This is the House Health Care Committee. It's Friday, February 11th. It's 1.17 in the afternoon. And I want to welcome everyone who's participating in our testimony this afternoon. Let me say at the outset that we are continuing our work to address workforce issues, healthcare workforce issues. And this afternoon in particular, we're focused on the workforce issues within the mental health services community. And given, I think people have been given some advanced notice, but we're going to ask each, we've got a lot of witnesses and we're gonna ask each witness to try to keep their comments within a 10 or 15 minute timeframe, if at all possible. And to the degree possible, also be sure to focus on recommendations that you have that we might be able to incorporate into our recommendations in addition to understanding what the current difficulties are. So with that, I'm going to first turn to Lauren Layman from the Office of Professional Regulation, who, as I understand it, can help us understand their role in the licensing of mental health professionals and help us understand if there are obstacles that might be addressed, if they have a sense of any obstacles that might be addressed in terms of mental healthcare workforce. Thank you, Representative Lippert. My name for the record, my name is Lauren Layman for the Office of Professional Regulation. I'm a staff attorney there and I'm testifying today about our regulation of the mental health workforce. We have about 12 different license types right now for varying mental health work professions and each of them is within their scope of practice is some form of psychotherapy. We have several different forms of regulation and I'll walk you through the types of those regulations as well as a list of the licenses as well. And we've submitted this in a memo testimony form to Claire, so she'll have that for you to review afterwards as well. So there's really three different types of, it's all called a license and regulation, but there's three forms of regulation that fall within that term license. One of them is a license, which is a little confusing, one's certification and one's registration. And I have to apologize, my son is home today, I just need to turn off the monitor, right Jack? No apologies needed for young children or pets.  Homesick, you're homesick for one day, you're homesick for a week these days. Yeah, there's a lot of nodding heads on this screen. We're there with you. Thank you and thank you for being so flexible with me. So there's three different forms of registration or of licensure and they come in varying degrees of requirements. So we've got a registration, which is mandatory. Everybody who practices the profession that's registered needs to do it, but there's no qualifications to obtain that registration. So we've got a roster for psychotherapy, we've got massage therapy, anybody can obtain that license without demonstrating or that registration without demonstrating any qualifications and they have to do so to practice in the state. The second form is a certification. The certification is almost the opposite of a registration. It is voluntary, you do not have to obtain the certification to practice in the state, but if you choose to obtain it, it is solely qualifications based. So it's a way to hold yourself out as a professional to the public saying, I have these qualifications. Dietitians are one form of this that we have and psychoanalysts are another. It's a way, and it speaks to the community and the public and the consumer who might wanna select somebody who's a certified by the state as a certified dietitian or whose qualifications have been verified by the state. It's kind of a side here. There's certifications offered by private organizations as well, third-party organizations and those, while they might be based on the same qualifications and OPR even relies on those certifications for our own regulation processes. The legal form of certification, the certification that OPR does has a different effect than that private one does. The legal certification is a government stamp that you have achieved these qualifications.  So while they both have a certification, there's a different impact and a different effect from that legal certification. So certifications, qualifications-based, but voluntary, you can go and be a dietitian in Vermont without getting the certification, but to hold yourself out to the public as a certified dietitian, you need to come get that certificate from us. So we're wanting to focus primarily on mental health work first. So that's, if we... Yes, sorry. ...are kind of outside of our scope this afternoon. Sure, it all brings me back and I'll hurry along, but, and then there's licensure and licensure is mandatory and both mandatory and these qualifications-based. So right now we have about 12 different types of mental health professionals that we regulate in OPR, from a rostered professional, which is a registration. There's no qualifications required to obtain this, but if you're going to practice psychotherapy in the state, you need to register with the Office of Professional Regulation, whether that's your career plan or you're in training to get another credential, you need to register with OPR on the roster. Then we've got several three certification-based professions. Two are related to alcohol and drug counseling. One's alcohol and drug certification and one is the apprentice addiction professional. And both of those have limits on where they can practice the individuals, but their certifications, they're not required to practice, but for reimbursement and other purposes, that certification is needed. And there's also a psychoanalyst, which is a special form of therapy and psychotherapy and work through many institutions and have a very specific type of education. The biggest bucket we have for credentialing and regulation of mental health professionals is licensure. We license advanced practice-registered nurses, psychiatric, license alcohol and drug counselors, license clinical mental health counselors, license marriage and family therapists, license master's social workers, license independent clinical social workers, psychologists at the master's level and psychologists at the doctorate level. We've got boards for psychology and ally mental health, which covers the roster, clinical mental health and marriage and family therapy. Social work is in that alcohol and drug counseling professions are all both advisor professions and APRNs are within the nursing. And I'm happy to answer any questions. That's all I have for today. Okay. Well, we've gotten a sense of the breadth of OPR's involvement. I think one of the questions that I don't think we'll get into it right now, well, perhaps represent Goldman, you have a question? Well, I do. And I don't know if we wanna talk about it now, but I think there are two bills coming through around certification, adding certifications for mental health professionals. One was peer counselors. And then there's another one for a mental health level. And I don't know what OPR's position is on those or if you wanna speak to it. I'm happy to look into, sorry, Representative Lippert. Thanks. I'm happy to look into those bills and our director, Hibbert, will look into them as well. For certification, I would need to know a little bit more information about what those levels would be. As you can see, we have 12 different types of profession and each of those professions have multiple pathways to obtain them. And in selecting and making the determination of, between a registry, a certification and a licensure, there is an analysis in law based on policy, which is A, is there a harm from unregulated practice? And B, what is the least restrictive method for licensure possible to protect the public? So if licensure has been selected, it's because there's a need for that extra regulation to protect the public. So I'd have to explore the certification more. So one of the questions, which I'll just pose, but we'll not try to get into right now is, and part of why we were hoping, we're wanting to hear from you is that it's been suggested that there may, there's a, we're faced with a crisis in the mental health workforce. And one of the suggestions from the, at the state level, are there barriers currently within the Office of Professional Regulation that add to the pressure within the workforce? But I'm gonna suggest that we look at that. We contemplate that at another time, having now gotten a set lay of the land. And I would welcome anybody who is testifying later if you feel like there's something related to that. You can speak to that as you're testifying as well. So thank you. I think at this point, I'm going to turn our attention to Julie Tesler from Vermont Care Partners to speak to us. Julie? Hi, Harris. Okay, let me, I'm having, we're having some, are we having technical difficulties here? Julie, can you hear us? I don't think Julie Tesler is hearing us. I have our text, let me text her. Okay, let's do that. And then if we'll, we'll come back to Julie if we're not able to connect very shortly. So, audio down there. Yeah, something's not working. She says, she's not being led into the meeting. Okay. Oh, well, it was confusing to me because she was on our screen. I'm on now. But you're on twice with two different devices. So that's, that's, yeah, okay. I'm sorry, my computer is wonky and it has a blank screen. I can't see anything. So I didn't know whether what was going on. Okay. My apologies to the committee. Okay. So we, yeah, we were looking to have you speak to us and then hear from some of the other folks from other agencies. Thank you for this opportunity. And I want to start again by thanking this committee for your ongoing commitment and support for community mental health. It's been years of support and it's made a big difference for us over time. We're very appreciative. I did listen to yesterday and I know there's some very, there's some questions about the designated agency system specialized service agencies and how it all works. I don't want to take too much time today to review that because we have a lot of things to talk about with our request for the 10% and our workforce challenges. But I do want to definitely make the offer to meet with any members who would like to learn more and get those basics. And we will be sending out an annual report to each of you to your homes in paper that hopefully will be helpful to you. But I'll quickly just say there are 16 member agencies for much your partners who are both designated agencies that have this bottom line responsibility to meet the needs of their community and serve mandated populations, including children, severe emotional disturbance, adults with severe and persistent mental illness. And then the specialized service agencies like NFI have a specialty that they can provide in different regions of the state. We serve last fiscal year 36,000 for monitors as clients and then touch the lives of another 50,000 more because not everyone who we serve becomes a client. Sometimes we serve a whole school when there's a trauma, suicide, car accident. So not everyone becomes clients and not all the families we work with become all members don't become clients. Our funding is majority Medicaid, vast majority Medicaid. So under like some of the health providers that you provide services or you oversee and have policy roles with, we can't cost shift. We have almost no commercial private insurance, almost no private pay, very little Medicare. So our funding is basically Medicaid and some state grants occasionally a federal or private grant and that's where our money comes from. And where does our money go? 85% of it goes to compensation for the staff. The other 15% is for things like information technology, electric, electronic health records, transportation, heating, buildings, things like that. So