Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Good afternoon. This is the healthcare committee back for our part of our afternoon session. We're going to take up page 73 this portion. And we're going to start off with a legislative council, Katie Glenn. She's gonna take us through the bill.

[Katie Glenn (Office of Legislative Counsel)]: Good afternoon. Katie with the ops, the one third control. Let me share a draft. Since this committee last looked at this language, there has been some work done on drafting an amendment. So that is what you are seeing in front of you. This first Section A of your draft is being struck out instead of amended. That's a big difference since the last time you saw it. And that's because there is an existing inconsistency between the two sections we're looking at with regard to who does the first certification, what professional, whether it is a psychiatrist or a physician. This language that is being struck through says it's the policy choice of a theis psychiatrist, which is different than what it says in section two and also not consistent with practice. That's the testimony you heard. So this language is being struck through. Section two, instead of maybe I should just step back and remind us about the what we were looking at. We looked at that timeline. I don't want to call it a timeline, but that flow chart of the different elements of involuntary commitment. And one of the initial stages of that is that there could be an application and certificate for somebody to be examined to see if they meet the statutory level of care for involuntary commitment. So that's what we're talking about, is who can fill out that certificate. So I hope that helps sort of reminding us the conversation that we had. Section two says that upon a written application, existing law is of an interested party, and the change is a qualified mental health professional, which is a special term. And I want to say it's defined, but I would have to double check that that's true. Made under pains and penalties of perjury and accompanied by a certificate. Instead of by a licensed physician, this is really substance of what you're looking at. It could be a health care professional who could sign the certificate. And then we have a list below of who could be a health care professional. This person is not the applicant. And 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. That's this statutory defined term for somebody who could be held for involuntary commitment. The application and certificate shall set forth the facts and circumstances that constitute the need for an emergency exam and that show that the person is a person in need of treatment. No changes to subsection B, so I'll skip over that. Subsection C, this has been rewritten because it seemed like the language in the existing law was kind of clunky and folks were having difficulty getting their head wrapped around it. So this is an attempt to make it hopefully more readable. And that language is admission of an individual to a designated hospital for care and treatment under this section shall be overseen by a head of hospital who may designate a person in writing to discharge the authority granted in this subsection. So you're getting rid of a cross reference that of cross references to nothing, because there's no reference to a head of a hospital in subsection A. Then we have language that the designated person must be an official hospital administrator, supervisory personnel, or licensed physician on duty on the hospital premises other than the certifying, again, instead of physician, a healthcare professional. New subsection D, that prior to issuing a certificate prior to this section, a healthcare professional shall successfully complete a training developed and administered by the Department, meaning the Department of Mental Health. So that means that any profession who is issuing the certificates would have to go through a training. And it leaves the specifics of what the training looks like up to the department. And then we have our definition, shorter than the last time you've seen it. So we have a physician and APRN. They can already do the certification. So the new addition is a PA, a physician assistant. And that's it. Very quick clarification. Is department defined elsewhere? Yes, I believe so.

[Rep. Alyssa Black (Chair)]: Everybody digested this?

[Katie Glenn (Office of Legislative Counsel)]: Elsewhere in this bill, elsewhere in Statute, yeah. I know you can double check, but

[Rep. Alyssa Black (Chair)]: Okay. Time off.

[Katie Glenn (Office of Legislative Counsel)]: I've got It's working the little hanging. I just wanted to share. Yeah. I will double check for you. Time off.

[Rep. Alyssa Black (Chair)]: One, was there question?

[Unidentified Committee Member]: Well, you said this anyone digested it. By the same, I've eaten it. I need a minute to digest it. Anything like mullet ores.

[Rep. Alyssa Black (Chair)]: So you need more time.

[Unidentified Committee Member]: I do have a question, but I'm trying to, I was waiting, is now the time? No. Exactly, so I'll wait.

[Katie Glenn (Office of Legislative Counsel)]: No, I'm set. Finish.

[Rep. Alyssa Black (Chair)]: I'm good. You. That's when I stopped and speak because she was asking a question. Yeah, I didn't know what was going on.

[Katie Glenn (Office of Legislative Counsel)]: I was just clarifying something, thank you.

[Rep. Alyssa Black (Chair)]: All right, now, other questions? I'm gonna wait till

[Unidentified Committee Member]: get to the bitter end.

[Rep. Alyssa Black (Chair)]: No one else? No questions at all? You did a good job, Katie.

