, past weekend of it was an auto accident involving alcohol and a 16 year old died. And to me that's a child that's hurting. So how do we sort of identify them as well? We're focusing on the ER and that's in a really important place. But I think we have to also broaden a little bit and think about other children who are hurting. So I just want to throw that out there. Well, and I want to just say that I think that I will give credit to the commissioner of mental health this morning in bringing into the conversation the commissioner DCF and the commissioner of Dale as well or the folks from Dale because there are definitely young people who are not in the ER but who are whose lives are so disrupted that they are in the care and custody of the state and clearly are in need of tremendous, tremendous support. Okay, I think I'm not going to take a break right now. I think I'm going to suggest that we bring this to close or close for the afternoon. We will find a way to reschedule what we were going to do earlier and I'm not going to try to do it now. And we'll work our way through this. And I think I want to just say that I think this is an important piece of work for this committee right now. And it's not just measured by what bill we passed or what bill we didn't pass or what's going forth between us and the Senate right now. I think this is an important piece of our work collectively as a healthcare committee. So let's stop for, I'm going to suggest we stop for the afternoon. We're back here tomorrow morning as a committee when in fact, interestingly enough, we're going to, we're going to be looking at several sections of the budget and then we're going to be hearing from a number of advocates late in the morning as well around some of the work that is still ongoing. And we will then in the afternoon, hoping the floor will allow it, we'll come back to some further discussion around this issue tomorrow afternoon. But in the meantime, we will reflect on what we've heard today from each other and spells from our witnesses.