this, any increase you give us goes to the staff but sometimes our fuel costs go up too. So sometimes we have to cover that as well. And Vermont Care Partners is a trade association and a nonprofit that supports this network. And I don't wanna take too much time as I already started late. So, but I'm glad to talk to anyone about that. I do wanna go back to a little bit of history about healthcare parity. The legislature years ago really made an effort to ensure that there was mental health parity with other healthcare. Unfortunately, when we have not received adequate funding over the years, we don't receive the increases state employees receive and other healthcare providers receive. We can't provide parity with there's no parity in access. If you have a mental health condition, there's no guarantee that you can get service. And unless we get adequately funded, parity is a dream deferred. It's not gonna happen. And that's where we were before the pandemic. And then the pandemic came and the demand for services increased and the acuity of the people we serve increased. So it's added a lot of stress. And our role is to meet the needs of Vermonters in the community. And I can't say that we're adequately doing that now. And I hate to say that. Last year, last fiscal year, our turnover was at 31%. That's the highest it's ever been. For the 25 years I've been here, I am pretty certain that when we do the numbers, this July, the number is gonna be higher because we have a 20% vacancy rate. In some of our developmental disability and some specific programs, the vacancy rate is higher than that. We've already had one agency that provides developmental services close. So what does that mean to the staff? They're overworked, they're exhausted. Some are working 80 hours a week, some are working over a hundred hours a week. They're doing this with a heart and soul. It's a lot of effort to provide this work. And some of you do provide direct services and understand what that means. One of the directors said this week, we're holding it together with duct tape and sweat. And what does it mean to the people we serve? It means we're not providing the quality of services they should have. We're not providing quality of life. We can't focus on that. We're focusing on health and safety. And even sometimes there are certain situations where we really can't guarantee we're providing health and safety with the level of staff turnover and the level of vacancies, we're not providing the quality of care we should be providing. And it's very concerning, very scary. It's certainly not something I ever wanted to say to this committee that that's where we're at, but that is where we're at. The people we serve have been devalued and the staff and their work has been devalued. It's a very hard place. I've had staff talk to me about feeling moral injury when we ask them to do work without giving them enough resource and ability to do it. We're asking too much of them. We've had residential programs close and reduce hours. We've had crisis bed programs close and reduce hours. There's every three months we count who's waiting for service and how long they're waiting. So at our last count, there were 342 children waiting for services that were not providing that they need. And some of them have waited for up to six months. There's 437 adults were waiting for services. Some of them have been waiting for nine months for those services. Now, I'm not saying that we're not providing any service at all to them, but we're not providing them the services that they need and want. So of course that leads to some people's conditions getting worse, going into crisis, going to emergency departments, needing in patient care. And many of those situations if we had adequate resources, they wouldn't have happened. So it's a pretty sad state of affairs. And the other area that's very concerning is the students in our schools. This is obviously been a very, very difficult time for students, they've been isolated, they've not had their supports and many are having behavioral, emotional and social challenges and we're having a very hard time staffing the school-based services. So some of them are in schools and not getting the services and supports they need to thrive in school, to do well, to manage. So it's a difficult place and our human resource directors will give you a little more information but I'm just going to review what our ask is. We're asking for a 10% Medicaid rate increase. We're not telling you that this is going to solve the problem. This is going to help a lot. 3% will not make a big difference. When you go to our lower salaries, a 3% rate increase means they get 42 cents more an hour. It's not going to make a difference but a 10% will bring us to a better place. It will help us provide minimal salaries that will meet the level of fast food and other job options that people have. It can help us maintain clinicians and higher staff to work in the schools. After we, if we could get the 10%, we would still be asking the state government for additional catch up in the next few years and hope that we could achieve that in a few years and then we would like to get annual cost of living increases similar to state employees and healthcare providers so that we never find ourselves in the situation again. That's important. The other thing that you have done for us is helped us with tuition assistance and loan repayment and we're going to report on the start of that. We're excited about it. We definitely could use more and it does help. It makes a difference. We really need your support so that we do have a workforce and a good quality workforce that are well trained to do this work. So I'm going to leave with that and I hope folks will hold any questions until we get through the Vermont Care Partners witnesses and then, because some of your questions could be responded to during our presentation. Thank you for this opportunity. Thank you and we'll hear from, I think the next two witnesses are both from Healthcare and Rehabilitation Services and from the Claire Martin Center. Yes. I'm going to make one comment if I may that I think there should be some serious thinking done collaboratively about how to look into the future and set forth a plan to bring parity to salaries. There's no way we're going to achieve that this year and I'm not sure we can achieve even all of what we'd like to achieve this year but I think that we need to say we need to establish the goal of establishing financial parity for salaries and we need to set in motion some type of planning process if that goal was even accepted as a goal but I think that I think we're past the time when we just remain hopeful. I think we need to actually establish a goal and try to find a plan and a way forward. So, but I'm going to be very clear. I do not, that's not going to be achieved this year but I think we should just going to put it out there. I said it. Okay, so let's hear from, so I believe we have, is Ann Biladu? Folks help me with names if I fracture them, I apologize. It is good, it is important for people to hear the names pronounced properly and sometimes when I don't know someone, I don't know how to say it. You said it perfectly. Okay, thank you, Ann and then after Ann we're going to hear from Jenna Trombly from the Clare Martin Center and again, I apologize but we have a press of time. So we'll ask you to keep your comments focused and help us understand the problem but also help us understand what you see as a set of solutions. Ann, welcome. Thank you, Representative Lippert. I appreciate the introduction and thank you all for your efforts on furthering community mental health and for inviting me to participate in today's testimony. My name is Ann Biladu. I'm the interim co-executive officer and chief human resources officer for healthcare and rehabilitation services of southeastern Vermont. Some of us know it as HCRS. So I'm going to use the acronym of HCRS as just a little bit easier. So for those of you who may not know, HCRS is one of the designated community mental health agencies. We provide children, youth, family and adult mental health services along with developmental disability services in the Wyndham and Windsor counties for approximately 4,000 clients. We have 500 employees, roughly, give or take. 100 of those are clinical staff, direct clinical staff. I'm currently the co-chair of the DASSA workforce group along with Cheryl Biladu Wilcox. No relation, by the way, from such a highly unusual name. From the Department of Mental Health and in your documentation package, you should have the DASSA workforce group recruitment and retention strategic plan to reference as you consider these items. In addition, I was also on the 2021 Healthcare Workforce Subcommittee looking at the statewide healthcare across the workforce across the state of Vermont. I'd like to start off today sharing a recent conversation I had earlier this week, actually, with one of our master's level children's clinicians, someone who has a couple of years of experience at this point, she is licensed. She said to me the following things. She's not sure she wants to stay in the community mental health model. She feels her work is undervalued by society, the state of Vermont, the community. She feels our clients, the most needy, underserved and marginalized, are not valued as human beings. We're talking about children here. This is a children's clinician and these are the most acute children that we're serving in the state of Vermont. I was so sad to hear that from her. I think it's so sad to hear and to even share with you, but that is the state, these are the things that she is saying to me. She believes that the state doesn't care. The funding is too low to provide the needed services. The number of children on the wait list feels daunting. We just lost four children's clinicians, three of them to private practice. The administrative demands are way too much and very stressful. Private practice would allow her to see much easier clients and she can choose who she takes as a client and there is nowhere near the administrative burden and it would pay $20,000 more than we can pay or she could work for the state or a school system and make $20,000 more. And she's asked, why would the state fund other state funded systems the amount needed to pay much higher salaries but not community mental health where it's needed most? She feels disheartened and sad for our children and families who struggle every day. She needs more money to live on and money for loan repayment. I actually thought I was talking to her only about loan repayment when I got on the Zoom call with her. So we ended up having a very different conversation and spent maybe 5% on loan repayment. So our average starting pay is $48,000 for a master's prepared clinician. In 2020, livable income levels for full-time workers as you may know, ranged from nearly $13 an hour for people without children in rural Vermont to nearly $42 an hour for a single parent with two children in the Burlington area. So about 27,000 to 87,000 a year respectively. If you age that data by 3% for two years because we're in 2022 now, that means today's value is 286 to 90, just over $92,000. So that is for all positions across the state. We're here today talking about a lot of positions but primarily bachelor and master level positions where earnings are falling along those barely livable wages. The report details out the cost of basic needs for seven Vermont household configurations, adjusting expenses as you would expect based on household size and type, one or two parents, et cetera, et cetera, urban, rural and the needs including food, housing, transportation, childcare, healthcare and other costs. Many of our educated professional staff right now are reliant on food subsidies and housing supports. These are master's level clinicians trying to do incredible work across our state. So let me give you some real examples. So we've had an open position for a developmental services assistant manager for four months. We finally got a great candidate made an offer, she accepted, she was ready to start this Monday. So three days from now, yesterday she emailed us to say that she was offered a job somewhere else for $15,000 more. And she couldn't turn it down and how can we blame her, right? These are living wage issues. We offered her the absolute top of our range and it still was not enough. And looking at 15 of the last clinician exit interviews we've done over the last two years, when asked why are you leaving HCRS, the response was directly related to the pay that we can offer for this position, especially in relation to the amount of work and level of stress the job entails. So let me give you some quotes from their exit interviews. The amount of paperwork required is incredibly time consuming. Some of it is very redundant and it's overwhelming as a clinician and for the clients, they are not easy to understand. Notice the client piece on that one. The pay is poor, the paperwork is overwhelming and it impacts client care. He is experiencing burnout and the work is too overwhelming and stressful and feels unsustainable. Turnover and just our developmental services department at the end of December, 2021, we had 22 direct service provider openings and we had no choice as an agency along with a number of other agencies but to increase that starting wage by over $3. What a hit that is for our organization. However, here we are almost two months later, we now have cut that by 50%. That's how much of a difference pay makes. So that's incredible with just over a month or so, we had that kind of a dramatic increase in candidates.  