So I'm going to start the meeting. My name is Kevin Mullen, Chair of the Board and I'm going to call this meeting to order. Susan Barrett, do you have any comments as the Executive Director? No, I don't have any additional announcements, Chair Mullen. Okay, great. So the purpose of this afternoon's meeting is to discuss a Certificate of Need application for a secure residential facility. And at this point in time, I'm going to appoint Laura Belevo as the herring officer and turn the meeting over to her. So Laura, whenever you're ready. Yes, I'm ready. Good afternoon. My name is Laura Belevo. I am a Staff Attorney for the Green Mountain Care Board and I will be serving as the hearing officer for today's hearing. It's a hearing on the application of the Vermont Department of Mental Health for a Certificate of Need to develop a secure residential treatment program at 26 Woodside Drive in Essex for individuals requiring residential treatment program services for mental health conditions. The docket number for this case is GMCB-002-21CON. We're holding this hearing primarily remotely via Microsoft Teams. We also have a physical location for this hearing in compliance with the Open Meetings Law. And that's here at our offices at 144 State Street and this location is staffed in case someone would like to attend here. Given that all the board members are participating remotely, I'll start by making sure the board members and participants can be heard. So I will start with the board members. Mr. Chair, can you hear okay? I can, thank you. Member Holmes, can you hear me? Yes, I can, thank you. Member Lunge, can you hear okay? Yes, thank you so much. Member Youssefer, can you hear okay? Maureen is not on this. Oh, okay, so Maureen is not attending, great. Correct. And Member Pelham, can you hear okay? I certainly can. Wonderful, all right. Representing the applicant today is Karen Barber, Department of Mental Health General Counsel. Ms. Barber, can you hear okay? I can, thank you. And as you mentioned before we started, your name indication is Anna Strong because you were having technical difficulties, but you are in fact Karen Barber. Yeah. The healthcare advocate has intervened in this matter and is present today. I believe Eric Schulteis is here. Can you hear okay? Yes, I can, it's gonna be Mike Besser and Sam. Excellent, okay. And Mike Fischer, you can hear okay? I sure can. And Sam Piesch? Yep, again, that's Piesch, tough questions. Oh, I'm sorry, thanks. No problem. Excellent, and we have Joanne Carson, our court reporter on the line. Ms. Carson, can you hear okay? I can, good to see you, Laura. Thank you. So as the chair alluded to, normally we would have a sign-in sheet documenting who's in attendance today, but we can't do that remotely. But I can, I have a participant list and I can see the people or telephone numbers of the people who are on the call. So what I'm gonna do is go down the list of people I see and ask if each person I call on can please state their name. And if they are here representing an organization, the name of your organization. And I see 802, 234, 2505. That may be our conference line. Oh, thank you. I'll move on then. Joe Aja? Joe Aja, we're building your general services. Great, and Donahue? And you might be muted. I'll come back to Ms. Donahue. Susan Barrett, who is the executive director of the Green Mountain Care Board. Elena Barrabes with the Green Mountain Care Board. Bob, who is a guest? Bob, could you tell us your full name and if you're representing an organization? Sure, Bob Beck, I'm with the Howard Center. Thank you. Kathy Fulton? Yes, good afternoon, Vermont Program for Quality and Health Care, thank you. Excellent. Abigail Connolly from the Green Mountain Care Board. Abigail is keeping us all held together here, so I wanna make sure she can hear okay. Yes, thank you. Excellent. Dale Hackett? Dale Hackett, independent, just here as a guest. Thank you. Devin Green? In front of the Vermont Foundation. I'm sorry, could you please say that again? Devin Green from the Vermont Association of Hospitals and Health Systems. Thank you very much. Elliot Rubin? Yes, I'm here, independent Elliot Rubin, just representing myself as a guest. Wonderful, thank you. Eric, we already heard from Grace Gilbert Davis. Hi, Grace Gilbert Davis, Blue Cross, the Shield of Vermont. Kathleen Hensie? Kathy Hensie, Department of Mental Health. And then we have Ralph Irish? Hi, Ralph Irish, Department of Mental Health. And then Donna from Green Mountain Care Board. Donna, can you hear okay? Yes, thank you very much. Kylie Kuiper? Yes, Kylie Kuiper, Office of the Healthcare Advocate. And Sabrina Karish? Sabrina Karish, Buildings and General Services. I'll go back and see if Ann Donahue can hear us okay? Okay, there is also, if anyone is having difficulty with the full teams function, I believe there is a call-in number available as well. Madam Hearing Officer? Am I now on? Madam Hearing Officer? Yes. Just wanted to point out that the way the team set up is you didn't see all the names, you have to click on the More button and there were several after Tejina. So there are, Jennifer Acalias? Hi, from the EVM Health Network. Maureen Leahy? Maureen Leahy from EVM Medical Center Psychiatry. Jeffrey LaCourse? Yeah, Department of Mental Health, here's a guest today. Hi, Russ McCracken? Hi, Russ McCracken, Staff Attorney and the Board. Aaron McKenney? Hi, I'm from DMH, attending as a guest. Mark O'Grady? Department of Buildings and General Services. John Olson? State Office of Rural Health, as a guest. I see we have Orca here. Rebecca Copans? Blue Cross and Blue Shield of Vermont. Okay, and Patrick Rooney? Patrick Rooney, Green Mountain Cowboy. Patricia Singer? Department of Mental Health, as a guest. And Anna Strong? No, that's Karen Barber. I don't know if Anna Strong is separately on the call? I am separately on, yes I am. Thank you very much, I'm attending for DMH. Wonderful. Susan Ridson? Yes, I'm here as a guest. Thank you. Samantha Sweet? Hi, Samantha Sweet, Department of Mental Health. Okay, Zachary Hozid? Zachary Hozid, Disability Rights Vermont. One more person that is not, that team is not letting me see who it is. If I didn't call your name, could you please let me know? Lucy Garan, MMR. Thank you. Madam Hearing Officer, I wonder if you could call on, I've been in touch with Ann Donahue over text, maybe try her one more time. Yes, certainly. Ms. Donahue, can you hear me? I can hear you, that's wonderful. Well, as happens with this, I've asked everyone to unmute, and now if I could ask everyone, but the person who's speaking to mute back up, that will make the quality of the call better for all of us. I wanted to note a couple of notes before we begin. All of the documents in the application to date are part of the record. Today's presentation and the transcript of the hearing will be added to the record. You can find the materials related to the application to date on our website. Now, the order of today's proceedings. First, the applicant will go through a presentation. They will be sharing this presentation with the board members and others participating via Microsoft Teams. Copies of the presentation have been posted on the Green Mountain Care Board's website for members of the public to follow along. The easiest way to access those documents is by going to the 2021 Board Meeting Information tab and finding the documents for today's meeting. Ms. Barber, as you and the other representatives of the department and buildings and grounds go through your presentation. If you could please just identify the page number of the slide you're on as you go. So if anyone who's calling into the meeting instead of watching the video would be able to follow along that would be very helpful. I'll ask board members to please hold your questions until after the presentation is finished. After the presentation is finished, I will ask the applicant some questions provided by the healthcare advocate. Following that, I'll be calling on board members individually to see if they have questions. Following the board member questions, we will take public comments beginning with the interested parties in the order of the healthcare advocate who is an intervener in the proceeding and representatives of the amicus organizations we have here. Disability Rights Vermont, I know has a representative here. I'll just ask again in case I missed it when we went through their original roll call if there are any representatives of Mad Freedom Inc. on the line. Okay, if they come, they'll be able to, if they come in late, they'll be able to join us. And then following the amicus organizations, it'll be other members of the public. And then following public comment, we'll adjourn the hearing and turn the meeting back over to the chair. So if we'll start with swearing in the representatives who are gonna make the presentation today, I have the list from the PowerPoint, is that an accurate list of who's gonna be speaking today? Yes, the only person we added was Marco Grady from BGS. BGS, great. So I'm gonna call on the people who are listed and ask you to take the oath so that your testimony can be entered into the record. So Samantha Sweet, Anna Strong, Ralph Irish, Yeah. Kathy Hensie, Sabrina Keras, Yeah. Joe Aja, and Marco Grady. Yeah. Please raise your right hand, all of you. And do you swear or affirm that the evidence you are about to give shall be the truth, the whole truth is nothing but the truth? Yeah. Okay. Ms. Barber, I will turn it over to you to start sharing and start your presentation. Skip is gonna actually share his screen in the PowerPoint. So I can see my notes. Good afternoon. My name is Karen Barber and I am general counsel for the Vermont Department of Mental Health, or DMH. DMH, along with the Department of Buildings and Grounds or BGS has filed this application pursuant to the Certificate of Needs Statutes to build a permanent physically secure residential treatment facility in FX to replace the current seven beds, DMH operated, middle sex therapeutic community residents. I will be the main presenter today but helping me are the following staff from both DMH and BGS. There's Samantha Sweet who is our mental health services director, Anna Strong who's a financial director, Ralph Irish who's the MTCR program director and Kathy Hensie who's our director of mental health and healthcare integration. From BGS, we have Sabrina Karish who's the project manager of this project. Joe Aja who's the director of design and construction and Marco Grady who's the deputy commissioner. This is how I plan to organize our presentation today. I'm gonna go through the legislative history of the project, the project overview and need, design of the facility, financing and then go through your specific criteria. Just a note, we've submitted a lot of information already to the board both through our initial application and through our responses to five rounds of questions. There's a lot of information in this PowerPoint summarizing all of that and I wanted to include it so it would be easier for you all to review but I plan to just highlight what DMH thinks is the most important during this presentation. Then of course we will be able to answer any additional or more in-depth questions and I apologize, I'm on slide four, slide five. This project is likely unique for most projects that come before the board because it has spent years going through the legislative process. This new facility and resulting CUN are the results of years of legislative initiatives, studies, plans and requirements to meet the needs of our mentors and build a permanent facility all of which included extensive stakeholder engagement surrounding need, citing design and programming. The planning for the design currently before the board began in earnest in 2019 when in Act 42, the legislature allocated an FY 2020 $3 million for the replacement land acquisition design permitting and construction documents for the new secure residential replacement facility, slide six and an additional 1.5 million in FY 2021. Slide seven. This session, the legislature gave us the most pointed direction in Act 50. In section three, which specifically appropriated an additional $11.6 million for BGS for the secure residential recovery facility design and construction. The language went on to specify where the facility must be built as well as including specifics about its construction and outdoor space. And in slide eight, I have included the entire text of the statute first to build. Slide nine. To back up a bit, the need for an intensive secure level of care was first identified as part of the ongoing planning process to replace the Vermont State Hospital in 2005. When tropical storm Irene flooded and closed the Vermont State Hospital in 2011, devastating Vermont State Run and voluntary psychiatric inpatient care capacity, the state implemented this new level of care. Passage of Act 160 in Act 79, both in 2012 codified the statutory basis of the secure residential recovery facility, the resident population it would serve and its state run operations role. Act 79 also specifically committed to building a permanent program. Slide 10. MCCR Open in 2012. It was built using federal emergency management FEMA funds and is essentially two FEMA trailers put together. It was never meant to be a permanent solution. It is a step down facility for those who no longer need inpatient level of care but continue to need intensive services in a secure setting. Every resident is involuntarily in the custody of the commissioner of mental health and has been referred from an inpatient unit where they were placed via an order of hospitalization. While we have on average about 300 people at any one time on orders of non-hospitalization, being sent to MCCR requires a particular O and H with the judge making a specific finding that there is no less restrictive alternative than a secure setting. Slide 11. Planning for a permanent facility began soon after MCCR is opening in 2012 with Act 178 of 2014 first proposing the creation of a 14 bed replacement facility. Then in 2015, Act 26 directed DMH along with BGS to further explore siting and design considerations as well as consider the broadest options for management and ownership. During this time, DMH posted an RFI and later an RSP and considered whether there should be more