Vermont Legislature SmartTranscripts:

[Alice M. Emmons (Chair)]: Who was the medical director for WellPath, and we as a state and DOC contract out with WellPath to provide health care and mental health care to our folks who are incarcerated. And the topic for this morning is really talking about the accountability project that is occurring in Chittenden County, and it does have some impact on DOC and as well well path. And it's really important for us to know what those impacts are. And also, in particular, if there is a goal possibly to extend this type of accountability court to other counties, it will have even more impact on DOC. And I don't want people to forget, yes, we're trying to take care of the backlog in our judicial system. Yes, we want immediate consequences for folks who are re offending, but the back end of that is DOC. And it may end up putting more pressure on DOC. And I think we have to be cognizant of that and bring that to the discussion as well. So I don't think very many people think of the back end of the program or the back end of the criminal justice system. And that's what we also need to focus in on. So at this point, I don't know if the commissioner wants to start or if it's doctor that will go.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: With your permission, I'll do it.

[Alice M. Emmons (Chair)]: You want to start and then we'll go over to Doctor. Eulager? Yes. Okay, welcome. Then Commissioner, if you could identify yourself.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Good morning, everyone. Thank you for having me again. My name is John Murad. I am the interim commissioner for the Department of Corrections, and it's good to see you all once more. Golly. Think it was only Only three days ago.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Two days ago.

[Alice M. Emmons (Chair)]: Feel like

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: yesterday. It feels like a lot. Well, that's I'm not I don't think so. We will that won't I won't feel that way. I'm very glad to be here and to get a chance to talk about this issue around both the I'll call it accountability court for the sake of conversation, but I don't think that's what they like to call it. It's a special court designed to clear through a long list of people who had five or more dockets, and those individuals had been waiting for trial for some period of time. And so it's certainly a large component of the backlog that has existed in the court system really since the pandemic. To my mind, it's been remarkably successful in that venue at least in Chittenden County. Chittenden County was really an ideal place to start it owing to population density, owing to the number of people that were there. And DOC played a role in the creation of the court from the beginning, when it was being discussed in the governor's office, and when the governor's team really contemplated it and conceived it with the clear collaboration from both the courts and from the state's attorneys and sheriffs and from other entities as well, because it really did end up being a really large full court press in order to accomplish this Burlington 14 plan, as the governor's office calls it. As part of that 14 plan, DOC was tasked with expanding pretrial supervision, which is something that was on the books already, legislative work, thanks to this committee and Vermont legislature. It was a pilot that we had initially begun in the Northeast Kingdom, but we hadn't really been able to get much traction with it there, and we moved it instead to Burlington to coincide with the creation of this 14 plan. We also expanded the availability of certain kinds of substance abuse treatment in our system, and specifically at Northwest and Chittenden Regional Correctional Facility, the women's facility, and the male facility that is most likely to be the location where people sentenced or remanded from the Chittenden Courts would go, the Northwest facility in Swanton. And so those two were sort of the first places, but I want to draw a distinction that this is not about the so called accountability court. This is really about us developing a new capacity for treatment inside the system that will be applied to anyone, because we weren't using this only In other words, as we develop this new capacity, it is not limited to people who come to us from that court. If a person every single individual who goes through intake at a Vermont correctional facility has a certain number of assessments, and they're done in certain amounts of time. Within four hours, they get a medical assessment. There's a mental health assessment that occurs within seven days. Other kinds of assessments as well, a dental assessment that happens on day 30. This is a new component of that assessment, and it will be applied to anyone coming through who meets the needs as it's determined in the preliminary medical assessment of having additional capacity for substance use disorder treatment. And so it's not merely folks who are being sent to us by that court. The court itself has been pretty successful. It's worked through more than a third of its docket, found resolutions for a number. It's anticipated that there will be additional resolutions made prior to the end of the court, which comes at the end of this month, winds down at the end of this month, and will be over in early February. And then the Chittenden County State's Attorney will absorb some of that role, and it's in flux how that will happen, and that's outside my expertise or purview about what will happen. Will it be a judge assigned for half a day, twice a week, or one day a week? Will there be a single state's attorney, a deputy state's attorney from the Chittenden County State's Attorney's Office? I don't know the answers to those things. But the idea is to try to continue some of the, I think, effort and success that's been realized by special prosecutor Zach Waite and the special court. It has not created a tremendous burden on DOC yet in the sense that these are sentenced people. They were in the court system already. There's not an additional group. Are they being pushed through more quickly? Yes, but that is to everybody's benefit in the end. Does it contribute somewhat to the disparity of sentenced versus detained individuals in our system that I discussed in our meeting two days ago? Yes, some of these folks are detained, but the truth is most are sentenced that have been sent to us. In other words, they take a plea at the court owing to the additional speed and pressure of relatively immediate accountability, and then they are sentenced. I think 10 or 11 have been sentenced to our custody, but a number have also been ended up in our supervision. So there is an additional burden of supervision, but pretrial supervision has only amounted to six total people, Six people that were put on pre trial supervision as a new kind of service that the DOC provides. So the others have been, at the end, have taken a plea, and then have been put on to supervision of some sort via probation. And that is a role that we are to play. If the sense that there's a little bit more because the court is more speedy, yes, that is an example of additional work for the department, but it's also work that we are supposed to be performing.

[Troy Headrick (Ranking Member)]: Let me back up the six people on pretrial. Yes. You tell me, I just missed the impact. Sure. These are folks who are placed on pretrial because of the accountability.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: That is correct. So those are individuals who were referred by the court to pretrial supervision while their case continues to move through the court. Of those six, no violations have been reported, at least in the last couple of phases. I get a weekly report to that effect. And there have been, I think only one, there's been a total of six received and only one is actively on pretrial supervision right now,

[William "Will" Greer (Member)]: as a matter That's of the

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: difference, yeah.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I think the others have either taken and ended up, now, most of those who take pleas will probably end up on our regular supervision being probationed or, well, not paroled, because few of them are actually going into the system. Some number, I don't know, sir, and I can find for you the answer, but I don't know the number of the, if there were, there have been six total referrals. One is currently on active supervision, the other five. How many of those were remanded to custody? How many of them are on supervision? I don't know the answer to that. It's also possible that some of them were found not guilty or ended up having no further interaction with DOC. 10 individuals have been remanded to DOC custody from the court, the accountability court. And right now, there's no direct process for those courts to refer someone specifically for a American Society of Addiction Medicine assessment, the ASM assessment, which is the new kind of assessment that we're going to be doing as a component of this treatment program. What I mean by that is that it's not up to the court to say, This person must get that assessment. That is a component of our normal intake process of the assessment that's done within the first four hours, and then the next lengthier assessment that's being done by a WellPath employee. WellPath is onboarding a new clinician who will be able to do that work and continue to do that work even after this court ends. It is our intention to be able to roll that out, certainly continuing in these two facilities, but ultimately throughout. And the ability to provide the next stage is also that that clinician would provide not only the ASN assessments, but also the therapies, including, for example, group therapies, etcetera, that are necessary to create a model that inside our system echoes what would be called an intensive outpatient program, or IOP, in the non incarcerated world.

[Kevin Winter (Member)]: Please, We'll

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: have you

[Alice M. Emmons (Chair)]: off, doctor, because I know

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Thank you. Sorry.

[Alice M. Emmons (Chair)]: Giving the introductory, but we'll get into some of the nuts and bolts. Right.

