Thank you for joining us this afternoon where House Human Services and House Healthcare are doing a joint hearing on something that came to us through the budget and at the time we didn't really have all the information for us to make a decision. So we thought it best for the two communities to come together. So it's psychiatric residential treatment facility. We have a long list of people who are going to explain to us what this facility is proposed for. We're going to have an hour and a half and then I do believe Human Services will be leaving. Healthcare will stay and if we need more time we'll have another 30 minutes and then healthcare will break but then stay in this room for our next topic. So any questions? No, we did not have this in Human Services on our budget in our budget area, but it definitely impacts children and youth that we have responsibility for both those in DCF custody as well as those through the Department of Disabilities, Aging and Independent Living. So we're happy to be here with House Healthcare Committee and to have an opportunity to hear more about sort of, but I guess I would call, I'm hoping to hear is about sort of the overall larger plan. Because we're seeing little bits and pieces of it, but need something that looks broadly so thank you. A vision. Yeah, what is the vision. So we're going to start with Monica. I know it seems far away. Because it is. Absolutely. Hopefully there's some extra chairs down there. Committee. So that's all right. Thank you over here. Thank you. Nice committee. Someone else. Here we go. Wrangle me. Great. Welcome. Thank you. My name is Monica will be. I am the Medicare Director in the Agency of Human Services in the central office. This is my first time providing testimony in this new role. And so if it's okay, I wanted to take just a moment to introduce myself since I am a new face. I'm a pediatric nurse by training. I specialized when I was in practice and intensive care and palliative care. And so, perhaps some of you and other spaces when I have provided testimony on things. Related to children and youth with special health needs. I was the director of that program at the health department for eight years. And then took a path supporting the immunization efforts during the pandemic and found my way here. This I feel very fortunate to get to be providing testimony on this topic because it is a space in which I have a focused a lot of my professional and personal interests in a long time. I have a lot of work here and children need the special health needs and over the course of the nine months working here. I've also realized that not only is this a topic area that I feel incredibly passionately about but part of the reason I took the role of the health department is because it's a space in which we have a lot of work here. And this is an exemplary example of where we're seeing a confluence of challenges and needs across all of our departments that are impacting not just the children and the youth that we're talking about, but also their caregivers. That is trying to wrap around these kids and their families and is truly unable to do so because of the lack of resources. So I am very, very happy to be here today. And I will also just take a moment to explain that the Medicaid director role has always existed. It's generally been held by the Diva commissioner or the Diva deputy commissioner, but as you can imagine that is a big job to have in addition to sort of checking the proverbial box of being Medicaid director as well. So it's wonderful to have the opportunity to be in this role in the secretary's office work across all of our departments, including the agency of education where we have quite a bit of Medicaid programming happening as well and to really try to start bringing some of these pieces together. So when you asked about what is the vision. That is a question that I'm also asking and that we're really starting to contemplate together. And I hope that this effort that has been going on for months across the agency is going to be a real framework for how we move forward when we're identifying initiatives and projects that need to be elevated and amplified because they impact all of our departments. So thank you very much for having me. I invite any of you to reach out anytime. It's really lovely to get to know all of you and thank you. So I'm not the content expert. I will open by saying that I am really a supporter, a convener and cannot take very much credit for the work that you're going to see here today. That is by and large been the work of the departments who have done an incredible job. Cheryl Wilcox in particular would be helpful to have Cheryl introduce herself before I go any further. It's really sad. Thanks for the record Cheryl Wilcox. I'm the director of mental health collaborations at the Department of Mental Health, which means that I am lucky in my role to be able to work across our departments at the agency of human services. And I hope projects that I am a part of and that I lead have many team members and the recognition that there are a lot of us here today is because it has taken a lot of us to reach this point. And so I hope that we can set the table of how, especially the psychiatric facility fits into a bigger picture that is very on the forefront of our minds and we have spent a lot of years looking at our system of care and communities and what we need for programming for youth and children, especially with complex needs. And so that is what we're going to convey today. I background, I haven't testified in front of any of you. I'm a social worker. So I went to college in Vermont I got my social work degree, worked with teenagers. I also worked in child protection juvenile justice as a foster parent for teenagers. It's an age group I love and care deeply about and so this project and the work in particular is something that is very close to my passion and what I care about and so it has been quite a journey for us to get here and we will be able to talk about how we arrived at this data we looked at and decision making on the way. So thank you. We got some great information from many of you talking to many of us. So we tried to culminate a lot of that and put it in some succinct slides that are something for you to digest, probably after this conversation. But we'll use them as a guide and I'll kick us off and then you're going to hear from each one of the individual departments as well. Oh, look at that. So is it okay if I use the acronym PRTF while we talk today. Great. So what is the problem we're trying to solve. This is something PRTF is is a resource that does not exist in Vermont. Mind you, we are accessing PRTF services out of state we are paying for them out of state but we don't have them in Vermont. And thus we are moving these already vulnerable youth and kids out of state further away from their local system of care and supports making it as you can imagine incredibly challenging for the people that are hoping to support them when they are hopefully back home soon. Incredibly difficult sometimes impossible. And so what this means is that our system of care is experiencing kids that are getting stuck in all sorts of places where they don't need to be a lower lower level of care where they're unable to be supported adequately and safely or a much higher level of care where they definitely don't need to be and it's hard to provide appropriate services when they're in a higher level of care than necessary. And the bottom line here is that the landscape has changed. I think that's something very important for us to think about when we talk about visioning that is something that's going to be in the forefront of our planning. The needs of these children and youth are far more acute and complex than our community based system can support them. Regardless of funding. And that is a really important thing for us to think about. This discussion is not just about a PRTF either, or a PRTF instead of community supports both are valuable. I'm just chuckling because there isn't any way that anybody's going to be able to read it. That's like a picture of a nice dog right now or something because people not read this to you. So do we have these on our website? Yes. We'll discuss this content later. This discussion is about PRTF versus home and community based services. This is about a continuum of care. This is about a system. This is about an ecosystem around children and youth in need. But the bottom line is that we have one of these parts of this system. We have home and community based services and supports. And yes, they need more support and resources, but we actually do not have this in Vermont. This is a pretty gaping hole. And unfortunately our community supports and community home and community based services are on life support right now because the system itself doesn't have access to these services, never mind the kids themselves don't. So as a result, not only are the children and youth struggling, but we're also seeing the impact this is having on the workforce and our designated agencies and in our SSA partners. These agencies have worked tirelessly and I know you know this to recruit and retain staff to improve the wellness culture within their organizations to recover from the catastrophic impacts of the pandemic. And by expecting them to care for children in the community that they cannot appropriately do so in a safe way is leading to increased burnout and turnover in their staff. This PRTF not only has an impact on the children and youth that we tend to serve but also on the system of care that is desperately trying to stay afloat. This is really about right sizing needs and care. The establishment of a PRTF is as therapeutic for the children that it serves as it is the workforce around us and preserving our system. The identification of a PRTF as a necessary resource needed here in Vermont has been the product of well over a year of collaboration across agency human services. This is not something that we just came up with and said hey that sounds like a good idea this has been a very acutely identified me through lots of collaboration and data calling and pouring over information. And this has also been proposed in collaboration with our DA's and our SSA's and it's a really wonderful thing when not only all the departments can come together and agree on a pathway forward but also our DA and SSA partners who are critically important in this discussion. And you know when we pause and we think about this and we think about other places where we're really trying to bring Vermonters home. I can't help but mention that this doesn't feel entirely dissimilar to the work that we're doing to bring home incarcerated Vermonters. And it, it feels like if we're really prioritizing that in other populations then we should also be considering prioritizing that in these incredibly vulnerable youth and children. I just want to check in and we should know this with all the witnesses. When do you want to take questions or people have questions for clarification like at the end. I don't know. I know that we have quite a few witnesses. I just want to make sure that we have an opportunity for members to ask questions but I don't want to interrupt like I just did but. And I'm glad you did. I am really open to interruption and if it's okay with members what perhaps what you know if we know that that's a question that will be addressed later on by a different member of our team then we can just say we'll address that shortly. Okay. Okay, I'll pause here though because then I'm going to turn it over to my friend. It might be good if you, you know, if the presenters can pause it at specific points to ask questions. So, yeah, of course, I have one. So, when I, when I look at the definition of the PRTF one thing that seems missing to me is psychology. And it is focusing heavily on mental health and psychiatry but I also know that we're looking at children and youth with developmental disabilities. And I'm just wondering about the, I guess the cadre of staff who will, who would be at this facility. Yeah, go for it. So it's a great question and it's, I would say the title doesn't really share kind of a full scope of what they would provide as treatment so it is made up of nursing psychiatry social workers. Other folks that provide mental health services so it runs across that and when you certainly have more detail about all the staffing that is needed for PRTF because it's fairly expensive. So, I guess because what what is proposing here is to serve, I guess, what I would say is a variety of youth with a variety of different needs. How will we be assured that those different needs will be accommodated. You know, I'm thinking about, I see educational so I can see that the conversation that I had with Jennifer has been reflected. I asked her what about education I know we have we get reports of youth right now with disabilities getting 2 hours a week, not a day a week. And I don't know exactly how that can be considered educational services so I guess we would want to ensure that the developmental disability needs of youth are being addressed at their stay there as well. And that's, you know, you know, learning different sometimes it's about communication. Sometimes it's about trying to figure out how to communicate their needs. So, I just want to assure that this is going to be a program. That is going to be able to address the divergent needs of a variety of youth, which I'll be honest, I think is a big challenge. And, you know, I said it's important for all of us to put our biases out on the table. I have a bias against facility based services for children and I'm just putting that out there as my personal bias. So, I am definitely going to want to assure that youth, particularly those in our committee's jurisdiction have their needs met in ways that are not going to traumatize them in any way further than they might already have been traumatized. Yeah, and I'm very glad you said that because, you know, I think what we're trying to achieve here is something where the children and youth are the common denominator. And it's not about if they're, you know, part of the mental health pathway or the Dale pathway or whatever the