than one location across the state, whether it should be state run, privately run, or partly state run and partly privately run by 12. During the 2017-2018 session, the legislature passed several bills related to this facility. In Act 84, 2017, they authorized BGS to purchase land and in Acts 82 of 2017 and Act 200 of 2018, they required DMH to do a further examination of the mental health care delivery system and examine coordination across service settings. Slide 13. Act 200 of 2018 included the specific intent to replace the temporary middle sex secure residential recovery facility with a permanent facility that has a 16 bed capacity. It also required AHS to submit a comprehensive evaluation of the mental health delivery structure. Slide 14. In January 2019, DMH presented the legislature a comprehensive report and then again in January 2020, we presented Vision 2030, a 10-year plan for an integrated and holistic system of care. Vision 2030 is the result of an extensive and comprehensive stakeholder engagement process conducted by DMH. Over 300 Vermonters participated in a statewide listening tour when DMH staff traveled around the state holding listening sessions. There was then a DMH think tank which meant for five full days over several months to craft strategies. The think tank had 25 members including psychiatric survivors, family members, peers, advocates, legislators and representatives from hospitals, CAs and one care. There was also a smaller think tank advisory committee that reviewed progress and provided feedback on draft. And finally, the draft plan was posted online for additional public comment and was specifically sent to various stakeholder groups for input, including the adult state program standing committee, the children's news and families state program standing committee, the Act 264 advisory board and all listening tour participants by 15. In December 2019 pursuant to Act 26, DMH submitted a report that outlined the mental health bed needs for residential programs across the state by geographic area and provider type. Specific to MTCR replacement, the report outlined the population to be served, the number of beds needed, justification for the ongoing need and the funding request in the FY20 capital sales. Slide 16, as mentioned earlier, Act 42 came out of that, which demonstrated the legislature's increased commitment to the facility by allocating to BGS 3 million and FY 2020 and 1.5 million in FY21. DMH and BGS worked together with a contracted architectural firm pursuant to Act 42 to design the state-of-the-art therapeutic get secure facility presented to you in the COM. Building design schematics included the involvement of key stakeholders during the summer and fall of 2020, which BGS will discuss further. Slide 17, this project was the focus of many hours of testimony and discussion during this last legislative session culminating in Act 50. I think it is important to note that DMH alone testified 12 times this year and has corrections in institutions, house healthcare, Senate institutions, and Senate health and welfare just on this project. Many psychiatric survivors, peers, and advocates also testified. Slide 18, now to the project overview and needs. DMH believes that in order to provide equitable care to Vermonters, a robust continuum of step-down treatment programs must be available and a permanent secure program is a key component. 19, this program targets a small number of individuals with complex needs who cannot be served elsewhere. These are individuals whose clinical presentations and safety risk means that they cannot be served safely or therapeutically in the community at the time they're ready to discharge from an inpatient unit. The goal of MTCR and this new facility is to move people as quickly as possible out of the secure setting and into more integrated community settings. This is not a long-term facility and residents from day one work towards discharge. DMH's goal and statutory mandate is to serve people in the least restrictive setting possible. However, at this time, there are individuals that need involuntary secure treatment and DMH must be able to provide for those needs. Slide 20, as you can see from the photos and as explained earlier, MTCR is two FEMA trailers put together. It was always only meant as a temporary facility and has far outlived its lifespan. The site has poor drainage and is difficult to maintain. The trailers have no permanent foundation and frost and moisture issues require constant repair to the structure, ramps and fencing. 21, here's some information about the MTCR program. 95% of referrals to the secure residents are from level one units across the state. I believe you're somewhat familiar with our system and I have a slide and a little bit that goes through it, but level one are our most acute beds. The other 5% come from general and patient units. 53 individuals have been served since we opened in 2012. The average length of stay is 10.4 months. Over 64% of residents have stepped down to less restrictive settings or independent housing. And as you can see, our occupancy rates have remained very high, 22. With this new facility, DMH is seeking to build a 16 bed physically secure recovery residents that provides the highest quality of recovery oriented care, ensures the safety of residents and promotes rejoining and rebuilding a life in the community. This facility will enhance equitable access to appropriate timely and high quality care and treatment. 23, how did we get to 16 beds? The legislature has directed DMH to study the need for secure residential beds on multiple occasions. The last analysis we did was in 2020, the DMH analysis of residential bed needs report. In it, we considered several factors when recommending 16 beds. The number of individuals on inpatient status with no discharge options due to acuity, meaning individuals where secure setting was the only discharge option. And on average, there are seven to 10 individuals at any one time meeting that criteria. The number of individuals on the MTCR wait list from level one inpatient units. Currently there are six people on the wait list which is about average. And the number of individuals served in the community on an enhanced funding plan who would need inpatient treatment without a community based option like MTCR. I think it is important to note that this report and the number of beds in general has been extensively testified to and debated about in the legislature. Well, we appreciate that not everyone agrees 16 is the right number. That is the number that was decided upon by the legislature and Act 50 specifically requires DMH and BGS to build a 16 bed facility by 24. So this slide highlights the system of care bed continuum for the most acute starting on the left. I just wanna highlight that. Well, this application obviously focuses on the need for secure beds as that is the project under your jurisdiction. DMH focuses on the system as a whole. It does not believe all that's needed in the system is secure beds. There are a lot of gaps in the system that we continue to work on. So just quickly, we have 45 level one beds which as I said are the most acute beds over three facilities. We have 156 general beds in six facilities and we have our seven secure residential beds. We have enhanced funding beds. We have 18 of those through programs like my pad at Pierce House. There's 47 beds across six residences for intensive residential recovery. We have 38 mental health crisis beds across 12 facilities. We have 152 mental health group home beds across 19 facilities, 19 homes. We have transitional staff housing and we also have 121 shelter plus care vouchers, 25. As you can see from this slide, the majority of our funding goes to community programs not in patient beds. And while this new residence will have an operating budget higher than what we currently pay for MTCR, it will not take away funding from any other community programs, 26. Where does our 244 million in annual investments in the community mental health go? Out of that number, we currently only spend about 3 million on MTCR. The rest of the money goes to various community programs and slide 27 provides an overview of those more in depth. Now with slide 28, I'm gonna turn it over to BGS to talk about the design of the facility. We started the design process in March of 2020. It was a trying experience to implement a collaborative design process while navigating COVID restrictions. We quickly learned. Excuse me, hold on a sec. This is the court reporter. First off, who is speaking and please slow down. Okay. This is Sabrina Karish from buildings and general services. Thank you. So we started the design process in March of 2020. It was a trying experience to implement a collaborative design process while navigating COVID restrictions. We quickly learned to use technology to allow for a distance collaboration process. We seek input throughout the different design phases from current MTCR staff and residents, staff at BPCH, the advocate community and staff at similar size facilities. The program goals were to enhance patient experience and healing through the design and layout. We wanted a less clinical, more residential feel. We wanted to optimize the connection with nature and natural light. Research shows that those two items have significant impact on overall wellbeing and recovery. Slide 28. This slide shows the state's energy plan as well as buildings and general services energy goals. We own our buildings for life. So we look at a life cycle cost to maximize our investments. We partnered with the industry Vermont, Green Mountain Power and Vermont Gas to explore alternative funding opportunities, incentives to reduce the upfront costs and to achieve our energy goals. We aim to achieve energy savings above what is required by the Vermont Commercial Building Energy Standards. Slide 29. We've conducted two site searches and considered seven total sites. None of the sites we looked at were deemed suitable for various reasons. The closing of the Woodside Juvenile Rehabilitation Center presented us with the opportunity to use land the state already owned. The site met all search criteria. The new facility will be located on the former Woodside site in Essex, accessed off of Route 15 in Colchester. The site is located in a populated area, but the natural site features provide a great deal of privacy. A steep wooded grade drops off from Route 15 to the north and east. The grade continues to drop to the south of the facility to the Winooski Valley Park. The Woodside natural area is to the west. There's a small trailhead with parking for a few cars on Woodside Drive. The wooded site and new plantings will shield the building and yard from public review. The main parking lot is to the rear of the building for a more welcoming residential feel. There are two existing buildings on the site. The main juvenile facility will be demolished. About a third of the gymnasium will be repurposed into BGS maintenance space. The rest of the gymnasium will remain programming space. The yard features walking paths, spaces for gathering, raised garden beds, covered porches, a patio area with a gazebo and free lawn space. Next slide. I will explain the floor plan and then we will look at some interior rendering. The building is a wide shape with the residential wings forming the arms, core program space at the center and then the administration area forms the base. We have addressed the legislative language to allow for separation of one eighth bed wing from the rest of the facility with this set of fire doors. There's activity space located at the end of the wing as well as access to the yard. The yards can be separated as well. All programs shift and change over time. We have designed as much flexibility into this facility as our budget allows. Next slide. When residents pull up to the facility, they will arrive at the drop-off area. They are greeted by the front porch. They will enter into a mudroom, an entry hall and then arrive directly into the center of the residence. Next slide. This is a rendering of the living room. This is to the right of the entry. This room serves a variety of uses just like a living room in your own home, reading, TV time, social time or entertaining visitors. This is not programming space. This is a lounge space for the residents. This is a congregation area across from the living room in the main hallway. And it is outside various activity spaces. This is just an informal place to socialize or step out of an activity. This is the multi-purpose room. It's across from the main entry and the living room. This room hosts a variety of activities and is located at the center of the residence to encourage participation in these group activities. It is designed to accommodate all residents at one time. Although the room is large, the design elements and natural light make for a warm and inviting space. This is the opposite end of the same room. There are computer stations on the far wall. The room offers excellent use to the yard. You can see the nurses station through the round window. Through the door is the dining room. Slide. The dining room has seating for 16. We also have options to sit at the island in the skilled kitchen or dine outside on the covered porch. There is a door to the porch just out of view in the foreground. The skills kitchen is accessible to residents to cook their own food or have group school building exercises. The commercial kitchen is located behind the skills kitchen. Staff will prepare all meals except for times when residents decide to prepare their own meals. The co-located kitchens also allow for collaborative meals between kitchen staff and residents. The door you see leads to the greenhouse. The greenhouse also has access to the yard where raised beds are located to support the program. Next slide. We wanted to maximize dignity and privacy while respecting resident safety. Each bedroom has its own bathroom. The beds are a full-size bed. There are also many storage options in the desk and wardrobe. The rooms feature various seating options including a comfortable lounge style desk chair and a window seat. Residents can have visitors meet with staff or peer counselors without having to sit on their beds. We wanted to enhance the connection to nature through art materials and maximize