[Troy Headrick (Ranking Member)]: So again, another clarifying. So 10 people have been remanded for custody. Yes. I think you said there's no there's no method right now for referring them specifically for the substance use assessment. So of those 10 people, some of them might have been only substance use assessment. Or are you saying that the 10 that have been remanded are there for other criminals?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: The 10 that were remanded, some number of them may have gone through this assessment, and others may not. I don't know the number for that. I will say

[Troy Headrick (Ranking Member)]: that they're all there for behavior that violates law. Affirmative.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Of the 43 total individuals representing, I think 800. Three eighty two dockets. So 800 is the total universe, sir, of dockets. The ones that have been resolved at this point is somewhere in the order of just under 400 dockets. Those represent 43 individuals who had among them nearly 400 dockets. And of those 43 offenders, 10 were incarcerated with us. Another four were incarcerated, but with a split to serve sentence, which means they don't automatically go inside, and others are on various forms of probation or other kinds of supervision. There were some that were ONH that were determined to need an order of non hospitalization instead. But of the 10 who went into custody in a facility, I don't know how many of those have been assessed to be candidates this next level of treatment. Okay. And while we can make assumptions that a significant portion of the forty three probably have either substance use conditions or underlying mental health conditions, I don't know the numbers to that. And I think a component of this too is that as much as AHS has embedded service providers in the three court in order to make assessments during the trial phase, when it comes to the sentencing part, it ultimately goes back to DOC to be the determiner of who's going to get what kind of treatment. Average

[Troy Headrick (Ranking Member)]: length of sentence on those 10, do you know that?

[Kevin Winter (Member)]: I do not

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: know that, But that is I I can try to find that information out for you.

[Alice M. Emmons (Chair)]: So those 10 that are incarcerated, they're they've all been sentenced? Are there any detainees in that?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: No. The these are 43 offenders who have been resolved, and so they would be sentenced and incarcerated, not detained.

[Alice M. Emmons (Chair)]: So they would all be sentenced?

[William "Will" Greer (Member)]: Affirmative. The 10.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Those 10.

[Alice M. Emmons (Chair)]: Those 10. Do you have any detainees that come from the court, the the three b court?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Understood. I don't know the exact number of that. The majority are not remanded to detention. They're placed under, as I said, we had the six that were under pretrial supervision at some point rather than being sent to detention. I don't know the number that were, for example, taken from court prior to resolution and sent to a facility to await that resolution. I don't know that number.

[Alice M. Emmons (Chair)]: We are talking about misdemeanors, not felony. Right. These are misdemeanors.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: No. I believe it is I believe it is all types. The dockets are made up of all kinds of crimes.

[Troy Headrick (Ranking Member)]: Isn't it most statement off of them misdemeanors?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Well, that is why they wouldn't have been seen already and why these dockets would have been allowed to accumulate.

[Alice M. Emmons (Chair)]: Right. Because multiple misdemeanors.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: But it's not it's not necessarily only. What's that thing

[Unknown Committee Member]: about Troy was that, like, some felonies had snuck in

[Kevin Winter (Member)]: there or

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: something like

[Kevin Winter (Member)]: that? That's the reason. Yeah.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: It's true. If you had five major felony dockets, you would not have been on this list. Would been seen. So you had multiple assaults and shooting and a home burglary with a person present. You would have not ended up waiting this long. These are generally lesser crimes, but not all.

[Alice M. Emmons (Chair)]: So when the births attend, they're sent to be They have a sent out, and they're sent to either right now, you're seeing this at the Chittenden facility or the St. Albans. Yes. So it's coming from a Chittenden Court. Yes. Do they in booking know that the person has come from meds and pants court?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: From the 3B? I don't believe so. It might be somehow noted in the paperwork, but I don't believe that plays any role in what ends up happening to the individual. I don't think there's any different intake process, nor do I think on some level the intake, correctional officer doing the intake cares. So I think they follow through the same exact processes.

[Alice M. Emmons (Chair)]: I just want to be clear here. There's no order from the court for those folks that they need to be in an enhanced substance use program at all? There's no direct response from the court or indication from the court, or is

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: That is the case, as I understand it. In fact, I think the court has been reluctant in the sense it doesn't believe it's got the authority to actually mandate that if going to DOC. The DOC ends up creating the determination of what treatment, etcetera, is needed. That's different for a person, for example, who gets an ONH. Then the court is making a different kind of determination. What's An order of non hospitalization.

[Alice M. Emmons (Chair)]: But if they become incarcerated, they have the sentence, and the goal is for these particular folks to have enhanced treatment, but DOC doesn't know that these particular folks went through the expedited court procedure.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: But DOC And

[Alice M. Emmons (Chair)]: put you hands behind your back because you don't know, so you've got to do this for everybody.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: We want to do it for everybody. I think that is ultimately DOC's goal is to say, we provide this new level for anyone, whether that person went through the 3B Court in Chittenden County or whether that person was arrested in Barrie and is brought to Northwest Owing to the closer facility might be Springfield or Rutland, but they are not allowed there anymore because they've been inside before and have had fights or something. So they're brought to Northwest, and they go through the exact same screening that anyone coming into the facility does, and included in that screening is an assessment that, Oh, you have a substance use disorder that not only will be eligible now for the MOUD that we have been providing for several years, but for this additional level of treatment that we are working to get going. And again, I don't wanna misstep or put my foot in my mouth, and I'll leave that to the doctor. Put his foot in his mouth? I'm sure. He's more familiar with anatomy than I, and I'm sure he will avoid that. So

[Unknown Committee Member]: wait, you're telling us you don't know where your foot is?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I don't. I'm not entirely certain.

[Alice M. Emmons (Chair)]: So right now for the accountability court, the focus is Chittenden County and St. Albans for the folks of gone. You're hoping to beef up the MOUD program to be more, I don't wanna say inclusive, but to be more expansive in what you're providing. Well, don't

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: think it's beefing up the MOUD program. That is a program in and of itself that we will continue to deliver as we do right now. I think that this is about an additional level of treatment that enhances what MOUD allows. MOUD provides a symptomatic break for a person by ameliorating symptoms, and then the new treatment is something that gets at the reasons for those symptoms. That is as I understand it, but again, I should probably be cautious.

[Alice M. Emmons (Chair)]: Right. So I know when we put in the MOED program, Matt, at that time, we were very clear that we wanted it to be modeled after what's out in the community. We didn't want to offer more than what was in the community. We didn't want to offer less. We wanted it to be the same. So are we going down the path of offering more to folks who are incarcerated than what's being offered to folks in the community, or is it bringing it on par?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I hope the latter, that we are bringing it on par. I think that it's sad to say that many of the folks who end up in custody probably are not accessing this level of care in the community, but that is not to say that it doesn't exist. And I also want to be clear that, and I believe the doctor will confirm, there are certain aspects of care in the community that we cannot replicate inside, and therefore, is it the same or identical? I don't believe that one could say it is identical in the sense of making a definitive legal statement. This is identical. There are necessary differences owing to the custodial setting, owing to the availability of certain kinds of In a hospital, there are many more specialties that are immediately available to provide service. That is never going to be the case inside a facility, even as we build up capacity and onboard additional kinds of clinicians, etcetera. But our goal is to provide something that echoes what's available in the community in a best case scenario. Is that more than an individual who has been arrested, prosecuted, sentenced, and sent to us might've gotten otherwise? Yes.