pathway is. What we're trying to achieve here is an opportunity for kids to be cared in a multidisciplinary way by a multidisciplinary team that is going to be able to meet their needs in a flexible way as things change. Because what we're seeing is that our system has been built. And I say this, you know, with, I know that it was built with best of intentions, but it's built in a silo and these kids don't function in the silo. They need a little bit of this and a little bit of that and a lot of this and a lot more of that and things might change and they need more of this. And so in order for us to actually make something effective, we have to have that multidisciplinary team there on site to meet their needs when they need them to be met, not in six months. So, you know, when they can get through referrals. So I think that's really what we're trying to achieve here is not thinking of kids as falling into any one bucket or category, but really identifying them as what their needs are and what they need in order to succeed. And hopefully come back to the community and be cared within the designated agency or, you know, through another community based support. And I think I also would add I appreciate your point about having youth be there who are right for the place and having the supports and services. So this is a 15, one, five bed program, which means it is not for every youth. And that's part of the referral process. It's part of the assessment of is a huge appropriate for this. So if we are looking at a youth, the severe developmental disability who is nonverbal or has a disability again, areas that they need special support, this probably will not be the place for them. We don't think this is going to answer every. So it's not going to be the solution for every child and youth. And so it's part of why we've also been doing this across our multiple departments. So we can think about that. It's part of the work we're doing on a contract to say like, here's what we think is appropriate. Here's what could be because we also need to think of the mix of youth that we have together in this program. And I would say as someone from mental health, not from developmental disabilities, I also has, when I think about residential or group care, it has been something that I struggled with, like, how do we do that as a, it's the best thing.  And this also when we have it done the right way with the right youth together, they also get peers they have belonging there with other youth who are struggling who can support each other. And for me that is a huge pivot point for me in thinking, like, we, we only want this for youth that needed at the time they need it and it for a peer to have there has to be a mental health challenge so they also could have a developmental disability. They also might be struggling with substances but it's it's because of medical necessity of having a mental health challenge that makes it appropriate for them to be there. It's very highly regulated in that way. So I think that's another piece of this as well that we've been looking at. I think I think I've asked this question a couple times and I'm still not quite sure of the answer and I'm looking ahead at your slides and I'm not sure if that's going to answer me.  And then I'm thinking of combining is, you know, you talked about somebody with a developmental disability, and then somebody with a substance use, like, should they be in the same facility together. Or can you describe for us who we're talking about. Yes. I think the other piece. I would say it's having and I know there are other people that have worked with children and youth and. And I feel like sometimes when we talk about youth that are struggling this much it can make it seem like oh these are bad kids or these are dangerous kids or that and I just want to be careful. Also, when I convey that these are children and youth with really acute challenges that also have trauma histories and things that brought them to having the behaviors and challenges they have. So, for this level of care we're talking about youth that have probably had a history of hospitalization or in patient care. Some of the youth we see waiting in our emergency departments that have tried to hurt themselves or have tried to die by suicide. So, it is really significant like this is not a program if you the struggling with anxiety or having a hard time kind of regulate themselves sitting still in school like that is not this level of care. It's a level of care we haven't had and so we do have youth that are sitting at the wrong place that may be in patient and they've been there for weeks or months and and they're stable and they don't need that nowhere for them to step down to or go to. And so, it's that kind of level and I know as we talk about like also you may have substance use may have a developmental disability again. There is a really incredible team that sits together every week called the case review committee, and it's made up of folks from mental health and from developmental disabilities and from the agency of education. And they are the folks that look at referrals for any residential level program and they would for this, and they're making referrals based on what's appropriate so they're looking at a lot of information together. And would say, okay, this is a youth that a psychiatric residential treatment facility would be best for them. And so having them go there so it again it becomes really specialized and it's from looking at what has gone on for youth and making sure that if we have them together that's another consideration. Like and it's part of what the case review committee does they look at this group of youth and and we want to be careful about the same thing like there's certain youth that work really well together and then others where it wouldn't be good for them for a multitude of reasons and that is part of the consideration. And the other piece and I know it's further in the slides is the age group we're talking about is 12 up to 21 and that sounds like a big stretch. So it's if they were there by 18. And it doesn't mean that those are all the ages we will have but that is the rule for a PRTF set by the Centers for Medicare and Medicaid Services. So that's, we're not talking about little children in this program, although 12, I would say still little and young. So that that's all part of the consideration that goes into this. So we have two questions and then we're going to try and move on and and then Brian. The earlier slide had mentioned, not locked beds, but a locked program lots out of doors. And when I look at the whole, all of the new programs being proposed under the HHS umbrella, I'm seeing like 41 new locked programs beds and lock programs in psychiatric hospitalization for kids. They can only be placed in a locked psychiatric unit with the child's voluntary consent or a specific court order saying, you know, this level of locked care. So I'm wondering whether that will be the same for this and also, and maybe this is also a future slide but also the rules and use and oversight of restraint and seclusion and what will happen that. And this, you know, a lot of ways that are the same level of restrictiveness as an inpatient psychiatric unit locked doors and I don't know what the restraint seclusion issues will be. Yeah, it's a, it's a great question. So, one thing I would say you're right so about it's PRTF can have locked outer doors, not locked bedroom doors. When we talk about locking it's something that we take seriously and many youth who will need this level of care also have histories of running away and that creates other dangers as a youth leaves and they're lost or we think about other things that can happen to youth that are vulnerable. So that's a part of the decision making for restraints, exclusion and restraint there's because this is something that is licensed by the Centers for Medicare and Medicaid Services so Dale actually has a team called Survey and this is where it gets really lovely like all of our departments really spent a lot of time together so they are like an arm of the Centers for Medicare and Medicaid Services and so they monitor any seclusion and restraint based on the federal law. And we will be looking at that we being the multiple departments as well be reviewing those because of when anything that happens has to be reported whether it's like a hand moving someone or a restraint and so those are pieces that we will get and be looking at. And I hear you about the beds there's, you know, we, we've pulled some data from over a decade ago and our decrease in being able to serve youth in state at a residential level of care has diminished by about 100 beds, and that includes any locked facility programming and it's why we're now in this position where we have youth in this level of care out of state, very far away. So, those are all pieces we are thinking about and looking at and so will there be a court order if the use is not providing consent since it's a lot. So, this, this program, you have to be voluntary. So it's not a court order and I, any of us that have to talk to teenagers like aren't usually raising their hand like yes please let me go there. So it also becomes a conversation of, you know, how, how can we make sure you're here and for anyone that works with this age group, like that becomes a different conversation but it is well it's voluntary. Brian and then we'll move on. So, luckily, most of my questions got answered and there's only 1 left. So, so 1 thing we see is in the current situation when youth are placed out of state is, is this like severing their connections to resources in their communities, not just their families, but social support and professional. You know, like providers of services and I noticed that Medicaid is funding the facility. I'm curious if what the possibilities are for integration of community based services to maintain continuity of care for youth. For example, contracting with existing providers or contracting with providers before they discharge so that they can start. You know, have like a warm hand off or could those providers bill Medicaid directly while they're in the facility using like a code, the appropriate code. Like, have you have you explored that option and considered ways to maintain continuity of care. At the facility. What I was going to say, I mean, you're describing best practice for transition from any setting to another setting and I appreciate that very much because you're right. I mean, in Vermont, theoretically, just by proximity geography, we should be able to create some type of continuity and discharge and I, I don't want to make assumptions because the operational details are not in my wheelhouse here, but it's very hard to do that when they're out of state or absolutely right. Do you want to speak to me specifically now? Yeah, I know. Yeah. Part of the PR. Now I'm happy because I've been saying psychiatric residential treatment facility that acronym stop rolling up my tongue. Part of it is while they're there making sure there's connection to community and discharge planning that doesn't look like just a discharge plan. There you go. It's about how you have connection and they and having visits or having family or doing other things in communities. So it is a piece that we are hoping will be much tighter than what we see when we send up out of state. That's good. And one, one thing just to consider is the potential for building telehealth facilities from the start because now with, with, with the remote, you know, with remote treatment, it's possible to, to maintain therapy in a way we couldn't before. And we don't see that out of state, but if it's within state before any interstate licensure compacts pass like there's no, that barrier is not there. So it's, we have a great opportunity. So I appreciate that you're looking at that. Thank you. Go ahead. All right. So the next slide. Oh, sorry to back thing. One more back to that things. Here. Try one more back. It's the horrible slide. This one. It's the horrible slide that we broke all the power plant with us. So I am not going to read this to you as well. I said, we're not going to do that. This is to really show progression that we have been focused on what we need in our system of care for you for many years. And I will say I've been in my role for nine years now. And so I was a part of the 2017 legislative report and the consultation we got across our departments in 2020 saying what is our. What does it look like for any of our community based and residential care. And so this is really for you to be able to see how we are working across departments because I wouldn't want you to think that we came in here just individually and said this is what we think it was a lot together. And that includes family services and work that they're doing. Are there youth that are justice involved and for youth that are in the retreat, there are meetings every week where departments are coming together to talk about youth that are there. How do we work together? How do we move youth into the right place? And then also our state and our agency team, which not only has our departments, but also has family voice. And the Vermont Federation of Families for Children's Mental Health and Vermont Family Network are heard of that monthly meeting. So all of these pieces to say like this was part of our thought process and that we don't have to look at this horrible slide for a second longer. So we can go. Yes. I feel like probably we got to help us. I think we talked about all of these pieces as well. Questions. Right up front. So go to the next. And I don't know that I think we've talked about this quite a bit as well in terms of thinking about the children and youth here as a common denominator and how in order for our departments to collaborate and successfully wrap around and support them together. It's challenging to do so given that we have this whole in each one of our programming right now. And this would certainly fill those gaps within each one of our departments in order to more collectively serve these children and youth. Next slide. So, yeah, sorry. Yeah. No, please don't. No, you. So I feel like we covered some of these pieces and