natural light. This slide shows the current project schedule. We are completing construction documents this week. The construction manager has begun advertisement and is preparing bid packages. We are requesting the CON be approved by August 31st. The August 31st approval date will allow site work to begin by October 1st. In addition to needing time to demolish the existing building, we have difficult soils on this site which require the site to be pre-loaded. This cannot be completed when soils are frozen so it must be done this fall before soils freeze. If we are not able to begin this fall, construction will be delayed until soils defrost in the spring. This delay will delay occupancy by roughly five months as well as increased costs between 250 and 650,000 based on the construction manager's estimation of the station. Now I'll start with, start back in this Karen Barber with financial expenditures. So we've submitted a lot of financial information so I will just briefly overview them. Construction and related project costs are $21.9 million. Construction costs include new construction, renovation, site work, related expenses and management. Related project costs include debt financing expenses, architectural engineering fees, permitting, equipment and fixtures. I'd note that the state finances long-term capital projects with general obligation bonds which are typically 20-year bonds. These are tax exempts and the full-facing credit of the state are pledged to the payment of the principal and interest. Next slide. Room and board rates for residents are established annually by the Department of Disabilities, Aging and Independent Living and the rate is based on the Social Security Administration cost of living guidance and rate changes. Gross resident revenue is a combination of self-pay from residents and Medicaid. Operating expenses are funded by 0.8% self-pay from residents and with federal and state funds. Otherwise, I note that the state pays the interest expense, not the project. The cost of debt financing and depreciation is not built into the project cost when determining revenue requirements. The cost is depicted here only for disclosure purposes. Next slide. Utilization rate is based on 90% occupancy which is consistent with the utilization of the existing facility. The residents is a standalone self-contained facility operating 24-7. We anticipate needing 49 clinical FTEs to meet our licensure requirements and an additional 14 non-clinical FTEs to support the operational and administrative needs of the facility. Next slide. Now I will quickly review all the criteria you consider when making a decision. When I, as I said in the beginning, I believe we provided you with most of the information you need, so I will just quickly review these. As to the first criteria, DMH adopted healthcare payment and delivery system reform in 2019, beginning a shift in community-based reimbursements to the designated agencies. Vision 2030 aims to provide remonters timely access to whole-health person-led care that achieves the quadruple aims of healthcare. By fully embracing an integrated system that works collectively to address population health, wellness, and equity, remonters will have improved access to care, the healthy aren't happier, and the state will realize significant economic benefits. Next slide. We need to be able to provide the right care at the right place at the right time. And again, while our goal is to serve people in the least restrictive setting possible, there are a small group of individuals that continue to need a secure setting once they no longer meet hospital level of care, and we must be able to provide them that care.  And on the other end of the system, people will be forced to wait in EDs for beds to open up. The system depends on flow, and that depends on having various levels of care available. DMH recognizes and has testified extensively about the fact that there are lots of gaps in the mental health system of care. There is no debating yet. Yet this is not an either or situation. It is a yes and. We cannot only build on secure beds. That is just not the reality of the needs of remonters. The all-pair model requirement is to contain the cost of meeting the community need. That's not always the lowest cost option. And without these additional beds, the only option left for these individuals is remaining in inpatient beds at a much higher cost. A lack of this intensive level of service for individuals who need it is directly increasing costs that do not contribute to efficient services. We see people cycle through the system less and have better outcomes if they are served at the appropriate level of care. As to your next criteria, I think as we've already reviewed, there is a current need that isn't being met based on the wait list for MTCR, and we know based on numerous studies, there's an additional need for beds. And our mandate against some of the legislature is to build 16 beds. Next criteria. This criteria is tied to the residential needs study, which documented several important points about the need for this facility. The occupancy rate for group homes is extremely high. Population proposed for this project requires support and supervision that exceeds that secure community care. And within inpatient psychiatric hospitals, there are seven to 10 individuals at any one time that need a physically secure setting. Next slide. For this criteria, Act 42 appropriated four and a half million as an initial investment in the recovery residence and this year's capital bill allocated in another 11.6 million. G&H currently has three million annually allocated in the budget for the operations of MTCR. The larger residents with additional treatment and service capacity as well as additional staffing will require additional funding to operate and our annualized funding requests to support these operating costs will be in the FY23 budget process. Next criteria. This project is really about assuring people have access to the appropriate level of care. And like we've said, this is the only one of its types. We believe there will be reduced costs in medical care from unnecessary days of continued hospitalization. We believe the project will positively impact wait times for hospital beds and emergency departments for individuals waiting for services and the availability of emergency care capacity. Timely transfer of persons to the right level of care when they need it supports the most efficient use of existing healthcare capacities and allows expenditures and charges to accurately reflect the cost of services and care delivered. Next slide. Next criteria. The benefits of receiving the right care at the right time and at the right place is advantageous to all members of the public. This project helps support individuals being able to move in a timely manner from a higher level of care to electrostrictive settings and supports the provision of a full spectrum of residential support options to meet the specific mental health needs of individuals. Next slide and criteria. As we've discussed, there is no real alternative to this level of care. Well, ideally everyone could be served voluntarily in the community and insecure settings. That is unfortunately just not the reality of Vermont cases today. We are talking about really complex cases with very real public safety concerns. Bails community placements do not support individuals on their path to recovery and lead individuals to being bounced around and living in an emergency department. It is also important to note that no one goes to this facility without a court order after receiving due process and having been appointed an attorney to remotely delay his mental health blockage. Next criteria, or well, second part. In terms of location, BGS did a lot of work to find this location as you heard. The legislature heard testimony on it and specifically required us to build there. Next slide and criteria. I think we've answered in our application and some questions about energy efficiency, but this slide just highlights some examples. Next criteria. Again, I think we've reviewed extensively the needs and I've again included that language from the legislature requiring us to build this facility. Next criteria. For those who need this level of care, it is the only facility in Vermont available. It will greatly improve access by over doubling its bed capacity. As you can see from the pictures and some more information to comment about programming, the quality of care will far surpass what is currently available. And for all Vermonters, this will greatly help with the flow in the system for those seeking mental health care treatment, as well as those that need to access the ED for other reasons. Next slide and criteria. The recovery residents have a unique mission and program with licensure as a therapeutic community resident. Its purpose was defined in Act 79 and the ongoing need for a permanent replacement has been the subject of acts and reporting requirements to the legislature for the past several years. MTCR serves an otherwise unmet need and DMH has not found an alternative willing entity to develop a comparable program. To date, DMH remains the only entity adequately fulfilling Act 79 statutory obligation to assure this level of care is available. There will not be any adverse impacts to existing services provided by DMH or any of our other providers. DMH has the necessary experience and bandwidth to run this new facility will have unnecessary funding and is in a good position to recruit staff. Next criteria. This is a much easier location to access than the current facility. It is just off the interstate and it is very close to a bus route. Next criteria. This does not involve the purchase of new health technology. It was not cost efficient given the size of the facility and the current MTCR operates without any HR. Next criteria. This facility will operate as a statewide resource for the bubble of care affording equal access to individuals regardless of ability to pay. Resident care will be delivered in an integrated and holistic manner based on evidence-based practices. It will be licensed as a therapeutic community residence and be subject to all applicable inspections and regulatory standards. Residents in this program will have access to and oversight by disabilities rights for months in its capacity as the state mental health care on this one as well as legal representation by the Vermont Legal Aid Mental Health Law Project. Next criteria. This facility as proposed, reports the atrap principle. It needs a critical health need for those in need of this level of care. No other provider in Vermont provides this level of care. Next slide. In terms of cost containment, the lack of sufficient beds for people who need this level of care creates a cascade of cost throughout the system as those in need and care wait in hospitals and those in need of hospital care wait in emergency rooms. In addition, when an acute mental health needs goes undressed and untreated, the person's condition may decline, leading to a longer and perhaps more challenging recovery period. The quality of care environment and the new facility will far surpass what has been available in what was envisioned to be a temporary facility and program. In terms of payment and delivery reform, DMH fully embraces the quadruple aim and has recently convened the Mental Health Integration Council in concert with the legislative charge to integrate health assistance in Vermont. This facility has been developed as a critical service in the vision of a fully integrated, equitable and responsive healthcare system. Next criteria. As we said, there are no other services like this new residential. No one will be denied service based on the ability to pay and no one would be denied services based on any other reasons such as race, gender, sexual orientation or age. Next slide. Next criteria. The Vermont Blueprint for Health Designs Community-led Strategies for Improving Health and Well-Being. And the DMH Recovery Residents will play a key role in that work. While the Recovery Residents will be a clinical treatment resident, it will also focus heavily on providing non-clinical interventions and activities. The program is focused on building a culture of care that not only treats those seeking care with respect and dignity, but supports them in leading the development of their treatment plans and recovery goals. And there will be a strong connection to community providers. Next criteria. The vision for this facility is to provide integration and coordination of healthcare services in a holistic manner, addressing mental health, physical health and substance use. Next slide. For mental health, we will have evidence-based practices, connections with community mental health providers and a robust staff. In addition, we will offer, sorry, next slide, medication management, therapy, groups, life skills, leisure skills, health and wellness, and peer support. Next slide. For physical health, we'll have 24-7 on-site nursing, yearly physicals, connections to community PCPs, connections to community health centers, dental and mission care, and nurse-led groups. Next slide. For substance use treatment, we'll have in-house therapists and psychologists, integrated treatment plans and assessments, access to community treatment groups, and in-house groups on co-occurring treatment. Next slide. And next criteria. The DMH recovery residents would significantly enhance Vermont's progress on healthcare reform. We would provide the appropriate care in a timely manner, approve patient experience, approve provider experience, help improve community connections, help community needs identified in the community health needs assessment and contain costs. Next criteria. It's applicable given it's not an emergency CON or connected to a hospital, but I would just note again that we've been planning for this facility since Tropical Storm first closed the Vermont State Hospital and we opened an MCCR in 2012. And then for the last criteria, again, no one will be denied services based on ability to pay. No one will be denied services based on race, gender, sexual orientation or age, and the service is statewide. And now we're available for questions. Thank you. I will, the first thing we'll do is I will read the questions from the healthcare