[Unidentified Committee Member]: I guess maybe I have one question about the use of, it's a pre existing word,

[Katie Glenn (Office of Legislative Counsel)]: but to use discharge the authority, is that just understood? Designate in writing. Don't read it all in context. I feel like the meaning feels clear to me, but if it doesn't feel clear to the committee, we could think of a synonym for that. It's preexisting in this It is.

[Unidentified Committee Member]: In the original draft of this bill?

[Katie Glenn (Office of Legislative Counsel)]: It's in statute now. I just wasn't sure if

[Unidentified Committee Member]: it was a term of art in this setting or not.

[Katie Glenn (Office of Legislative Counsel)]: No, I don't think particularly to discharge the authority. I think it just means to carry out as designated.

[Rep. Alyssa Black (Chair)]: Any other comments, questions?

[Unidentified Committee Member]: I'm just gonna wait till the other witnesses are done, and then if they don't answer, it's it. Okay,

[Rep. Alyssa Black (Chair)]: All right, Katie, thank you very much. Ian? You wanna come up and then take the hot seat and introduce yourself? Thanks for coming back, by

[Unidentified Committee Member]: the way.

[Rep. Anne Donahue]: Representative Ann Donahue, thank you

[Rep. Anne Donahue]: very much for inviting me to comment on this, because it's certainly an area that I've followed for a long time. And I just want to I'm not really thrilled with this, but I'll get through why I think it's probably worth doing. I think it's important to step back and say, this is almost practically the only circumstance in which you can take away someone's freedom to leave a locked facility unless you've been charged with a crime. And so there's a lot of weight to that. If you've been charged with a crime, for one thing, there's got to be probable cause that you committed it. You can't be held without bail unless it's a really serious crime, and this is being held without bail. And it's not some hypothetical future danger. It's you've done something. It's not like you might. We're balancing, obviously, society's altruistic interest in care, but I think we got to keep that in mind. And the safety valves, if you have, that we have in this process is three parts. And that's my one area of concern. You're dealing just with the middle part. And there's a context of the first and the third. So first there's how does a person who doesn't want to be brought to the hospital get to the hospital? And then there's what's going on in the emergency room? What is it that allows them to be held for twenty four hours? And then there's what's the threshold for saying somebody is gonna be admitted against their will. And this is dealing with that middle part. My own preference would be there would virtually be no barrier for Part one. And we have warrant requirements and so forth, which I think can be to the detriment of a person and not an extremely high imposition on civil rights. But currently in our third part, we have a serious problem, and that has to do with our lack of providers. That's the reality. But a psychiatrist is supposed to make that decision of whether a person's going to be locked up and held against their will because their illness is so significant and it presents a danger. And that's routinely done by teleconferencing. Not an appropriate way to make that kind of a diagnostic and therapeutic decision and able to really interact with a person. And that's why changing the middle one makes me nervous because if we had a really strong, good part three before the big decision to admit somebody and hold them, then accommodating things with this wouldn't be a huge concern. That's a reality we can't really address. We don't have psychiatrists who can come in the middle of the night in the Northeast Kingdom to assess someone. So we're kind of stuck with that. But I put that as part of why am I cautious about this? Because we're slightly reducing the amount of the level of review that goes into part two when we have a horrific part three in terms of protections. So, what is the key to this second part and why is it reducing it a little bit? I think what people have to be aware is that the physician role in the first certification is not the psychiatric role nearly as much as it is, are there any other, are there other medical things going on that could be producing the symptoms? There's a huge area that's well documented in healthcare. And I always forget the correct term, but it's basically diagnostic misperception. It's a different word from misperception. But it's the fact that bias exists in our society, implicit bias, unintended bias. And when it comes to psychiatry, people get their medical problems dismissed based on their psychiatric presentation. And I had a sister-in-law who died because of it. She was repeatedly seen in the emergency room with severe stomach pains. She was sent home. It's your psychiatric issues and she died in bed one night of the physical. So that's really important. And I think we do know that today advanced practice registered nurses and physicians, or this is adding just specifically physician assistants, are pretty well schooled in all of that diagnostic work. But addressing implicit bias in terms of psychiatry is really still in its infancy in our healthcare system. I would feel better if that was more advanced. I know there's work going on it. Hopefully something like that would be caught at the point of admission by a psychiatrist. But since they can't palpate your stomach or do things like that through a video conference, that weakens it. So in saying all those as precautions, I think this should go forward. I think given the status of, for all sorts of reasons, the issue around people having to wait long periods in emergency rooms, and looking at the person who's on the ground probably most able to make a good decision about that first certification. I am comfortable with it. Waiting a long time in crisis back when I was waiting a long time in an emergency room in a psychiatric crisis waiting for not even certification, just admission decisions because I was a voluntary patient. And one time, horrible as it sounds, I had to wait five or six hours. It was horrible. And yet, in the current day, people wait days. And I just can't begin. I'm doing it as a comparison because I know how horrible it was, waiting five or six hours. And yet that's considered super fast today. So waiting and not having your needs addressed, it's a problem that we have to confront and deal with. And so I think this is something that does need to move forward. But I would hope you would keep in mind Parts one and Parts three, because it is they work together, and this is being taken up in isolation.

