Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, we're back and we have with us Liz Fruto. Hi Liz. Thanks for joining us, especially short notice today. And, you know, I specifically remember when the nurses, nurse practitioners and everything were in our committee last week that they had spoken about the bill that we're taking up H573. And we're speaking in support of it. Really wanted to invite you in and give testimony on this. And maybe you can clarify for us sort of how this works in practice. I think that would be really helpful.

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: Yeah. Thank you for that opportunity. It's nice to see you guys again. For anyone in the room who doesn't know, my name is Liz Kudo. I am the director of emergency services at Caledonia Hospital, but I'm also a director for the Emergency Nurse Association, which is where I've gotten into a lot of this work to make sure exactly what we're doing, which is you guys working to improve the system and us on the ground that are doing the system are actually on the same page of how this is going to improve access to care and the quality of care that patients in Vermont receive. So in regards to H573, this is a bill that we've had a couple conversations on, and what we've really wanted to do with this is ensure that the resources that we have on the ground in front of these patients are the ones that are actually able to implement and initiate care to actually reduce the delay in care. So, five seventy three is, you know, from our perspective, having a physician assistant as one of the people who is primarily in emergency departments completing these EEs, them being outlined as one of the assigned medical professionals is really going to help improve the access to care because right now it's delaying it. So the way that this works, I'll explain the process as an overview and then kind of get into a little bit about how this would be really helpful. A patient can come in under an emergency evaluation in two ways. So they can voluntarily come in. There are situations where they have a support system that have really helped them get to the brink of at least getting into our doors voluntarily. And then through evaluation and conversations, it is decided by the physician as written right now, the physician or the NP that is in the emergency department that this person needs qualifications for an emergency eval, meaning, we have to keep them here for further evaluation for inpatient services. Again, this is really well defined, by the mental health provider manual, the department mental health manual, your statutes in regards to really a risk to themselves or a risk of harm to others in their community. So the provider then completes the emergency eval form, which is provided by the Department of Mental Health Online. Those individuals that are trained to complete those go through a standard training process, for completing those appropriately, how to make sure that we're writing them, so that they are supportive of what the patients are needing. And then that starts the process of a two certification process. The other way somebody could come in is if there's somebody in the community that is not agreeable at the time to come in, the qualified mental health professional could submit for a warrant. And then they essentially have this application process, which is standardized. They submit for a warrant from a judge and a judge would decide based on the evidence provided to issue in a warrant for that individual to be brought to the hospital by police. They can be put in a protective custody while waiting for the warrants, but they can't, in this one of those gray zones, they can't come into the ED without the warrant. So I rely a lot on our collaboration with our police department to make sure that we're keeping people in a safe place while ensuring that a warrant gets them to walk through our doors legally. And then be here for the provider to complete that emergency eval again, as defined by a doctor or an NP at this point. From that point, that provider would write the first certification as outlined in legislation from that timestamp, the Department of Mental Health has twenty four hours to get a second certification. And what that really does is it really allows that there are certain situations in life, I won't get too into it, as you can imagine, that potentially caused someone to be in an emergency crisis that once that situation kind of resolves or somebody comes down from their initial reaction, the second evaluation ensures that that individual is not having their rights taken away or they're not being pushed into treatment that they wouldn't necessarily need because this event or what was happening was really situational. So from twenty four hours, the Department of Mental Health arranges for a second evaluation through, most facilities use telepsychiatry, so they will set that up. And then they do a second certification, which is again, the same process that outlines assessing that individual for either further care, involuntarily versus saying, we don't feel like this individual's EE would uphold and therefore we would then kind of back down what options exist for that patient. Do you want voluntary treatment? Do we let you go as discharge? And how again, do we kind of follow-up situationally based? So again, it's a two part process that is already in place, which is great because I think it really does protect patients having a two part evaluation to ensure that they're going to the right place if they are not going voluntarily. And what five seventy three does is it really actually aligns with your statutes. So under Title 18 Health Chapter 179, warrant and certificate for emergency examination, F really outlines a person transported pursuant to subsection of this section will be evaluated as soon as possible after arrival at the hospital. A lot of hospitals, smaller ones specifically, are only staffed by PAs at night. So right now, as we've discussed with Vas and my colleagues, if somebody comes in under a warrant or we're concerned about them needing an EE, their care is being delayed because we only have PAs on staff. And that has been something that we have transitioned to from a resource availability, from how our EDs are managed and staffed. And to be honest, there are facilities that actually already do this under agreements. So really what H573 does is it aligns what we have in house to do for patients that come in. And again, the PAs that are here are seeing these patients that are voluntary. They're assessing patients that have emergency crisis under the voluntary status, not the involuntary status right now, as well as continuing the care while they're here. So it really just helps us get them the access to that care sooner. So this timeline of getting their second cert, getting them to the appropriate facility within seventy two hours after that, isn't further delayed by the lack of resources that we have in house at that time. So the PAs would get the same amount of training it's as it's outlined in the qualified mental health professionals manual and standards by the Department of Mental Health. For the qualifications to do emergency evals, they would get the same training that our NPs and our NVs do. It would just realign the services and the people that are already here being able to provide this. And, this has been a great conversation that I've even had with DRVT, which is supportive of making sure that patients are getting access to the care that they need sooner rather than it being delayed.