[Alice M. Emmons (Chair)]: So I'm remembering when we first rolled out MAT, M O U D, however you wanna frame it, there was a lot of pushback from the staff, in thinking they were coddling inmates or giving them something to keep them addicted, that whole gamut. If you're going to be beefing up the MOUD program, is there thoughts on how to work with our correctional officers, how to work with staff within WellPath that they would be more aware of the reasons why and not have the stigma that some of them may have? Is there any thoughts on that? Because when I rolled out, there was quite a bit of pushback in the staffing.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Yeah, no, that's a terrific suggestion. I actually think that for some officers who have concerns around whether or not, for example, MOUD is being used by those who perhaps don't have all the opioid addiction symptoms, and therefore might use it in a way that is not the same as a person with a really deep opioid addiction, I think the notion of having an additional layer of treatment in which one must participate, not must, it's not a mandate, but in which one would participate would probably be helpful in saying a person is not mimicking symptoms in order to get a dose of bupe who does not need it, and is therefore using it to get whatever effect it has on someone who doesn't have substance use disorder. Because they also have to go through or are being encouraged to go through a process that really wouldn't be relevant to them, which is a level of behavioral therapy treatment and group discussion, I think it would probably minimize the likelihood of people making statements that are inaccurate about their own substance use disorder or lack thereof and hiding that lack thereof in order to get bup. I think it would make it less likely if we were to roll this out. I believe that is But the idea of communicating that to staff and then making that understood is a really great note and one that we should take a whack at There's

[Alice M. Emmons (Chair)]: a lot of pushback from that. It tries a question, but hold off for a second, Troy. So if you're gonna be expanding, if you're thinking of expanding the program, is there any change in state law around the MAT MOUD program that would need to be updated?

[Troy Headrick (Ranking Member)]: I don't know on that.

[Lisa (Director of Communications, Vermont DOC)]: I don't believe so. It might be helpful.

[Alice M. Emmons (Chair)]: The law only allows MOUD for sentenced folks, not detainees.

[Lisa (Director of Communications, Vermont DOC)]: Okay. Well, in that case

[Alice M. Emmons (Chair)]: And we wanted to update that last year, but I didn't have enough votes in the committee to get it through. But you've been doing detainees. Yes.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: We detox detainees the same way as we detox somebody who's sentenced. Again, and so far as the intake process and the assessments that are done, it's no different. I think the issue here would be if there is a certain level of treatment that requires a certain amount of time, how do we put a detained person in that or not? But then again, a detained person, there's a range of detained persons. There's detained persons for violent crime who will be with us for a long time, and there's detained persons who will be with us for three or four days. And so they're simply not going to get the next stage of the treatment if they're with us for four days. They'll get that initial intake. They might even get the assessment, which might help them to understand, yeah, I do have this issue and I need this treatment, I'm but not gonna get it here because it's Friday night, I've been remanded, I've been sent, I'm assessed. Monday morning, I get arraigned and I get released.

[Alice M. Emmons (Chair)]: We have some questions, Troy, and then Will.

[Troy Headrick (Ranking Member)]: Any movement or changes on using injectables? I have not dealt into that discussion,

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: so I don't know the answer.

[Alice M. Emmons (Chair)]: They don't have his feet on the room totally yet.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: That's fair. As we've determined, I don't even know where they are. Oh,

[Lisa (Director of Communications, Vermont DOC)]: please. For the record, Hi, Lisa. Hey, sorry. Director of Communications for DOC. We have not further explored injectables. Greatest and I'll let you speak to this too if you want to add. But the greatest barrier right now is the cost. However, with the eleven fifteen waiver now in effect, that might potentially be an option for some individuals who are sentenced.

[Troy Headrick (Ranking Member)]: But later, right?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: They're they're

[Unknown Committee Member]: supposed

[Alice M. Emmons (Chair)]: to Did we ask for

[Troy Headrick (Ranking Member)]: this last year? Do we know what the cost is?

[Alice M. Emmons (Chair)]: We did. The decrease

[Troy Headrick (Ranking Member)]: in cost?

[William "Will" Greer (Member)]: It's $1,200

[Lisa (Director of Communications, Vermont DOC)]: We calculated it for you, I'll have that figure right off the top

[Troy Headrick (Ranking Member)]: of the

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: head. Yeah.

[Alice M. Emmons (Chair)]: It is substantial.

[William "Will" Greer (Member)]: Will? Yeah. So actually, my question first was gonna be about injectables, my other one going back to the sentenced versus detainee population for the MOUD. So you're saying right now you do offer the detainee population MOUD? While they're with us, yes. Okay. Is there a certain timeline that they have to be in the facility for them to be on that program?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Only long enough to be there for a medical cycle, to have gotten the assessment that they need it, and then be there for med line the next day. So that's the only issue, and some people never get to that point. The assessment is conceivable that you brought in at night, It's not a Friday night, it's a Tuesday night. You're brought in, you're assessed, but you go to arraignment the very next morning, and they release you from arraignment. So you never actually get into our system And of

[William "Will" Greer (Member)]: so I think, reflecting back on where we were last session, I think that was a lot of the concern was how can you guarantee that if you start someone on an MOUD program while they are a detainee and they are released, how do you ensure that continuum of care? But what you just said a minute ago, and I wrote it down, was that they are similar levels to what are provided in the communities, but do you all, when you start someone in the facility and they do get released, do you ensure that they are receiving that community care once they begin it in the facility? The doctor's nodding, so I'll leave that to him.

[Alice M. Emmons (Chair)]: You've addressed that in statutes for reentry, and I think it's the same for detainees as sentenced.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: So it is.

[Alice M. Emmons (Chair)]: Yeah. We did that a few years ago.

[William "Will" Greer (Member)]: Okay. So then here I guess here's my next question, and I guess this would be more for Doctor. What exactly because I remember us discussing, age 32, what exactly is being requested with this committee that would change your process right now?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I don't know that there's much that is being requested at the moment.

[Lisa (Director of Communications, Vermont DOC)]: That is accurate. There's also a distinction between the treatment that we're expanding, and I'll let Doctor. Gingler speak to this, program. So we're not actually expanding the MOUD program right now. It is something separate.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: We are creating a new kind of treatment within the range of treatments that we provide, and it's associated with MOUD, but it's not an expansion of MOUD remains a distinct process, which is the distribution of medicine to ameliorate substance use disorder and its symptoms.

[William "Will" Greer (Member)]: So then just help me follow along, because I'm having trouble connecting the dots here. That MOUD program, or sorry, this new program you're creating, is separate from MOUD, but is it similar, or is it separate and that it's more

[Alice M. Emmons (Chair)]: its type? Or it augments.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: It it I will leave this to the doctor.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: No. See. Okay. Okay. He's gonna

[Alice M. Emmons (Chair)]: put his foot in

[Kevin Winter (Member)]: his mouth.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah. Okay. You found it? I know.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I have I have managed to locate it well enough to avoid putting it in my mouth. Anything

[William "Will" Greer (Member)]: else? No, I'm good. Kevin's question. Totally

[Kevin Winter (Member)]: different track. Remind me how LOPATH bills for the services to Vermont State. Is it per person, per contract, per prescriptions? How does that billing get calculated? It is based

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: on headcount, and it's a headcount range. When that gets crossed, we reevaluate the contract. There's also additional rider not riders, that's an incorrect term, but there's different schedules of compensation beyond headcount for things like hospitalization. And the first phase of the hospitalization is paid by one party, and then additional hospitalization fees are paid by the other party, and then beyond that, we work it out in the terms of the contract. So it's a little bit of both. It's both the overall headcount and the range, and frankly, our headcount has gone up. And we do need to think about how the budget changes changes with our WellPath partners. And then the other piece is not just the headcount, but the specific services provided, particularly when it comes to the need to send somebody to hospitalization or to do things that go beyond sort of the normal process. So what I'm

[Kevin Winter (Member)]: hearing And the doctor, I think is So what I'm hearing is it's an all inclusive up to a point, and then if you gotta go to the hospital, that's over and above. That's a la carte.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: And I think the most important point that I always emphasize is WellPath does not do better by withholding care. There's nothing in there, there's no incentive. When I'm approving non formulary medications, I take it very seriously because actually a pass through, so it's the state's money we're spending on approving those medications, so we don't do better.

[Kevin Winter (Member)]: Overprescribe

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: that's right. Right.

[Kevin Winter (Member)]: Great, thank you. You probably told me that last session.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: No, that I have to remind myself.