[Rep. Alyssa Black (Chair)]: And do you have that written, what you've said to us?

[Rep. Anne Donahue]: Yeah, have it written in notes. I could quickly type it up because it wasn't that long.

[Rep. Alyssa Black (Chair)]: It would be nice to have that.

[Rep. Anne Donahue]: Yeah, because I

[Katie Glenn (Office of Legislative Counsel)]: can remember your parts.

[Rep. Anne Donahue]: Is how do you get

[Katie Glenn (Office of Legislative Counsel)]: to the hospital? Part three

[Rep. Anne Donahue]: is how do you get admitted against treatment?

[Katie Glenn (Office of Legislative Counsel)]: I'll- And two, rule out the medical costs.

[Rep. Anne Donahue]: Well, it's that emergency room clearance that we think they should be held until a psychiatrist sees them and decides on admission. So, I think one of the key functions is ruling out medical causes. It is also a kind of mental health screening as well in terms of should this person be held for a psychiatric examination for admission.

[Katie Glenn (Office of Legislative Counsel)]: Thank you. Great.

[Rep. Alyssa Black (Chair)]: Thanks, Anne.

[Katie Glenn (Office of Legislative Counsel)]: Thank you. Thank you so much, Anne.

[Rep. Alyssa Black (Chair)]: Next one, next witness is Jane Collin. There. Hi, how are you doing?

[Unidentified Committee Member]: Sorry, all.

[Rep. Alyssa Black (Chair)]: Thanks for coming in.

[Jennifer Colon (Director, Office of Professional Regulation)]: Thank you. Well, I'm going be short and sweet. Jennifer Colon, Director of the Office of Professional Regulation. Thanks for having me today. So in the first iteration of this bill in section C, where health care professionals define, there were numerous professionals listed that are regulated by the Office of Professional Regulation. In this iteration of the bill, those have all been chopped out. So what's left is APRNs. OPR regulates APRNs. My understanding is they were already able to do this well within their scope of practice. If the committee, at some future point, decides to reconsider other mental health professionals, like psychologists or licensed clinical mental health counselors, we'd be happy to come back and testify and give a perspective on that. But at this point, they're not in the bill. As you know, OPR regulates over 50 professions. A lot of those include health care professionals. And we license over 80,000 individuals and businesses, and public protection is our mission. So if at any point this bill kind of implicates any of our other professions, we'd love to come back and share more information with you. But right now, APRNs are in there, and we're already in there. And that's the one profession we regulate. Board of Medical Practice regulates PAs. Great. Thank you. Any questions about that? I'm Any not making any kind of recommendation. This is not our process. So this is not a recommendation we would make. What I was saying is if this committee is going to reconsider at any point because of access issues or whatever, adding in other professionals, we'd be happy to come back and talk.

[Rep. Alyssa Black (Chair)]: We appreciate it.

[Jennifer Colon (Director, Office of Professional Regulation)]: Okay. Really quick. Yes, I have

[Katie Glenn (Office of Legislative Counsel)]: a question.

[Jennifer Colon (Director, Office of Professional Regulation)]: Since we said the Board of Medical Practices regulates Physicians assistants, PAs. And so they're the profession that was added in Section C. So they would probably have more to say on that. Great. Thank you so much. I know.

[Rep. Alyssa Black (Chair)]: Thank you very much. Have two witnesses that are on Zoom. The first one is Philip Schafer, his emergency physician assistant, emergency physician assistant.

[Phil Shafer, PA (Grace Cottage Hospital)]: Hello,

[Rep. Alyssa Black (Chair)]: can you hear us?

[Phil Shafer, PA (Grace Cottage Hospital)]: Your guys' video and audio froze on me. I'm not sure if the problem is at my end. Oh, there we are. Can you guys hear me?

[Unidentified Committee Member]: Yes. Yep.

[Rep. Alyssa Black (Chair)]: Now we can go.

