Vermont Legislature SmartTranscripts:

[Chair Alyssa Black]: Good morning. It is Thursday, February 26, House Healthcare. We had to reschedule a little bit today, so we're just having our one witness at nine and then we'll be back at 10:30 with the rest of the witnesses. So we have Lindsay Owen or Lindsay Cina Moore. I'm looking at your Lindsay Cina Moore from Disability Rights. I'm going to pass things over to Daisy, member of Berbeco to sort of lead this discussion. So you go ahead with your testimony, Lindsay.

[Lindsay St. Amore, Executive Director, Disability Rights Vermont]: Thank you so much. Good morning. And I appreciate the community's flexibility to allow me to testify first thing. I am Lindsay St. Amore, formerly Owen. I just updated my name for everyone I so that that's the am the executive director at Disability Rights Vermont. I've been before the committee briefly before in the past. I've been with the organization for thirteen years. I am a practicing attorney as well, the vice president for the Vermont Coalition for Disability Rights. And the Disability Rights Vermont is also the mental health care ombudsman. So age five seventy three is very much a part of what we try to monitor and keep an eye on and something that I'm really grateful for the opportunity to speak to. And I think this committee and other stakeholders and members of the community may be a little bit surprised at DRBT's position on this particular bill in terms of our support for expanding the types of professionals who can do that first certification. And I have provided some written testimony. I don't wanna read it verbatim for the committee because I wanna be respectful of your time. If you have specific questions, then I'd like to be able to respond to those. But in general, Disability Rights Vermont is very, very much committed to making sure that people receive services in the least restrictive setting to meet their needs. And that is not inconsistent with also supporting that in a broken system or a system that could be a lot better. We also are committed to making sure that we minimize the amount of harm and rights violations that occur in the systems that we do have. So allowing for physician assistants in emergency departments to perform this first certification as kind of the boots on the ground and really having that exposure to this environment and the people that are in these crises makes a lot of sense. And I don't think that it runs the risk of kind of swooping in unnecessarily larger groups of people that might be subjected to involuntary treatment. And I think that's one of the concerns. So there was some recommendations in my written testimony for ways in which we might be able to safeguard or kind of keep an eye on that concern because it is a valid concern when the state is otherwise still pretty focused on institutionalized care. And so being mindful of the need for these first certifications to happen quickly to get people where they need to be, and also making sure that there are rails in place that prevent misuse of an expansion of this particular system. So I've had conversations with Elizabeth Quoto, who I believe is gonna testify later from Copley. And we've had great conversations about kind of what happens to these individuals who don't get this first certification because there isn't a qualified professional to do that first cert. And what happens now is more alarming than the risk of what might happen if we do go forward with expanding to this physician assistant population. And that is because these individuals who present to the emergency departments in crisis, without that first cert, they're kind of held there against their will, which isn't really lawful. But they also can't be let go because the emergency department is also responsible for discharging people who haven't received the care that they needed under EMTALA. So it really puts emergency departments in between a rock and a hard place in terms of trying to do right by the people that are presenting to their care who don't have anywhere else to go. And we've developed a system where people in need of psychiatric emergency care are funneled through an emergency department that isn't equipped to provide that level of care. And so that's kind of the system we're dealing with. So allowing for those procedures and processes to happen more quickly and more timely is in DRBT's position going to prevent more harm. It's gonna likely result in people hopefully being moved through the process faster because it's gonna start once that first certification happens, it kickstarts the timeframes to do the twenty four hour second certification. Certification. And then the seventy two hours before that person needs to be potentially placed in an inpatient setting. Until that first cert happens, these individuals could just be held in limbo. If they're really, really in need of that level of care, they could be at risk of seclusion, restraint, involuntary medication, and whatever the emergency department feels that may be necessary to kind of contain the situation and prevent harm to everyone involved in that environment. So I'll pause there. I do think you know, we would be supportive again, not of the bill as written, but with the limitation that'll be restricted solely to expanding to emergency department physician assistance. Again, with some recommendations for the committee to consider, including that whenever that first certification happens, either asking for a second certification or saying, no, this person doesn't actually meet criteria to be held, that that certification form be filed with either the Department of Mental Health or ideally with the Mental Health Care Ombudsman, DRBT. And then secondly, there's a recommendation that we included that I think came up years ago is that there's a preliminary hearing that's allowed in these involuntary treatment holds, but it has to be requested by the person who's in crisis. And they have a short window to do that. They've got five days from being admitted for an emergency examination. And then that opportunity is lost. So the recommendation would be that that preliminary hearing no longer be put on the shoulders of the person in crisis, but rather a formality of the system that it becomes automatic like it does in any other judicial proceeding. So for criminal defendants, it's automatic. For juvenile cases, it's automatic that their involuntary hold is reviewable. And so we would just ask that that be something the committee consider to make it equitable across all judicial proceedings.

[Rep. Daisy Berbeco]: Thank you.

[Chair Alyssa Black]: Thanks. That was really, really clear.