[Alice M. Emmons (Chair)]: So is there any other questions for the commissioner while he's up, or is there more you want to share with us that you dare?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: But I can think, man. What? I think I just I want one more clarifying question going back to the accountability court, because you mentioned that the people that are going through the three docket are at St. Albans. Is that correct? No. The mails on that docket, if remanded to our custody, are sent to St. Albans facility. But there have actually been some people going through the 3B docket who were not at St. Albans. They couldn't be. There was one individual, for a variety of reasons, just was not eligible to be in that facility.

[Alice M. Emmons (Chair)]: So how did you know that? How did you know that that person came from that Court 3 B?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Because And

[Alice M. Emmons (Chair)]: They got moved to either Newport or Springfield, but how did you know that?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: They were summoned to the court by the three they were summoned to the 3 B Court, we were able to say they're they're not at the nearest facility, nor can we move them to the nearest facility, owing to the reasons

[Alice M. Emmons (Chair)]: at hand. So they were already a detainee? I believe so, yes. And how many situations have occurred that it's been a current detainee that would then be subject to the

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: That That is the only one of which I'm aware.

[Alice M. Emmons (Chair)]: Can you refresh us, and maybe you know this and maybe you don't, maybe it's Doctor. Eglcher, what our contract, how much we pay WellPath?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I don't have that exact figure in front of me.

[Alice M. Emmons (Chair)]: That would be good to get so the committee members know. And it's a three year contract that's renewable, and it's hanging up for renewal.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: It is. It is a

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: it the the it is a component of this year's budget, which I really can't

[Alice M. Emmons (Chair)]: The DOC budget they submitted in FY twenty seven. Correct.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: And I give those numbers at this time, but yes, it is the WellPath contract and any changes that are or are not needed to it is a component of that budget.

[Alice M. Emmons (Chair)]: You'll have to go out to bid, won't you, for a new contract? Or is it implicit that there is a renewal clause?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Don't know the answer to that.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: There's a two one year renewal clause. The first one would start this Okay.

[Kevin Winter (Member)]: Great. Last year,

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: when doctor was here Yeah.

[Alice M. Emmons (Chair)]: You get to know. It's good.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Was 39,000,000

[Alice M. Emmons (Chair)]: I was thinking

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I divided by the 1,400 prisoners at that time, which was $27,000 per person per year for meds. Now that was based on 1,400 people, were up from that number. They're at sixteen fifty. Yeah. That's the number we were talking about last year at this time.

[Kevin Winter (Member)]: But that's what you said to us last year.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: So You can subtract from that the one fifty. I don't believe WellPath provides the care for those who are in Mississippi.

[Alice M. Emmons (Chair)]: You don't know if that could be

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Sure, then, but it's about the 39,000,000 was the number. Actually raised the per person cost. So it's actually higher. Yeah. Correct. It could raise the But don't know you could buy Well

[Alice M. Emmons (Chair)]: But I don't know if you could Well, Mary, for most out quite quite the

[Troy Headrick (Ranking Member)]: amount. On

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: top of

[Alice M. Emmons (Chair)]: But you're paying for staff.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah.

[Alice M. Emmons (Chair)]: You're not just paying for Mitch. You're paying for staff in the whole operation. So I think you gotta be careful. It's not you take that 39,000,000 divided by the number of folks who are incarcerated because it's not those folks. It's fair. Who are getting all of the money from what I mean, you're paying for doctor. You're paying for the infirmaries, staff in the infirmaries at all of our facilities.

[William "Will" Greer (Member)]: There are levels of care that make

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: us full system much more expensive than it would be to take care of anybody than a twenty

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: four hour nursing staff at every Yeah. Actually, that's pretty cheap. It's like 26 or 27,000 per person. I just took the 150 out of the $16.50. You're about $26.25, $26, but that's pretty cheap when you talk about-

[Alice M. Emmons (Chair)]: 20 fourseven care.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: When you do 20 fourseven care. I

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: mean, yeah,

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: it's not bad.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: So I think we have to be

[Alice M. Emmons (Chair)]: very, very careful with those numbers because you can get interpreted.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I don't share

[Troy Headrick (Ranking Member)]: that with anyone, but in here, right?

[Alice M. Emmons (Chair)]: The overhead and the camera had the overhead costs. So it's not direct medical. So it's not direct medical bills or whatever the folks who are incarcerated are getting, you've got the overhead costs of the staff. Yeah. Then the operations of it.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: No, you're absolutely right, ma'am. It's no different than noting that there are, per person, it is less expensive to house a person out of state in Mississippi than it is to house them in Vermont, and yet moving folks out of the state doesn't actually save us money in Vermont in the long run because the overall costs are really built into how many correctional officers we have and how many buildings and facilities we have and how much food we bring. The food is nominally affected if we move people out of our facilities to an out of state facility, but that is a fractional component of what we're actually calculating. And so the per headcount cost does not really change at all if we have 300 people out of state or 150 people out of state. And I think it's probably useful to think about the medical costs in in a similar way. That said, the the headcount is a component of our contract, and if there are changes in that, they will be presented in the budget coming up. We only move our

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: healthiest people out of state. That too.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: That's not me. We're taking that. So it doesn't

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Depends on the Right.

[Alice M. Emmons (Chair)]: Depends on the base. I gotcha. It's just maintenance like blood pressure, cholesterol, maybe a little diabetes may be a little different. Yes. Cancer. Alzheimer's or whatever it may be. So let's put the doctor in on that sheet. You all. You. You'll be coming back a lot.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I feel so focused.

[Unknown Committee Member]: Sir, you're following this?

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Oh, thank you. Yeah, I don't want this. No, you don't want this.

[Alice M. Emmons (Chair)]: So welcome.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah, thanks. Good to be back.

[Alice M. Emmons (Chair)]: Yeah, so if you can introduce for the record.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Sure, yeah, it's Shamu Liger. I'm the medical director of WellPath at the Vermont DOC, board certified in family medicine and addiction medicine in the past Vermont for a number of years before I did this.

[Kevin Winter (Member)]: You're right.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: I'm I'm I'm happy. I just thought so first of all, commissioner, thank you for going through the many things that I that are out of my wheelhouse, and maybe I mean, I'm happy to take this whatever direction, but I was just keeping track of some of the things that I can clarify from leaving off where the commissioner stood in. I think the place to start, and we got there a little bit, was the difference between MOUD and substance use disorder treatment. And MOUD is medications for opiate use disorder. So that's really buprenorphine, methadone, and naltrexone, and that's what it is. Now, it's related to the other treatments, but the other treatments are therapy, their dialectal behavioral therapy, their cognitive behavioral therapy, their group therapy, that's all inclusive, including the medicines in substance use disorder treatment. So far, we have been offering medications and we've been offering counseling in groups, etcetera. So that's the difference. So there's substance use disorder treatment that's all inclusive, there's therapy, and then there's medications for opioid use disorder. The thing that's important to know, and this can make it clearer about what we've been asked to build here, when you talk about therapy, there are different doses of therapy. Similar to if somebody has pneumonia, there's oral medication, there's IV medication, and there's the intensive care unit. When somebody is being treated for opiate use disorder, some people, we give them a pill in an outpatient and send them home and see them again in a week. Other people are at an inpatient facility and are seen every day. So the commissioner records the ASAM levels, the American Society of Addiction Medicine levels. I meant to bring the book. I don't have it, but I can speak to it. It's a big book. There are several different levels, one, two, three, four, five, and there's 1.1, 1.2, 1.3. Right now, we really offer, before this enhanced SUD treatment, we offer really level one, and level one is where we're giving you medication and you have access to some groups of therapy. As the levels go up, it's an increase in contact hours with therapy, and they can be pretty intensive. I think it's nine to 20 for level three, which is what we're asked to build, and I should clarify here, I have expertise in medications for opiate use disorder. I can speak to some of the therapeutic things, those are my colleagues that do that. So, if we get into the weeds on therapy, while I certainly interact with it and have opinions, I can't speak to the nuance of some of that. So if it's ten to twenty hours, you have to bear with me.

