Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, thanks. Welcome back everybody. Have Kelly Klein in with DMH. Thank you. So thanks for coming in. You're welcome. Not a problem. Just wanted to know if you'd like the thoughts on the Department of Mental Health, on this bill, whether this is needed,

[Kelly Klein, Department of Mental Health]: if it would work in practice. So the first thing I want to address, which is a more clerical issue, I think, is that when we were reading this, what is stated as 7,110 as requiring a board certified board eligible psychiatrist or a resident in psychiatry really refers to 7,508, which is the second certification process. So just to really clarify that point, that 7,504 is the first certification, which requires right now, it says a physician or designee, not a board certified or board eligible psychiatrist. In practice, that is what we follow as well, which is the second certification is required to be done by a board certified or board eligible psychiatrist or a resident in psychiatry versus the first certification can be done by a physician or a designee, which for the twenty sixth VSA can be an APRN as well at this time.

[Alyssa Black (Chair)]: Are you

[Kelly Klein, Department of Mental Health]: suggesting we need to change 7,110? Something needs to be edited. Okay. Yes. To make sure that it is aligning because the bill proposed is for first certification, but that language specifically about the board certified, you know what I'm saying? Okay. Thank you. That specific part is for second certification. Is

[Alyssa Black (Chair)]: it? There a

[Kelly Klein, Department of Mental Health]: line? Yeah, page one.

[Alyssa Black (Chair)]: It's right. Thirteen, fourteen. Thank you. We'll get clarification from the

[Kelly Klein, Department of Mental Health]: And so right now we do have the capability for nurse practitioners, APRNs, to complete the first certifications. They still have to go through the designation process with the Department of Mental Health. I think addition to this would be if a physician's assistant could also do that process, which we are not directly opposed to. However, the part of statute that allows APRNs, the nurse practitioners to do this is the 26 VSA, which says that they can sign anything that a physician can sign. And that's where physician assistants have not fallen under that in the past.

[Alyssa Black (Chair)]: So that's on the next page. I think I'm a little confused. Is everybody else?

[Kelly Klein, Department of Mental Health]: I've been to.

[Alyssa Black (Chair)]: Right now you're not following statute then.

[Kelly Klein, Department of Mental Health]: Yes, we are. We go under the 26 VSA, which allows APRNs too. We do not allow physician assistants to sign it because they are not encompassed in that 26 VSA, as statute reads right now.

[Alyssa Black (Chair)]: Okay, but so Oh, I'm sorry, go ahead. You're saying right now it reads that a board eligible psychiatrist has to complete the first certification.

[Kelly Klein, Department of Mental Health]: It doesn't read that. That's just in this proposed bill. It says that. Or there's an inconsistency in the statutes. Which that part I'm not

[Alyssa Black (Chair)]: That piece, I think we'll pick up after another conversation. Can you

[Kelly Klein, Department of Mental Health]: just speak to the change of addition of the APRNs? So the APRN is already included in our first certification designation. They're already PAs. PAs are not. We would be opposed to the addition of physician's assistance being included in the statute as it reads at this time, unless there's a requirement for additional education, because APRNs have specialized education more specific to psychiatry, if they're in that work versus physician assistants. It's a more broad training. So we would just request that if this does go through, that we have the ability to provide enhanced education.

[Alyssa Black (Chair)]: And then APRN working in an emergency department have not necessarily any more training in this because remember, this is a certification to essentially rule out a medical condition Unless they are a psychiatric nurse practitioner, which in an emergency department would not necessarily be a psychiatric. In fact, it probably wouldn't be. Would just be a generalist, which would be the exact same as a physician assistant. Not the exact same,

[Kelly Klein, Department of Mental Health]: I realize. Right. And the training hours is different as well. And so they do receive more specialized training as they go along. APRNs, yes.

[Alyssa Black (Chair)]: Go ahead. I think it's a scope of practice issue that if we included that, and there's no language in here about scope of practice, but included that we could say that APRNs whose scope of practice is approved by OPR to include psychiatric blah blah, whatever, and the same might apply. Well, then it would go through the medical board, the PAs, it's a whole another land. Would a physician assistant be able to treat a voluntary person coming into the emergency department who's coming in for? Yeah, and they

[Kelly Klein, Department of Mental Health]: can still treat an involuntary patient as well.

[Alyssa Black (Chair)]: From what I understand, it's about certification to then move to the next level of certification by a psychiatrist, which really that certifier is ruling out whether or not this is a condition caused by a mental health diagnosis and eliminating any differentials for say, I mean, delirium because of a medication. Substitutes. Well, I know that it could be anything.

[Kelly Klein, Department of Mental Health]: They may or may not be. They may or may not be because the way that the first certification actually reads, it does not require that they've completely ruled out a medical condition as of yet. What it states is that there has to be a major mental illness and that major mental illness has to be directly causing the dangerousness. And it goes through a section where it asks if a lower level of care is and that includes voluntary admission. So the big part of this is making sure that anybody doing the first certification can do diagnostics, obviously, which physician's assistants absolutely can. They also can determine the dangerousness. And if they have the capability to do admitting within their hospital. So admitting privileges throughout any hospital would be necessary in order to do the first certification. To do that last part, says this person requires admission. I can make that decision and that they're not appropriate for a lower level of care.

[Alyssa Black (Chair)]: But also they have to make a determination whether or not it's being caused by their mental. Correct. Yes. That's not any other illness. Yes.

[Kelly Klein, Department of Mental Health]: Yes. That's every part of it, though, too. Is also the warrant should be saying that the first certification and So the all three independently have to be saying that.

[Alyssa Black (Chair)]: Any questions other than I guess I'm still not clear. Other than various things around the language, which we can work with legislative council on, from a standpoint, does the Department of Mental Health support this changed policy or not support changed policy?

[Kelly Klein, Department of Mental Health]: Department of Mental Health does not support the change that includes the other health professionals, but I think that was taken out as of now. Just to be clear, we don't For support physician assistants, we support the change so long as it's broad for healthcare in general, that they are able to do the same signing as physicians. The Department of Mental Health does not believe that it is appropriate to change it just for mental health. Do you need additional language in the

[Alyssa Black (Chair)]: bill in order to support the bill? Yes. Could you provide that language?

[Kelly Klein, Department of Mental Health]: We could. I would need to go back to our legal folks and see what they would recommend specifically. But yeah, if we had further language that allowed physician assistants to also sign in the same way that APRNs can within our current statute, then we would support the bill.

[Alyssa Black (Chair)]: And you're talking about in Title 26? Yes. Okay. Any other questions? All right. Thank you. So I'm assuming Liz is not here yet. Okay. Sorry. We're having a little we have witnesses that can only come in at certain times. So we're