again about the intensive placements and the numbers that have gone down. So, I know we're sitting in front of you wanting to stand that has more beds and feel like we are trying to get back to a place where we actually have the programming in our state so that we can keep. The kids here bring some back and have closer ties to their community and their families. We also think by having this in state that our hope is that youth and children will need to be in this level of care as long as sometimes they are out of state because they can connect back to their community and see their families. And so, you know, there as much as we may not love this idea. I think there is always going to be a need for this level of care because of acuity and mental health needs. I'm wanting to keep it safe and the community safe if they're struggling. And so it's, it's both we need to stand up programming and community support something they are equally important. Next slide please. So we've talked about some of these pieces around hoping for shorter lengths of stay. Also just being able to move the youth room where they need to be so right now you are getting stuck in patient. And so we are being honestly supported in the community in a way that isn't safe for youth isn't safe for the staff, helping them and for family members and so this provides that filling of the gap that Monica spoke to. So that hopefully youth will be moving more through where they need to be. And that means, you know, youth that are waiting in the emergency department, it may not be that they directly would go to a PRTF their steps in between. But it means that if there are youth in the emergency department, there is probably another place in our system where other youth are stuck that they need to go to. And so youth having options and us being so fit them to the right place where they're going to get their needs met. We also for for families I mean it's hard. When your child set a state to have access to be able to see them to travel. It's another significant stressor for families. And so all of these are pieces that we think having this informat would really help youth and their families. I know we have a couple questions I'm going to let them continue a little bit longer and then we'll go and thank you. So next slide. So this is point in time data. So we pulled this last week. So this is the kind of data that the case review committee that I talked about tracks about referrals made to programs and it shows where youth are by department. So how many are in state, how many are out of state and then out of state how many are actually in a PRTF that's out of state. I also will say these numbers fluctuate by the day. So this looking at data like this is how we helped to figure out the right size program in Vermont again it's you know right now. There's 16 youth out of state and a PRTF there are another 22 youth pending referral for residential or PRTF so we know it's not going to serve every youth. But it also is going to give us enough ability to move you where they need to be and where it's best for them. So this is just one piece of the data that we started tracking years ago so that we could plan better for things like a PRTF or other program. So this is just a pause for art. Yes. Thank you for your presentation is the PRTF, the highest most acute level of care for children. It's below inpatient so inpatient hospitalization is the highest level so at the retreat, if they're inpatient hospitalization. I still don't understand so this is a low level of care you said. So it's it's confusing and oh perfect. Yeah, so the piece I will say about this you'll see the PRTF at different levels and it's because our systems have different services and support for them. But it is so if you look at the mental health one like inpatient is the highest level and then if we talk about there's a step down from inpatient hospital diversion and crisis stabilization so really short term like a few days. Okay. And so a PRTF is not hospital level of care. Okay. But it is very treatment focused so it is for youth with really significant mental health challenges. Okay, then stop right there when you say just for a second just so I understand. Significant mental health challenges does that mean mental illness or does it mean something different. And I always get confused here because we hear this a lot. Can you help me. I can. I might have to try real hard with me. So I will tell you I say mental health because we're talking about children and youth and but yes it's having really significant illness. Okay, that is mental health related. Okay, so it is now illnesses been diagnosed and those are the folks that are going to be. Yes. And so it's part of like looking at like, again, you could have some lower level struggles they're having like with anxiety. Yeah, right. It's not that like it's really severe challenges that impact them daily. Thank you. And when I think about those level that level of care question was a really good one and sometimes I have to frame it. Almost like in a medical system to think of something that might be maybe feels a little more accessible to our brains or at least mine. So, you know, you've got an ICU where you go after you've had surgery. And then you have a rehab facility where you're going to get a ton of care intensive therapy around the clock support. And then there's home where you get care in your home. But if you don't have that rehab in the middle, you're stuck in an ICU in a hospital where they're not actually equipped to give you all the PT, the OT, all those services that you need to arrive and reintegrate into your home environment. So we're in the rehab. Yeah, you're stuck in the hospital, or you're going home and getting not enough, not despite not not because the system's not trying, but this system over here at home can't can't backbill what you really needed in that in the middle. How long will these kids stay in here for a good question. Yeah, okay. We've got some data. It depends because it's based on them needing this level of their assessed very every 30 days, like looking at what are their mental health needs. Are they getting better? Can they step down? We don't want them there too long there. Okay, thank you. Melanie and then Dan. I'll start speaking about the family connection and also speaking about the community. I was curious because a lot of our facilities for inpatient are in the south or will be in the south. I'm curious as how about transportation and how to get families physically to be able to access for your children. Because that is often such an critical part of the healing, especially using your analogy if you're going to be able to get back home is having that nexus. And it's great that they're not out of state, but still Southern Vermont can be very far. Yes, I'm just curious if you could speak to how that is being addressed. Yeah, I, you know, it's a great question. It's something we worry about and there is like, even when folks are out of state, the department's help families are able to go help them like range transportation or with funding. And so this would be the same like they making sure and then also the priority up with that. So that's that's a component that there are such as if the family doesn't have a car or access to enough money to get gas or all those pieces in this month. Um, could you go back to slide where it shows the where the how many people are on the waiting list or how many. I just wondered of the 22 that are waiting for referral. Where are they? How long have they been on that list? Um, I don't have the how long they've been on the list in front of me. I can tell you they are usually waiting at the wrong level of care. So they are. They may be at home with wrap services that are not enough. And so they aren't feeling safe. Their parents, family aren't feeling safe. They, because it's all over departments, they may be DCF may be staffing them. And I certainly will let DCF folks be more to that. But there are staff that are also with kids 24 seven supporting them and try to keep them safe and keep themselves safe. It may be that a youth is at a patient hospitalization training for a more appropriate residential bed. So there are lots of places they can be waiting and they are usually waiting in the right place. So people do the best they can and it's it has. It's not good for the youth. It's definitely not good for families who are scared or for staff. And what's the reason is, I mean, is it just that there's not the capacity to put them in a PRTF, whether or not in state out of state, whatever. What's the reason that there are wait lists out of state as well. So, and it's, we aren't the only state obviously challenged by workforce. And so some of it is not having the staff, some of it is out of state PRTFs that will accept youth from different states. And so they end up on a wait list there. And so that is also constant triaging that staff across our departments are doing for big youth waiting. But are they getting what and we're often working with our designated and specialized service agencies who are also trying to wrap kids while they wait for this. Okay, thank you. And to put a fine point on that it's really important to think about what's happening in those places that are trying to keep these kids safe. Because it's not a therapeutic. It's not therapeutic what's happening there. And those, whether it's the DCF workers or the designated agencies or SSAs. They're needing to be more intensive than they are designed to be is negatively impacting their ability to serve the kids and youth that they are intended to serve. And so the, the, the ecological impact here is hard for us to quantify. And we see it in the staff, like they are so drained because I hear people say, where are the designated is where the SSA is. They're trying so hard, but they, they can't manage these. It's not appropriate for them to be here. So. You can see how the ripple continues. I'm just going to take another couple of questions that we're going to need to move on to want to make sure that we get all the president and we're only going to be here. My committee is not going to be here for until 230. So, we're going to go Noah and then topper and then just want to let witnesses know that we're going to do. Dale and DCF before mental health. And I know there was some other questions. Health care. I can wait because we'll be here longer. That's okay by the time. No, thank you. Sure. Just to help me understand the nature of the facility. Could you just tell me the top 3 or 4 diagnoses that the youth will have in this facility. 3 or 4. 1 or 2 is okay also. Sorry. Who's in there? Who's in there? Right. But yeah. Yeah, I. So, kids that have severe trauma that may have emerging psychosis. So, like schizophrenia. Other, since similar. We could probably pull some data. I'm offering some we could probably pull some data about the kids in Vermont that we currently have in PRTF. So, that would be helpful just to see if conflicts.  That'd be helpful. It says that they're complex. And have multiple coexisting conditions and diagnoses going on. For sure. Thank you. Yeah. Thank you. Topper. Thanks for coming in and I don't dispute how hot everybody's working. I just want to say that up first. I have a question. You made a statement, I believe, and if I didn't hear it right, just say you didn't hear right. You can't provide the services in a home. That you provide that you will be providing in this particular facility. My question is, why not? It's a great question. So, and I think there's a handful of answers. The living, the level of staffing that that would require. We're talking about some kids that in the community would probably be best served by two to one 24 seven. Our workforce does not allow for that. And to be real, I don't think it ever is going to allow for us to provide two to one services to the number of kids and use that would need it in order to safely and successfully live in the community. The logistics of managing the logistics around that are overwhelming to even consider. And that's not even to say that that would be the right answer because it's not just a human there to make sure that you don't hurt yourself or someone else. There's so much more therapeutic in it that goes into it so that hopefully we move out of this level of care. This is a system. This is a continuum that we expect children and youth to move through. And so, from scaling and titrating services in a home with the workforce challenges we have even probably under the best of workforce circumstances would be incredibly hard, although a beautiful idea. The other piece so other than the logistic piece, you know, I think back to my time as a, I was a lend fellow so the leadership and education and neurodevelopmental disabilities over at EVM and I had the opportunity to learn about the importance of leadership in the neurodevelopmental space. The thing was the best about the education was it was, you know, me is sort of like a healthcare provider in the field, but then I was learning against, I was learning next to self advocates and advocates and family caregivers and of this population and no one model. What I learned to took away from there is variety is the spice of life.  