[Alice M. Emmons (Chair)]: Is that per week or per month?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Per week. So it's a very intensive therapy.

[Alice M. Emmons (Chair)]: The goal is to get to level three Absolutely. With And

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: that's a big It's a big lift. It's a big lift and it's being done very quickly. I have no problem with that, that we are asked to come up with something within a month or three. If somebody approached me, this has never happened, but maybe one day somebody with plenty of money to spend would approach me and say, Hey, let's set up something to do something good in the community. I would say, Okay, what do you think, in a year, year and a half? This was three months. So, if, as I discuss it, it sounds like it's under construction, it's because it is. And Secretary Samuelson challenged us to roll something out that's a minimum viable product, was what she said, and that's what we're doing. So, if it sounds like it's under construction, it is. I agree. I am thrilled to death to have potential access to ACM level three. The reason is for exactly as commissioner and the chair were discussing and others, that it was a very big lift to convince some people that medications for opiate use disorder are a good idea. I can tell you very clearly, and whenever I am seeing a patient face to face, we'll make it hopefully apolitical, we'll, Hey, you had a heart attack. We want you to have another one. Well, I don't wanna take six medicines. Well, I think you should, but here's the most important one. Here's the next most important one. Here's the ones with data to save your life. Okay? When I'm having that conversation about buprenorphine with somebody, this is the one with lots of data to save your life. So I'm not trying to be whether people believe in it or not, people ask me, would you believe in it? Well, I don't believe in it. There's data. There's reason. That's why we use the medications. That being said, people make silly choices with their buprenorphine. They sell it. They give it away. They don't take it the right way. And that gives people, including myself, makes people cautious. In previous iterations, you would be punished if you did the wrong thing with your medicine. We take it away, we reduce the dose. That's a problem, because then the national guidelines say when somebody does the wrong thing with their medicine, now of course, if you're really doing something criminal with your medicine, that's different, but if you are undertreated or if you are making poor choices because of your disease state, the right thing to do based on national guidelines is to increase the dose of therapy and monitoring of treatment, and we have traditionally not had an increased level of surveillance to give to people, so I'm very excited about the possibility of increasing that. So the question came about, is this more or less than what we've had in the community? And I think there's some relativity to that question because the people who are in our facilities by nature have more severe disease than the people in the community. So if you're thinking about, well, are we going above what the community is able to give? I'll tell you, already for psychiatry, you have better access to psychiatric care in our facilities than you do in the community, And not that we shouldn't have access in the community, but as it should be, because that's where people really need it. We need to be able to stabilize. So I think it's a challenging question. I still think all in all, we're a little bit below what we have in the community because of some of the resources, including injectables. I mean, if we were at par with community, we'd have a lot of injectables. So we are asked to build this option for this ASAM level of three care, and we're doing it. It's not fully in place. There's this question of who gets assigned to this. I want to be careful because a lot of the pre trial stuff I'm not expert in. People come in and we treat them. There's been some efforts to communicate with the court, and I would misstep. I would totally take my foot, which I know exactly where it is. Is that clunky? Yes. There were two other things that came up that I wanted to bring up. The evaluation. So I just want to add some nuance to what the commissioner said, which was very I was very impressed with your medical your medical knowledge is better than my the correctional knowledge, but the the we don't we do an evaluation on everybody. What we're not doing right now is an ASAM level of care evaluation on everybody. So that's a little bit of a different thing, because guess what? We've only had one level of care. So while we say, Hey, are you having depression? Have you had trauma? Do you have anxiety? Do we need to give you these therapies along with the medications for your opiate use disorder? So we absolutely do that. The additional evaluation here, and the question is who gets that evaluation, and I don't have a clean answer for you right now, but I hope at one point everybody will get to have this if it's appropriate, is that ASAM level of prepare assessment. Right now, our director of reentry and recovery services is doing them because we don't have anybody to do them until Monday, and then she's training that new person. So that is the nuance. That could be available to everybody. Right now, only it's going to be available at Chittenden and Northwest. It would be really nice if that's available everywhere. And I'm going to aspirations here. I would like it to be like, Gosh, this person has been noted to be diverting their medication two or three times. They might need a higher level of care. No matter what facility they're at, that would be a very good place to be at. And I think that's a disease. I would love injectables. What are we asked to build? And it's gonna get people on board. I really do.

[Alice M. Emmons (Chair)]: So if we're on this may be more a question for the commissioner than for you. But if we're gonna initially roll this out in the Chittenden facility and the St. Albans facility, and you just alluded to there could be someone in our other facilities that really could use this, would there be movement of offenders within the facility so that that person who may be in Rutland or St. Johnsbury or Newport or Springfield could be moved up to St. Albans?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Would love us to both answer that question if that's because I get asked by your team often, or I'll ask them, I'm like, Can we move this person to be closer to the specialist? And they're very collaborative, they always say yes. I don't know how you feel about that. Because population and services, Northwestern has, I think, some of the sexual offender programming.

[Alice M. Emmons (Chair)]: Depends on the programming that they're involved in. But if they're involved in that programming, but there's someone in another facility that doesn't need that program, you're going to pull a person out of the programming to do a switch?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Well, So we're always thoughtful about that. And that's BTD.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: So then that creates challenges as far as if somebody is attending programming and if right now Northwest is the only place where a male can get this ten, I mean, ten hours a week to twenty hours a week is a lot, That's Particularly when you have to recognize that you cannot just put the person in a room for that entire period. There are head counts that have to be done. There's movement for food that has to be done. And these things are, it is a prison. You're not allowed to just sort of move at your own pace from place to place. That is going to interrupt the ability to have ten hours easily delivered in concrete discrete chunks. That said, if that is where we're doing it and there is an individual at

[Kevin Winter (Member)]: the

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: moment, let's be, we don't necessarily have the ASM level of assessment being delivered elsewhere. So I don't know that I would know that a person at Springfield needs this additional level of treatment at the moment. Is that something we would like to increase? Sure, but the individual who's being onboarded is a licensed, rostered, master's level clinician, and that's a hire, that's a big hire. I'm really impressed that WellPath and deeply pleased that WellPath was able to post for that and get that person hired and identified in such a short period of time. But that's one individual who will now be doing assessments at two different facilities, and then will ultimately be starting to deliver some of this treatment at those two facilities too. And that's only because those two facilities happen to be close enough to each other that commute is viable. It is not viable for any of the, well, maybe Northern and Northeast kind of, but not really. And so how are we gonna do that? This is all additional talk. We're not anywhere near doing that at the moment. So would we, if we identified an individual at another facility, bring that person? All things being, if we can, yes, and we'll explore it. I'm glad to hear the doctor say that the teams are really, that they are willing to do that and that they work to do that. But if the only way to do it would be to move an inmate who is in sex treatment or sex offender treatment, excuse me, at Northwest out, then I probably would not recommend that that be done. And I'm not, let me be clear, I'm not the one making these determinations. I don't even dial into these determinations. They're made by really expert people at the staff level below.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: And we do it on a case by case basis all the time.

[Alice M. Emmons (Chair)]: So that eight to ten hours per week, is that done individually or is it group?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: It can be both. And it includes a lot of things we already do. Especially for when somebody's new in the program, and that first week, they might already get four hours, you could use case management time, seeing the provider, and especially in the first week or two. So it is a big number. One of the things I was very cautious about, and thankfully everybody was responsive to that, because there was a bit of an effort, well, let's count everything we already do. I'm like, no, no, we're not just going to say, hey, this is level three based on what we do already. We have to add new services. But there is some stuff that's already happening. So it's not necessarily one on one.