[Alyssa Black (Chair)]: Very, very helpful, really. So can you because I think there was some confusion a little bit ago. So there is a certification process that a provider has to go through rather regardless of if they are a physician, an NP. Yep.

[Leslie Goldman (Member)]: Certification or training?

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: Yep. So there's training in regards to how to complete an NP. It is outlined, like I said, in the qualified mental health professionals, Department of Mental Health Manual and Standards. And that would be, applied the same way to the NPs and the, as defined doctors that are able to do this right now. So it's not changing how these ZEs are done. Those individuals would get the same exact training that they do now. They continue the care of these individuals. They do the care of the voluntary individuals. It would just improve the access to care for those that honestly truly need it timely based on our resources.

[Alyssa Black (Chair)]: Thanks. So helpful. Any questions for Liz? Oh, go ahead Leslie.

[Leslie Goldman (Member)]: So, I don't know anything about this kind of process. But apparently DMH has some kind of manual that you use to train your staff and set standards. Like, I don't know about the seventy two hours, that's new. So if you could just give a short description of what that is and what it leads to in terms of training and goals, I guess.

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: Are you talking about what the providers are specifically trained with?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yeah, yeah.

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: So again, this is all like public knowledge. I dedicated a lot of time to making sure

[Leslie Goldman (Member)]: that it's just one mile,

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: that we are following that. So, the Department of Mental Health, just in line with your statutes as well, does have these definitions outlined. And if you go to like, there's definitions, emergency eval, legal process, emergency exam, warrant, court ordered. There's a specific process again in their education and their allowance to do this. So the Department of Mental Health owns the checklist of education and training that the individuals assigned to have to do this, and they go through it. But if you're looking through this document, it even outlines, which is really honestly a quick reference, wonderful for supporting how to make sure that we're documenting appropriately. So documentation guidelines for emergency eval. And then the physician certificate for emergency exam, the physician or APRN completes that found on the DMH website. And then the training again comes out of DMH. So DMH is the one that has previously set the expectations for what training individuals get. And that would just, the same training would be applied to the PAs.

[Alyssa Black (Chair)]: Allen, do you like to?

[Leigh (Department of Mental Health)]: Yeah, I just wanted to expand on what training we have currently and how that would apply to PAs. So the training that's completed right now is completed by any physician that wants to do first certifications in the state. So typically it's an emergency physician, but it could be internal medicine or someone else that might be working in a catchment area that might not have as many physicians. And it can also be an APRN that completes the training at this time. And what they do is they go through a, we have a PowerPoint available on our website that has a training that explains the statute as it stands, the process, how to do the documentation, and they complete a quiz on that. And then they also send a mock first certification to the Department of Health. And that is reviewed by myself, the commissioner, and we approve, or we ask them to do some edits so that they really understand how to complete the process. And we would want physician assistants to complete that same training. And we would enhance that training available to everybody if physician assistants were added to that as well.

[Leslie Goldman (Member)]: What do you mean enhance?

[Leigh (Department of Mental Health)]: We would want to include some additional information about diagnostics and make sure that that information is available on our current training. So would you

[Leslie Goldman (Member)]: do it anyway even if we didn't do the TA thing? Eventually, yes. But this would motivate you to do it sooner. Yes. It. So, talked about scope of practice, but it doesn't sound like that's necessary. Does that sound right to you?

[Leigh (Department of Mental Health)]: Sorry, ask that again.

[Leslie Goldman (Member)]: Well, in regard to OPR, office professional regulation and licensure, we have to submit a scope of practice. Would it include psychiatry or doing these examinations as part of a scope of practice? But it sounds like with the training that you're doing, maybe that's not necessary. The Department of Mental Health wouldn't have a stance on that part because that's the OPR. No, I get that. But I just want it covered. I'm just making it hard to understand that we have the right person doing the right thing. And it sounds like if you're doing that, then we don't have to go that way. That's what I'm wondering.

[Alyssa Black (Chair)]: Liz, did you want to?