So this has been the case for years but it has become even more extreme due to the lack of livable wages and the emotional stress experienced in dealing with such an acute population. The current demands on clinicians working with children, youth and family are at an all-time high and occur simultaneously with clinician vacancies creating kind of a perfect storm. Schools and private practices as I mentioned offer dramatically better situations and clearly greatly reduced administrative requirements and the stressors of COVID have profoundly impacted all aspects of what we all know as the social determinants or social contributors of health, loss of housing, acute illness, loss of income, increase in the rates of suicide and overdose, all are factors currently affecting all of the clients we support. So the number of families that we're seeing struggling with the very basics is overwhelming and adding to that fact of course is that all children are bearing an additional burden of losing critical opportunities for essential socialization and learning due to COVID. Prior to COVID, we would see youth in active crisis a few times a week and the incidence of acuity currently is stunning. Nearly every new client who walks in the door is needing immediate triage to address critical need relative to their mental health. This is a dramatic difference in the last two years and we simply just don't have the staff to adequately manage the number of clients nor the acuity of need they currently experience. Hospital waiting rooms are jammed, hospital beds have decreased and yet no additional resources have been created in the community to support certainly youth in crisis. The requirements of Medicaid and DMH for reporting require that clinicians, their sacrifice time from their sessions to complete the necessary documentation, taking away valuable treatment time or they end up sacrificing their own personal time in the evenings after work. So many of our clinicians work after hours to keep up with the documentation. And by the way, just in case you may or may not know this, the standard clinical intake documents require that we ask clients and or parents in the vicinity of 350 questions in an initial session. That's right, 350 questions in the initial session. Wow, all has to be documented of course. HCRS is actively working to reduce the administrative burden of our clinical staff but that requires additional administrative staff, something that is not accounted for in our payment reform reimbursement. But by far our most significant issue is the high turnover of staff, particularly those in direct support roles like clinicians and the impact that has on our clients who need consistent and reliable support. Additionally, we mostly provide services to individuals who have a high level of support needs and mental health acuity. And because of the rate of payer, we are only able to recruit entry level providers. So there's a real mismatch between who we're able to recruit and the services needed. So a client who is too acute to be seen by a licensed private practitioner or an embedded primary care social worker is referred to HCRS where they may be seen by a clinical intern or an entry level clinician. We have a second year advanced standing student right now with a caseload of acute clients so even a manager would be challenged to provide a high quality of care to. Additionally, the rules, regulations and compliance standards that result in that administrative burden coupled with the witnessing of suffering day in and day out, which is very true often results in burnout and providers leaving the field altogether. So we need increased reimbursement for higher wages for recruitment and retention, more staff to reduce caseloads and reduce any reduction in the administrative burden. I do want to share for a moment what's happening in our developmental services area because that's also part of our conversation. A high turnover has always been a given in that field and that's largely because the system isn't funded in a manner to be able to pay adequate wages for the complex work being done. Prior to the pandemic, this resulted in difficulty attracting highly skilled or even just skilled professional higher turnover rates. And for those who do stick with us many needing to have a second job in order to make ends meet which contributes to burnout and decreased quality of care. And since the pandemic we've had an even harder time hiring and people were aware that the work is worth more than what we could pay based on our reimbursement rates. And with the workforce shortage people started to have more options where they wanted to work and may choose to do easier work that paid. So we know pay makes a very big difference. The vacancies in high turnover have a ripple effect where there are vacancies it becomes impossible to provide all the services someone needs. And this puts a tremendous strain on natural supports and paid home providers. And we've this year seen a record number of home provider turnover and natural support saying that they just can't do this anymore. And we know it's in large part due to our workforce shortage. We currently have over 20 clients in need of new homes. We are definitely seeing a rise in serving people with higher acuity needs in developmental disability services. And having rates that reflect the actual costs involved in delivering high quality services would be it's just really, really needed. You know, this is complex work and requires an awful lot of skill in training. And so what can you do? What do you need? Here we go. Yes, 10% in additional funding as Julie mentioned we need our state leaders to change and reconsider documentation requirements to minimize the gathering of data and excessive documentation on the clinician and client relationship. We need loan forgiveness and tuition assistance funding. We did receive 1.5 million in funding for one year which is very much appreciated but it's not enough. We need about $6 million a year. Other healthcare fields in the medical arena have annual funding but we do not and that needs to change. The loan forgiveness is a critical way that we can attract and retain new grad candidates. We're offering 3000 per employee per year but the need is actually closer to 10,000 per year. And these programs by the way do not cover developmental disabilities which is just not right. There just needs to be much more. They need to be there just as much. So we need to be able to provide career pathways for all of our staff to increase their education. So having the flexibility to provide tuition assistance and loan forgiveness to all of our staff is incredibly important. So we may have a finance staff member trying to get educated as a clinician and we really need the flexibility and ability to do so. I also wanna state that we very much appreciate the partnerships that we have with the Department of Public Health and Dale. And having said that again we just need these programs to be paid, payment to be increased, the amount to be funded on an annual basis and to be flexible according to agency needed to include developmental services. I really appreciate your time and consideration today. Thank you so much. Thank you. Very quick. We're not gonna do questions. I'm sorry. I'm sorry, really less. Go ahead. What's your quick question? I'm just really having a hard time trying to figure out how to actually hear from people as well as our staff. I just wanna know what slide on your presentation would summarize what you said in terms of your request. Are you referencing the workforce group document that I included in your packet? Sure. So if you look through that document you have it, there's an awful lot on compensation. There's a lot of categories in that document. But if you look specifically in the categories of compensation and tuition assistance and loan forgiveness, you'll see some of the information detailed out there. Thank you. You're welcome. Okay, great. So I'm just gonna say this and I'm gonna, it's gonna maybe sound inappropriate, but I don't mean it as inappropriate. We've heard during our budget adjustment requests a lot of the same situations. And I'm gonna ask you to try to help us hear what we need to hear additionally to support the request that's in front, which is a significant request. And so maybe it's exactly what you're needing to share with us. I'm struggling to figure out what it is that is the best way to make the case from your end rather than have us, yeah, let me just leave it there. So Jenna, I welcome your testimony. I generally do. I just know that it's hard on your end to feel like how can we possibly have these people understand what it is we're facing. So let me back myself up and say welcome and thank you. Thank you very much, Representative Lippert and the committee, I do appreciate the opportunity. And while I have written comments that I sent in and will primarily stick to those, I will try to weave in any more that I can think of to try to address your comment to make those points a little more clear and try to help in that a bit more if I can, hopefully I've articulated some of that in these comments and we'll... I'm sure you have. I hope so. So as you've just said, my name is Jenna Trombly. I'm the Director of Human Resources and Compliance here at the Clara Martin Center, located in downtown Randolph. Sun is shining beautifully behind my back here, as you can see. I am the Director of Human Resources and Compliance at the Clara Martin Center. As I just said, my organization provides mental health and substance use disorder treatment and support services to people in the central Vermont and Upper Valley regions. I've worked at the Clara Martin Center for the past 30 years, with roughly half of that time in my current role and half as a direct care case manager, therapist, clinical supervisor, and program director. Six years ago, I joined my fellow human resource directors of the designated and specialized service agencies of Vermont Care Partners to sound the alarm and the fragility of the DA-SSA workforce in Vermont. The report we sent