[Troy Headrick (Ranking Member)]: I'll set up for you for data on knowing a year from now the efficacy of these increases.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah, that's a great thing, and it's a great question. I guess I'm What

[Troy Headrick (Ranking Member)]: will your measures be to?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah, well, that's what I'm wondering, and I would put that to

[William "Will" Greer (Member)]: what would you all want

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: the measures to be? I could think of some,

[Troy Headrick (Ranking Member)]: but I don't Diversion.

[Alice M. Emmons (Chair)]: Diversion would be the big one.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: I think diversion would be one. So much of this extends a lot of opioid use disorder treatment, including medications, is saving lives after people leave. That's a hard one. That would be mine, but how would be? Sometimes.

[Troy Headrick (Ranking Member)]: And some of it's going to be qualitative. But do you have a data team that is putting this in place? And do we know what our measures are now of how I don't know how you're measuring success right now for substance use treatment.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah, so we have CQI. We have continuous quality improvement. We have a very nice resource related to CQI. The measures are challenging because of, forgive me, it's because of Correct It's very challenging to Because why? Because correct Tech. Tech is our electronic health record. So we are continually evaluating what metrics do we follow and are they the right ones. But you're right, I don't know that we've identified one specific one. There are CQI measures for MOUD for buprenorphine. Our people continued from the community. Our people started within I forget which number of days. I can't rattle them off. I'll talk about that.

[Troy Headrick (Ranking Member)]: And then what are your hurdles right now for tech and Wi Fi?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Oh, those are thank you. Those are huge. Yeah. So in the spaces that we've identified at Chittenden and Northwest, they're not wired with WellPath Wi Fi, and so we can't do the evaluations in certain places. And it's had problems in I take it with a grain of salt because I don't know the specifics, but getting to be able to do tablet evaluations and segregation and etc, there are considerable IT barriers. What do

[Troy Headrick (Ranking Member)]: you mean by well path Wi Fi?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah. So there's a DOC, and there's a well path. There's different

[Alice M. Emmons (Chair)]: They're different because it's real

[Unknown Committee Member]: because of what you're

[Alice M. Emmons (Chair)]: HIPAA.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah. Yeah. That's the question.

[Alice M. Emmons (Chair)]: So is there any thought, we've heard this over the years with Corrections, that Corrections provides services such as substance use disorder treatment. There might be a higher likelihood that people will be sentenced to corrections to get the treatment because it's not available at the community. Has there been and and we've heard that for years, DOC is always reluctant sometimes to provide these services because they're afraid more folks will be sent

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: to collections. So I can only give an opinion. It's an informed opinion, but it's not substantially evidence based. I think that's where your sickest people go, and I think that's not a good reason not to offer treatment. That's my opinion, if somebody personally. I think we need to offer it. Buprenorphine is much more widely available in the community than it is than primary care is. We have a really nice medical community. Buprenorphine is much more easily available than it was a decade ago. So those services are available. We're not obviously going to mandate anybody to be in treatment, so just that it's available doesn't mean that it's It's to be medically necessary by law. Agreed, but even if it is medically necessary, people still can say no. So just because it's there and available, they're more likely to get it, but we're not going to So I think we would never say, Well, we're not gonna give insulin to a diabetic in the intensive care unit because they shouldn't be, because then they can get it for free there or something. And that's how I think. If the answer is different, that's fair. That's my point.

[Kevin Winter (Member)]: If I understand all the great information you've given us, we're currently providing ASM one level to most of us all. There is opportunity for ASM level two, but the person has to be incarcerated longer period of time. Otherwise, you can't even offer it to them. No, it's all level one. Okay, it's all level one. So that's fine. But there's actually up to level three that's been defined someplace or you're trying to

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Trying to build level three at Chittenden and Northwest.

[Kevin Winter (Member)]: Okay, so, and once again, this is layman's terms. For the level one, you assess the needs of the person. If there's an immediate obvious, you try to provide that for relief and recovery.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: It's based on that. Oh, I'm sorry, please.

[Kevin Winter (Member)]: Well, and you'd correct me, but I'm just trying. Level two might start getting involved with therapy and group discussions about why you're finding yourself here. Level three, you might get psychiatrists and psychologists and all these other specialists involved. I mean, the level of care is going up depending on the level. I I guess I I'm wondering if and I'm this is crazy but maybe level four would be you're you're going in they physically don't need drugs but they're psychologically broken and they need to be helped and then level five could be, you get through all of those and then you're helping them have a skill, some place to go to live, maybe a job, maybe insurance. My my point is is that this elaborate process to help people actually get out of the bad situation they're starting in would be loveless. It's high in the sky right now. But I would see that that's what we would eventually love to be able to do because there's more opportunity to get better when you're incarcerated because you're not distracted by everything else. And if we were providing the right health so that they don't just go out and fall right back in the same hole again, Yes. That would be wonderful.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: You're bringing up several points, which are good. So the stratification level one, two, three, four, five, obviously there is one. It's a little different than what you outlined because all of the things that you outlined are actually available in level one. You can see a psychiatrist, you can get therapy, we help you get a job after, or I don't know, that's not ours, but we do some skills coaching, things like that. That's all level one. Really, the change in level two, three, four, five is around the dose, like how much time you're spending every week.

[Kevin Winter (Member)]: And

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: then there's aspects of it being residential. We're already residential. And to your point, are some things that make recovery in prison easier because you're fed, you're housed, and etcetera. There are some things that make it harder too, because you don't have some of your supports, But we have this very flat system right now where it's hard to escalate. I don't have anything to escalate to, and I would love to say, Gosh, that person's really sick. Can we please, instead of letting them just fail at level one, can we please have level three? That's what I'm excited about.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: If I may clarify, the dose is not a medical dose necessarily It's of a dose of therapy an hour at and a all the effort that goes in in the clinic I are appreciate that clarification.

[Kevin Winter (Member)]: And you would love to do something, but is it because you don't have the time or the resources to develop the proposal? Or is it It was

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: very resource intensive, so it's personnel in space.

[Alice M. Emmons (Chair)]: No, no, I appreciate that. That's my concern, too.

[Kevin Winter (Member)]: So is your development, I don't mean to be crass, a sales pitch to the state of Vermont, or is the state of Vermont paying you to develop this next level care?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Well, and for clarity, and I don't So we were asked to develop this by the government, happy to. And I've said this in this committee before, I'm not the dollars and cents guy, but I did say, We can't do this if it's not resourced. I'm not going to pretend we're doing this because I didn't want to set up for failure.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Right. WellPath did not upsell us. We asked a lot of them.

[Kevin Winter (Member)]: No, no. I'm not suggesting we did anything wrong or right. Just, as a sales guy, I know that some proposals are paid for. Fair.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah.

[Kevin Winter (Member)]: Okay? And some proposals are generated because you want to gain more business. That's either way is fine. Just, I would love to see us get through levels one, two, three, four, five, X, Y, and actually have people fixed.

[Alice M. Emmons (Chair)]: And I know that's not the right word, but helped. It'd be interesting to see what's in the governor's proposal for the DOC budget. It's where the rubber hits the road. And we got two weeks to go.

[Kevin Winter (Member)]: Yep. Long two weeks.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: And I'm sorry, don't mean to but that's as a medical provider, I'm prepared to die on a hill about not promising something that we can't deliver to our patients.

[Kevin Winter (Member)]: Thank you. Sorry.

[Troy Headrick (Ranking Member)]: You said something in that exchange that just flagged something for me. So I'm going to develop my question here as I go along. Thinking and talking is not always my best approach. We're so used to it, Troy. So you were talking about some of the things that make it easier to do treatment in our facilities, housing, food. Mentioned one thing that makes it more difficult, disconnection from circles of support. And we've tried to improve that. I think the Kids Apart program is a small little way in which we make sure the people that we house are connected to the people that are important to them. Here it comes, people. Talk to me a little bit about access to telecommunications, access to means of communication to those services of support. Because one of the things we're discussing is the privatization of telecommunications in our facilities and the limits that that creates for people if they want to connect with people on the outside. How does that intersect

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: with this world? Yeah, and so that be a security and housing question more than a medical one.