[Phil Shafer, PA (Grace Cottage Hospital)]: Okay. Sorry. For some reason, the audio and visual froze, and the the audio has been coming through choppy. I hope the problem is not at my end, but let me know if if it is not clear. Thank you for allowing me to present some testimony today. Thanks for allowing me to do it remotely, so I didn't have to drive up to see you guys, although I have been anxious to see Vermont's Capital since I've moved here. My name is Phil Shafer. I'm a physician assistant. I've been practicing emergency medicine for just over thirty years. I've just been in Vermont for just over four years, however. I work at Grace Cottage Hospital, which is a very small critical access hospital in Townsend, Vermont, Southeast Vermont. And this bill is important to me and to us in our practice for a couple of reasons, and I promise to keep it short and sweet. Being a critical access hospital, often the only emergency provider is a PA or an APRN or or a nurse practitioner. Sometimes we have physicians depending on the scheduling. And at our place we have hospitalists during the day which again can be a physician or APRN or PA. But we have very limited resources hospitals in Vermont do. After about five or six in the evening, the emergency provider is the only provider in the hospital at our place for the rest of the night and the hospitalist or physician or supervising physician are available by phone. Routinely, psychiatric patients or patients that family or friends or EMS is being called for come into the emergency department to be screened for clearance for admission to the hospital. The vast majority of them are voluntary. They want help. They realize they're in a crisis and they're seeking help, whether it be inpatient or outpatient. But on a regular basis, PAs are called on to decide whether it's a medical or a psychiatric condition. And if it's a medical condition, we deal with it on the medical side. We also see patients who are unable to recognize they need care or are an extremist and we have to I don't want to use this. This is all about, you know, taking away somebody's liberties or or their ability to make decisions for themselves. But this happens on the medical side quite a bit, with head injuries and encephalopathies or other, disease processes that involve cognitive function. And so we see and deal with this and make decisions based on that quite a bit independently. So it's not outside our scope to also decide when somebody clearly is suicidal or homicidal and clearly does not recognize the need for attention and also is not interested in getting help. And so in the evenings and nights when these folks present, the decision that is made to put somebody under emergency evaluation status or EE status is sometimes pretty complex. You have to involve you're out in the waiting room talking to often their parents or their loved ones, their neighbors who are witnessing what's going on every day, and are giving you clues on the patient's recent activities and what they've said and, what, presents as a danger to themselves or others. And you spend quite a bit of time in the room and hopefully developing a report with the patient. That becomes very complex and, confusing sometimes, confusing to the patient. When you add another person, you've decided, okay, we have talked to all the interested parties, And now you need to get somebody else involved, I. E. The physician to come in and start the process over because they have to certify that they've evaluated this patient for X amount of time that they've spoke to these folks and repeat the process. Now it's not without worth doing if it leads to better outcomes or for more accurate care for the patient. But I would argue that it currently only serves to extend the amount of time they're in the emergency department, which is a horrible place for patients who are seeking psychiatric care because they often get very little. They can look at their medications if they're willing to take them, but don't have an on-site psychiatrist. We have HCRS come in. The crisis worker evaluates them, but they don't make recommendations on treatment, they don't alter their treatments while they're in the emergency department. These folks just kind of hang out. As Anne, I apologize, I didn't get Anne's last name, as she testified at the beginning, hours seems like days to these folks. When you're talking about extending it by several more hours just to get another person involved and repeat the process, it can be very upsetting to the patients, it can be upsetting to everybody else involved, it can be confusing to the patients and everybody else involved. And so I think this is important. Do not think that there is a side of this that is detrimental to the patients. This is a decision that we do not take lightly and it involves a lot of thought and input before the decision is made. I just that's pretty much all I wanted to say. I just wanna make myself available to answer questions from representatives if if you have them.

[Rep. Alyssa Black (Chair)]: Alright. Thank you. Questions?

[Unidentified Committee Member]: Thank you for being here, or there. There is this training component subsection D, Department of Mental Health. How do you view that aspect of joint legislation?

[Phil Shafer, PA (Grace Cottage Hospital)]: I think that's great. Where I came from, where I spent most of my practice, over twenty five years in Michigan, we did not have that. It was it was basically on the job training. And I when I came here four years ago, my boss who is very involved in this type of issue, pointed us to that website, said, look, PAs can't certify for EE, but you ought to go through and and see what our criteria is and and what the rules and regulations are, and it's and it's a good resource. I I think that's excellent. I I think that Vermont has set up a a nice program that way.