Everybody needs something different and it looks different for every person and for me this is thinking about the menu of services that we need to provide a mistake in order to best care for these kids. So what you described while I think would be beautiful and a great fit for some people if we could staff it might not actually be the right thing for them or what they want. So now, now I have a response to that. I can't remember what year it was Brandon train school was closed. We promised people that the services that they were getting would be provided locally. So what you want to make sure now, yeah saying is we can't do that. Is that what you're telling me. Yeah, I mean, I don't know what services were provided at Brandon training school that we provide that we promised to provide locally. I have no doubt that when that closed. There were the absolute best of intentions to provide them at a local basis and in a common community based way I had absolutely no doubt that that was the desire and the hope. But we're also reckoning with reality. And so how do we keep the health and well being of these children and youth. Their families their caregivers and hold true to that and recognize what resources we have to support them. It is incredibly hard. And it's not going to make everybody happy. I often think that if we're able to effectively improve the system of care in one place that just like we're seeing how it's not working in one place there's ripple effect we can improve it in one place there's ripple effect. So, I would love, I would appreciate more history and more of a lesson on on what that dialogue like what those promises were and because I understand that that is a huge part of Vermont history and there's there's a lot there. I think also just to step in just for a moment I think that you know, we're all familiar with a designated system that designated mental health and developmental disabilities system of providers and being a designated agency carries with it. A set of rights, but also a set of responsibilities and we just have some questions about, you know, how much are we carrying forth on the responsibility side and recognizing that, you know, it's a struggle to have cost of living increases it's a struggle to keep some of the staff all of what you said, this is all those same struggles and we seem to be okay with putting a boatload of money into a facility based program and that same boatload of money. I think some of us have questions about whether or not that same boat load, which would also be Medicaid eligible could potentially serve some of these folks in the community. And I think, you know, I'm just following up on topper but so we just left with some of those questions, because it's not going to be inexpensive to run this facility and and thinking about mixture of populations and you talked about how many years and I'm thinking of, you know, bullying on my side of the thing and I'm thinking of things that, you know, have the potential to increase the trauma for children and youth in this facility. I mean, that's just because I, you know, I'm thinking in that way but I appreciate, you know, your comments topper and I appreciate also that we need to take a look at what's in front of us now and to figure out, is this going to be something really beneficial and for me the question is the jury is still out on that but I guess I'm willing to look forward and say, you know, let's see if this has an impact like we hypothesize that it will as a missing component in Vermont's system of care. But I don't want to, I guess, let up on the pressure of our designated and specialized service agencies to serve these kids in the community and our education system to meet the needs of kids, not at two hours a week. So. And the other thing is, there's a lot of gap to older people that. Yeah, let's not, yeah, let's not diverge into that. This is only about kids up to 21. We do a good job for the most part for kids. But that's the other. Yeah, we're not doing that here today topper. Yeah, you can move ahead. I just wanted to add, I think, you know, if we think of parity between mental and physical health. I also this is a specialized area of care. And so, when you ask about diagnosis, I honestly like they don't roll up my tongue because I, I don't think in those terms. Like what a youth would look like that's having a struggle so severe depression where they are wanting to die or they are cutting themselves like that is a level of care. That we need in addition to community based care. Like, I don't think we. We need both it's both aunt, like we need both of these because someone trying to have eyes on a youth 24 seven in a home when staff may be there and then they have to leave. And like, I think it's it is a risk if we don't have all these levels of care, the way we do for physical health. So, so let's, let's continue on. So, this goal, it's always important to remember that these children and youths already exist. We are already paying for services for many of them delivered at the state. This rate would actually include room and board costs, which is unlike other residential programs. And there is already based funding a base funding line item to establish this in state service. We're beginning with six months. Really for us to get a sense of what this looks like and as we start up and then ongoing funding decisions will be made very much based on these pressures as we do with other Medicaid reimbursable services. So, next steps in this, which there have been many and continue to be. Or we are doing contract work. We also, because this isn't a service that we've provided doing a state plan amendment to add it. We did reach out and got a copy of the certificate of need that the vendor had put in to see if they would need one. So, that's additional information. The reason the funding request is in is because before any youth can step foot, they obviously need to step up and be ready and then start having you either who are on this wait list or maybe out of state to come home. And then it's also on our radar that there's a moratorium on independent schools. So, to the education point, there is the ability to do. To have in person through learn well, which does tutoring. It's four and a half hours a day. It's not a full school day. So that's another piece that's on our radar as well around this. Yeah. What was the gate of the green mountain care board and I'm not getting ceiling. It was August last year. That is, that was not for this program. It was for residential programs and bring that here is reevaluating that because it was not, it was not a representation of this program. Okay. So that it talked about both of it, but I appreciate that. Okay. Thank you. You're done with us. Okay. So, yeah, just one thing because you're the into you're the interagency person in Monica. So, you know, we all have this saying that when everybody's in charge, nobody's in charge. And so I have this, I have this thing about oversight quality assurance. I know Dale's going to be sort of the certification surveying certification. It's kind of different than the sort of ongoing day to day check ins around the progress of the youth and the coming back to what Brian was talking about earlier, the continued connections to the community. And who at the state level is going to be sort of like overseeing the quality and the, I guess, vendor agreement. I guess it'll be a Medicaid provider agreement since it's not going to be a grant. It doesn't look like it'll be a grant to be Medicaid billing. So, so who's going to have overall responsibility for the PRTF at the state level. Diva's holding the contracts. We mentioned when we said literally every department has a hand in this. And right now I think, I think I'm really holding this from a responsibility standpoint with incredible support and partnership and legality from my part. So, if we, if we, or when I might say, when we get a constituent call and a frantic parent calling about a complaint about the care that their youth is getting. Monica is the person we're supposed to call<PHONE_NUMBER>. I think I made that up. I don't know. I've got, I've got to look it up. I'm on my. That's all right. I compute my brain. Thank you. Just a quick follow up to that question. Will there be any external outside of a just oversight? We have CMS rules and rights that we have to follow. It's a great question. CMS can ask Dale's survey and certification to do this or they can do it. But when I say it's part of Dale, like they're really separate from being part of Dale because they are an arm of CMS for this particular thing. Yeah, survey and certification kind of like follow their own set of they're, they're mostly federally funded. They're, they're followed their own thing around hospitals and inpatient facilities. So, in Dale language, we'd consider this an inpatient facility, but okay. Thank you very much. Appreciate it. So, who wants to go next? I heard you say you wanted to prioritize, prioritize. Dale and DCF and DMH last. Yeah. Sorry, you can just, you can, you can decide amongst you who wants to go first. Yeah, we won't forget to. Yes. Thank you for bringing that up. It's like Dale's coming. All right. Thank you. Thank you. I really appreciate that. This is a very cute picture has to be guess that that kid's not going. It's not true. Good afternoon. Good afternoon. So for the record, I'm Jennifer.  Sorry, it's a big room far away. For the record, I'm Jennifer Garabidian. I'm the developmental disability services division director. Emily Feddersen. I supervise a specialist team for the division and currently covering the children specialist roles. So we do have just two quick slides. Most of the information was covered by our colleagues, but it will give you an opportunity to obviously ask us and ask questions about sort of our role. Yeah. We would just like to highlight that although certainly residential level of care and support is not generally something that falls within the review of developmental disability services, which is primarily a community based. Set of service supports. Our, the developmental disability services act does provide a set of guiding principles. Chief among is the principle for children services. What is that children remain with their children, their families and communities. So having children end up in facilities outside of the skin really flies in the face of that building a PRTF in Vermont. We bring them closer to their homes and communities while they're receiving treatment and allow as we've discussed for better transit and visitations and connections to their communities while they're receiving care care before returning back to their home. In large part why we are in support of stuff. So, we experienced certainly recently a number of examples of individuals who have had delayed transit delay transitions or troubling transitions because of a lack of community engagement prior to their discharge date. And because they've been in Pennsylvania or Florida or Massachusetts and receiving entity and community providers have not had adequate access to develop relationships built trust or simply need the child before bringing them back to this day. So having a facility here in Vermont certainly we feel would benefit our agencies in their endeavors to help their transitions. Next slide please Rebecca. As Monica and Cheryl discussed our current state has resulted in repeated presentations to emergency departments admissions to the retreat without appropriate disposition and in adequate community based supports. Certainly kids are being supported in the wrong level of care currently. And the community surpasses our community based capacity. DA's and SSAs as well as other community partners are not able to adequately meet the complexity of care in the community. So we are sending bills to PRT apps out of state having something in state with certainly better meet our children's needs. So having treatment and stabilization prior to returning to the community based supports would allow us to better meet their needs and get them into home and community based services much more quickly. Additionally having in state option would help as we transition children to guardianship. When kids are out of state we have an additional complexity related to having guardians, especially public guardianships often registering a guardian out of state of Vermont guardian out of state is particularly challenging and sometimes we're not recognized. That can be an additional complexity and supporting young adults who are out of state. I believe that those are our slides of there are any questions. Oh, I did want to add though there is a billing mechanism that was brought up that agencies are able to stay up to date on that the child supports and how they're doing and to be ready for them to transition but that doesn't replace the face to face in person. Relationship building so the child actually feels comfortable with a team that's going to be supporting them when they return to Vermont so I just wanted to make sure. So we'll be the mechanism that the department. The department uses in order to support the designated and specialized service agencies to be able to. Have these children and youth return to the community as soon as possible. So what kinds of supports are that is the department prepared to provide to the DA's and SSAs to help them carry out their roles and responsibilities as DA's. So as Melody is referencing currently DA's can continue to build for services program while children are in residential facilities so they can continue to maintain that contact. Typically bridge services is a more widespread service so it not only is it with the child but it's with the family so it would allow both transition supports. To be built between the family which might get a, I forget, I apologize, I forget who asked the question about transportation, thank you, transportation services and connecting the family with the child. So it could perhaps facilitate some of that but also connect the child and the case manager, the service delivery entity where the child is receiving the stabilization services at the park. Yes, he just heard about kids with mental health issues. I was developmental disabilities relate to that. So I know the difference between. Yeah, thanks for asking that's a really important question. So as Cheryl mentioned that there's a really important screening process that goes. And so these are really the highest level of parents children so these are kids with developmental disabilities who have co-occurring needs. So they likely have significant trauma histories co-occurring mental health conditions. Perhaps some substance abuse issues so they have a really complex presentation and have those co-occurring they like they do have a mental health condition as well as a development. Okay, so these are the hate to use phrases but the toughest route to to share. Yeah, yeah, we are talking about a very small slice of the population, and it really is that then diagram of kids who have a big constellation of peak, and they're hitting a bunch of our different sectors. And just a quick follow is a lot of this genetic they were born this way and that's what they