[Rep. Daisy Berbeco]: So, just want to clarify your comments,

[Chair Alyssa Black]: and I'm

[Rep. Daisy Berbeco]: looking at your, so it's all it's at the bottom one. All certifications, to be filed and reported to DMH and to you. It says and or, but maybe it should be to you. Mean, I'm just thinking about the ombudsman and responsibility to help an individual to get to that five day hearing so that it's I mean, it makes sense to me that it shouldn't be their responsibility during crisis. So who's gonna hold that? And it makes sense to me that you might.

[Lindsay St. Amore, Executive Director, Disability Rights Vermont]: Right. And so what happens now is again, like until that first certification happens, no one really knows that these people are stuck in this situation. Even the mental health law project who gets automatically appointed once somebody's application is filed. But in that interim period where there's just the emergency examination, there isn't any automatic representation appointed. There's nobody kind of having the back of the person in crisis except for maybe emergency department staff who see the need to get them moved quickly. So I think having somebody like the mental health care ombudsman receiving those. So there's two things, the first certification receiving just that information to know whether or not we are somehow capturing more people than originally intended, because this is intended really to be an expeditious bill. We're just trying to move people through the system faster, capture more people in the system. And then the second piece around the preliminary hearing is that the onus is not on the person themselves, but really it's just an automatic right to review that happens as it does anywhere else. I think the Mental Health Law Project who's set to testify may not be as supportive of that particular piece because of their own capacity and resources to be available to provide that representation. So again, to Jack and his team, I really wanna be mindful of how to support them if they are going to have to be reviewing more and more or representing more and more people in that situation. But it also seems like the right thing to do if we do it in criminal justice and juvenile justice.

[Rep. Daisy Berbeco]: Can I keep asking? Yeah,

[Chair Alyssa Black]: well, hold on, Daisy. So, Lindsey, I'm hearing that you would not be in support of the bill without those three changes, really, add emergency department in front of the words physician assistant. And then at the bottom of your letter, there are two recommendations. Number one is the filing of the certification. And then number two is around hearings. So it's three changes that you're requesting?

[Lindsay St. Amore, Executive Director, Disability Rights Vermont]: It's three changes that I'm recommending. I think that making this change is going to be better for people in this broken system that we have. So this is not the hill that I would die on. The hill that I would die on is building more beds in an institutional setting. So DRBT is supportive of this bill with emergency department being added before physician assistance. The two other recommendations around the preliminary hearing and reporting to DRBT as the mental health care ombudsman. If those are critical hangups for the committee, DRBT is still supportive of making this change because I do honestly believe that it's going to minimize harm and improve due process by kicking those timelines into gear when this first certification happens. So we are supportive of this bill for physician assistants in emergency department settings. I think that it could be improved by adding those recommendations, but it's not something that we're gonna revoke or take back our support of this bill if they're not included.

[Chair Alyssa Black]: I appreciate those recommendations. I just wanna note that because of the implications or impact of the process of the EE, the bill is created and intended to be incredibly narrow so that we can focus all of our input from witnesses on that very specific thing. And so we haven't taken any testimony on these things. And so I just want to note that I am going to talk to you about those two recommendations, even though it may not be something this year. Sorry, I just wanted to clarify that for the committee that it would require a lot more testimony to move those two pieces.

[Lindsay St. Amore, Executive Director, Disability Rights Vermont]: Absolutely. And it was just something I wanted to get in there. So it was on everybody's radar as a potential need, but understandably not to take away from moving this particular bill forward.

[Chair Alyssa Black]: Thank you. I just had one question. Because you had started your testimony by talking about the process that we have designed and that it is not an optimally designed process of doing this through emergency departments. And I understand that that's how it is now, but if we added emergency department physician assistant to this, we would then have to go back and fix it if we ever did design a more optimal system for this. And so, I'm concerned about that, that now we're relegating it to a system that we have coupled together and we're putting that in statute as if that has to be like that forever and ever. And maybe one day we can design a better system.

[Lindsay St. Amore, Executive Director, Disability Rights Vermont]: Right. And I think the possibility of designing a better system that does not include emergency departments is far, far away. And so I think adding that particular restriction makes a lot of sense right now. And it's not necessarily that, and this is my testimony just on the fly speaking as I think, which isn't always ideal. But in talking with stakeholders and people who work in emergency departments, they're not currently designed or set up to provide this type of care. That doesn't mean that there isn't a way to create and to carve out like some hospitals have tried to do therapeutic spaces within emergency departments that may have properly trained staff that may be better equipped. So I don't know because a lot of other urgent and emergent care does go through the emergency department. So maybe that could be the potential space, but right now it's not set up or designed in a way that's supportive of people in psychiatric crisis. It's responsive to medical crises, but it's just a different environment that's necessary when we're talking about mental health. And so I hope that's a little bit more clear that it's not necessarily the It's the way that Vermont's emergency departments are designed currently. Not to say that forever they'll have to stay this way and that they can't themselves improve with the right investments and whatnot. So I think it's a safe addition to the language to say emergency departments, because I think that there's potential for emergency departments to become better suited to meet this need of the system we've created already.

[Chair Alyssa Black]: You so much, Lindsay. Thanks and thanks for flexing on your time today. We do have to, we have to go off now. So thank you again.