to you then stated that chronic underfunding of the DA and SSA system if left unaddressed would be devastating. At that time, we could not imagine continuing to keep our doors open without an immediate and sustained infusion of adequate and reliable funding to support our workforce. Some of you were on this committee at that time and you may recall that the comprehensive paper, including essential recommendations needed to keep our community-based system of care intact. At that time, we urged decision makers within state departments and the legislature to act swiftly. While we acknowledge and appreciate the support that we have received, our challenges do continue to grow and I will share with you now a few examples of what we're experiencing. One year ago, my organization had 11 open positions for recruitment. Today, we have over 40 open positions, many of which we simply cannot fill primarily due to wage gaps with other employers. My experience echoes ands. We've made offers to people that have accepted them. Days later, turn them down, have not shown up, have emailed the day of to say they're not coming. That has become unfortunately more common. The impact of so many open positions means that we've been able to accept fewer referrals for our independent school, which serves students who need a higher level of care than a traditional public school can provide. It means we cannot provide necessary one-on-one behavioral interventionists to support students in their public school classrooms. Of those 40 open positions, I believe around 15 or 16 are school-based, as Julie cited earlier, many of them are school-based positions. For us, it's in the 15 or 16 realm. It means clients who come to our buildings to be seen in person must wait outside while direct care staff balance, providing care to clients, while also filling in for vacant, administrative assistant positions. It means we've been unable to provide support and recovery-based services to clients who need them. And it means we have many staff who have picked up additional responsibilities, extra shifts, including overnights and weekends, and are exhausted by working longer hours with no end in sight. As an example, we've been advertising for a clinical supervisor to oversee our medication-assisted treatment program for over a year with barely a handful of applicants. The position offers a $10,000 recruitment and retention bonus. We've been offering that for months with little to no applicants, and the only serious candidate we considered for the position was employed at a Vermont hospital, making considerably more than we could offer them. The same program has half of its counseling positions open, leaving the remaining counselors with caseloads of 100 or more adults, all of whom are addicted to opiates, and are in dire need of both medication and counseling. One month ago, my agency made a formal job offer to a qualified candidate for the position of emergency clinician. The candidate was bachelor level, was currently employed by the State of Vermont with the Department of Child and Family Services. The person let us know that our offer was $23,000 less than what they were currently making. This is not an uncommon situation. As we continue to experience a widening gap between the salaries we're able to offer and what applicants are able to receive elsewhere. Fully staffed, my agency would employ roughly 190 to 200 people. In calendar year 2021, 75 staff left the organization with the majority citing a job offer with higher salaries. When positions turn over, client relationships are interrupted, the burden of training new staff increases and team members who remain take on more work to help fill the void. In addition to compensation challenges, you've heard this already, our clinicians are increasingly hampered by a growing demand for additional clinical documentation, data gathering and recording, and other administrative tasks that take them away from spending time providing care to clients. In the past three months, we've had two of our longtime licensed clinicians resign from their full-time therapist positions, citing excessive clinical documentation as the primary reason for leaving. We need our state leaders to reconsider documentation requirements to minimize the gathering of data and excessive documentation in the client-clinician relationship. As you consider options for providing resources to our system of care, please consider that while our agencies offer many different services and programs, we do have unique challenges. We have different benefit packages, in some cases, some are negotiating with unions for salary and benefits. I would respectfully urge that any additional resource allows maximum flexibility so that we are able to put it to the best use possible here. We are pretty exceptional at being creative and stretching the resources that we have to try to cover as much of the gap as we can, but any restriction on how funds are able to be used will narrow our ability to put those resources to the most necessary use. An additional obstacle to consider are the rules related to reimbursement. There's clinical licensing and supervision requirements that restrict certain licensed staff from supervising other licensed staff and impede new clinicians from seeking and obtaining licensure. The rules we create to set standards and benchmarks cannot be so stringent that the average master's prepared clinician is driven away from seeking licensure or cannot find an appropriately licensed supervisor to work with them in the licensing process. We are currently working with state leaders to request reconsideration of a requirement for licensed drug and alcohol counselors to seek an additional credential to provide mental health counseling. Currently, the LADC credential is accepted by private third-party insurance for this service, having a higher bar for Vermonters with state-sponsored insurance as a barrier to access and would force LADCs to seek additional licensure to continue providing mental health care. On a positive note, one month ago, we did launch the new tuition assistance and loan repayment benefit that was funded by the legislature from the Tobacco Settlement Funds. We had 31 out of 106 eligible staff apply with several more staff asking to be included after the posted deadline for applications. Nine staff applied for tuition assistance to support with coursework. That represents eight different colleges, but I'll mention two of them are with Annemarie Seafari, who I see on the screen, and responded to that primarily because of some of those opportunities that Annemarie had sent to our agency that we shared with staff. So it was a wonderful opportunity for them to go back into school. The portion of funds that my agency received will likely support two thirds of the applications we receive. We anticipate that more staff will be interested in this program as awards are applied and as word spreads. To make the program an annual ongoing benefit to retain staff year over year would require two to three times the amount received in this initial offering. And if the benefit were expanded, as Ann said, to include developmental services, the need would be even higher. I do look forward to reporting back to you in a year on the impact of this new benefit on retention at my organization. And I want to really recognize and thank the committee, especially the committee chairman who's been a shepherd of this program for a good number of years. I think we may have started this process three or four years ago and it's wonderful to see it be put into play. In my role as the human resources director, my ability to recruit and retain staff is a direct impact on our ability to serve clients. Our agency's mission is to take care of others. My participation in sounding the alarm in our workforce crisis in 2016 was an ethical duty to inform decision makers and state leaders of the growing challenges that stem from many years of inadequate funding. The message is simple. If we want a community-based system of care in Vermont that provides necessary developmental mental health and substance use disorder services, then we must provide adequate funding to support that to happen. It's as simple as that. In closing, I do want to acknowledge that this committee has had a proven record of success in strengthening health care policy, improving access for care for services. I commend the committee for its work on access to therapy and other services via telemedicine. That legislation has been essential to our ability to provide treatment services to clients over the past two years especially. Further legislation to fortify our workforce would have a direct impact towards ensuring that Vermonters have access to services both by telemedicine and in person. Thank you for the time. I do appreciate it and will be available for questions if we have time. Thank you so much. And some of us share the frustration that monies that were appropriated some years ago didn't make it to you. We'll be there. In the way that we fully intended but some of it's finally making it. That's right. Okay, thank you. I'm going to, oops, has my sound, is my frozen or my sound is gone? You're good. I'm good. Okay, something changed on my end. Suddenly there was this dead silence. There was a white noise in the background that's gone. Oh, that's okay. That's what it is. Okay, thank you. So thank you, Jenna. And thank you for, you know, so many of us share your deep, deep concerns. And yet it's incredibly important. It is important for us to hear where we are at this point in time. So thank you for taking the time and thank you for persevering in your work, in the community system. And please find a way, if possible, to extend that appreciation to your colleagues from our committee. Thank you. I'm going to turn now to, now I understand, well, I see Chuck Myers from NFI. And my understanding is that there may be some different staff with you than was on my list. So I'm going to turn it over to Chuck and ask you to take the lead in having us hear from you and your staff. Well, thank you, Chairperson Lippert. Thank you, committee. Thank you so much for your determination and commitment to supporting the mental health services, the public community mental health system. What I would like to do, I was told we had 15 minutes between three of us or actually between two of us, I asked for three of us. So I've got two staff members, at least who are willing to talk about their experience that's Ben Rees and Amethyst Barfsfield. And I'd like for them to go ahead and speak first if it's okay with the committee. And then I'll be glad to follow up. Happy to have that happen. Thank you so much. So Ben, do you mind going first and talking about your experience? Not at all. So my name is Benjamin Rees. I work with NFI. I am a community integration specialist, a new college grad and this is my second job coming right out of school. We, I'm here today with NFI and Chuck and I assume everyone else that I'm just here to talk about the discrepancies that we're having between our profession and what's going on with the rest of the workforce. And mainly that I straight out of college started working at a gas station and with a BSW and to make ends meet. And when that happened, I was okay with it but it was a temporary thing. And NFI approached me and asked if I could work with them. And I did and I love it. Now that being said, I took a pay decrease to join NFI where I found and all of my colleagues share these sentiments that I found that working in a less stressful situation at a gas station, I was making more money. So I closed up the shop at the end of the night and went home with NFI. I wouldn't trade it for the world. I love working here. I love the work we do with the children but the stressors that are associated with that and go into that. I use the passion versus pay when I explain