[Troy Headrick (Ranking Member)]: I'm curious to your medical thoughts on that. Does this treatment work better if they have more and easier access to the people that care about them? Depends who it is.

[Kevin Winter (Member)]: So

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: if you imagine in our women's facility, and forgive me, I'm going to be very generalized, but a lot of the people that profess to care about them have treated me Yes, very I agree. So some of that access would be bad news. It shouldn't be. If they had access to their grandmother who's been their stable support in their life, and that's the person, so from a clinical standpoint, that would be nice.

[Kevin Winter (Member)]: Yeah. Sure.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: I wanted to come back to something just briefly, is that you also mentioned one of my big concerns, which is housing and other supports after corrections. And I'm concerned and I'm not I'm gonna be neutral on the governor's proposals. Our job is to but one of my concerns in looking at the big thing is I'm wondering where's the post incarceration support if we get somebody better. So just, again, that's a professional, not a political opinion, but I'm just worried about that.

[Kevin Winter (Member)]: So are we.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: So are

[Alice M. Emmons (Chair)]: we. There's two things I'm concerned about. One was just what we just talked about with preemption. But are we able to have enough space in our two facilities to provide this enhanced programming?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: We've talked about that. We went to Northwest. So I don't know. Think a concern that I heard yesterday that was voiced, to fill my concern out a little bit, was that both Chittenden and Northwest, the commissioner's team has been very like, Hey, well, what do we need? How are we going to make this happen? There was an idea in early October that we would pretty quickly have 20 or 30 people in this program right away. We don't, and that's okay. We're building it. If space is sitting vacant for a little bit while the program ramps up, it's going to get eaten, and I don't know what this committee can do about that. But so yes, space is a concern. People have identified it. I don't know what the future of that is. Space is a big concern.

[Alice M. Emmons (Chair)]: Well, not just Chittenden and St. August, but it eventually expands to the other facilities.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Everywhere. To give you an example, at Northwestern, our current MOUD case manager at Northwestern does not have a place to do private assessments. He's using whosever office might not be in that day, and then sometimes he's meeting in Sally Ports. He doesn't have a place to sit and do a private assessment. And that's a facility that we're expecting to do this. And that's anybody's fault, it's just the space. It's the space we have. So

[Alice M. Emmons (Chair)]: on the reentry piece, I know we have in law that WILTPASS, particularly, I'm just gonna focus in on the MOUD. And now if you expand that substitutes treatment, if you expand that, currently by law, you're required to give them enough dosage of buprenorphine or whatever to hold them over until they can hook in with a hub. That could be two days, that could be five days. And it's also up to WellPath to help make that appointment. So my question is twofold. How is that working? Is it working? And then if we have this extra this other level, how can we ensure we need to update statute to include this? And what do you foresee WellPath having to hook in with a hub, I would assume, to make sure that the person continues with that level of treatment.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Sometimes it's a hub and sometimes it's a support. For this particular level of treatment, it's not necessarily an indefinite treatment. It could be a four week or three month treatment, and it is true that we think some toddlers will give us, and this is all getting to your question. Because, for example, if you start to unpack the abuse you'd had as a young person, and then midway through that therapy before you can put it all together again, you're released, that's bad news, right? So we don't want do that. So the modeling is that this would be a program you would complete, whether it would be, you know, four weeks or twelve weeks, and that would my colleagues would know better exactly. My concern, the biggest thing and I actually don't have the answer for how it has affected, my biggest concern right now about post release access to medication is the exodus of Better Life Partners from Vermont. And so Better Life Partners is one of our community buprenorphine providers.

[Alice M. Emmons (Chair)]: Where are they located?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: All over the state.

[Alice M. Emmons (Chair)]: All over?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah, I don't know exactly there. They have some local staff and they use some telehealth providers to provide. It's a pretty low barrier system, which is good and bad, but they're leaving Vermont. And it has been much easier to get somebody an appointment up till now with a buprenorphine provider than it has a primary care provider. And that is likely going to change over the next I can't remember when they were leaving Vermont. It was sometime I think they're continuing their current patients through February. Bless her mind. It's like I have a concern about the community access. Is there a statute we need that would help us? I so since you asked, it would be nice. The risk, there's some risk to sending somebody out with a lot of buprenorphine if it's gonna take them some time, and I keep that very there's some risk to not sending them out because that's and I've reviewed this before. Your risk of dying from overdose in the first week after incarceration is something like twenty eight times that of somebody else, so it's very, very high. I have a hard time convincing my providers. Once we had somebody who couldn't get something for, I think it was seventeen days, and they wouldn't write for seventeen days. I wrote for seventeen days. But if our providers had some protection Who wouldn't write? One of my advanced practice providers at the site. So when you

[Troy Headrick (Ranking Member)]: say you wrote, what does that mean?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: So I did the order. Okay. Because they weren't willing to take on the risk, and And I I'm not trying to be The reason I was is because the risk to me is higher if they didn't have it. Right. And so if there was some, I don't even know what that would look like, but some statutory protection, and I think the state has done this, one of the things that comes to mind is there is a decriminalization of having a certain amount of bup on hand that wasn't yours, if it was a certain number of doses, that made it a little bit easier for people that opened. So if my providers had a little protection for like, look, you're not It's more important for you to treat people and close that gap than it is because we can't determine what they do with Rebuke. I don't want my providers to be irresponsible. I'm not saying, here's three months of your Rebuke. Good luck. Like, that's not what we're doing. But they start to get squeamish when it's more than

[Alice M. Emmons (Chair)]: So could you clarify what you mean by my providers? Is that

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Oh, I'm sorry. Yeah. So as the medical director, I supervise about 10 advanced practice providers that do most of the care. We have a couple part time physicians.

[Alice M. Emmons (Chair)]: You have private providers in the community?

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Nope. These are our providers, well, half providers at our facilities. So this is when somebody's going out the door, we give them medicine, we give them, and I've had people concerned about Giving them medicine. Well, not five days, not seven days. This one seventeen days, or eighteen, I can't remember what

[Troy Headrick (Ranking Member)]: the Yeah,

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: it's about two weeks.

[Kevin Winter (Member)]: Why is the distributor, I don't remember the names, leaving Vermont or shutting down-

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: Better Life Partners? I don't know.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Mean, I have some Better Life Partners, as kind of a low barrier provider, there's some scrutiny that maybe you have too low of a barrier. Are you giving to anybody? And I'm not making an accusation. I don't know that they've had lower barriers than others. I don't know. It could just

[William "Will" Greer (Member)]: be a financial viability thing. I really don't know. So we're looking for a shield law of some sort?

[Troy Headrick (Ranking Member)]: I don't know what that means, but where Protecting these providers from liability if they dose appropriate levels of

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: If, yes, somebody can't get an appointment for twenty one days, that's the best we could do. We bend over backwards, and we do. Our staff detained and left from court. Let's get them an appointment. Oh my gosh, how do we figure out how to do this? They need twenty one days. We give them twenty one days. They sell it to their neighbor who's also on Xanax and dies. And then it's our fault. But we're putting people's lives at risk by not bridging.

