Vermont Legislature SmartTranscripts:

[Speaker 0]: Welcome everybody, it's House Healthcare February 18. When we did sort of our priorities for the rest

[Speaker 1]: the the rest of of our time until

[Speaker 0]: crossover, we had identified H573.

[Speaker 1]: And so we're doing a first walk through of

[Speaker 0]: it, hearing a little bit of testimony on it this morning.

[Speaker 2]: So

[Speaker 0]: thanks Katie for being with us.

[Speaker 1]: Yeah, you're welcome. Good morning. Katie McLean, Office of Legislative Counsel. Before we look at the language of the bill, it's fairly short bill, and I think we can explain it hopefully relatively quickly. But I was realizing that this might be the first time this year that this committee has thought about involuntary commitment. So I thought maybe we could just take a brief step back and I could give a very, very high level overview so that I can sort of focus you in on where the change is happening within a larger system. So we can get a level set of how

[Speaker 0]: it happens today so we know what we're changing. I think that's a fantastic. So

[Speaker 1]: I have some slides that I've sort of repurposed for this morning to talk a little bit about involuntary commitment. Involuntary commitment is a longer process by which somebody who is identified as meeting the statutory level of needing care in a hospital level setting would end up at a hospital. There is a court process involved. But before any of the other court processes happen to commit a person to a hospital, there's a process by which a person is identified as needing that type of assistance and brought in for an evaluation. And so that is sort of where we're looking at today. So I won't go into the back end of the process, but here's a slide just to show you that there are lots of ways that somebody who is having a serious mental health crisis in need of hospital level care might get into a hospital. They may voluntarily go there. The forensic examination is for people who are criminally justice involved. The piece we're going to be talking about today is this sort of purpley box, an application and certificate for emergency exam. So that's one way that a person would be evaluated for hospital level care. And then there's a second sort of, I think of them as sister processes. And that is the other box at the top, the warrant. And that is if a physician isn't available to do the affidavitation process in the purple box. So those are the ways that somebody could end up in the hospital. Okay, so first we have this application and certificate for emergency exam. This is really the focus of the bill you're gonna be looking at today. So there is an application and a certificate. And those two items are the authority to transport a person and to admit a person to a hospital to conduct an emergency exam to determine if they are somebody who meets the statutory definition of a person in need of treatment. And that means, for all intents and purposes, that they're a danger to themselves or others. And so there is an application by an interested party and then a certificate by a physician who is not also the applicant. And we'll look at language. Initially, the language says it should be a psychiatrist, but if there's not a psychiatrist, then a physician. And then we have language that APRNs can conduct the same type of evaluations that a physician can do. So what this really means is that the certificates are being conducted either by physicians or APRNs right now. This application certificate must state the facts and circumstances constituting the need for an emergency exam. And the person is held for admission at a hospital for an emergency exam, again, to determine if that person is a person in need of treatment. That's a statutory term. So we'll be looking at that today. Sort of the sister process, the way I think of it, if there isn't that medical provider, the physician or the APRN available to do the certificate, then there's a process by which a judge can issue a warrant to bring the person in for an exam in lieu of that medical professional. And in this situation, there would be personal observation by a law enforcement officer or mental health professional that the person's conduct constitutes reasonable grounds to believe the person is in need of treatment. The person presents immediate risk of serious injury to self or others if not restrained. And so then the application for warrant would require an emergency circumstance. The physician's certificate is unavailable without serious and unreasonable delay. So the court weighs in and says, yes, the person could be brought in for further examination. This is my last slide. This is meant to step back and show the big picture of how what we're talking about today fits into the overall process of committing somebody to a hospital for involuntary treatment. So if you start way over at the left, this is the authority to hold a person for admission at a hospital for an emergency exam. So this is what we're talking about today, this first dot all the way to the left. And more specifically, we're talking about one of two options, and that is the application and a certificate by a physician or an APRN. The second avenue is the warrant. And then if the person is brought in, then they have another exam. That's the second dot. And that exam is conducted by a psychiatrist as soon as practicable, but no later than 24 after first initial certification, the first dot. And if the psychiatrist doesn't think that the person is a person in need of treatment, the person is no longer held. If the psychiatrist does think the person is a person in need of treatment, they're held for seventy two hours. And within that seventy two hour window, the person either accepts voluntary admission or there is a petition before a court that's filed by, I think usually DMH, to hold the person involuntarily for a period of time for treatment. So that is sort of the big picture of how somebody is held involuntarily. But what we're again talking about today is this first dot all the way to the left, application and certificate. So

[Speaker 0]: if I'm clear, essentially, you have to have an application to then start the process of certification from a psychiatrist? Yes.