it is that everyone goes into this profession with passion. It's what we want to do. No one's here because it's easy, it's not. And that passion when you start off is very high. It burns down quickly when the pay is not up to the amount of work you're putting in. So the discrepancy between the two is volatile and that's why our turnover rates we're facing right now are so high and retention rates. They're not, people cannot continue to make and this is not a slight on gas station employees but people can't continue putting in the work and the hours of working with these kids, seeing their struggles, helping them through it and having, but they can't continue to do that when they could just go find another job scanning Mountain Dews at the register. And I'm here to advocate for the fact that the retention rate is so low, the turnover rate is so high because mental health funding and the community-based services we're offering are not getting the attention that they deserve in this. And it's just, it's heartbreaking because we, one of our clients who thankfully just graduated had five case managers in the two years they were here and those case managers left to pursue other careers because it's just not cutting it. It's not the passion versus pay is not there and with everyone else has referenced the amount of paperwork the amount of time that goes into it. It just doesn't seem equivalent to any other profession right now. We've over at CBS we've been trying to hire a new clinical case manager for months now and much like others have said that I've gotten ready for about four or five interviews only to have them canceled day of or day after or day before, sorry. And because either they're getting paid more out of state where they can go and it's a livable wage or they found one of them found a job at Trader Joe's that was paying a couple of dollars an hour more than what is available to people that are working and want to work. But there comes a point where you want to work you want to engage you wanna help but feasibly it's not livable. And that's really why I'm here. I'll take some questions if anyone has any. Thanks Ben. I think my understanding is Chairman Lippert will have a time for questions at some point in the future perhaps today a little later today. Is that right or? Well, let's hear from folks and then we'll see where we are because I guess I wanna say I don't have a question Ben Benjamin but I'll just express my appreciation. And I understand the passion versus pay dilemma but so just let me express my appreciation. Let's hear from your colleagues. So without Amethyst would you like to to address the committee? Thanks. Yeah, sure. Hi, my name is Amethyst. This is Alex who's able to join me. We're residential counselors with the NFI hospital diversion program. So just kind of echoing what's been said as far as staffing we once were a 10 day program 365 24 seven and due to staffing we're now only able to operate as a five day program which I think affects care long-term we're not able to build the same rapport we're not able to access the same resources for aftercare and discharge planning. Yeah, I just feel like we're not able to like be as effective in crisis stabilization while we're so short-stacked. So Alex and I are two of three full-time residential counselors right now. And that's all we have which also means we're on call more and we're being called in more frequently. It's more emotionally stressful and guilt-provoking to call out sick if we really need to because we know that that will call someone else in and someone else will have to do a 16 hour day so that we're not there. Yeah, it's hard to keep like engaging and getting everything done that needs to get done and effectively engage when there's so few people. We're also really challenged to actually engage effectively because we're so understaffed but I work 10 hour days and most days in a month I don't get a break at all during that 10 hours which means I'm exhausted and drained and just have a harder time focusing and being present with our clients because we don't have the staff for me to take 10 minutes off the floor to recharge before the next activity and so it really impacts our ability to provide quality care when we're so understaffed that we can't take breaks or take time off at all. Yeah, I also think that short staff and kind of high turnover rate leads to a real inconsistency in like team building and ways that staff can support each other which can also be exhausting when you're trying to interact and be therapeutic with clients and you're also running a list in your head of did this get done, this has to get done, I have to do this and not knowing if your team is also aware of those same needs because your team is changing all the time. Yeah, I think that's been a unique challenge as well. Yeah, I think we've had in a year that I've worked here five or six staff leave and a lot of that is because they can find better paying work somewhere else or work where they have better hours or more consistent schedules than they do here and that really impacts our ability to function as a team. Yeah, jumping back to Alex was saying about breaks just echoing that even when we were a 10 day program on weekends, staff were doing 16 hour days often with no break as well and being short staff doesn't allow for efficient pass offs or passing along important and relevant information for switching from one shift to the next as far as like client needs and client concerns and things that might be helpful for someone else to know instead of just arriving and trying to catch up as fast as you can to what's happening. Yeah, I think that might be it for the dimension. That's a lot and thank you. Yeah, thank you. Again, is it Amethyst and your colleague there? Alex, thank you Amethyst and Alex, I do see that Representative Black has a question. We are going to take some questions. Go ahead. I have no question. I just have a request. I was hoping that a variety of our witnesses could possibly send us their written clinical documentation requirements. I personally would really like to look and see what we're dealing with here. That was it. Just a request. OK, that's a very, very important and useful request. And I think for those of us, some of us who were stunned by the 350 questions that were required as an intake interview as well, some of us familiar with some part of that, but nothing to that degree. I'm going to see Representative Goldman. Well, that was my request also, is who is in charge of intake requirements? And how can that be addressed? So I don't know. I'm going to turn back. I have my own idea of who. I mean, the Department of Mental Health needs to be hearing a lot of this directly, is my view, because they ultimately, although they are also constrained. I mean, we are constrained at multiple levels by federal requirements, but where the state. I think one of the questions is, and I think I think I'm just going to say this, articulate this, where can we intervene? Where do we have the ability to intervene? We may not be able to change certain things that jeopardize federal funding and federal support, which is absolutely crucial, but to the degree where we can as the state in the midst of this crisis, change, reduce administrative burden without losing accountability and without losing accountability for what needs to be done in terms of quality and safety. We need to be doing that. And it sounds like just it sounds like a chore that nobody is going to relish doing, but we all know it has to happen. I see Julie Tesler. Is that a hand, Julie? Here's a comment. Yeah, I just want to quickly say that Commissioner Emily has met with the Board of Vermont Care Partners on Wednesday, and she did identify her intent to work with us on documentation. Great. I'm going to say something else here. Ben, thank you for taking time in addition to everything else you do and for Amethyst and Alex. We've had requests to say, we need to hear from people who are actually doing the work and not just from their directors. And so I've and I know that that doesn't mean that the people who are representing you aren't sharing what needs to be shared. But there is, I think, I think the commissioner needs to hear as well from. We must hear from people who are struggling on the front lines because that also matters. And that is not to dismiss or demean those who are representing people on the front lines, whether you're an HR or in an executive position because I know that is important as well and Chuck as well. So I'm going to turn it back to you, Chuck, if you have some comments you'd like to make at this point briefly. Well, I see Representative Cortis. We're going to play this by ear this afternoon because I wasn't sure how things were going to go. And everyone on this screen, including ourselves and you, have had a long week already. So let's do what we need to do and represent Cortis. It's hard for me to find the words other than to say that I've been deeply impacted by what you've shared today as I have been in past years and share the frustration of my colleagues on the committee that while we have been able to help, we haven't been able to help nearly enough. And frustration isn't quite the right word. It's a more intense feeling than that. And I had that thought in those feelings when I heard what the proposed budget amount was for 3% and that it wouldn't even that would not necessarily go directly to the folks in your organizations providing the care. So I'll just say that I hear you. I'm beyond frustrated. And I think we need to find a way to get we, meaning the committee and other legislators, need to take your voices, lift up your voices and get a lot louder in the work that we do. Thank you. Again, I'm going to turn to Chuck. And then I do want to hear from Annemarie Seafari, who is with us from the Clinical Mental Health Counseling Program at Northern Vermont University. And Robert, I'm looking at you. He's coming. He's coming. No, I just wanted to be sure I was looking on the screen trying to see if I was missing him. So let's check a few comments from you and then let's hear from Annemarie. Thank you very much, Chairperson Lepert. Thank you again to the committee for your commitment. I realize this is the Health Committee, not the Mental Health Committee or Human Services Committee. And it's real important that we understand that mental health is a real important part of health and that we're trying to build a system in Vermont that's about building health, helping people develop and retain health, not just treat symptoms of disorders, diseases, and injuries. So thank you for your commitment to that.  