are. It's incredibly possible that they have the genetic conditions. And that was part of it. Yeah, not necessarily. No, I understand. Yeah, but yeah, it's just want to understand what we're talking about. Yeah. And I think I just have one final question. So, before the break we heard testimony from DCF staff around the incredible challenges that they're having doing what they call staffings. And they pointed to a large contingent of those being youth with developmental disabilities and would you envision and maybe I'll ask Erica this question as well but would you envision that some of these youth are people who would be accessing this this level of service. It's possible that some of these those children could rise to this level. Without knowing more I guess I'm not entirely perhaps the deputy commissioner would be better situated to answer that question she works in that population a little bit more. I can say that we are particularly proud of the relationships that we're deepening with DCF and some of the work that we're partnering with our Vermont crisis intervention network to provide some additional support and training for the tremendous work that the FST team is doing to support those kids. So again, it is a pretty modest number of kids that we would expect to see with developmental disabilities who would rise to the level of admission here but certainly, you know, we are working hard to address the crisis that's happening where kids are being staffed directly by DCF. Thank you very much for being here today. I appreciate it. I think we'll move to the DCF folks. Ever since COVID we haven't had the nice big room where we have joint hearings and all this stuff. So we have to make do with what we have. Welcome. Good morning or good afternoon. I should say I'm Erica Radke, deputy commissioner of the family services division. Good afternoon and it's a pleasure to be here with you all. My name is Tyler Allen. I'm the adolescent services director for the family services division. We have just a couple of slides and I know you've heard a lot of materials. I'll go through those pretty quickly and then if you do have any questions to answer those or. So, one thing I wanted to point out is that the. The PRTF really is a nice part of our continual care that we would like to see added. Part of our high end system of care, which is described in detail in our act 23 report identifies for distinct types of programs that really bolster the most critical elements of our family services division statewide system of care. And those programs are the short term secure stabilization, short term, secure treatment, staff, secure crisis stabilization and the PRTF. And really adding a PRTF to this treatment array. It really aligns and supports our long held values and goals as a division of. Ensuring the right program at the right time for the right length of time for that small population of youth that we have that are placed in residential care. And I did want to point out, I think it's important to note that of the, we have about 9404 kids in care right now, only 8.9% of them are in residential care at this point. The next slide. Want to mention that, you know, PRTF level operates, not only as a step down from a higher acuity level of placement. Such as, but you can then use it as an intermediate step to a lower level of placement such as community community based residential care, or even foster care with support and stabilization. So, in certain situations, PTRF and promote the doubt that I've been seeing lately in the number of DCF youth that are in residential care. And that's another important reason for us to want to have a PTRF here in Vermont. I know we've talked about a lot of other reasons in terms of having this care where youth can have family and community nearby as well. But also the idea of having a PRTF when it's appropriate for these youth to be able to move down to a lower level care to have it right here in Vermont, because I do hope that that would promote when appropriate that type of progression. In terms of talking about the downward trend in residential care for DCF. As of February 1st, we had 84 kids of 94 that were in our custody, which were in residential care. So that was 8.9% out of 944. Yeah. Yeah. Thanks. Like I said, this number's been trending down for years and it's really the lowest that it's been in a decade. So, in comparison, 10 years ago, we had 15% of our youth placed in residential care. But I do want to note that the numbers don't tell the whole story. Part of the reason we've had this downward trend since the pandemic at least is that we have our system in care is operating at about 51% of its pre pandemic capacity. And that means we don't have enough barriers necessarily to meet the needs of our youth. And that's resulted in what people been talking about today is a number of our youth then being staffed in alternative settings, such as emergency rooms, district offices, and other locations throughout the state while we're waiting for a more appropriate setting. And of course, that's absolutely not good for our kids. And it does put a significant stress and strain on my staff as well. So when I look at the people like, yeah, I look at this as having just part of our continuum care having adequate treatment settings inadequate numbers. So that'll provide a well rounded system in order to care for our kids and the best way that they need and then hopefully then promote an environment for step down when that's medically indicated so that these kiddos can get back to community base care, probably with wraparounder support services. Thank you, Erica. One quick question. So who is going to be doing the everybody's talked about the admissions or assessment the initial assessment that to determine whether or not this level of care is the appropriate is that going to be done by CRC is that going to be done by the retreat who is who is doing the initial sort of assessment and referral for this level of care. That would still be within that CRC. It would. Okay. Thanks for those and health care. What is the CRC process. It's the process that Cheryl explained at the beginning and that it's the community review committee where you have members of Dale and DCF, AOE agency of education is also involves that as well as the Department of Mental Health. So it's a committee of people who meet every every week to go through those cases that are brought by any agency that are saying we believe that this level of care is indicated and then as a group they talk about what is what is the recommended level. The CRC stand for community review community review case review. Apologies. I said community review committee the first time. It's kind of the process you have to go through before you get approved for out of state residential and just the second half of that. But once the referral is made, does the retreat then they also have an admission process or do they would they automatically take a child or would they then have an admission process as to whether they felt felt the child met their level of care. That's an excellent question representative. I believe there is an admission protocol involved. I don't think I can speak to all the detail of what's in there, but they do have an admission protocol and that's really about identifying. Is this youth going to have their needs to be able to be met within this milieu at this time. Yeah, go ahead Jessica. Thank you very much and also thank you for the tour in middle sex that helps me to think about what this PRTF could look like in comparison, I believe, because it seems like there is more of a holding pattern right now. And so I go back and look at the chart that had the pink in it and there's a line DCF. Youth in and out of the state program that isn't a PRTF is 39 youth in and out. Of the P of state PRTF 10. I'm just curious how though, are you thinking that all of these folks that are on this list that are in and out and so forth are they. When they're in, are they in middle sex right now and. Okay, so they're in community, a community spot. Smokes are all out. All out. Out. Okay, so. Yeah. In and out of state. In and out of dash of dash state. And mostly I'm just trying to figure out there seems like there's a lot more. Kids that need a spot. Then there is back. I was trying to figure out how they really got to 15. It seemed more about Medicaid eligibility than it did anything else to be honest, but. Yeah, there are a lot more kiddos that you bet and that goes back to that 51% reduction in our. Good capacity and then what the time what's what I know that you talked about the timing a little bit in different in the different reports, but what are what do you think today. As far as little sex or PRT or the PRTF or talking about. I believe our objectives. I'm looking over to our colleagues. We were shooting for this summer for the PRTF program to be operational. There's a number of steps involved in and actually making that happen. Middle sex. I think a similar timeline. We do have the renovations to that facility already completed, but there's a lot of steps towards actually getting a provider on getting staff hired getting training put in place. We're doing that contract finalized working through those components. So we have been more hopeful that this month was going to be the month for middle sex. I would like to clarify that middle sex distinctly is a program for youth that have really attached their case profile. It doesn't mean there aren't treatment needs. We don't believe any place within a program should have treatment needs that we are addressing in a treatment program. That being said, when we talk about our high end system of care, we refer to a type of system of care as crisis stabilization program. That is really identified as a programming that should be very short term. It is about finding out what are the assessed needs for treatment and getting them to those assessed needs in order for them to be in a secure placement like we're talking about with middle sex. They would have to have a delinquent delinquency attached to them that make them appropriate for that level of care based on their their exposure to, you know, to the juvenile justice system, which is different than PRTF. It doesn't mean that they can't be placed in a PRTF with a delinquency, but it is not a requirement. Let's check in. Can we switch to Vaz? I want everyone to see the weights in the hospitals, if that works, and then you all can determine where you are. I think the one last question why we just because it is specific to this witness is actually the same thing I asked Dale. So we have a need to increase our capacity and residential. We're still at far below what we were prior to COVID. What is the department doing? We don't really see budget requests to increase capacity there. Like we haven't seen budget requests from Dale to, you know, assure that we can meet these kids needs in the community. What is it that the department is doing to try to increase the capacity of our, you know, the folks who are doing residential in state that we have lost? It all depends. A lot of what we've been doing is trying to, you know, work with what we have, right? So we've been trying to increase our foster care group. And that's what one of the slides there does mention that the high end system of care task force is thinking about doing a foster care summit looking at retention, but also recruitment. And we would be trying to look for recruitment, particularly for more specialized foster parents or parents that have will be interested in having training to handle our more high end youth. Another thing is one of the budget requests is for support and stabilization funds. And that's specifically to provide a wraparound for kiddos Island foster care primary foster care settings that need attentional help as far as their mental health needs. And that's something that has been really successful in keeping kiddos home. So then they don't necessarily have for foster homes. So they don't necessarily have to go to residential care. In terms of residential care. We have been really focused on our secure. You know, area of treatment that we've been discussing. And also, there is a smaller program in kingdom. We are working on for a staff secure crisis stabilization program as well. And that would be a two bit program. So we're really trying to do a few levels in terms of the highest secure. And our staff secure a couple of beds there, and then really trying to bolster our foster care ranks with that stable support stabilization wrap. And then that's what we've been focusing, but Tyler, do you have. I, one thought that's been occurring to me that I'd like to offer to the committee to consider. I don't think it's a perspective we haven't talked about yet among across our group, which is. And it's unique to DCS perspective on that DCF does hold a value that we want to be serving the kids we serve within the community close to their family as much as possible. But also part of that is we recognize DCS involvement with family often comes with its own gravity its own weight DCF becoming the custodian in a family. Introduces a degree of challenge to that family dynamic that isn't, you know, that we'd hope isn't necessary. We hope to avoid as much as possible. And so when we talk about a program like a PRTF program that is more accessible to youth in Vermont. And we talk about those youth who are. As we've said already placed within an inappropriate level of care where we can't meet their needs, whether these is a DCF staffing situation or they're in a hospital setting too long, or they're in a crisis stabilization program or something like that. Those settings or within the homes in the community, those settings provide a greater likelihood that other factors are going to come up while a kid is not getting what they need within their family environment. That's when perhaps an aggressive outburst or an assault happens within the home where the family says I can't do this anymore and I can't pick them up from the house. It can escalate things. And so that is sometimes when DCF actually is coming to the table as the custodian because things have gotten worse and so having access to this. Even though we're talking