[Speaker 1]: So there are two options for getting somebody the second, they call it the second cert, the second emergency exam. So the first option is what we're talking about today. An application, somebody sees behavior that they think might rise to the level of needing file an application. Along with that application is this certificate. The certificate right now is by a physician or an APRN. So that's what we're talking about today. Alternatively, there's the warrant process if the physician and APRN aren't available quickly. Did that answer? Yes. Okay.

[Speaker 0]: But we're not talking about the

[Speaker 2]: warrant part. Okay.

[Speaker 3]: And the application and the certificate and number one on the first dot are done by two different people or can be done by two.

[Speaker 1]: Yeah, the person who's doing the certificate can't also be the person who's filing the application. And those two documents together are the authority necessary to transport the person to hospital where they can go to the second dot, the second emergency exam, the second cert.

[Speaker 4]: So what are we doing now?

[Speaker 1]: Yep. Can you see my mouse? Yeah. So we're gonna be looking at a bill that's just dealing with this number one. K. So where's the mouse? Right here. Okay.

[Speaker 4]: But right now, what is the scenario?

[Speaker 1]: Oh, I'm sorry. So right now, the bill that we're gonna be looking at is going to expand who can do the certification. So right now, physician, APRN. Right. And the bill expands. Mhmm. We'll look at the language. Okay. But other professionals who can do that.

[Speaker 4]: With certifications and trainings and all that?

[Speaker 1]: Well, they're licensed professionals. Okay. So I'm going to take this down and switch documents, if that works.

[Speaker 0]: Thanks for the overview reminder. Okay.

[Speaker 1]: And here's the bill itself. Okay. So we have this language in title 18 about certification of mental illness. So a certification of mental illness by a licensed physician required by section 7,504, that's the section that requires certification, shall be made by a board eligible psychiatrist, a board certified psychiatrist, or a resident in psychiatry under penalty of perjury. In areas of the state where a board eligible psychiatrist, board certified psychiatrist or residents in psychiatry are not available to complete admission certifications to the state hospital or its successor in interest right now, level one beds throughout the state. The commissioner may designate other, right now it says licensed physicians, which we know also includes APRNs in terms of authority. And the proposal is to change that to health care professionals. So it would be other health care professionals as appropriate to complete the certificate. And then in the middle of page two, define, well, what do we mean when we say health care professional? So as proposed and this bill is introduced, it means a physician, an APRN, those two are already allowed to do it, a physician assistant, a master's social worker, a clinical mental health counselor with a master's degree or greater, or a marriage and family therapist. So those would be the new professions that could conduct that certification. I

[Speaker 0]: remember somewhere along the line where it said which had specific training in psychiatry.

[Speaker 1]: That was from nurses. Because I'm thinking about a family therapist

[Speaker 0]: who may or may not have specific training in this realm. Wasn't there somewhere along the line that we talked about specific training in the knowledge space of this? I was just looking at

[Speaker 1]: the mental health and AI bills that you have on your wall last night, and I think there might be language in one of those bills that talks about with regard to nurses having specialty or specialty practice in psychiatry, but it definitely doesn't say that for every profession listed.

[Speaker 0]: It's a worry for me.

[Speaker 3]: I'm going give a spoiler alert

[Speaker 0]: to save us all time.

[Speaker 3]: There is going to be a recommendation, I think, by several stakeholders that we pare this down so it's just the existing APRN and physician, and we are only adding the physician assistant. So that's going to be my recommended starting point for discussions.

[Speaker 0]: So let's hear testimony on the others and then maybe the question might not even apply. Oh, Brian, go ahead.