advocate and after you respond to those, we'll open it up to the board. Madam hearing officer, can I ask a question? Yes. I just wonder if it makes sense for the advocate's office to get to frame our questions and ask our questions. I understand your interest in facilitating a fast meeting, but we won't need to speak in the public comment time if we get to ask our questions. That sounds reasonable. Sure. Okay. Thank you. So I have a very brief introduction and then Sam's gonna ask the three questions that we framed earlier. We really just wanted to, it's important for me to say that our interest here is to make sure that there is a good public meeting. I appreciate that the applicant has, it feels like they've done many meetings on this, but nonetheless at this stage of a decision, it makes sense to us that there'd be a meeting like this as is always the case for the Green Mountain Care Board, the practice for the Green Mountain Care Board. So I appreciate having this opportunity. And then the other thing that I wanted to say is a full recognition that the HCA's office is not the expert here. We are really here in support of making sure that all voices are heard. And so while we do have a few questions, I think my full weight goes behind the questions from the members of the public as well. So that's my framing. Sam, why don't you go ahead and ask the questions? Thanks, Mike. Good afternoon, everyone. Just as a reintroduction, my name is Sam Paich. I'm a health policy analyst with the Office of the Health Grid Advocate. Just want to thank the Madam Hearing Officer, members of the board and the staff for the opportunity to ask questions and thank also to DMH for the presentation. So I'm just gonna go ahead with my first question. Could you please explain your analysis for the current lack of community health capacity and how this new facility contributes to the system of care in Vermont? Sure. And I think we somewhat answered this, but I could kind of review it again. So as I said, the legislature has directed DMH to study the need for community mental health capacity, specifically secure residential beds on multiple occasions. And as I reviewed previously, Act 82 of 2017 and Act 200 of 2018 were bills that required DMH to undertake in-depth examinations of the mental health care delivery system and coordination across service settings. I also spoke at length about vision 2030 and how much work went into examining the mental health needs of Vermont. In terms of this type of bed, as I said, the last analysis we did was in 2020 with the residential bed needs report. We considered several factors in coming to the number 16. As I mentioned before, and I think it's important to note again, that the report and the number of beds was really debated about quite a bit in the legislature. And again, what we appreciate, maybe not everyone agrees that 16 is the right number, is the number that came out of the legislative process. And it is the number that DMH and BGS are required to build. And again, I'd note that while this application focuses on secure beds, because that's what's in front of the board today, there are many other gaps in the system. And we realize that and we are working on them. And as you've seen from the legislative history, we've been required to do many studies on that. And we remain focused on the entire system of care, even though this itself was just focused on secure beds. Thank you. So the second question is, to what extent is the funding model based on residents consistently filling beds? How do you ensure that there's no financial motivation to fill beds? Sure. So the funding model is not based on residents consisting filling beds. The funding is primarily paid by federal, 56% and state, 44% dollars. Federal medical assistance percentages and state Medicaid support the operation needs and expenditures of the facility regardless of the number of residents. Residents self-pay by individuals or their insurer is only 0.77% of revenue supporting operating costs. In addition, MCCR is the last residential facility to be considered as a discharge option. And there are three layers in place to assure referrals are appropriate. First, inpatient hospitals are the ones that are making the referrals to MCCR based on the individual's acuity, dangerous behavior or criminal charges. DMH's care management team reviews every referral for appropriateness to the program. And third, no one has actually accepted or sent the program without a court order in the form of a specific O&H with the court finding no less restrictive alternative is appropriate for the individual. Thank you. Third question is, I just jump in and just say that for us non-lawyers if you could explain what an O&H is. Apologies, yes, sir. That's the order of non-hospitalization. Thank you. Thanks. Third question is, how does the facility align with Vermont's community health goals and the all-payer model? Sure, so I think we have touched on this too, so I hope it's not too much repeat. But the project is committed to improving the quality of mental health care for Monter. We want individuals to receive the right care at the right place at the right time. We don't want anyone staying inpatient longer than they need to be there, nor do we want to see people waiting in EDs. Population health depends on a fully articulated system of care that provides ready access to appropriate care. And our ultimate goal is to serve the individual in the most exclusive and least restrictive place if possible. We know that based on the data, we do need a secure and safe place for some individuals to step down to. And this state-of-the-art therapeutic community will have a holistic approach to healthcare and integration. This facility will also greatly reduce the bottleneck that occurs as hospitalized individuals are ready to transition to a lower level of care, but frequently wait to be accepted, leaving those currently needing inpatient treatments wait in emergency rooms for a hospital bed to open. In this way, this facility is a keystone in the mental health system of care continuum, critical to ensuring Vermonters can access the care they need when they need it. And as to the all-pair model, I think I touched on these before, but it's really about containing the cost of meeting community need. Data supports the fact that on any given need, there is capacity in the community that does not need the needs of individuals presenting, both for admission and discharge. Again, cost containment doesn't necessarily mean choosing the lowest cost option. And without this level of care, the only option left is inpatient care, which is a much higher cost. This facility will increase bed capacity, allowing for more movement to the inpatient system of care. And by allowing Vermonters to step down to a facility when their level of care needs bed, it makes room for others to access that level of care. We believe that this lack of intensive level of service for patients who need it is directly increasing costs that do not contribute to efficient services. Thank you. Madam hearing doctor, I was wondering if it'd be possible to ask one clarification question in addition just based on the slides that were presented. Yes, that's fine. Thank you. So last question, thank you for the time. I didn't see in the slide on trainings. I saw a couple of things about trauma-informed care and I didn't see any trainings about cultural competency, language access, ESL or implicit bias, trainings that are a little more in the realm of anti-racism and access, health equity. So I'm wondering if there are any trainings like I also plan for staff and administrators at the facility. Thanks. Who wants to talk? Do you want me to go ahead? I'll have Sam do it. Oh, if that's the same thing. So here at the EMH, we actually have an anti-racism work group going on and we have also done trainings at Vermont psychiatric care hospital as well as implementing some trainings at MTCR. And so we are also partnering with Vermont, I'm gonna ask for the deaf and hard of hearing to bring in more trainings and more therapists as well. So we are in the process of developing more trainings for our staff. And that will be definitely part of the new program. Thank you. Those are my questions. Thank you. Okay, thank you very much. And now we can move on to questions from our board members. Board member Lunge, would you like to go first? Yes. Am I unmuted? You can hear me okay? I can hear you fine. Great. Thank you. Thank you very much for your presentation. I appreciated that as well as the written materials. I do have a few questions. In terms of the connection to the all-pair model, the all-pair model has three overarching goals and three high-level population health measures, which include increasing access to primary care, reducing deaths due to suicide and drug overdose, and then reducing the incidence and morbidity of certain chronic diseases. Could you please tie your application to those three population health goals? Yes. Kathy, is that something you wanna take? Yes, thank you. Thank you, Robin. This is Kathy Hensley, Department of Mental Health. Hi, Kathy. Good to see you. It's nice to see you. So can you just list the three for me again, Robin? The three that you mentioned? Absolutely. Increase access, and again, it may not meet all of them, but these are kind of our three high-level goals that are guiding light on population health. So increasing access to primary care, reducing deaths due to suicide or drug overdose, and then improving either the incidence or morbidity of common chronic diseases like heart disease, diabetes, the ones you would suspect. Yeah, thank you. So these are actually fundamental pieces in the new programming for the secure recovery residents. It's very much founded in principles of holistic care. The each resident at the facility on their team, they will not only have a peer representative, they will have their local CRT director, the community rehabilitation and treatment manager from the local DA to work with them. And all of that is driving toward connection back into the community services, and each resident will have an annual exam with the PCP, with the local PCP will be connected with a local community health center. They're strong. The way that the, when you saw the design of the building and Trevina talked about the outside and that it's very much designed to facilitate activities, exercise to facilitate a much more holistic approach to health. In addition, you mentioned suicide and drug overdose, DMH is deeply invested in the zero suicide work that we're leading throughout the state. And we are working very strongly with the primary care providers across the state, bringing that into primary care for suicide prevention. And the trainings are throughout with all providers, not just primary care, but to address and be able to recognize suicidality. Drug overdose, another piece of the approach program, the treatment program at the facility is to be very connected in with substance use treatment and services. And again, the whole connection with the DAs where this will be very woven in with DA services and working to support those to make sure it's a very intensive program to ensure that as it's something like more than 54% of current residents at MTCR have transitioned back into the community and the whole push is for recovery. So there's a very intensive focus on getting people connected in the community to services like substance use if that's needed. The whole co-morbidity is a primary focus. And in part of this too is that the treatment plans, every effort will be made that residents are very involved in their own, creating their own treatment plans that ownership is a big piece in recovery and success in recovery. The individual morbidity, chronic disease, heart disease again, that goes back to this very strong connection with local community health and the focus in the programs within the facility itself and then with the transition working with people as they transition back into the community to keep them connected into those services to support holistic health, not just mental health. And I would just note that the zero suicide framework promotes a robust continuum of step down treatment programs to assure there's continuity of care across all levels of care. And we believe that this is an important part of that continuum of care. Thank you. I had a question about the private pay model recognizing that it's a very, very small amount of revenue but how does private pay, how does that work? Like is it a day rate? Is it a fee for service? Could you just please describe that? Yes, I'm gonna turn that over to Anna. Hello, this is Anna Strong, Financial Director for the Department of Mental Health. Hi Anna. Unfortunately, I'm hello there. I'm off camera. I don't have good camera connection. However, the payer model annually is the Department of Aging and Independent Living establishes a rate based on the Social Security Administration guidance for cost of living allocations. So it shifts what an individual or resident who received Social Security Administration benefits, which is quite a few of the population, more than half of the population who received these benefits. And they are billed a per diem rate based on the ability to pay. So the Social Security Administration allows people to keep a considerate portion of what they receive depending on their benefit amount and needs. So a resident is billed a per diem rate while they are a resident or when they step down into continuing care after they're discharged from the facility. Okay. I really, I wish that I had brought one of my colleagues of me who does this direct billing. However, the way that that works is a monthly letter is written to the resident. Most residents have a payee. Please correct me if I'm wrong. Skip Irish who's the head of the residential facility. And we work with the payee to determine the individual's needs. Most individuals at the facility do not actually end up needing to pay anything to stay there. Some of the residents are eligible for insurance through the Centers for Medicaid and Medicare or CMS coverage. And so their insurance can be billed and staff at the existing residential work with them to put all that together often in concert with their payee or the resident is charged a small reasonable fee that allows them to also keep a living amount for themselves. Some residents maintain, of course, a home or apartment or a life outside of their residential stay that they will return to. So in consideration of all of that, it's a sliding scale fee and it is established by the Social Security Administration. And depending on a resident, is that enough information for you? Yeah, I mean, as long, so it's I, is the sliding scale fee that's set according to Social Security Administration benefits apply even if the person doesn't have social security benefits. So they're not on SSI or receiving Social Security disability. I mean, maybe that doesn't happen. Maybe there aren't patients in that situation. I'm just trying to understand sort of the range. No, Robin, you are correct. I thank you for bringing that up. There are residents who do not fall into those categories most residents do, like well over 95% do. However, those who do not for different reasons, they, what happens internally at the Department of Mental Health is that we have a form that is filled out by the resident, often their payee, often the support staff at the facility that determines basically their debt to income ratio. So if someone has no income, they are not charged for their stay. That is when the state and federal programs, you know, cover the cost of their stay. Okay, thank you. Thank you. That was helpful to have a better understanding of how that works. So I did have a follow-up question on the ability to segregate both halves of the facility and the legislative requirement. And it sounded from, it seemed like from the testimony today that there were fire doors that could be closed in order to ensure that the serenity room and the laundry were available for that other half of the facility, which were concerns raised by Representative Donahue and one of her public comments. Could you confirm that or explain that to me a little better?  