about the very highest level of residential care that we would be offering in many ways some hospital. There's also a preventative lens to this, which is we are keeping these families together and working together and that's really about DCF as well. How we can work with them without having to open up custody in a case. Thank you. Thank you very much. I appreciate, appreciate you being here. Thank you. Sorry, it says. The worst. Has to go pretty quickly. So, I'm going to go through. Evan green from the association of hospitals and health systems that I have with me today. And the hurricane also with us. And thank you for having us in I want to quickly note. We are here to describe the ripple effect that you've heard about from Monica and Cheryl earlier and the impact that it has on hospitals. And I do want to briefly thank Emma and the emergency departments because they work very hard to collect this data often the state is hand collected. And right now, we're working with VDH to have it automatically collected, but this has been a tremendous effort by Emma and we really appreciate it so thank you. And what we want to say is we want to start off with some good news, which is that. Evie volumes have decreased from this time last year. Had about 50 youths. An average waiting over 24 hours and emergency departments. That has been reduced to 20 we think there is potentially some impact from all the DMH. initiatives that they've started. And we think that this is a great trend. At the same time, 20 youths waiting emergency departments is 20 too many. And often. These youths are the majority of those waiting are waiting for multiple days, not just 24 hours. So the way we took this data was we looked at all the. Young folks coming in with a mental health complaint as a primary complaint. We narrowed it down to those waiting over 24 hours. We thought that that was the population we should be looking at and. Most often the folks who are waiting over 24 hours are waiting for multiple days. And we do think. That that is due in part to being unable to get placed right now. We only have 1 inpatient unit in Vermont. And. For for young folks and we. We have seen there that there's been an average of 9 post acute adolescents who are waiting per month. And at times there have been almost half of the inpatient census waiting for placement and this could be due to trying to identify a placement. Waiting for placement to become available or guardians not picking up the youth on the discharge date. So we do think that that. Sort of middle level care that steps down care would help. Pressure is not very possible is currently. Great. That was quick. Thank you. Questions anyone. I'm looking at your presentation when you when you use the term youth. What does that. That's a really I feel like I feel like we've heard that's a really good question. But that is a really good question. Actually, the data we've cut free. It was based on anyone under the age of 18. But while we were talking, I did run the same numbers for youth age 12 through 21 and the trends and the volumes will be seen. So we can cut it anyway. I would say. Yeah, I. I get really confused and isn't hard, I know, but. It seems like. You have heard. That beds are available in places and they just. I get confused as to why it's still in. I don't know. I mean it. We've had a health care at least to my memory this year. We heard that.  Are as restrictive as they were. Why we still have kids waiting. Yeah. And I would say, you know, the increase in bed availability, the efforts by brought up a retreat to increase transportation options. For example, all those initiatives within the last year, I think it's what's contributing to the number of kids waiting less and less. So going from 50 in March of 2023 to about 20. In January, but I think we haven't quite done the system of care work to really get at those. Right. This might be kids with more acute needs or, or complexities that. That kind of fall into this. Okay. Yeah. And so I think. I think that's where this middle level of care can help kind of create more capacity. Okay, so we are improving, but this. We still have a ways to go. Yeah. Yeah. So everyone holds still you're going to go. Yes. So, for human services committee, we will meet back in committee at 3. So you have a little bit of a break right now. And everyone else could stay. You'll get a break at 3. Make sure. Take your name. Take. Yeah. Yep. No, stay. Just want to say thank you to our colleagues here and house health care and to all the witnesses. Sorry, we can't hear. I'll get this a little later. Hey, good looking at your slides. I do have questions, but I'll be in touch. Well, I better have. Yeah. I asked them only why is this good. Yeah, I have happy family. And they've got like. Yeah. Right. Health care. Does anyone have questions for. Right now. No. I'll take it. I have like sort of like confirmation. Just some. Would it be fair to say that one of the benefits of this additional treatment. Is that it, it like. There's a word we use. I can't remember what it's called. It's not clogged. Hello. There you go. It's like it's related. Yeah. It's like fluid dynamics. You know, like, but the idea that like. People could go to the. P. R. Yeah.  And so like having this piece where people could flow through it, then it allows people to move through the other levels easier. So I mean, it sounds like it's another important. That's exactly right. Yeah. It's part of the care. I have a question. I'm not sure if it's going to be for you too, or for DMH. So we talk about the, the. What, what group is involved in that placement process, which looks at the kids staying in the hospital? I think that might be a question for. Okay. So we'll, okay. So we'll wait till. Okay. Yeah. Any other questions for boss top. Yes. The people that you have in those possible beds that are staying there. Are they justice involved youth? Are they. We can follow along. Yeah. I don't believe they are. I don't think they are, but we can. Not. Yeah. Well, and if anything, their, their justice involvement is not the reason. Yeah. Okay. Yeah. The reason for delay is that there is a level of care that it's not available. Right. So it's not like there's a port date or. Well, just saying is there. It's not available. It's not available. It's not available. It's not available. It's not available. Support treatment and support for people who are, let's say intellectually disabled. Is that what you're saying? Well, this data is looking at, I mean, that is possible, but this data is looking at primary complaint as mental health complaint. And so there could be co-occurring. Okay. But I just want, like we, I think we could ask a follow up question to the retreat on folks who are delayed children and youth who are delayed placement and ask how many of them have an intellectual or developmental disability and how many of them are just. Developmental disability. Yeah. We can see what we can get. Like if there's more context to those kids, we can. I'm thinking of the kind of people that would be going into this facility that we're talking about. That's why I was asking what kind of people are in your hospital beds waiting. Yeah. Yeah. Are they just, are they just as involved or not? Okay. Thank you. Let me take that back. I would say I will look at our numbers for what we collect point in time. My impression is most of those individuals are not justice involved. DMH on the justice involved side has dozens, I would say in any given year. I'm, I know I'm looking at Emily. I mean, I think we can talk a little bit about what our hospital units look like from a mixture of both folks who have a developmental disability, mental illness, substance use challenges. I think we can talk about that. When you come up. I think that's a really good question. Okay. Why don't we make the switch? Thank you. Thanks, Emma and Devin. Thank you. And then I do know people have had questions. I promise we will get to them. So I'm hoping others in the room can stay till three. Yeah. Usually I have. Go ahead. Good afternoon for the record. My name is Emily pause commissioner for the department of mental health. And I'm Laurel and the director of the child family. So we also have a couple of slides to talk through with folks. I also wanted an opportunity to talk a little bit about some of the questions and testimony that you all have heard today. So first, I'm going to go into those comments before I get into our. Two slides. I apologize on behalf of us. We don't have a picture of happy families, but that is not because we don't care about. This was just our stock PowerPoint. So one of the common themes that I heard earlier during testimony. Was the makeup of a particular unit. And who is on that unit and concerns about bullying or mixing folks with different diagnoses in one space. What I'd like to comment on is that individuals who are in a hospital level of care. And also this level of care, which is a step down from a hospital are oftentimes on a mixed unit. Whether it's a person or a person, which is a step down from a hospital are oftentimes on a mixed unit. Whether they're in Vermont or at an out of state facility, individuals with complex needs are typically receiving services all within the same unit. They don't. Most facilities are not able to, nor does it require separation. Purely based on somebody's diagnosis. So I wanted to take an opportunity to put that out there just because that seemed to be a concern that folks were for voicing. The other thing that came up was around concerns around seclusion and restraint practices, which is something that we all think about. None of us want to put hands on an individual or seclude them. But that does happen. And that is a tool in the toolbox, so to speak. What we would look to do though is continue our work with the PRTF that we've done across our healthcare system with six, four strategies and six core strategies is an initiative that the state has undergone for the past might be 10 years old now or more to have a goal of zero seclusion and restraint. And six core strategies is a multifaceted approach to leadership style, workforce engagement approaches to treatment and engaging with individuals who are in the care of the folks, whether that's in a facility, whether that's in an emergency room, whether that's out in the community. So that everyone understands that the goal is zero restraint and seclusion. And there are facilities who achieve that. And so when we think about the Brattleboro Retreat, they've had a tremendous shift in the amount of seclusion and restraint that they have engaged in on their inpatient level. They've engaged wholeheartedly in the six core strategies approach. And we anticipate that work to continue if we move forward with a PRTF there. And they've been at the table for those conversations and how to engage their workforce on that project. So I just wanted an opportunity to put that out there before I talk about our circle. This group is usually seeing our pyramid. We switch things up by different audience. But today, I thought it might be more beneficial to talk about our circle, which is someone to prevent, someone to call, someone to respond, and somewhere to go. And I chose this because some of the conversation has been, we're only hearing about beds. And you're only hearing about beds in this particular conversation because it's a conversation about adding beds. But we also do have a lot of initiatives that this legislative group has been a part of in the last couple of years outside of beds. And so I want to reflect back on Monica's comment. It's both and. So when I look up and I see someone to prevent, we've done extensive training across our system with trauma and resiliency. We continue to do our suicide prevention work. And then our community investments, such as our Vermont child psychiatry access program. We've all had a presentation on, but for those folks not familiar with that program, it provides access to psychiatry consult services for individuals or primary care offices throughout the system. That's something that's currently grant funded, which a lot of these things are grant funded. And so you don't see budget asks for them because we currently have federal dollars to, to engage in those programs. Anything you want to add related to someone to prevent. I think a lot of the others, community based services can be that. So the school based mental health work that happens, the earlier upstream work, the early child, family, mental health and systems work that is available with families with young children, but also in childcare centers. All of that is the earlier upstream intervention. And then we've had a lot of opportunity to talk about the nine, eight, eight suicide and crisis lines, which is not diagnosed diagnostic specific. Anyone who is having a self-defined crisis is able to call nine, eight, eight and have that call be answered. Almost 90% of the time by somebody here in Vermont. And we know how valuable that is for our communities. That is also grant funded. So just making sure that folks are aware of that. And then we also continue to operate our crisis text line and our pathways warm line, which is another opportunity for persons with lived experience to utilize a separate warm line. Should they feel that that is more their style or they would benefit more from. And then we've also engaged in our mobile crisis response or our enhanced mobile crisis response that goes across the age span. This house healthcare has been instrumental in our enhanced mobile crisis response program. That's a co-occurring program. And so that two person team can respond to a substance use issue, a mental health issue, and is compromise or compose compromise, composed of somebody with a lived experience and a mental health clinician. And then finally, there are somewhere to go. So we currently have a unit at the Radleboro retreat that serves adolescents. They also have a unit that serves kids who are younger than 12. We have engaged with Southwestern Vermont Medical Center to build adolescent capacity, inpatient capacity there. We did that as we saw the capacity needs grow for inpatient level of care, as well as diversifying from the Radleboro retreat. And