And I appreciate your willingness to tolerate and try to understand the complexities involved. And they get to be pretty complicated. You've already heard a lot of testimony from a lot of people. What I'd like to do because I think I could say a lot of what other people have said and would sound very similar, I'm going to try to move to a little different perspective on this. And that is I want to reinforce the notion that public mental health systems across the country, not just in Vermont, have been enormously underfunded since the United States government started shutting down state hospitals in the 1960s and 70s and promised to move dollars to community-based systems of care. In Vermont, we've done a better job of that than in most parts of the country. But even then, it's not really, we've not moved many dollars into the community-based system of care. Although we have a fairly robust system of care as Anne and Jenna and Julie have talked about. And as you've seen demonstrated by our colleagues right on the helping lines here with Ben and Amethyst and Alex. And so the notion that I talked with US representative a few months ago is that the notion of an infrastructure injection of resources is really important. We need an injection of resources to help establish a foundation of infrastructure because we've been so underfunded for so long there aren't many college graduates like Ben who are willing to go out and think about working in a helping profession like mental health. They want to go into banking or coding and make video games or whatever. So we've lost a lot of opportunities. Part of that's because the funding isn't guaranteed. When somebody comes to NFI, I can't say I'm going to guarantee you're going to have a 2% increase every year, a 3% decrease depends on the salaries. In some years, we've actually had to reduce our salaries. That was a long time ago, thank goodness. So what the designated agency, what the Vermont Care Partners is suggesting is a 10% increase this year. And then I applaud enormously, Representative Lippert, your idea of getting buy-in and commitment to a planning process because for those of us in the mental health community to come to the legislature for you to spend your time and for us to spend our time every year saying the same things you've heard today for most of this testimony when everybody knows that is a waste of time. And it's not very respectful. So coming together to make a plan for a multi-year, how we're going to start building that foundation of funding and resources for the community mental health and disability system and substance abuse system so that in three years, there can be maybe an indexing to the increases that state employees get, the public agencies, the public mental health, substance abuse, developmental disability agencies would get some amount of that or something akin to that. Or that would be reviewed every few years. But a commitment to a long-term planning process that that would be a huge injection of support for this foundation and for our agencies. I can't tell you how critical it is. We have never before been at such a critical place in the development of behavior health care. And that's because our physical health care colleagues, the physicians and our educator colleagues, those folks in the schools have figured out that you can't separate the mental health or the brain, the emotional well-being from the physical health care needs or the mental health issues from the reading, writing, and arithmetic that happens in schools. So they've started hiring the folks we train. As a result, from your perspective. Can I say we actually designed the system so that they would have those folks in their schools? Yes. That was something that our system decided needed to happen. Exactly. I was there. I'm just going to get on my soapbox right here. We actually said, you need these people in your schools. They then, we assigned some of our people to work there. They were working next to colleagues who were being paid far more. And the schools changed some of their staffing. So they created the positions. They then hired our staff, which was absolutely the right thing for the staff to be able to access that pay and those benefits. But it became a kind of self-defeating in a degree that we have been advocates to bring our services into other service systems over the years. And we need that. Yes, Representative Chairperson Lippert, you are exactly right. And we've done the same thing in health and physical health care systems. That's right. The problem is that both of those systems are much better capitalized than the mental health system. Absolutely. And there is this situation where our system of services broadly has been devalued and not sufficiently funded and now so insufficiently funded that, in fact, the crisis, which we all knew was coming pre-pandemic, has been made critical as a result of the pandemic. And so I'm going to stop there for now. But may I continue? But yes, you may continue. And I think your point is well taken, that the health care system and the education system has been successful in securing the capital and the capitalizing and the resources while the system of mental health care and disability care has not. And that's not a reflection on those who've been advocates. I want to make that clear. This is not pointing a finger at people who've been advocating. But I think it's part of a larger systemic issue. And I think that's part of what you're getting at. And I apologize for interrupting you and jumping in, but it's just like. Oh, thank you so much. No, Chairman Lippert, this is exactly the point. And it's so critical for you as lawmakers to understand that to the degree we are not successful at adequately funding the public mental health system, not only is that process unfair, and there's a huge cost that the taxpayers have contributed to train that workforce. The bigger and more problematic issue is that the ongoing cost of mental health care increases significantly by 50% or 75% or sometimes 100% because that's the amount of additional pay our clinicians are getting when they go to work for physicians up groups or hospitals or schools. So that means that the mental health services that are so vital. And I want as many people as many places as possible to be providing them from a larger systems perspective because the need is huge out there. It has never been so dramatic. It's never been so huge. It's never been so acute or so intense. And we haven't even yet seen the crest of the tsunami wave that's hitting us. And our system is fractured. We will be swamped and overwhelmed. And there will not be much system left if we don't get this fixed. And we don't have long to do it. I know it takes a while for legislative processes to happen, and I respect that. I appreciate that and value that. I've got to tell you, there are three national organizations that have said we are in a crisis for children in adult and adolescent mental health. They are the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatrists, and our own United States Surgeon General.  This is the future of our country, of our society that is in dire need of enormously more services than we currently can provide. So I do want, I had a couple of other things. Oh, if I could just continue, just for a minute. Just briefly, seriously, I want to hear everything you have to say, but we need to also hear from your colleagues as well. Thanks, Chris, and I will yield. We've said that there's a 31% turnover rate and a 20% vacancy rate. All I want to do is combine those two and let you know that the true impact of that means 50% of the workforce in public mental health either isn't there or is learning their job. Thank you very much for your time. Thank you, Mr. President. This system should be being paid for training the workers that leave to go work in every other system. And with that, I'm going to transition to Annemarie Seafari from the Clinical Mental Health Counseling Program. I wanted to say NFI for Northern Vermont University. We'd like that. Thank you, Bill. Am I able to share? I brought some PowerPoints just to keep me on track. Am I able to share my screen? If our, I'm techno ignorant, so if Claire and Neil can help you make that happen, I'm happy to have it happen. I will try and see if it...  Great, so you're seeing my PowerPoints, correct? Yes. Okay, great. So thank you, Chairman Lippert, and thank you to the committee for having me here today. I am the director of the Master of Science in Clinical Mental Health Counseling, which is a weekend format program at Northern Vermont University. I think I was asked primarily because our program was developed at a time that was very similar, that the workforce was under duress. There was a big need for more people in the workforce. So I hope what I can do today is amplify, add to what you've heard from everyone else, as well as tell you a little bit about what we do. So you're gonna hear a little bit about our programs, a little bit about our history, and then a thank you for the critical occupation scholarships that you provided last year, and that I believe you have put in the budget for the coming year. And I will go up with written comments that have a clearer need and ask. So as I said, I'm the director of the graduate program in clinical mental health counseling at the Master of Science at Northern Vermont University. We are one of two sister counseling programs at Northern Vermont. There's been a long-term Master of Arts in counseling offered on campus in Johnson. They have concentrations in clinical mental health, addictions, school counseling, and a general counseling. And they've served primarily folks in the northern tier of the state, central and northern Vermont, but certainly people from all over the state in a wide variety of formats. They offer weekend courses, they offer traditional once a week courses, a wide variety of formats, weekend intensives. Our program was designed in the mid-1990s out of a workforce development initiative involved service providers, people in recovery, peers, family members, a large contingency of stakeholders in mental health. It was designed to be weekend format offered one weekend a month across the calendar year, all day Saturday and Sunday to be highly accessible to working adults. It does have specializations in working with children, youth, and families and with adults. And I'm gonna talk a little bit more about what we've been doing to make it accessible all around the state. Right now, the face-to-face courses happen in Williston, but half of our coursework is offered over Zoom. So I'm gonna come back and talk to that about that a little bit more. We have an integrated approach to mental health and substance use disorder counseling because of some grant funding we had at the start of the program, which allowed us to do that, to make sure that we covered both. So the mission of the program has always been to promote community wellness, recovery, and resilience. It's had a thread of leadership and systems change and people, our students work in both public and private practice settings. One of the unique things because we are located in Vermont and because we were started in such a collaborative way, most of our part-time faculty are people working in the field. For example, Joe Lasek until he became medical director at CSAC always taught our psychopharmacology course as well as sending us his students as students, people who were working in his clinic with people with mental health and substance use disorders who wanted to improve their credentials. And we hope we keep a close connection to state workforce development. The thinking behind that was that we want the faculty to be learning from the field and the curriculum around evidence-based practice and promising practices. And we wanna be able to also return people to the field who are really well-prepared and offer the university's resources as well. So it's designed to be a highly accessible model. We recruit a cohort of about 15 to 25 students typically to go through the program together, which means they become really a community of learners. Our students are typically people, I'm talking specific to the MS in clinical mental health now but I think there's some across, that's similar across both programs. Our students are adult learners who are already working as direct service providers in mental health roles. They also come from law enforcement, their career changers from nursing and education. So that community of learners becomes really important because they study together one week in a month, they go try it at work, they come back and talk to each other. It's one of the most important pieces of the program that they're bringing their personal and professional experience there. As I said, classes meet one week in a month across the calendar year. Since the pandemic, we segued very quickly to Zoom. We thought our students wouldn't like full weekends on Zoom but they did. They actually did not like doing things half on Zoom and half asynchronously online. They really wanted the connection with