[Kevin Winter (Member)]: I have a question. What percentage of doctors are getting rich because they're over prescribing? I know that's a ridiculous question, but it's hard for me to believe that doctors would do that. So I would think it would be very low, and I don't know how they could get away with it, with how much focus there is on it.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: I trained in the opioid crisis during the OxyContin days, so when I was in training. Nobody that I knew wanted to get rich being a pill factory. Nobody. Everybody, it was the challenge. It was how do we help people be healthy? So, maybe there are people doing that with buprenorphine, I don't know who they are, but this is something you get lots of scrutiny, either perceived risk to your medical license, and sometimes I felt almost criminalized or scrutinized, less so in Vermont than in other places, but I'm like really for trying to save someone's life. My

[Kevin Winter (Member)]: brother, who's a retired doctor, said that one of the biggest problems is through medical school they were trained that pain is bad and you do whatever you have to do to eliminate pain and he now on the flip side is saying, no, that was a wrong approach that some pain is necessary and better off for the patients because in fact, they avoid many other problems downstream. So, the training was actually at fault rather than trying to get rich. We were just saying, Well, where are you? Level one through 10? Well, I'm at eight, so here's too much.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: So we had conversations and training. This was 2006. I sat in a room where an anesthesiologist said that there's no reason for anybody to be in pain ever, and I thought that is just not true. I wish it were with all my heart, but it's not true. And then we had to do this pain score. And then, so I remember sitting in residency worried like, okay, if we don't treat this person's pain, we're gonna get sued. If we do treat it, they're gonna overdose and we're gonna sued. I almost left primary care over this. And this is twenty years ago. It's part of the reason I'm in addiction, because I just didn't think that So we're in a very different place.

[Alice M. Emmons (Chair)]: There's a lot to process here. A lot to think about.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: I

[Alice M. Emmons (Chair)]: really applaud what you're doing. I applaud what the department is doing. I think it's going in the right direction. I know there's gonna be an increase in your budget in order to do this. Don't do this without money. And that's what we have to balance out as legislators. We're on a tight budget. People wanna cut costs. People wanna shift money to a program. So it's gonna be a balancing act. I also understand the space constrictions. There's a couple of things going through my mind right now. One thing before I forget this is the Wi Fi connection. I want an update from DOC, Agency of Digital Services, whatever it's called. ADS.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: ADS and BGS would all be a part of that.

[Alice M. Emmons (Chair)]: So the three of you, DOC, BGS and ADS.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: I can get I don't want

[William "Will" Greer (Member)]: to volunteer them to be

[Kevin Winter (Member)]: you may call anyone you wish me. I

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: but I'm happy to get that information.

[Alice M. Emmons (Chair)]: No. I'd like the three entities to testify before us to figure out where we are because it was we did some legislation last year to really help DOC to access some dollars to start providing WiFi within our correctional facility. So that's one thing.

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: They got money last year, right?

[Alice M. Emmons (Chair)]: Yeah. Well, it hasn't been expended and put in because we're hearing that Wi Fi is still an issue. So I wanna schedule some time to talk about that. The other piece is the whole what you're extending out from MOUD to the level three for substance use treatment as a whole. And I think we really need to look at statute for that. We do have the bill age 32. We had the final draft was 4.1. I would like to work with our legislative council person to listen to this testimony, to look at current law that we have and the proposed changes in our last draft, because I think we're gonna have to revisit this and really look at it to make sure the law complies with what the practice is proposed to be.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: Yeah.

[Alice M. Emmons (Chair)]: That's where I'm coming from. I hope the committee agrees with this. We can't have something in statute that is not reflective of what the practice is and vice versa. And I do support the expansion of this. I think it's really helpful, but there's gonna be some real limitations. I'm worried about the increased population that's coming in in DOC, that's gonna put more pressure on this expanded program. Also, there is a report due to us, will be coming in in February. If you folks remember, there was 200,000 appropriations bill for DOC to look at converting the old work camp up at the St. John's Berry facility into a treatment facility. And how that would play into this. So we've got some moving pieces here. And if we do expand, it's out of our bailiwick, it will be more in the judiciary committee and appropriations committees. But we'll be part of it, I'm sure, at some point. The expansion of this pilot project of the accountability court or the three b court into other counties, that's gonna be an expense to our general fund. That is not gonna be done without some infusion of dollars. We took a judge out of retirement to do this. Now, yes, these dockets are in the court system as they are. Maybe it's just a simple thing as reorganizing the court schedules. Or maybe it isn't. State's attorney had a dedicated state's attorney that they pulled from Washington County. They can't do that for all the counties. And the Defender General has not come in and testified, but will. The Defender General right now doesn't even have enough staff to legally represent folks and having a hard time hiring folks. So there's a lot of pressures out there that will have to be addressed to expand this. And you expand it, it's going to put pressure on DOC one way or another. So I just wanna voice that because it's gonna cost resources. It's gonna take resources. Can't provide the buildings are there, but the building doesn't provide the service. It's people within the building that provide the services. But I commend the

[John Murad (Interim Commissioner, Vermont Department of Corrections)]: department for

[Alice M. Emmons (Chair)]: doing this. But we also make have to make sure that we fund what needs to be funded, and then we update the law to make sure that it's reflective of what's really happening? And that would be something I would hope the committee would be willing to work on.

[Kevin Winter (Member)]: 32. Right?

[Alice M. Emmons (Chair)]: Mhmm. 32 is the vehicle. And maybe we start from scratch again. We gotta find out what the current law states and how we do it. Because the current law doesn't allow you to even treat detainees. And that was one piece we're trying to correct last year.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: We need to stop. Let us know. But we don't even know who they are.

[Troy Headrick (Ranking Member)]: We didn't say

[Alice M. Emmons (Chair)]: That's it. I mean, you don't go into those levels. You don't go into those levels. Are they sentenced? Are they detainees? Did they go through this accountability court? You don't know who went through the accountability court, right? You don't have a clue. So those 10 folks who are currently incarcerated from the three B court, you have no idea, right, who they are.

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: As far as I know, that has been a topic of discussion of how the communication would happen between the court. That's been a topic of much discussion, if the mechanism has been worked out or not aware.

[Alice M. Emmons (Chair)]: Those are layers that we're going to have to get into. Does that make sense to the committee?

[Troy Headrick (Ranking Member)]: Yes, ma'am. This is just

[Unknown Committee Member]: a question about future testimony. I don't know when or even if it would be appropriate. But to hear more about the parts of the practice that you can't speak to well, you talked about colleagues who are actually doing the therapy. But also, this program is being built. And I know the budget is being built. When do we who

[Lisa (Director of Communications, Vermont DOC)]: do We

[Alice M. Emmons (Chair)]: have to wait almost to hear the governor's budget to see what's included, because they can't share too much.

[Unknown Committee Member]: Well, so the money, no. But in terms of what is going on or would go on or we want to go on, the way for those yeah, Okay.

[Alice M. Emmons (Chair)]: But it's tied into what the governor's proposed budget.

[Unknown Committee Member]: Yeah, fair enough. But Emmons, you would be able to recommend someone to speak to us about that.

[Alice M. Emmons (Chair)]: I mean, that works. That's fine. I just don't wanna put you in a position of having to speak before

[Unknown Committee Member]: Oh, maybe that's fine. I just wanna hear

[Dr. Shamu Liger (Medical Director, WellPath – Vermont DOC)]: that support too. Yeah. Yep.

[Alice M. Emmons (Chair)]: I think it's also important to have Tony Allen in as well for all these conversations. He's with the Department of Health and he's the opioid person there. We work very closely with him when established the initial law of MAT within our correctional facilities. Think it would be important to have him in the room as well whenever we discuss this. And he's a great resource. Tommy's a great resource for that. So I'm going to reach out to Katie McLennan. Katie was our legal person that did the initial draft. I'm going to encourage her to look at the video of this, YouTube, and maybe we can start somewhere on 32, age 32, and see how we can start addressing what's going on. Anything else? That's all, yeah. Are we finished?

[Kevin Winter (Member)]: It's lovely.

[Alice M. Emmons (Chair)]: Thank you.