[Speaker 4]: Is there I can't scroll ahead right now, but I'm wondering, is there more to the bill or is that the real,

[Speaker 0]: meat There's of the more.

[Speaker 4]: Okay, I'll wait.

[Speaker 1]: There's another section. This is the language specifically about the application and the certificate that we've been talking about. Here it says, written application of an interested party made under pains and penalties of perjury and accompanied by a certificate by a licensed physician. And the proposal to be in conformance with section one that we just looked at is to strike licensed physician and say a healthcare professional as defined up above in seventy one point one zero, so as defined here, or cross referencing, who is not the applicant, a person shall be held for admission to a hospital for an emergency exam to determine if the person is a person in need of treatment. So we're just making those two sections track with each other. And then there's this language about how the head of the hospital could admit the patient. And then we have a sentence that says that a designated person must be an official hospital administrator, supervisory personnel or licensed physician on duty on the hospital premises other than the certifying healthcare professional rather than physicians. So it's just trying to continue to have conformance with the change being made in Section one. And this would take effect July '26.

[Speaker 0]: Brian, did you have a question?

[Speaker 4]: Yes. Yeah, I have a question now. I'm curious why we need to add providers to this process. And if we don't know right now, witnesses can answer it, but that is a question I have. I can speak to that, please.

[Speaker 0]: Although I'm sure we'll have witnesses.

[Speaker 3]: Yeah, we'll have witnesses.

[Speaker 0]: I don't know if everybody recalls also when we had the nurses in here last week. They were indicating strong support for this. And they are advanced practice nurse practitioners who already are able to do this and they were advocating for extending it to physician assistants. Anyways, we'll hear testimony. Any questions for Katie on the language or the process as it is now? Okay. Thank you. Thank you

[Speaker 3]: for making it so simple. This is not, in actuality, a simple process. You made it really easy to notice.

[Speaker 0]: All right. So let's turn to Kelly Klein. Kelly on Zoom. Trick is here if you want to do her first. Oh! Okay, let's do Trick.

[Speaker 5]: Thank you.

[Speaker 0]: We're looking for testimony on Did you just hear on the bill that

[Speaker 5]: I did. Yes. I have read over the bill. In looking at the additional personnel who would be able to provide the first cert, I have no issues with including a physician assistant. I think that makes sense. I will say that the additional mental health personnel give me concerns simply because they're not medical personnel. And I'm going to speak from my experience. I want to be really clear. I'm representing one VA. And here, our crisis clinicians are generally the ones who do the application for emergency examination. So, those are the traditionally those are the folks who provide that application. And the first certifications are done by our ER personnel. And my understanding of the first certification when we have one completed, it is by the medical personnel who have medically cleared that individual. They have done all the tests, done all of their observations to really rule out any medical condition that could be causing the concerning behaviors. And a doctor can do that, a nurse practitioner can do that, a PA can do that. That makes sense to me. Basically, that first certification is them saying that they agree with that clinician, this is not due to a medical condition, this is due to their mental health condition. And I would have concerns about non medical personnel doing that. And again, I'm one I'm one DA. We have a very good relationship with our emergency room. We are the only mental health that goes into our emergency room. So there are times I know you referenced the second certificate that's done by a psychiatrist. We have at times if we're not able to move someone to a hospital within that twenty four hours, our medical director does the second certification. And so that is him or her agreeing with the medical physician and the crisis clinician. And so for us, that works. And like I said, it makes sense to me that a physician's assistant could certainly do that. But someone without that medical, I think it's, I would have a hard time saying how would that person be able to say this is a new medical condition. I think it's important that that is said by a medical person. That's just in my experience. That's how we translate that first certification. That's always done by somebody with a medical background. Does that make sense? Is there anything

[Speaker 0]: That's else to incredibly helpful. Okay. Wondering if in your experience you would think that by expanding it to another medical professional who staffs emergency departments, physician assistants, providers, and if by adding this designation of another licensed professional that it might actually speed up the process a little bit so that the person would be able to go through this process in a more expeditious fashion and determination could be made quicker?