having a more integrated system for youth who need inpatient care. And when I say integrated, I mean an inpatient unit that is located within a medical hospital. We've also engaged with our psychiatric urgent care, which is also somewhere to go. Pre-emergency room allows folks to get seen, brief interventions up to 23 hours a day. Our children's residential system, which is also known as our P&MI system. For this group, you have seen budget requests related to the P&MI system. And that is a lower level of care than a PRTF. And then the micro-residentials as well as somewhere to go. So I wanted to highlight these as the conversation has really focused on whether or not the dollars that could be spent on a PRTF could be best served somewhere else. I'm going to go back to Monica Oglebay's comments about both and yes, and that is accurate. We're spending dollars as it is sending folks to Florida. And when we talk about transportation to Radleboro, if it were me, I would much rather make a trip to Radleboro than I would to Florida, I guess, for a variety of reasons. So those have really stuck out to me as really important things to digest and consider as we think about supporting youth in our communities, which we're proud to do in Vermont in a way that helps them become more healthier individuals, their families become more healthy, and hopefully aren't relying on the highest levels of care once they become adults and so on. Anything to add from your lens? Not for this, but I heard questions related to kind of more of the utilization review process. So I'm glad to talk about that if this is the time. I'm done. So I know there are questions about both determining who are the kids and that medical necessity phase. I think that was addressed about the case review committee. Technically, it's each department holds the delegated Medicaid authority from Diva to make that medical necessity determinations or department, but based on the discussion and recommendations within the case review committee. I also want to note that case review committee has those AHS and AOE representatives. It also has a Vermont family network family voice representative in there. So we try to bring in to make sure we have that lens perspective. So there are representatives from each of our departments. They have different titles like for DMH. It's our care managers who are in there for DCF. It's a residential coordinator. I might get their titles wrong. I apologize. And for developmental disability services, it's their children's specialist, but they all have a care management type of role in our different departments. And so we are reviewing clinical information, educational information, placement history of those youth. I understand the team that has been working with that youth and family in their communities, they've gone through a coordinate service planning process to make that recommendation for a higher level of care. And then that medical necessity determination is made. The CRC approves what type of setting and programming could best meet their needs because we don't want to compete for beds. We want to think about all of Vermont youth and triage youth together. And then once, and then a referral needs to be made to the programs that have been approved. And so that is the responsibility of the local team. And so our state representatives work with those local teams to make those referrals to little additional steps. When it's an out of state program, we have to come by with the interstate compact for children to make sure that that state accepts, that we're sending a child there, and we still have responsibility for them. So there's just some additional process that needs to happen with that. Once the program, they often do an interview with the child. There's additional process on their end. And then if they accept it, there might still be a wait until there's an opening of a bed. And that's dependent on someone within their program being ready to discharge, which we know is dependent on whatever their community programming can be put together in that timeline. So the time between having that referral to CRC getting that approval, that can be fairly short. But then the process of making the referral to the program, having them review and make a decision, and then having that opening actually occur can take months. We try not to have it take that long, but that is sometimes the reality. And so there is a need for that youth to be held by a treatment team somewhere in the interim. And there are many conversations that occur with families, with treatment providers about what is the least restrictive setting where we can support this youth in that interim phase. And that's really individualized for each youth. And of course, the question of do we have whatever is needed available? Once the youth has been admitted into that PRTF program out of state, those state representatives, the care manager type roles, continue to oversee their stay there.  To understand what is the treatment that's happening? What are the concerns or issues that have come up? How is progress being made? Are we meeting the goals for that level of care? We don't see these admissions into residential programs as meeting all of the needs of the child. We have some treatment goals that we're trying to attain. And then we want to get them back into their community to continue the work because we know that that's not, it's just a piece in the continuum of their services. So that utilization review process is happening for those youth by our state representatives, but also we want to make sure that the local providers are involved as much as possible. It might be a local DCF social worker, or it's a designated agency that they've been involved with that youth before, whether it's the development disabilities part of that designated agency or the mental health. And in many cases it's both of those development and mental health folks. And that will help with preparing for what is the transition plan for that youth? Are we looking at needing to find a developmental home? Are we looking to need to apply for a developmental services waiver and getting that process going? Are there needs for a different foster home or do we want to get a referral into a micro residential program for them to step back into the community and start attending public school supports? So those are all of the conversations that are happening. And within that what's happening with the family and the family work that's occurring by the residential program. What supports does that family need for them to also be preparing to have that youth coming back to the community so that we don't want to just be treating the youth. It is very much a family system approach. So I know there are some of the concerns within those conversations arise families expressing concerns about this treatment approach doesn't seem to be working. Can we try something else? We might bring in OT or what else can we tap into the community? When a youth is placed out of state and has Vermont Medicaid, the out of state program enrolls in Vermont Medicaid. So that has to happen before we have them admitted so that they can bill Medicaid. If that youth is in Florida or Pennsylvania or even Cape Cod, there are, I don't know if there's a PRTF there, but there are some residential programs and they have dental needs or they need to go for an annual physical or they get injured and need to have care, physical care. It is harder to make sure that those providers are also enrolled in Vermont Medicaid. Even if I should add to that prescription medications and where are they getting this from? We work really closely with Diva and their provider engagement folks to have them reach out to say, are you willing to become a Vermont Medicaid world provider? But there have been times where people haven't been willing to and then we have to figure out, especially if you've had chronic conditions that need regular care, getting them back to Vermont to see the provider here. And that is an added expense and time and travel for that youth as well. So that's just, I wanted to add to that picture of the benefit of having someone remain Vermont for this level of care. Thank you for that. Is that everything? Okay, so we're going to open it up to questions and so we'll just pop it up for you too. I know, we'll do the Daisy first if you still have a question. Okay, Alyssa and then Topper. I don't know if this is for anyone in the room, probably AHS, whether than anything. So, you know, we've had references to Brandon in this conversation and the chair of human services, you know, talked about some of her biases and we talked about seclusion and restraint and I'm thinking about Woodside. How is this, how's this different than Woodside? What did we learn from our other experiences because I think we've learned that we go into the best intentions with things and sometimes they don't always work out the way we hope in the end. So, are we thinking about that sort of thing? What are we doing to put things in place? I mean, it seems like it's being housed in AHS but every, each individual agency has a little piece of it but not enough of a piece of it to be held responsible for it. So, I guess I'm putting it out there of how are we going to do better with this? Can I ask a clarifying question? Yes. What does responsible for it look like? Well, I think that if you look at ultimately what happened with Woodside, it became sort of a hands off which then allowed maybe some things to happen where youth were not receiving the care that they were supposed to be receiving and so there wasn't oversight and accountability. So, I guess that's what I mean. Well, I think the oversight and the care was in the same, so I see Shayla came in. Who? Who would like to answer this question? Well, I'll take a stab and Shayla can ground me if it's two out there, which is good at doing. Well, and I would say that I wasn't at Woodside but I do know that there are a few folks in this room and within all of our departments who did work at Woodside and as a state we are 100% committed to not repeating the past and so you see Dale, DCF, DMH, AHS here today because we're committed to kids being served well and being served when and where they need it. And so without going in and rehashing all of what we've read or heard about Woodside, I can tell you that from my work we're committed to not holding kids against their will longer than necessary and that's why we've engaged in conversations and contracts around six core strategies because that speaks, that's a modality that can support that work and that's why you have Deputy Brad Key here to talk about how challenging it is to keep kids and staff safe but nobody wants to be putting kids locked away in a room somewhere and I think that's the feeling, I don't know if that's the fact but I know that's the feeling and so that's my initial response and Shayla can correct me and Monica Ogilby gave her phone number earlier and I guess some cheese. She, open and loose, she's responsible. Good. Hello everyone, Shayla Livingston, Policy Director for the Agency of Human Services. So thank you, Emily Mack, going to correct anything you said, that's accurate. I do just want to draw your attention back and you can look at the slide deck. I won't make us look at it again but that slide that had the three different departments and all their different levels of care. One of the things I think is really important about this level of care is how it fits into each of those departments flow. You heard a lot about system flow and it is very different than a secure facility or DCF for individual children and juveniles who are justice involved. That's a different setting and a different type of care that is still needed in our system but is definitely very separate from what we're talking about today. A child might or a youth might step down from that level of care too in the RTF setting in this system, right, that is the vision but it is again very separate and distinct from that type of care. It is voluntary, it is overseen by CMS and regulated by the federal government and reimbursable by Medicaid. All of those things are not true for that secure level of care that you are thinking of. Thank you. The other thing that I'll add. It's up to you. If you could just say who you are. The other thing that I'll add is we can't forget the past. We have learned a ton of lessons. It's important to honor that traumatic history and it's equally important not to let those fears drive our decision-making for the future because things have changed so much and we shouldn't lose sight of the harm and trauma that can occur when children are getting the right level of care. And so we are right now traumatizing and harming children and youth that are in the wrong level of care. So we're still hurting kids even though we don't mean to and we have a solution and a pathway and an option in front of us with buy-in from hospitals and the agency and our designated agency and SSA colleagues. And that's pretty meaningful. That doesn't always happen. So I would be remiss not to add the harm we're doing with it by not doing this. All right. Eric, Brad, I know that we're talking about PRTS, but I'd be happy to come back and really talk about what we're doing as far as lessons learned from Woodside and moving forward with our permanent facilities that you would be interested in because we have definitely taken seriously what we're on and on that what's called and we do have that in here. We're moving away from that. Great. Thank you. All right. I know we have Topper, Daisy, Art and Melanie and Brian and then we have to move on. For those here for 315, we're going to be late. Sorry. Okay. I'm going to be quick, I hope. Somebody, I think it was the first group that went up here, talked about the kind of people, individuals that would be in this facility. And I think I heard you say it would be a mix of people. Some of them would be, I'm going to say, they would be environmentally disabled with a caveat on intellectually disabled. And some would be justice involved. Am I right in that mixture? I think the mix is going to be very fluid. You're right in that there's no prescribed mix and that there's going to