So this did come up during session when the plans were presented to the legislature. There was discussion about whether or not it could be used to separate. There was discussion about whether or not we should redesign the entire facilities to make this happen. If you look at the actual legislation, it says through interior fit-up versus building design, the 16-bed facility shall include two 8-bed wings designed with the capacity to allow for separation of one wing from the main section of the facility if necessary. Both wings shall be served by common clinical and activity spaces. So that is what was done. There is a fire door. We didn't redesign it because the legislature didn't want us to do that because we told them how much it was going to cost. As you saw during Sabrina's presentation, we can pull that slide up again if you want. There are fire doors that mean that it can be separated. The laundry is just outside. The legislation doesn't require the laundry be inside. It requires common clinical and activity spaces, which is contained within the wing. Okay, thank you. And then there was also, I also wanted some clarifications about the outdoor space and in the answers to our questions you did list the gazebo and the raised garden beds. Those are within the current budget that you've submitted. Is that right? Yeah. Okay. So the areas that as you've described them are, won't need additional appropriation or anything like that for the amenities in the outdoor space? No. Just confirming the BGF. No. Oh, on camera. Thanks. Thank you for shaking my head. Okay. And then I did have one last question about the electronic health record and what you looked at in terms of the affordability. And specifically I was wondering if you considered sharing an EHR with either the Berlin facility or with several of the designated agencies. It's my understanding that they share a common EHR because certainly having some sort of electronic ability to communicate will improve your community integration and the ability of primary care and others to understand the treatment. So could you speak to that a little bit? Yes. I'm trying to find where we answered it. So these were discussions that occurred. As you may know, there was a complete leadership transition at TMH when we began this project to where we are at now, including everyone who works on this project. So, but I know that this, let me find my notes. I know it was considered. I have it tabbed. So I can tell you what you said. So I know they did look at that. And I think where the cost prohibitive piece came in when we were talking to ADS about it was trying to build firewalls. So say we tried to use VPCHs, I think what we were finding was it was gonna be cost prohibitive to try to create those firewalls to separate it. The same with trying to hook up with something like UVM or the designated agencies. But I think it was that piece of it, that firewall piece. That was really what was really pushing the cost over the edge in terms of what made it feasible. And yes, I think that will continue. At this point, we have an EHR VPCH we put it out for bid again at one point. We would consider also putting out this new facility with it to see what it looks like right now. That's just not in the plans. I think in addition, if you want Skip to talk about it, they do have kind of a robust system that's working for them. And I think we could kind of walk you through that if you want. But it is certainly something that was considered and that will keep on the horizon if we put the hospitals out to bid again. Yeah, and that would be great to just walk us through a little bit how that care coordination will happen absent electronic resources. Sure, yep. So when you say care coordination, are you talking about within the facility? I'm thinking about one of the areas that you've mentioned is patients being able to get an annual visit. If they need follow up visits, for example, the primary care office has an EHR. And so that's kind of how providers are starting to understand the full picture for a patient. So how will you ensure that providers outside of the facility will have full information related to the patient and vice versa? How will that information flow absent electronic means? Excuse me, this is the core reporter who's answering, going to answer this question. So who's in the background? This is Ralph Irish. I can't hear you, who is it? Ralph Irish. Thank you. So currently we are using paper and we're bringing that information with us to all appointments and then bringing the information back and disseminating it to staff and putting it in their paper charts. I don't know if we had an EHR, if it would be connected in that way anyway, so that outside providers would be able to access it. I think that is kind of some of the problems with the firewalls that are currently the issue with getting it set up on someone else's EHRs is them having access to other information that they shouldn't have access to in someone's chart. So I think even if we have our own EHR in-house, it's not gonna be shared through electronic means like that with other facilities. I believe that is not something that occurs at VPC Asia I think because of the, there's with 24 years to not say it's having a unique, yeah. Although patients can provide permission to have that sharing happen under federal law. Yes, yes, it's just not automatically, yeah. Okay, thank you. That's it for my questions. Great, board member Pelham, do you have any questions? I do, I was waiting for you to call on Jess in the alphabetical order, but I'm good to go here. So thank you very much for a very intense presentation and for all of you that have stuck with this for a number of years now, just the perseverance is amazing. It's for me, it's causing a little bit of deja vu because when I was finance commissioner, we were closing the brand and training school and downsizing the state hospital to 50 beds. And so the process of moving all that money out into community-based services was an extraordinary task now that I think about it. But it was not me, it was mostly Con Hogan and his folks did a great job. So my first question here just has to do with benchmarking construction costs for facilities like this. And so I'm looking at your $16 million in construction and the additional amount bringing the total project cost up to $21 million. And just wondering, has any research been done or are there any benchmarks as to whether or not that per bed cost on the total project cost that $21 million, it's $1.3 million a bed. Is there any point of reference for what this proposal is relative to what happens in other states or other facilities of this nature? Joe A. Jeff from BGS. In our history of building facilities similar to this for slightly different and having our contractors present estimates, this is where we get our data from for that. And we have looked at other facilities in past years for other projects in other states and it's on board with roughly the same cost. A lot of the cost can differ because of the different sites that are proposed and where we construct. So in this situation, you don't have any land costs. The state already owns the property and part of the building, I think the gym is gonna be retained and used. And I just, there's one way of developing project costs just by having a wish list and then people pay for but it also helps to have some benchmarking relative to what the market is out there. And if you do have any information in that regard, I'd be interested in seeing it to this. This is an extraordinary thing to think about about $1.3 million a bed. It's a lot of money. If you have it, if you don't, you don't. I'm also interested in the operating costs, the $9 million plus or minus and wondering if that fits in with the global commitment cap. Couple of years ago, there was constraints on our budget at the Green Mountain Care Board because people were worried about breaching this global commitment cap. And this is a fairly significant increase, I would think going from a $3 million, which is what the current project is for the Middlesex Project and to $9 million. So are there any concerns or discussions about breaching the global commitment cap that might affect other people, other entities that are reliant on global commitment? Sure, I'm gonna hand that one over to Anna Strong. Hello there. This is Anna Strong from the CNN Business Office. This has been a point of discussion with the AHS Central Office. We do have a waiver with CMS, an agreement that exists and it's always sort of a moving object, being processed as it goes. And I'm gonna for now call it a good space discussion that in the requirement and need to create a more robust residential facility, we do have full approval for this annual budget amount. And I would be more than happy to provide you with some backup documentation for that. That's not a problem. So prospectively for 2023, the agency would say that this project fits on an operating basis within the global commitment budget and could tell us whether or not that was achieved by constraining some other or that it's just allowed within the global commitment money. That can absolutely be confirmed. I believe when it became a part of the capital bill, it was wholly embraced and accepted by the agency of human services. As part of the budget going forward, I believe without an adjustment to another entity, but I would love to confirm that for your piece of mind and my own. Okay, the capital end of this wouldn't be funded and I'll think by global commitment. So I'm just talking about the operating budget.  My next question was that chart, you don't have to go to it, but it was the one that kind of showed the stairs associated with the system of care and the debt continuum. And so at the upper end, whether you level one facilities and then the next step down were hospital beds and then the next step down was the secure residential, this project. And I'm just wondering, so the two above it certainly would be considered institutional facilities. And I think representative Donnie who has made this point, this one is being described as a community facility. I'm just wondering is, are those designations some kind of a formal process or could this facility also be designated as an institutional facility? Well, I think when you're generally talking institutions, right, you're talking like a hospital. So there is a difference in licensure. So MTCR is licensed as a therapeutic community residence and it will continue, it's mandated by Act 79 to be licensed as a community residence. It will continue as licensure as a community residence. So it meets all of those standards and it is a community residence. It's always been considered a community residence by the legislature. It is very different from a hospital level of care. Hospitals obviously are licensed differently, have a lot more requirements or CMS certified and joint commission accredited. None of that applies to the secure residential. As again, it really is a residential facility it's licensed as such. We have never considered it that way. We've always considered it a residential program. That's always been the way it's been referred to by the legislature and always been our mandate is to build this as part of our continuum of care in the community. So re-designating this, I mean, I understood the point that Representative Donnie was making in terms of this going into some kind of base division of the community investments in community facilities versus institutional ones, but it sounds like this is pretty well dug in as a community facility. That's what I'm hearing you say. Let's see. I think my last question is just kind of looking at the pipeline again and the tension, this ongoing tension between community facilities and institutional facilities. What would you say was the last major investment that the state made in the community-based services outside of this project? And what is the next investment that the department agency is thinking about in terms of investing in the improvement of community-based facilities? And is that something you want to take? Let me see. I'm going to look to Hannah for financially. How much? I know this is Samantha Sweet, sorry, from DMH. I know there was a large rate increase into our DA system. We've also been working on embedded mental health clinicians with law enforcement. That is something that we are trying for almost over the