[Katie Glenn (Office of Legislative Counsel)]: Thank you.

[Rep. Alyssa Black (Chair)]: Other questions?

[Unidentified Committee Member]: I have a quick question. We just heard about implicit bias. The training cover that? I'm just worried about it now that I've heard it, that when someone comes in with medical issues, that because they might have a psychiatric history, is there in the training that you do, does that cover? I'm sure

[Phil Shafer, PA (Grace Cottage Hospital)]: if that question was for me or for the representative there who knows about the training or how.

[Unidentified Committee Member]: He's not there anymore. Okay,

[Phil Shafer, PA (Grace Cottage Hospital)]: Yeah. So that is step number one. I mean, when people are presented to the emergency department for clearance, as we would call it, that is goal number one. Is this an encephalopathy? Is this a medical condition that's causing that I'm sorry, that's causing a detriment to their capacity or their decision making? And if so, we need to address that. That actually is the first process before psychiatry, before HCRS gets involved, before the first cert is done is is to decide and sometimes that involves CAT scans, sometimes it involves labs and drug screens and and sometimes it involves observation. If they're intoxicated, we observe them for a while and see you know are they still imminently suicidal when they're sober, that type of thing. And so I agree with you that is that bias is real in medicine. Is real when it comes to psychiatric and medical, organic medical conditions. Having a diagnosis bias is a real problem in medicine and we should all strive to minimize that and to keep an open mind.

[Unidentified Committee Member]: Thank you.

[Rep. Alyssa Black (Chair)]: Other questions? Okay, thank you very, very much for taking the time.

[Phil Shafer, PA (Grace Cottage Hospital)]: Karen, thank you.

[Rep. Alyssa Black (Chair)]: Enlighten us. Okay, last witness is Trey Dobson. He's an MD in the emergency at Dartmouth Health.

[Dr. Trey Dobson, MD (Dartmouth Health)]: Hi there. Well, first off, I wanna recognize representative Donahue's comments. They were right in line with a lot of the physician thinking and Phil's comments, and I don't want to sound like an echo chamber, so maybe I'll just make a few things. First off, Phil said, it's well within the capability of a trained physician assistant to make these decisions, to determine whether or not a patient has decision making capacity, and they also have the resources of a physician, typically by phone or somewhere in the building, and physicians use physicians for the same thing all the time. If you didn't, you wouldn't be a good physician. The second, all the discussion on bias is, you know, that's very prevalent in medicine now. It was not fifteen to thirty years ago for sure, but we're not just talking about mental health presentations. If Phil or I see someone with heart failure, the first thing we say is, who said it's heart failure? Put that diagnosis off to the side, try to make sure it's something, not something else, and that's certainly true with mental illness. And you know, we have a lot of staff around us, and they are, you know, doing their thing, talking. We make sure we just silence and work on, first off, is there a life threatening condition going on? And that can take a few hours, as Phil noted, sometimes requires adjunct tests. So I have no problem with this bill. In fact, I've been practicing here for twenty one years, and I've always found it a little ridiculous that I have to come in after someone who's got the capabilities and has made a decision and come in and verify, which of course I do without bias. I set it to the side, I spend over an hour, and the value added is very little. I don't think once in practice I've overturned someone else's decision on that. And remember, we do this all the time with medical, and it's not involuntary you know, first certification. People come in, as Phil noted, with encephalopathy, intoxication, injury, illness, cancer, electrolyte abnormalities that want to leave, and you know, we can't let them leave. That's our responsibility is to provide care for them. Here, we've ruled those things out, and we have said, this appears to be a mental illness where you do not have the capacity to understand the consequences of your decisions, at least not right now at this point, and so we need to hold you involuntarily for a second certification by a psychiatrist. Perhaps your situation will change by then, because it often takes a while, or perhaps not, and at that point you need inpatient treatment to help you through this difficult time. So I'm available for questions too, as Phil said, not only now, but at any time, and I don't want to just keep saying the same thing over and over.

[Rep. Alyssa Black (Chair)]: Okay, thank you, doctor. Questions? Sounds like everybody knows. Pretty straightforward. Pretty straightforward, that's right. All right, sir. Thank you very much to both of you.

[Unidentified Committee Member]: Thank you.

[Katie Glenn (Office of Legislative Counsel)]: Thank you.

[Rep. Alyssa Black (Chair)]: Thank you. Thank you very much.

[Phil Shafer, PA (Grace Cottage Hospital)]: You're welcome, and thank you.

[Rep. Alyssa Black (Chair)]: Okay, we can go off.