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: Yeah, I think that's a great question. I think that that's been something that, again, I don't know why PAs were left out of that. Again, to kind of highlight that from a scope of practice standpoint, organizations, larger networks are already doing this under agreements. So they have an agreement that for the scope of the practice that the PA is working with the MD on, the PAs are already doing this. So, they're kind of collaborating and working together and they have that backup. But again, the qualification in the background, as they just outlined, that's managed by the Department of Mental Health would really, ensure that everyone has access to do that because the facilities that only have PAs are the ones that are having that delay. And I think it's really important, like I said, to highlight that emergency departments are the only place that people in this state can get access to inpatient services consistently, whether it's voluntary or involuntary. So what this bill does is it aligns, we've had this conversation, funnel of everything that comes into emergency departments these days. We're doing our best to manage absolutely everything with the challenges of resources on the outpatient end, but aligning actually what is in our emergency departments that allows the only route of access to inpatient psychiatry to be expanded to the people that are actually here doing it is really just going to consistently validate Section F, which is as soon as possible after arrival at the hospital, because those are the resources that we have. And again, the qualifications don't change. I stand with DRVT having these conversations and with the patients, in my ER and every ER I've worked in to make sure that their rights are protected in these situations, especially where it's involuntary. And the qualifications of the individuals that are in here to be added to this will be the same for anyone. And those expectations will be upheld because again, we're talking about unfortunately someone's challenge to make their own decisions right now. And we want to support them getting to that place. And the ERs are the only place that are able to do that.

[Alyssa Black (Chair)]: That's interesting. I didn't know that. Go ahead, Hannah. Hi. Thank you for being here today. Just a really quick question. The timeline that the training takes, The additional training? Think she's How long are you?

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: Is that for me?

[Alyssa Black (Chair)]: Yeah. Could you hear me? I'm sorry.

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: Was asked, like, what the timeline was?

[Alyssa Black (Chair)]: Yeah.

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: I'm sorry. Can't see who's here. I think that they would be able to answer what the, you know, trigger timeline of being able to distribute this to PAs, especially in emergency departments, for getting that access. That would be a little more on, I don't know how you guys distribute that.

[Alyssa Black (Chair)]: Leigh, did you want to answer that?

[Leigh (Department of Mental Health)]: Yeah. So currently the process takes probably approximately one week to complete. A person has to be already licensed in the state of Vermont so that part is already complete. And then it depends on how long it takes them to go through our educational material. And then once they get the first certification to the Department of Mental Health, the rapid turnaround around forty eight hours. If there are edits that need to be done, that can delay the process significantly, especially if there's more than one time that needs to be edits. But otherwise, it's a wrap. Thanks.

[Alyssa Black (Chair)]: Any other questions? Thank you, Liz. Really appreciate you coming in short notice. So it looks to me, unless anyone else has any other thoughts, we're gonna Daisy, are you gonna work with Katie on clarifying some language problems? It sounds like topper that we might need Didn't answer. Did that. Would you like to testify? Would you like to come over and sit in my chair? Was just gonna say, look, there's somebody in for toppers. Come on. Come on up, Devin.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Devin Green, Vermont Association of Hospitals and Health Systems. And I was able to phone contracted counsel on this question about the supervisory authority piece that you pointed out in section c. And our understanding is so federal law requires a physician to admit, and that section includes the added layer of protection of the head of the hospital or whoever is designated, including a supervisory personnel to also admit the person. So it's a little bit of a two pronged piece for admission to designated hospitals, which have the inpatient units.

[Alyssa Black (Chair)]: It's like an extra layer of protection. And that's federal, a federal requirement or? No, no, no. You the second layer on.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: You put the second layer on the federal requirement is you have to have an admitting physician. And then on top of that, we're saying you have to have someone authorized at the hospital to also admit.

[Alyssa Black (Chair)]: And this section pertains specifically to somebody who's being admitted to a psychiatric inpatient Yes. So theoretically, everybody would have a lot of expertise. Yes. Is

[Leslie Goldman (Member)]: the commissioner the head of the hospital? Or is that the Well,

[Devin Green (Vermont Association of Hospitals and Health Systems)]: we have designated hospitals. So there's the Vermont Psychiatric Care Hospital, which the commissioner is the head of. And then we also have inpatient psychiatric units at Rutland Regional Medical Center, Brattleboro Retreat, UVMMC.

[Leslie Goldman (Member)]: Okay, so there it's the CEOs.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yeah, or whoever they designate or a different physician. Again, it's a two layer process as outlined there.

[Alyssa Black (Chair)]: Windham Center, right?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yes, and Windham Center. I knew I was forgetting one. Yes. Any

[Alyssa Black (Chair)]: other questions? Good. Okay, thanks, Debra. Thank you. Thanks for getting that answer for us really fast. Okay. So it sounds like we need to work on a little bit of language and unless there's other testimony that anyone would like to hear from, I think we'll wait and come back to it when we've got something. A new draft. A new draft. Thank you so much. Thank you, Liz. Thanks, Liz. Thank you, Liz. Yes. Really great to know what's happening in practice. All right, we can go off. Oh, so for the rest of the morning,

[Liz Kudo (Director of Emergency Services, Caledonia Hospital; Director, Emergency Nurses Association)]: we

[Alyssa Black (Chair)]: watching are the Green Mountain Care Board meeting from January 28, which they had a great presentation on reference based pricing and implementing reference based pricing. Since we're working on that, I thought it would be really a good thing if we watched it. So that's what we're going to do. We won't be on live. It'll just be all of us sitting around watching Green Mountain Airport. So follow along if you wish. We can go off of live.