threshold with implementing that as well as I believe we're using some COVID dollars to have a case manager within each one of the agencies to provide support to those that have been affected by COVID-19. We are continuously looking at other ways to increase capacity within our community and within our DA system. We work strongly with not only our DAs, but pathways for months regarding housing and we have continuously increased the number of shelter plus care vouchers that we have in our system over the years that has grown quite a bit each year. Those are some big ones that I can think of off the top of my head, and but I am sure that there are others. Well, thank you for that. One last quick question is that there was a reference in the material to 12 beds at Brattleboro Retreat that I thought what I took away from that was that they are available and up and running, but because of the problems that the retreat, they're not accessible. So do you have any insight as to whether or not there is a game plan to add those 12 beds? Do you want me to take that? Yes, okay. So this is Samantha Sweet again from DMH. Yes, Brattleboro Retreat is ready to open the doors for the 12 new level one beds. However, they're not able to do to staffing and they're not able to retain staff or hired nurses in that area issue for them to bring traveling nurses into the area. So we're actively working on bringing people into that area and what can be done for housing. Are they able to use other buildings on their campus to for housing or hotels in the area? And so we're constantly looking at how can we increase our staffing in order to get more inpatient beds online? Okay, thank you. Yeah. Yes. Thank you. Next we'll go to board member Holmes. Great, thank you so much. And thank you again for, as others have pointed out, all the important work and the long work that's gone into this application and all the stakeholder engagement you've done. Let me just actually, many of my questions have been asked by my fellow board members. So thank you to my fellow board members for that. Let me actually start with a question that you just finished up answering around or mentioning was the staffing challenges that the Brattleboro Retreat is facing and some public comments and other comments have referenced concerns about staffing, whether this is gonna be indeed able to be staffed with the increased capacity. Can you speak a little bit, somebody speak a little bit to that and how you might overcome that obstacle? Yes, I can speak to that. This is Karen Barber. So the current staff at MCCR would account for nearly half of the staff that we would need at this new facility. As for recruiting new staff, we have several plans to support our additional staffing needs. One of the factors supporting this chosen site was its location in the largest population center of Vermont. In addition to the normal recruiting practices of the state, we plan to engage local undergraduate and graduate programs to try to recruit staff and interns to create a steady go of potential ongoing staff. We already have contracts as numerous traveling companies that currently provide staff for VPCH and MCCR, the Vermont Psychiatric Care Hospital, VPCH. And we'll continue to utilize those to focus on our staffing. Those contracts also do allow us, they're not just for nurses, we also can get mental health specialists to do those contracts. Sorry, this is very important again. You're going too fast. I can't understand what you're saying. I apologize. Where do you want me to start? We already have contracts with numerous traveling companies. Yes, that we currently use at VPCH and MCCR. So we continue to utilize those. Those are not just for nurses, those are also for mental health specialists, which those are the bulk of our staff at our facility are those mental health specialists. If we cannot get enough permanent state employees, we could utilize those contracts for that. We do generally have enough mental health specialists at our facilities, it's more nurses that we struggle with. I think as Sam talked a little bit about in terms of housing, it's a big priority of the Agency of Human Services right now to figure out how we're going to provide housing for traveling nurses. You know, I know we're working right now to contract with a hotel in Williston to try to get some nurses in at VPCH. So we're thinking really creatively. And by the time this opens, I feel confident that we'll have a housing plan. In addition, regarding the advanced degree professional staff, you know, given we're in the Burlington area, we feel like working with the undergraduate and graduate programs will be able to recruit staff. And as for psychiatry, we anticipate expanding our current contracts with UVMMC. UVM provides psychiatry for both VPCH and MCCR currently. Great. So I know that MCCR currently operates at seven beds at 90% capacity and there's a wait list. I also understand all the work that went into determining that 16 beds was the appropriate need. I guess my question is, if you find that the facility is under capacity or not being utilized to its full 16 bed capacity, which frankly, there's a part of me that hopes that's the case, right? Because that means there's less of this acute need, right? But if it turns out that there is some slack there, what are the plans for using those beds? How could you, you know, pivot and use that maybe one of the wings, what would you use it for? How do you maximize the use of these beds and ensure that this is efficient use of space? And what's the plan B? Well, I think that's not an easy question to answer right because I don't know two years down the road when this opens or a year and a half, what the needs are gonna look like and what populations we may need to serve. I think one of the other things we need to be careful about is funding. So we need to be, right now, this is a Medicaid-funded hospital, right? So we need to be careful not to try to use it as a forensic wing, right? Because that would impact our ability to use Medicaid funding if we were trying to use it purely for like a forensic facility. You know, obviously there are some gerry psych issues that we're constantly struggling with and where do we place folks that are needed nursing home level of care and also have complex mental health needs. So I think it would really be an analysis that we would be required to do by the legislature because they're the ones that have required us to build this and it would be really a conversation with the legislature. I'm sure there would be reports and analysis and then presentations to the legislature about what would make sense and then really taking their lead and determining what they wanted us to use the facility for because again, they would need to allocate the funding for it. So we would really, it would be working in concert with the legislature depending on the needs at the time. Okay. And I guess my only other question really is in the presentation and the application referenced I think 64% of relatives successfully transitioned to the community. I'm wondering if you can speak about what happens to the other 36% of residents. I'm gonna hand that over to Sam C. Hi, this is my assistant. So unfortunately, we have I would say a large majority of the other percentage are returned to inpatient units. Whether they stop taking medications, there's an act of violence or they return to the community but it's not in a really successful way. They have been able to leave the discharge from the facility AMA. But I would say a large majority of those are returned to the hospital for further treatment. Okay. And that's because the need there is acute enough to be in an inpatient setting. Yeah. Okay. I think honestly, I think most of my questions were asked and answered already by others. So thank you. Wonderful. Mr. Chair. Thank you so much, Laura. Karen, in your presentation, you talked about the fact that ideally this care would be in a community setting. And you said, unfortunately, we don't have that infrastructure in place. Does the department have an analysis by geography of where the shortcomings are? You mean where residents are primarily coming from? Well, which communities are not meeting the needs of being able to provide behavioral health in a local setting just like they would their physical health? Oh, I think what I meant was there is ideally everyone received services in the community on a voluntary basis. And what I meant was that we're not at a place where everyone is capable of doing that. Right now, we just do have a small segment of the population that requires involuntary secure care that just can't be provided in the community because their needs are so high. Ideally, no one needs that level of care. And so, I think we talk a lot about prevention and working on child mental health and all of those things to try to support people. And so that's what I meant was that we just, unfortunately, we don't live in a society right now where there's no involuntary care. And that's the goal, right? The goal is a purely voluntary, non-coercive system of mental health. That just doesn't exist right now. And so DMH has to build for the reality, which is the fact that there are folks that continually get put in our custody by the court system to receive secure care. That's what I meant by that, does that make sense? Yep. So right now, if you don't have capacity, what happens to that person that the court has deemed to be under your custody? They remain in a hospital bed until a bed at MTCR opens. So oftentimes in emergency departments, right? Well, so everyone coming to MTCR is coming out of an inpatient unit. So they're actually waiting in an inpatient bed. But what that means is that there are people waiting in the ED for their bed. And that really, they're ready to transition to a lower level of care, but we can't put them in MTCR because there's not room. So they wait in an inpatient bed and then someone in the ED is waiting. So there's a triage. Yeah, yeah. Perfect. Okay, you talked about the stakeholder engagement and the think tank. Can you, can you expound upon that and who was involved in this? And was there consensus? Cause based on the public comments, there seems to be a lot of disagreement about whether or not this is the right proposal at this time.  We try very hard to listen to everyone and take into consideration everyone's ideas. I do think that there is a fundamental divide between kind of the recognition that there is a need for this level of care versus believing that everything can be served in the community. So I think we did as much as we could to involve stakeholders.  We definitely talked about the secure residential. Not everyone agreed. It was a great idea, but there are certainly folks that really do support and understand the need for this level of care. The adult state standing committee met and discussed this secure residential facility eight times between 2020 and 2021. And they provided feedback on everything from the colors of the spaces to the layout functioning concerns they had, plans to testify at the legislature and updates on planning. There was consumer input specifically on architectural design at three different community stakeholder meetings on May 13th at June 30th, 2020. And then again on March 4th, 2021. And then there certainly was a lot of testimony in front of the legislature, both for and against the facility. So we certainly don't come to you and say that there was brought, that everyone agreed that this was a good idea. Certainly there are a lot of people that do support this project. The legislature supported the project, but certainly there are folks that don't support the project. Okay, I wanted to follow up on a question that member Pelham asked. He was focusing on the Brattleboro retreat and this kind of ties into that discussion somewhat in that I'm curious what the department felt happened to people during the pandemic because the Wyndham Center, which I think is nine or 10 beds was taken offline to go strictly for COVID use. And you know, Brattleboro never could find the workforce. So that was problematic. Did these people just defer care? I can answer that. So this is Samantha Sweet and part of my role, I oversee the adult care management team. And so I have one staff that is dedicated solely to triage. So her job is to triage people out of the emergency room into inpatient units, the most appropriate bed. And so what we saw at the beginning of the pandemic was that no one went to emergency rooms. It was almost like no one left their home, no one was going anywhere. And so we saw numbers plummet looking for inpatient settings.  