[Speaker 5]: I think it's going to open up more individuals to be able to provide that service. So I just think naturally it would occur at a faster rate. We have mainly nurse practitioners and docs in our EO. There are some physicians assistants. So it would increase our capacity in that regard. Speaking of other DAs, I know like HCRS, they are serving five different hospitals, five different emergency rooms. I can't imagine how big a difference it could make for them. You know, I'm sure it would be speeding up their process. Because we have just the one ER, I can only speak to that experience. I'm sure our emergency room would very much appreciate that ability to use more of their staff to provide that support. A, it makes it faster for them, it makes it faster for us, because there are times we do have to, and I'm talking hours, not days, You know, where a physician is a very busy night, we may have completed the application for emergency evaluation maybe 7PM, but the doc is not able to do the first certification till some, you know, maybe midnight or one in the morning because it's been so busy in the ER. They just didn't get a chance to do it yet. So I think having additional staff in that regard will speed up that process. It for us, it would be a matter of within those hours. I think for other places it could be helped more significantly. Like I said, for us, we don't run into that challenge too much. Our docs, we have a really good working relationship with our ER, so we have it down to a pretty good practice. But I have no doubt they would appreciate the ability of PAs to also be able to provide that.

[Speaker 0]: Yeah. Any questions? Richard? Sockers, go ahead. The

[Speaker 2]: last paragraph.

[Speaker 5]: Pardon me, I didn't quite hear that.

[Speaker 2]: I just said the last paragraph. See, we are talking about a supervisor. How do you feel about that last paragraph as a whole?

[Speaker 5]: I apologize, let me, if you'll forgive me, I need to just pull up the bill so I have it in front of me.

[Speaker 0]: Existing. Yeah. This is existing. Is that all right?

[Speaker 2]: I don't have a question.

[Speaker 0]: The whole paragraph. You don't agree with the whole paragraph? Did we legislate counsel?

[Speaker 2]: Everybody else is alright.

[Speaker 0]: Other questions for Trish? This has been really helpful, very helpful. Thank you so much.

[Speaker 5]: Your Have a good morning all. Thank you very much. Katie,

[Speaker 0]: do you the last paragraph, do you think you could just sort of provide some clarification on where in the process that you laid out for us? I think you're right at the beginning of the meeting's testimony, where she laid out how the process currently works. Do you want me to explain that again?

[Speaker 2]: I don't want to take up time, but maybe

[Speaker 0]: Well, I think it's important that you and I and everybody, because it's a really confusing process.

[Speaker 2]: Let's do that.

[Speaker 0]: Judith? Sure.

[Speaker 1]: This is paragraph that's existing law. The only change is making a conforming change with the other change that's being made in the bill. And this language is about sort of the head of the hospital ultimately having admittance and discharge authority. And it says that the physician, the certified physician on the application can't be the same person who is making the admission decisions. And so the change is to strike physician and say, healthcare professionals, to open it up to whatever healthcare professionals this committee decides that wants to have that certifying authority.

[Speaker 0]: So this is after the process of certification has happened, the second dot on your thing, that there needs to be a physician at the hospital where the treatment is going to be, they have to also certify that they have to approve the admission, correct?

[Speaker 1]: It's not really a dot on the It's sort of just the fact that there is somebody in charge of the hospital and in charge of admission and, what am looking for? And allowing folks to leave the hospital. So this is just saying that it can't be the same person who is in charge of that admission decision who is doing the certification. Got it.

[Speaker 0]: So could

[Speaker 2]: a supervisor of nursing, a nursing supervisor be a person who could do this? Because it's just supervisory personnel.

[Speaker 1]: I think you have to talk to a hospital.

[Speaker 0]: The hospital just walked in the room.

[Speaker 4]: We'll give you some time.

[Speaker 0]: Okay, let's Liz Coochow can probably answer that. Liz is going to speak to us about how this operates. Alright, now I think we'll pivot to Kelly. She's walking up.

[Speaker 1]: Single point of entry, right?

[Speaker 0]: So she'll be here. Oh, okay. So we're just now waiting. How about we take a ten minute break? Perfect.