the faculty and with each other. So our new, for our two new cohorts that we are starting now, right now in January and in the summer and in the fall, half of the courses are planfully on Zoom, November through April, and then we will meet together one weekend a month in the summer and early fall. So we attract students from all over the state already and this just cuts down on their travel while maintaining what students tell us they like which is a chance to get together with each other and a chance to be in the same room when they're learning clinical practice in the clinical practice courses. And so we're really looking forward to that. Most courses run for two months at a time. So students are taking one course at a time. So they're taking two courses in a term. The reason that's important is when they, most of them depend on federal financial aid. And so if they take two courses, which is six credits, they're eligible as full-time students for federal financial aid. So we think about all of those things with our students but they're taking one course at a time which makes it very doable for adult learners. We've also aligned this year with the NVU, MA, and counseling, obviously we have nine courses aligned but we also have been working in the state college transformation with the school psychology program at Castleton. It is a small program but Vermont needs school psychologists and we're going to allow their students to take half of our courses which is gonna make that program much more viable. Both the counseling programs at NVU are designed to meet the requirements, the educational requirements for LCMHCs in Vermont. We can say that because the Allied Mental Health Board, OPR, thank you, Lauren, pre-approves programs for the LCMHC and we are pre-approved just meeting the educational requirements. The ADC Board, the LADC Board doesn't have the ability to pre-approve right now but we believe we have 99% of their content. We've had them look at our curriculum informally. Okay, so the way I talk about this with students and everybody else is designed to be accessible but it's still graduate. So to be licensed as an LCMHC, the national standard is 60 credits, our program takes 63, the national standard is 700 hours of practicum and internship and if you do our program one week in a month and you don't try to accelerate, that takes three to three and a half years to complete. Tuition is fairly low. I know that because I look across programs and the state colleges have not increased tuition the last two years but it's still 629 a credit which is almost $40,000. If you had the fees in it is $40,000 across the three to three and a half years and books are about $200 a class. So can people rent books? Can they share books? Can they find, can we offer things in a less expensive way? We can but people want those books because they have to pass the national exams when they're done and then the thing I want everybody to hear because this is related to the scholarships is that at the graduate level there are no scholarships, financial aid is all loans. So even if all people borrow is tuition and fees they're getting out with about $40,000 in student loans. I just wanna say on top of that we hear from our students everything that everyone just said, right? That they are working in very stressful positions that they are asking their families to allow them to go to graduate school on top of everything else they're already doing. And so that's part of I'm about to move towards my thank you and request but I just wanted to amplify what everybody is saying. So if you look across our two graduate programs both the MA on campus in Johnson and our program we've both been in the Vermont for over 25 years. We usually have in an annual year about 200 students in the programs, 100 in each program. They are almost all working adults and they are all Vermonters. And if you know some of the data from the Vermont State College system about 82% across the board in Vermont State Colleges are Vermonters as opposed to programs where people, more UVM is a very important resource but much less of their students are Vermonters. So these are the current and future workforce in Vermont. That's who our students are. We are just our program alone, the MS the weekend format program has had about we are starting our 20th cohort which means we have 400 to 500 alumni in the state. And because we start about 20 to 25 people in a cohort we know that those students move into clinical and programmatic leadership roles in the state. Everything from outpatient clinician, director of children's services, direct clinical work and up to folks who have served as commissioner of mental health. So we know that they stay in the state. We did an alumni survey now it's old and I wanna recognize what Jenna and Chuck and everybody are saying, right? This is about five to six years old and we surveyed 600 people who had left the program across the five states that were in. We got a hundred responses which is pretty good for an email survey when you don't even know if their emails are still good. And what those people told us was 86% were currently working in the field in their state and 85% were either licensed or in progress towards it. So they passed the next exam they were doing their postmaster's supervised practice and a high level of satisfaction from alumni from their site supervisors and from their employers. So this is what I wanna say to you about the impact that you've all had and can continue to have. Early on when we started our program we were able to start it because the Department of Mental Health at the time gave 50% scholarships for tuition to direct service providers and 100% to people who were peers or people in recovery or family members who wish to enter the workforce. One of our alumni was the first executive director of Vermont Psychiatric Survivors. So those scholarships really helped us create the program and create a career path into the mental health workforce for those already in the field trying to improve their credentials and those who identified as peers and family members as well. Now, what happened last year because you created critical occupation scholarships? Historically, and we've been able to start about 25 students a year in our program at Vermont. Let me say in other states without scholarships we have not been seeing that. We have been seeing them hit what we know about continuing education is this. There's a line at which stressors go up where more people enter education because they think it will help them. And then there's a line that you cross where you get less enrollments because people just can't take it on. And I feel like we anecdotally we've been seeing that in the other states that we're in. You made a difference in Vermont because we had those critical occupations scholarships this year instead of starting 25 students in our program we have been able to start 50, 42 since January. And across the MA and the MS there have been 124 scholarship recipients to date and at least more 25 more in line. So who are students, they are the current workforce and they are those new to the workforce. And so I wanna amplify what everybody again has already said to support the current workforce you need workforce scholarships and loan repayment as well as the critical occupation scholarships. We are hearing from these 50 people who have started we're seeing our typical student supply I do all I have to interview everyone which is a good thing that comes to the program. So I know what they're saying at the point of application. And so we're seeing our typical applicants who are people who are behavioral interventionists case managers wanna move up in the field. We are also seeing people who are saying to us I've wanted to pursue a counseling degree for years and I haven't been able to and the scholarships are making it possible for me. So I wanna say that those scholarships have really had an impact in terms of the need in the future, I hope you will make clear that the scholarships can be used whether people are const have a concentration in mental health substance use disorders or school mental health because that's something that we're kind of trying to figure out at our end. The other thing I just really wanna say is that the critical occupation scholarships I'm not gonna get the terminology right. I think the terminology is last dollar. They really are covering out of pocket costs. These folks have no other resource, right? They're not dipping into other financial aid scholarships. This these are covering their costs so that they don't have to take on loans on top of jobs that are in that are not very well paying. So I was gonna talk a little bit about additional workforce initiatives at NVU. I'm not gonna spend time on that today. I do just wanna say we're working on creating more career pathways from the undergraduate to the graduate including looking at bridge programs and looking at our courses that are unique to NVU like the psychology of addictions make trying to actually Lauren's gonna hear from us soon. We just redesigned that to try to make sure it covers everything in the apprentice, alcohol and drug counselor, educational requirements. And we're open to further collaboration. I don't know where the peer, the folks in the peer specialist and recovery coach movements are going to wanna go in terms of certifications but we're open to further collaboration. We're always open to improving our content to include more for example and around developmental disabilities. We used to have actually in the first year of our program a certificate, second year and masters that did not lead to licensure, third year masters that led to licensure. Counseling professional national standards don't like that but that doesn't mean that we can't explore other ways to have stackable certificates again. So my last I'm gonna stop sharing my last comment was really that we can help get excited, people really excited about being in the public system of care and working in the system of care. They come to us that way, they leave us that way but they have to be able to eat, right? And so the need for good paying jobs, reasonably paying jobs and cost of living, I just wanna amplify what everybody has already said, you heard it better from other people but that's just critical as well as the loan repayment and the agencies being able to help people with tuition support. So I will just start, that's it. Thank you, thank you very much. Thank you very much for sharing that and illustrating what an impact it makes for us to be able to allocate funds, one of those funds being critical, critical occupation scholarships as a major part of that. I wanna, I just, yeah, my last comment maybe is thank you for including them in the budget for next year because now we're recruiting for next year and that's gonna be critical. And I also just wanna again to amplify what people have said, we hear across the Vermont state colleges that retention is hard. Students are coming to class stressed, they really are. And so if we can help with one of the stressors, people really wanna do it, but they need that financial support to feel like they can ask their families to make the sacrifice along with them. Thank you. Thank you, thank you so much. I think I'm going to turn, I see that Robert Altoff is with us from the department of psychiatry and Robert, we've had you speak to us before as well. I think during the budget adjustment process, but I welcome you to make any further comments at this time. Thank you so much for to the house healthcare committee and to representative Houghton for inviting me here. I really do appreciate having a couple of minutes just to talk about this. It sounds like you've covered an awful lot and I apologize that I'm sort of coming in at the tail end here, but so you may remember from my testimony before, my name's