But it was slow, it was slow going. And so what we're finding now is that we are experiencing kind of the mental surge looking for inpatient beds. So our emergency rooms are definitely taking the brunt of that. And one of the decisions we did have Wyndham Center as our COVID bed, 10 beds for adults that had tested positive for COVID-19 and needed inpatient services. Part of the decision to end that contract was that we really saw that the numbers went down significantly and we also needed those beds to come back online. And so we ended that contract with Wyndham Center so those beds could be utilized for generally inpatient beds, but then we contracted with Springfield Emergency Department for two beds to carry us through an additional three months for anyone that tested positive and needed mental health services. And so they did that for about three months. And then on July 30th, I think we ended that contract as we felt like we had been four months, almost five months with no one testing positive and needed inpatient units. So now those resources are going into general inpatient services. So we are still, I know, as you know, we are still experiencing a huge number of inpatient beds being closed and majority of those are due to staffing. So there's a lot of efforts being put forth to increase anything, any barriers to bringing new staff into those hospitals. Thank you. I think what I'm hearing you say that even if, and I'll say if, because I'm not completely sold that it's gonna be reopened as quick as projected, but if Prattleboro Retreat actually opens the space where state dollars went to and staffs it properly, that this facility is still fully needed and the two are compatible and mutual. Yes, it definitely is. If Prattleboro Retreat, hopefully Fingers Craft is open soon, they are a level one, so 12 new level one beds will be for inpatient use only. And so we need people from those units to be able to step down and that's what the new secure residential will be is for a step down from level one units. So over the years, having looked at a few of these projects, I think the last one as a legislator was for Berlin. And it seems that eight bed units seems to be the magical number. And I'm just curious if there's industry literature that confirms that an eight bed pod is the most efficient in terms of operations and financial costs, but also therapeutic for the patient. Do you want to take that? What if you know? I don't know. I am not sure anyone here knows the answer to that, but we could get back to you on it. That would be great. And a follow-up on that, with your new negotiations on the waiver and everything, has that whole IMD threshold of not getting reimbursed for larger facilities? Is that still in place or has it been removed or I guess that's the question. This facility would not fall under the IMD exception because it's not a hospital. And we're under the 16 beds. In terms of the IMD status of the 1115 waiver negotiations in general with the state, those are being done at the age level. So I am not sure the particulars of those. Okay, so if this was a 24 bed. The goal of this facility is for it not to be considered an IMD. Oops, sorry. And? Go ahead. The goal of this facility is for it not to be considered an IMD so that we can use Medicaid funding. Okay. But even if it was 24 beds, it wouldn't jeopardize your funding. It would. It would. Yeah. Yes, it needs to be under the 16. Yeah. Okay. Okay. And how would your ability to downsize be impacted by things like union contracts and things like that? If you were only using say six or seven on a regular basis and you felt it necessary to close one of the pods, what's the stickiness there? Will the union contracts allow that? How will that play out? Well, I think just closing say one wing doesn't mean you only need half the staff. So for example, at the APCH right now, we have had C and D units closed for a long time because of COVID and because of staffing resources. We're still utilizing all of our staff. It still takes a lot of staff to man all of the unit. So I think it would, if we permanently closed the unit or transitioned it to something else, then there would be staffing impacts. But I think if we just, if there were periods of time where it wasn't completely sold, I don't think it would really impact our staffing patterns. You're really not, I think it's only a 10, there was only a 10% decrease in staff. I think when we looked at it, if we had an eight bed unit versus the 16 bed unit, at one point the legislature did ask us to explore what if we just built an eight bed unit, how much would it save? And it really wouldn't save that much because of the economy of sale. We were utilizing on construction costs and then staffing I think was only about a 10% reduction. So you still need all your kitchen staff, you still need all your admin staff. And because we're a 24 seven facility and there are always folks that eat vacation or we see a lot of semblance or workers comp, you're always needing to kind of fill those holes. Okay. Of course, we all hope that there isn't the need and there's very few patients and things like that. But I think based on your answer, what you're telling me is that on a cost per patient basis, probably if it's, if you've pegged the right number, the most efficient cost per patient is at the 16. Yeah. Okay. So I could hear it in some of my colleagues' questions that they were troubled. You know, there was a lot in your presentation about what the legislature passed into statute and such. And yet there's, you know, there's a pretty scathing public comment. And part of that says that this will drive up the cost of care. Can you address that? I've touched on that. So clearly there will be a financial impact because we'll have greater operating costs. We do feel though that there is going to be cost savings that offset that because we're gonna be able to move people out of inpatient hospital beds. Inpatient hospital beds are the most expensive beds for folks to be in, right? And right now you have any one time seven to 10 people waiting in those beds that don't need to be there utilized. So that's money that doesn't need, that's not an effective use of that money being spent, right? MTCR is a lower level of care and cost less per day. You also have people waiting in emergency departments. As we know right now, there's a lot of people waiting in emergency departments. That's a very expensive. If you have adequate flow in the system, and again, we are not saying that the only thing we need is these secure beds. And all of a sudden the magic, magically the system is going to flow. But what we're saying is this is going to really help the system because the folks that we're talking about are the folks that are really hard to transition. They are the most complex cases. They're serious, usually public safety issues that make it very difficult for them to go anywhere other than a secure setting. And so they're kind of gumming up part of the system. And so if we can help with that system flow, you're gonna save money on both ends. So this board has consistently made it very clear that we believe that parity should be real between behavioral and physical health. And what I think I'm hearing from you is the right care in the right setting is going to be better care for the patients because just like we would never expect to sit in an emergency room for days to have a broken limb put into a cast, nobody should be stuck in a hospital emergency room while they're waiting for the right setting. Am I interpreting you correctly? Absolutely, absolutely. Yeah, we feel this is an essential level of care to assure that people who need this level of care are receiving it in a therapeutic setting. MCPR right now is not a therapeutic setting, right? It was meant to be a temporary facility. It's been eight years and we have done our best and we've had really good outcomes. But the individuals that need that level of care deserve a facility that is state-of-the-art that is therapeutic and that needs their needs. And everyone else also deserves to be able to move throughout the system quicker than is happening right now. Okay, that's all the questions I had, Laura. Great, I wanted to give the other board members an opportunity to ask any follow-up questions that might have arisen. Actually, I just have a quick one based on Kevin's recent question. Can you just remind me the delta between the average cost per day of a patient on the waitlist in an inpatient bed versus the average cost per day for a patient that will be in this new residential facility? I mean, that's effectively the cost savings. Can you just remind me of that delta? Wait, yeah, was it in the slide? I'm not at my computer either because my computer set off, so I can't find my note. While you're looking, Karen, I just want to comment that I'm really starting to see both your dad and your grandfather in your features now. That's a good thing, that's a good thing. We might have to get back to you on that. It was after your test. It was after my test? No, it was after. So I have it? Yeah. Okay, I'm being told it's in one of the slides. Okay, then I can look back. I just want to make sure it's calculated for the type of care that a patient on the in an inpatient bed would be receiving if they're on the waitlist, right? So I'm just trying to make sure that that's the calculation there. Oh, I have it. This is in legislative testimony. Oh, okay, it is in legislative testimony. That's what it was. Okay, so can you repeat your question? So the cost. I'm looking for the difference between the average cost per day for a patient that's in an inpatient setting, a level one setting on the waitlist versus what the average cost per day for that same patient would be when they move to the residential facility. Trying to understand the actual cost savings. Yeah, okay. So every hospital is a little different has a different per day, right? So this is testimony from March. And so it has a VPCH at $2,610 a day. The retreat at $1,776 a day and the Rutland South unit at $2,063 a day. MPCR is $1,200 a day. We anticipate the new facility will probably be about $1,565 a day. Okay, great. Thank you so much. Yeah, and I think the retreat number has gone up a little bit since then with the new contract and the payment reform we've done with the retreat. So that number is probably not accurate right now but the others I think are about accurate. So about 500 bucks a day, give or take. Okay, thank you. Any other board members? Okay, then I think we're all set with that and we will proceed to the public comment portion of the hearing. I will give the healthcare advocate an opportunity to speak again if they would like. No further questions, thank you. Great, is there a representative of mad freedom here who would like to make a comment? Okay, is there a representative of disability rights Vermont here who would like to make a comment? Yes. Great, please go ahead and state your name for the record. Zachary Hosead. You may proceed. Thank you so much. Thank you all for being here today for this opportunity. Just a couple of points I wanna make on behalf of the disability rights Vermont. I'll start off by saying that generally we agree that there has to be, that the secure facility has to be built and that the current placement in MetalSex is an inappropriate place. And then so we're grateful that the state is looking at how to replace that facility. But we do have a lot of concerns about the current proposed project. We're concerned that it's too large. You're not convinced that they're really at justification for 16 locked beds. Initially wanna emphasize that legally there's a duty to provide treatment in the most community integrated setting possible. As provided by the integration mandate the Americans with Disabilities Act and the Vermont Fair Housing Polar Combinations Act. And it's important for health outcomes as was discussed earlier, people to be in the community and receiving as much the community setting. There was some discussion about whether this is a community placement or an institution. And I can tell you from the perspectives of the residents, it's an institution. It doesn't feel very different from what I hear from a hospital. They're still locked away from the community. They don't have access to the community. People have to come to them. They can't go out. They can't be working, can't be looking at apartments. They're very restricted in what they can do and their movements and their ability to live their life in the community. So from their perspective, it really feels like an institution where they're locked in, cause they are locked in. It's also clear from all of this that our mental health system needs way more resources on every sort of level and continuum of care. And we're concerned that we're putting too much this very high end as opposed to more into the community. And there's a concern that there's been discussion about people waiting in hospitals or to get out of hospitals. And there was discussion about individuals are unable to be served in the community. And I haven't really heard a discussion of why that is and really is this adding this more secure beds is that really the solution to addressing the problem of people not being able to be served in the community? Are there aspects of other community placements that just need to be enhanced so that individuals can be served in the community and not in a locked setting? As we really encourage there to be more discussions and deliberation analysis of that. The other thing that we haven't heard much of that was concerning in terms of the backlog of lack of flow through the system, are there individuals stuck at the current secure facility that could be receiving services in the community and that they're, for lack of community resources, they're stuck in that placement. And from our experience that is that doesn't occur. And the question would be how much does that occur and would adding more secure beds just increase that problem? Again, we don't people being stuck at any point in the system. We want them as inscribed in the community as possible throughout. So those are, those are DRBT disability rights for months concerns. And it's also like to share with this board and with the community. So that I will, thank you. Thank you very much. And now I will open it up to the public. I will call on people as I see either hands physically raised or raised through the team function. And if you're here on behalf of an organization, please state the name of the organization and provide your comment. And I'll call first on representative Donahue. Thank you very much. Thank you members of the board for your careful attention and excellent questions. I'm not here on the behalf of anyone. I'm not here on behalf of the, I would say somewhat dispirited survivor or consumer folks who felt their voices were not heard or on behalf of the legislature, which is obviously out of session, but on behalf of myself, both as a person who's has the lived experience of severe mental illness characterized as a psychiatric survivor and also as a legislature legislator who is very deeply involved in the legislative process regarding this residence from the house health care committee. I really want to touch on two things. First is responses to some of the comments and slides from the department of mental health and then secondly, the specific requests that I made of the board for conditions on the CON in my public written comments, I'm not going to reiterate the discussions in those comments, just focus on the response of the slides. I think I want to touch on both what was said, but also what was said, there was a lot of emphasis on stakeholder input, input doesn't mean support. The vision 2030 were, and I was in the think tank, which I think it was about 20% of the members, not a majority who were actual consumers. There was a huge amount of support for community programs and a shift to more community resources. If you read the vision 2030 report, I