be a lot of intentionality in thinking about that mix of youth that are at the same time. Okay. I'm not going to give you advice or anything. I'm just going to make a statement. Take a look at the statistics of mixing justice-involved youth with people who are developmentally disabled. You might want to think twice about that. But that's one thing I wanted to say. Since I can't talk about our brand of training school, because my understanding is in 1993 is when brand of training school closed. So the kids with the youth we're talking about now, even the ones that are 18 or 21, they would have to be 31 years old for me to talk about. So I'm going to talk about the 18 to 21 year old. We mentioned, first of all, I'd like to have the agency say, to answer this question, is one of your goals or your mission to keep families together as much as you possibly can when you're dealing with kids? Absolutely. It is. I thought it was. Yeah. And that's why I asked the question about why can't you provide the services in a home? So I'm going to ask that question again. If I could speak to that. Yeah. Just because Laura Holland. You can't hear me. Can you speak up? No, she's going to answer. If I could speak to that. I think families would very much like to be supported to have their child at home, but not at the moment that we're talking about. They are exhausted, scared, really distressed. And I think they're seeking the right type of stabilization for their youth, so they can come back home. I think these are, these are really hard conversations that are happening with the families about their child with teams. And I think if with that stabilization, families wants to be able to support their kids coming home. They want their child to be getting the right type of care. And they know that sometimes this out of home admission into a more intensive treatment program is the step that's needed to then get back to that next phase. I think when we hear from families, when we hear from some of our advocacy groups, there is concern about the level of safety risk that families are trying to hold within their homes that they're not comfortable with. And that's sometimes why we have a child who might still be in a situation because as Tyler said earlier, families aren't feeling comfortable to go pick them up. It's around that safety concern. And I agree with you 100%. So let's move to the next step. Those kids, those youth, I'm talking about the 18 to 21 now. Those youth stabilize. And then there's, they're sent somewhere. Let's say they're sent home and their families need help with the, how come that's not happening? I look to our partners that for the age, anybody in the room, you know that it's not happening for everyone. Like, I guess there's a lot that we're missing. Some people, I think probably are being served. They are. And so I guess when you say, how come it's not happening. Everybody. Okay. Just not perfect. Go ahead. Anyone can answer that. Can you just. I'm sorry. Yeah. And can you just speak up to this? Yeah. Sorry. So I would say that we, we do find that we have 250 individuals under the age of 22 who are receiving home and community based services. The majority of those between 18 and 22. So the, the very age group that you're talking about representative. So many of those have not been to a PRTF in developmental disability services. So most of the people are, are getting home and community based services. And for those who go to PRTF or residential service, like residential facility level of care, they come back to home and community based services in the, the DS service. They come back to home and community based services in the residential and community based services in the residential sector. We see this as, as really kind of the top of the, the service, you know, field. It is really kind of the highest level of support and it's used for stabilization and support to come back to community based services. You'll, you'll notice on that slide that each system sees it, it kind of falling into a different level of, of the high end of services. So, you know, I think that it is, you know, I would love to talk to you more if you have particular examples that you'd like to have us follow up on, but generally we do see people come back to community based services. And it's about to do that stabilization stabilization piece to help the community providers. Be able to provide those services because as we discussed, really what we're finding is that these individuals exceed the capacity of community partners. So they exceed the capacity. For a, for a period of time. And so they need this higher level of support. I just need to get that. So, yeah. Okay. And I am so glad to hear. That he's 18 to 21 year olds are up to 20 years old. I'm receiving that service. I'm really glad to hear that. And I said before. That we're doing a pretty good job. For you. And so I'm going to close now. By just saying. We need to do it for people. That are 22. To 60.  And those people are not being served the way they should be. So. We got to do something about it. We got to do it quick. These people are aging out. Yeah. Happy to talk about that. Okay. Great. I forget who's next. Daisy. I've spent. Four of my last 24 hours talking with two families. I've spent. I've spent. Four of my last 24 hours talking with two families. Who have aged out their mothers who are caring for adult children. Who have incredibly complex conditions. And so I have. An appreciation for. What Cheryl Wilcox showed us was. Years of work leading up to the conclusion that we need this facility. And I commend all of the partners that have worked together. To propose this. I don't know if VDH or DSU was in the room. No. No. Okay. That's notable to me. And I'm curious why not. I also am curious where we can find information around what sort of assessment was done between the partners as to. Laurel, you outlined a really nice. Picture of what a family goes through in terms of a process for. Ending up in a facility like this, which is the last place I would want my child to go or to need to go. And given what I said about how I've spent four really difficult hours on the last day. Just listening to parents who have been dealing with this further almost. Their children's almost entire lives. I can't imagine what it's like. And we don't pay people who work in these facilities enough or people who do the H.C.B. Home and community based services enough. That's what the parents are doing. No one wants to do this work for $14 an hour. So my concern. Just to summarize is that. You know, I think it's a little bit of a. So my concern just to summarize is that, you know, Are we doing enough in the community to balance this? Like I understand there is a need. There is a very narrow. Section of. Our state whose families absolutely need. This service. And. We may need to offer it to them. Maybe. But what assessment the DMH DCF and Dale do. When you looked at that global picture and said, okay, here's our referral process for how a DCF kid gets to these services. Here's our referral process for a DMH kid. Cause I know sometimes they weave together, right? And how did you say. We need to first reduce the fact that we have 87 kids right now out of state because the first thing you need to do is reduce that number, right? And make sure that you're not doing something wrong at getting kids. Just do that bottleneck. So what was the front end assessment of producing the number of kids that even need this? So I, I'm, I'm going to, what I'm going to need to do is get all the questions on the table. And then I'm going to need to schedule time for us to come back to this because there's a lot of questions. And I want to make sure we're not rushing the answers. And that we have time for follow up. So if hopefully someone is grabbing these questions, Daisy, that was very good. And I want to hear more about that. I have one more question at short. Go for it. Um, will there be involuntary medication used in the facility? I don't know how CMS regulates, um, involuntary meds at a PRTF level. Um, so we can follow up on that. Is that what you mean? Like court ordered medication? Yeah, yeah. Um, we don't typically, uh, We don't want to, um, Right now pursue court ordered meds at a residential level of care. Um, so I don't anticipate that, but that's a rushed answer. And we can get you the facts on. Thank you. Thanks for your work, Melanie. Um, so for later when we come back, um, I am a parent that has to navigate the system of inpatient for a teenager and it is needed. advocate and to get supports. And so what I would like to understand is that the case review committee level is where do parents get support and how do they speak their truths and get help? And then at any time during that system, because it is your worst nightmare and it's your biggest responsibility and finding those resources are incredibly hard. So if we could just understand where that happens, that would be really helpful. And I don't know if the office's child, youth and family advocate has a role in this, but it just would be great to see that for parents and for families. Thank you. Yeah, I mean, my question goes more of a basic thing. We've heard just today myriad of circumstances, groups, locations and so forth. Is there a document or document somewhere that outlines what what the various categories of deeded care are, where the kids would go, what qualifies them for that and where they go.  Because we've just heard tons of stuff here. But putting it all in perspective is what it all means and how it fits together, which I hope it does. If you tell me it doesn't, and that's a problem in itself. But see how it fits together so we know who goes where and why and what's needed to pick. Is there something? I think that we could create that. What I'll go back to is a comment that was made earlier around access to ICU when you need it. We as humans expect getting access to an intensive care unit when we park in a compromised medical situation and we have access to that. What we are trying to do is afford that to children who are experiencing pretty significant mental health concerns, substance use. Right. And so what we want to do is have that group of folks also have access to levels of care that is a human. Right. No, I get all that. But what is that? So are you looking for what does that level of care mean? What does the level of care mean? What does it qualify for? Just so we can. So the medical necessities. What's the whole program look from soup to nuts? What does it look like? Because we just hear, I hear broken pieces of it. I don't know enough about it to put it all together into one coalesced form. You want to, what is it called, a P.F., whatever the acronym one. P.R.T.F. There we are. But who's in it? We've heard a bunch of people are in it, but I don't know what that means. I can't put the numbers to it. Right. So I think, I think what's key to Art's question is there's still like this, everyone's involved, and that's really hard to understand. So take that away and try and figure out how to make that a little bit more clear for us would be helpful. Brian. Yeah. Well, I just want to say I appreciate what you're doing. I appreciate that you're you're like pooling the resources under AHS and not being siloed in this approach. That's like a great strength of this proposal and something I'm curious about is like how we can track factors related to social determinants that lead to higher levels of care and like what in addition to the psychiatric mental health, like medical treatment, what kind of referrals to resources. I know DCF does a lot of this work with families all the time. Like I like I want to give you credit how much you prevent problems when you get involved in a family in a family's life early and get them resources and how that that can prevent custody. So I know the state's doing this work, but I think we could take it to the next level as we keep adding these components. And then, yeah, so that's the kind of the question is like maybe how can we do that? And like, you know, I was just thinking more about like what are the barriers for people getting services in the community? And it's all the things our committee knows about already like job vacancies, lack of supporting it, supportive interest, transitional housing or housing in general special needs. And I think one thing that this one element that this proposal addresses is the stabilization piece, because when someone's not stable, they just keep bouncing around. And so like we just need a good place for people to land sometimes and stabilize so the family can get on their feet and like have the right support in place to to manage, you know, to support their child. So I think this is a great piece and it would be cool if we could learn a little more about what's leading people to the higher levels of care. How can we use the higher level of care as an intervention? But then how can like you advise us to change other policies that might be beyond the jurisdiction of this committee? You know, around the social determinants. So that's the question. I know there was a lot to it, but I just I just want to thank you because I do think this is an important now that I've heard the details. I think this is an important component. And I want to reiterate or Brian said it is amazing and wonderful to see everyone in this room together and working together on this. And we I hear in your testimony, the emotion around this situation.  And I appreciate that. And I'm sure the committee appreciates that. So we're not trying to stymie that. But because everyone's in the room together and we don't normally have this, we have a lot of questions. So hopefully that's understandable. My questions, which can come back are more budget related. So I will just send them to Shaila and then we'll coordinate with Shaila. Once you all can, you know, think about the questions we have for a proper time to come back, understanding that the budget's in appropriations and we'll want to move as quickly as possible. So again, we appreciate everyone's time and and your thoughtfulness and what you're trying to do for kids of Vermont. So thank you. We are going to take a break until three forty. Do not be late.