Rob, I'm a child and adolescent psychiatrist. I'm currently the interim chair of psychiatry at the Warner College of Medicine and the healthcare service leader at the University of Vermont Medical Center for psychiatry. I will again make my comments brief. I know you've heard an awful lot about this, but I really appreciate in my current role, the challenges in recruiting and maintaining a workforce to help manage the crisis in mental health care, especially for children in the state. I've been a child and adolescent psychiatrist here since I finished my residency training, fellowship training in Boston in 2006 and have been recruiting over the last few years for both the Vermont and upstate New York for people who can help specifically in psychiatry for children and adolescents. I do have several ideas, probably many of them you've already just heard about it. I'm very appreciative by the way of hearing from NVU. I have a daughter who attends NVU, another daughter at UVM, so I'm always happy to see NVU represented and thank you for the work that you're doing. I do think that in the ideas where we talk about creating or incenting the workforce in Vermont to address that pressing need for pediatric mental health care, you have to start with something that's really foundational and that's the underfunding and undervaluing of the system of care in general. The public payers as the majority funders for our system really have to be able to provide a functional foundational system that allows us to take care for people from a residential care standpoint and load moderate high acuity outpatient all the way up through the continuum of care for high acuity inpatient services and in order to meet the need really of all Vermonters but particularly the most vulnerable in our youth. The workforce that we have without question is churning. There's been a significant sort of mix of people leaving and people coming during that and really all the incentives and pipelines that we generate can't overcome the chronic underfunding of the system if we don't do something about that. So as it currently stands, practitioners including social workers, licensed mental health counselors, psychologists, psychiatrists really across the board are really not incentivized to take care of children and families in any way. In fact, the private practitioners we find at least in psychiatry and I think, when talking to my psychology colleagues, psychology as well, don't really find it feasible to accept large number of patients with Medicaid reimbursement in particular where children and families are their primary focus. So without incentivizing to take care of children and families but at the same time making sure that adults are still being cared for there's really very little incentive to do the extra work that's required to see children and families in the outpatient setting. If you figure out the math, the math really doesn't favor an evidence-based effective approach of assessing and treating families and also getting reimbursed for that in the public funding system. So with that caveat really without the ability to pay counselors, nurses, physicians, assistants, doctors at rates that will allow us to retain them then the innovative training workforce management models really can't stabilize the workforce. So I just, I thought that it was necessary to start there because we have to be able to keep the workforce that we have and the way that we keep the workforce is allowing them to pay their bills. And it can't be that in order to pay your bills you have to sacrifice in the quality of care that you're providing to children and families. So there are other options of course to help increase the workforce and also increase the comfort level of those already in the workforce to manage children and families who struggle. I think you probably, it just sounds like from catching the tail end you've probably heard about a number of these the sort of idea of loan repayment programs have been successful, are very successful in bringing people to and keeping people in the state for at least a defined period of time that could be special programs for those who are taking care of the youth and the families. Scholarship programs for medical students to come to the state and train in the state. We find that those who train in the state are much more likely to stay. This is true for medical student programs and residency programs. The more folks we can train locally the more likely we are to satisfy our need for a workforce right here. We've certainly seen that in the state funded fellowship program that we started with in child and adolescent psychiatry. It was started as a state program and we have been now accepting and graduating for child and adolescent psychiatry fellows a year. We have a full contingent of eight of them, eight trainees right now and about 50% to 60% of those stay in the area. So we are creating a workforce for Vermont that way. Scholarship programs as you're hearing about for LMHC psychologists, social workers who are specifically willing to commit to working in child mental health. I think would be, are welcome. The ones that are there are very welcome. If we can manage to specifically target some folks who are interested in child and adolescent treatment I think that would be helpful. Certainly psychiatrists are expensive. Psychiatrists are, you know, important, but all of us, I can say all of us training at UVM are very appreciative of all the work that's being done that doesn't need a psychiatrist to do it. And we'd like to work hand in hand with our colleagues. Think you might also wanna consider training those who are already in the area but not necessarily in the field. So funding for some short-term training programs specific to child and adolescent mental health for pediatricians, pediatric residents, emergency room providers, PAs who are already in the region who might want some specialty support in child and adolescent psychiatry, same for nurse practitioners and other treatment providers. So we could conceive of providing some of the short-term training support and in the same way short-term training programs for our law enforcement colleagues and schools to respond to crises and to manage those crises in the schools. I think you certainly could consider just to help with the mental health crisis the more we can do to get techniques and models out there into the community so that we can prevent and manage crises before they reach the state of emergency room care or even outpatient care if we can help in the places where people are. And then from our standpoint, in psychiatry increased funding to expand psychiatry residency, the more doctors we have sort of going in, the higher the likelihood is that we will be able to produce doctors coming out who specialize in child and adolescent care. And specifically for us, maybe the addiction piece of things, we have a couple of child and adolescent addiction psychiatrists and we're working on additional addiction fellowship care. So we would like to be able to expand that so that we can provide support for youth and children. The last thing that I'll point out and then I'll stop because I think you probably heard these same messages before is to consider, continue to support the accelerated licensure and some reduced licensure costs or at least sort of reducing the workload to become licensed to practice telehealth for child mental health or for that matter to practice in person for child mental health. Basically the ability to grab some folks across borders who may be close by who could provide some additional support might be useful. So with that, I will stop. I'm happy to answer questions about anything I've said or really anything that I've said before now but I really do appreciate the opportunity to speak with you all today and I'm happy to stick around for a bit if there are questions. Great, thank you so much. And I'm gonna at this point open it up for questions from committee members to any of the witnesses who've been here and have stayed with us. We've heard from a wide range of issues and I'll just say that it's as frustrating as it is because so many of us know that dollars are at the bottom, at the underfunding of the system is at the root of many, many of our challenges hearing some of the, I'm also reminded of initiatives that we have tried to take and that we have taken that have made a difference along the way. And so we must, I'm speaking to ourselves in a way we must not allow ourselves to become so disheartened or discouraged that we don't continue to push forward and make change where we can and to recognize that we as legislators and as those who've been in elective office have access to levers of influence and that others don't and we need to continue to use them as creatively as possible. So let me open it up and I'd see that well, let me just one check here just yeah, okay. So I'll just kind of look and see if there are questions from our committee members or any other folks who wish to do something further at this time. President Goldman. I think this question is for Anna Marie because I heard you mentioned, well, there's a bill about peer support specialist certification and you mentioned that connection that you would be willing to work with that cohort and I'm wondering what that would look like in that kind of context. Yeah, I don't, so I'm gonna be cautious because I don't wanna go too far down that road, right? Because it's gonna depend a lot what the folks who are in the center of developing the peer curriculum want. But so what I was more trying to say is the state colleges are willing to be at the table if there is something that's a certificate or a degree offering that makes sense. I've seen peer specialists be really critical in other states, we're in five states especially in Wisconsin. So I think I was more trying to reflect that when there have been scholarships for people who bring their lived experience to the work it's made a difference and we're there to be supportive in whatever way we can. And I know that there's, I think that there's going to be a stakeholders group is what I've heard in the future. I'm not an expert on the next steps in developing the peer specialist. No, I appreciate that. But I really appreciate that you're willing to be at the table. Thank you. Thank you. And I should say that there are, there is an initiative in the legislature around peer certification as another piece of workforce development for our mental health services system. Yeah. And maybe I should have said we also have always welcomed people who bring their lived experience forward as students. And that really varies though, people who wanna use it in their education and people who are a little quieter about it. Many of us bring that experience forward. Right. Great. I'm gonna look to Representative Houghton and Representative Donahue in the room to help me, I don't wanna be missing someone, but again. I don't think so. Okay. Let me express my genuine appreciation for each of you who've taken the time to be with us this afternoon. We have decisions ahead of us in terms of making recommendations, how to strengthen the healthcare workforce generally and today focusing particularly on the mental health workforce broadly defined, substance use disorder, others, but mental health workforce. And some of your, as Representative Cordes said, I think on behalf of many of us, your comments are deeply felt and appreciated. I certainly appreciate them and we will use your testimony to help us make decisions and to also try to advocate within the spheres of influence that we have. So let's all work together. I'm gonna call this a day for the afternoon and thank you for everyone in your role, both providing care and advocating on behalf of the system of care. With that, I'm gonna say to, I'm gonna thank you all and I'm gonna say to our.