do not think there's any reference to the secures and I would suggest no members of the think tank discussed or considered this facility as a community investment. Secondly, the slides referenced act 26 and the residential needs report that was completed. Yes, that report supported the need for additional secure recovery residence beds, that equally or even more related to the cause of people stuck in inpatient beds. That flow, that emergency room out is the fact that group homes were close to 100% capacity across the system and supported community residences, residential apartments and so forth with supported staff are desperately in need of expansion. Those folks are also stuck in inpatient beds. They're not the same people, they have different needs but they are also stuck in inpatient beds, blocking people from accessing the care they need. There were hours of testimony in the legislatures by stakeholders, virtually none of them, other than hospital and DMH testimony were in support. Not only by psychiatric survivor and advocates but by the community mental health, the designated agency system testified not supporting the expansion of beds. Everyone agrees the current beds need replacement but the expansion of the department on one of its slides argued there's no adverse impact on other services and specifically said because it replaced the only such program but obviously there's a significant increase more than a doubling of the cost because of the increased beds. The fact is that one of the underlying disparities that blocks any kind of parity in mental health services in the state is that there's a far greater fixed budget that controls those investments. When you increase costs in one part of the system, it reduces the availability of resources for other parts of this. Increasing this cost will decrease other costs and I'll touch on that more later. In terms of criteria number nine that they referenced, the equivalence to other services, the parity issue that begins on their slide 60, they focus in responding to that on individual care, the integration of care for individuals but not on systemic issues. When it takes two months waiting to see a community mental health provider, people's damage said when acute needs go unmet, there's a cascade of clubs, absolutely. But when needs become acute, when they are unmet at lower levels, we have a crisis in access to care at lower levels. Where have you heard of this before? Our entire healthcare system reform is on a shift to lower level primary care to reduce costs and keep people out of the highest levels of care, of which this is identified by DMH as the second highest level of mental health, consistently goes backwards from the reform efforts and the all payer model, which focus on investing in the lower levels to prevent the need for higher levels. And so that relates to the specific requests I'm making of the board in terms of conditions to the CON. As I've said, there's no question of the need to replace middle sex, but if this is to expand to 16 beds, then I would really urge three. The first is to be really explicit that this is any knot in a community system or the community mental health system-based care. It's a budget issue, not a licensing issue. Slide 25, which is my chart, says it's saying, look at our investments. See, this is what we put in the community. This is what we put in inpatient care. And they're suggesting this is community care, not inpatient care. But if you look at every other criteria than the licensing, they have consistently, they share the staff between the Vermont psychiatric care hospital and the middle sex therapeutic residents. They're trained to give staff. The construction costs, it was a question about the benchmark. If you want to look at the benchmark, the cost for an inpatient is a million or a million plus per bed. That's not what you pay to build a community residence. The cost per day that was referenced is much closer to an inpatient cost. In fact, I use the inpatient cost, but on those upper levels of care, it is much closer to that than a typical community residential placement. It has always been considered as inpatient in bed. Every time we talk about the replacement for the Vermont state hospital, we talk about their health. Excuse me, representative Dunham. For beds. I just, I'm having a hard time hearing you're coming in and out. I don't know if that's happening for other people. If it is, I think it's important that you get heard. So. Yeah, I was going to ask the court for a question. Yeah. Are you able to understand representative Donahue? No, I can't hear it either. That's just what happens on these remote hearings. So. So I'm hearing that.  Yeah. Yes. Thank you. Thank you for asking that. I've turned it off and I'll just go back just on the points of why this is an institutional level facility, not a community residence in every way except for licensing. And that licensing is not the issue I'm raising. It's about budget and philosophy. The middle sex facility has consistently shared staff with VPCH. They're trained together. The construction benchmark is what it costs to build a hospital, not a community residence. The cost per day is much more in line with hospital inpatient costs. You were given the comparison to level one care, but other inpatient care needs to also be reviewed because the gap then before you drop down to actual community based care is very different. It has always been considered a replacement for the Vermont State Hospital beds. There used to be 52 Vermont State Hospital beds. It has constantly been reiterated and on line charts for bed replacements, 45 level one and seven middle sex residential secure recovery making 52 that replaced the 54. This is what everyone has understood and it has always been. This is a state run facility. It's the only other facility rather than inpatient where there is a specific court order required for the level of care that you cannot leave unless you're accompanied by staff that surrounded by a fence, a large high fence, which is not shown in the illustrations you see. And finally, it is an EMD, an Institute for Mental Disease, just like a hospital as DMH acknowledged. It can't be more than 16 beds because it's an EMD and it's in that classification. So I think that's really crucial that we recognize that this is not an investment in the shift from institutional care to community based and primary lower levels of care that we're trying to achieve in our system even when you look at our nursing home system and those facilities, our focus is trying to get people in home based facilities, not in more institutional facilities. Why is that important? It's critically important because the next time around when DMH comes wanting to build another facility, they're gonna say, look at our balance of investments. Look at what we're putting in community based care. It's gonna appear to be growing. That's not an accurate picture if this is misclassified. The community system is starving. People can't access community care and the department consistently says, it's about yes and the department says, we recognize all these other needs, yes and. That's really nice, but it's never the reality. It's always yes, but first. We need to build this. We need to build 12 new level beds, level one beds in Brattleboro, yes, but first. And I understand the needs that they are pushing to resolve. We need to accurately identify them as building blocks for the future. If we're trying to really have an integrated system that works towards healthcare reform in the same way by meeting lower level needs to prevent higher level needs. My second key request is that the board require compliance with the legislature's direction. The legislature was very split on whether there was an adequate showing of the need to increase to 16 beds. And the outcome of that split was to say, yes, 16, but only if they are fully separable. You have that separable unit so that if the needs as they evolve or identified to be two subsets of folks who should not be living in common beyond the fact that if you're calling it a residence, nobody lives with 16 different other people. An eight bed residential component just has a better feel to it. But the legislature wanted that ability for them to function separately. No, they did not want a costly redesign, but at that time, rooms were still being changed in size and in location. DMH met with me, talked about design and relocation. At that time, room sizes were still changing, building walls were changing, office wings were becoming larger or smaller and so forth. That was all still happening in terms of the ability to do what was being asked. Each wing has a laundry room. If only one wing has access to its laundry room when the fire door is closed, when the fire door is closed, you can't get to your laundry. When your fire door is closed, you cannot get to the serenity room which is supposed to be something by the program description that folks can access at any time when they want a quiet space separate from the hubbub of the living room area. So it may not be in huge degrees, but there was a recognized lack of meeting that request. The third piece is a relatively small one. And that is about people with lived experience. There was a reference to three different meetings about architecture and design and fit up. As the department knows, most of the time in that meeting was taken up by people who were extremely concerned about this happening at all. I don't think the voices of people who would like to discuss what sorts of furniture should be there, whether more of the space should be carpeted for a more residential feel should be closed off based on saying, well, you folks took up all your time talking about why you were opposed. So too bad that you didn't comment on this. Some people don't want to comment. They feel that it shouldn't be happening and they don't want to comment, but some do. And I was stunned to see that there was a purchasing list already locked in for furniture. When you look at the slides, that is hospital furniture. That is inpatient care furniture. It has all the accoutrements of people who need inpatient care in terms of non-ligature and institutional look and so forth. I think the department should be required to have to not jump over that step and give not just a committee like the standing committee, but allow for a public meeting where people are able to give the input into those physical, environmental, final decisions. So those are my three requests that this not be documented, recorded, identified as being a community-based investment. That on that little pie chart, it goes on the inpatient state-run side that it be fully able to be two separable residential wings for that flexibility of use and that there be a meeting with interested, anyone interested regarding furnishings, carpeting, various other elements like that. Thank you. Thank you very much. I see, right now I see one hand raised and that is Dale Hackett. Would you like to go? Hi, my name is Dale Hackett for the record. Can you hear me? I can. Okay. My first comment would be, I really don't like the fire door solution. Sounds like it makes more sense on paper than it will in reality. I don't know what the answer is, but somebody needed a solution. They found one on the paper and I think when they actually see it physically, this doesn't sound like a good solution. I'll leave that one alone. I have some other doubts. I think there's some other things that are looking good on paper, but aren't gonna be so good in reality. One, you still don't know, we're still in a pandemic. Whatever you've calculated your needs at, that's dynamic and gonna change going forward. But I think that's something we all know, whether we talk about it or not. The other is, I would question what community-based services is in this situation for this level of care. Am I looking to get these people in an apartment in downtown Montpelier as my ultimate goal of what community-based is with services provided? I've never really seen it well-defined what community-based services is for this population. I have strong reservations about not just whether or not you'll have vacancies in the beds or actually more need, demand than beds available, which is a likely scenario, I think it could happen. I also think you're gonna have a workforce issue. If you're tied to Medicaid, there is a limit as to how much you can pay. And that doesn't mean that you're gonna get the workforce. You just won't be able to pay them enough if that's all connected to the fact that this is supported by Medicaid, therefore there's a limit as to what we can pay. The housing issue is far more critical, I think, than people are giving it credit for. It's not just affordability, it's availability. You can't even find the housing. I'm reading the reports all the time, especially students coming back to college. There is no housing, never buying the costs. Can you even find one to say it's unaffordable? They're coming back and saying there is no housing. So I strongly question that as well, even if you could hire people to come and work here, where are they gonna live? And then the other issue that could come up is, are they gonna have daycare? Are they gonna have a school? And right now, those are crucial issues. So I'm just, I'll finish with that. Looks good on paper. I have a lot of doubts. That simplifies my whole comment. I'm not gonna get into more detail. I think that really does generalize it. Thank you. Thank you very much. Is there anyone else who would like to make a comment at this time? Hey, at this point, I would like to thank everyone for your participation and I think I can turn it back over to Chair Mullen. Oh, you're on mute. Thank you. And thank you, Laura. And thank you, everyone, a lot of information to digest. And there is an open public comment period now and anyone can make those public comments. So if you think of something later, feel free to just log on to that public comment period on our website and do so. With that, thank you for all the participants. And at this time, is there any new business to come before the board? Is there any old business to come before the board? I would entertain a motion to adjourn. So moved. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you everyone and have a great rest of the day.