Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome back. We are continuing on May. Sorry to everybody for all the updated scheduling and thank you to all of our witnesses who flexed with us, and one

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: of them being Commissioner Houghton. So thanks for being here. Yeah, thanks for having me. Oh,

[Alyssa Black (Chair)]: yeah, go ahead.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: I just want to remind the committee that we already heard from the Department of Mental Health on May last week or week before. So we have some testimony from them. However, they followed up with two separate emails. The most recent one, I invited Commissioner Houghton to come back and give her an opportunity to speak to the department's stance on this bill so that it was clear to everyone.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Go ahead. All right. Good afternoon. Emily Haws, Commissioner What? Not yet. Oh my God.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: It feels like it, I get it.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: It's a time warp in this place. So yes, good morning. Emily Hawes, Commissioner for the Department of Mental Health. And yes, thank you for having me come in today to talk a little bit about the department's position on H573. And so I do want to begin by acknowledging that the shared goal behind May, ensuring timely access to emergency care for individuals experiencing a serious mental health crisis. And no one should have to wait for an assessment or treatment in a health care emergency, whether that be physical or mental. And mental health is health care, and timely access matters deeply to the department. With age five seventy three, it seeks to address a perceived access gap for individuals, both youth and adults being considered for involuntary inpatient psychiatric care. And so I want to underscore some testimony that was shared earlier this week, highlighting that this is the only setting outside of the criminal legal system where a person's fundamental rights can be removed. And we should approach that as a significant potential impact on someone's life. And that reality is that we want to demand the highest standards and safeguards when someone is being considered for involuntary hospitalization. And what H573 does is lower that threshold of medical training required to make the first critical determination by expanding that certification authority to physician assistants. Physician assistants whose education and clinical preparation differ substantially from that of physicians. And from a parity and equity perspective, the Department of Mental Health cannot support reducing clinical standards for mental health care, especially in decisions that carry such profound legal, medical and ethical consequences. Individuals facing involuntary hospitalization are among some of our most vulnerable folks, and many present with complex psychiatric and medical conditions, including age related and co occurring physical health challenges. These individuals deserve the same level of clinical expertise and rigor that we expect in any other serious medical determination. And anything less reinforces the stigma, it deepens inequity and risks harm. Importantly, to note that wait times for involuntary inpatient placement have decreased over the past several years, even as inpatient capacity has tightened. And at the same time, the complexity of cases has increased, making access to physician level clinical expertise more, not less, critical. We fully recognize the immense strain of health care workforce shortages and rising health care costs, but those pressures cannot justify lowering standards of care in the one clinical decision that allows the state to remove a person's liberty. When rights are at stake, the bar must remain high. And for these reasons, parity, safety, stigma reduction, and the seriousness of involuntary commitment, Thank you. The Department of Mental Health respectfully opposes age five seventy three. Thank you.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: That's powerful. That is. Can I ask, I'm referring to your letter from February 18? What changed?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah, that's a great question. Having a little more time to digest and think about the global impacts of shipping something for one population versus a whole population. And also, just because some emergency rooms are doing this practice and having a physician sign off on it, doesn't make it the right decision to do. We should be working with those emergency departments to look at their operations. How the first certification works is that a physician has to be interacting and assessing that individual, not just signing off on what a PA or somebody else has advised them of the issues. They need to be seeing that individual. And so it was really taking a step back and digesting that information and looking at it in

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: a more

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: global lens. Did you have any conversations with PAs, APRNs, or physicians as you changed your

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: mind about supporting Yes. The Well, I've had some conversations before the session where I also articulated that it was not something that the department would fully support. But we would be engaged in conversations if we were looking at broadening the responsibilities for all medical and health care interactions, not just people with mental illness. So I did talk about that with those groups at the beginning of session. I certainly have talked with our medical director and the individuals who are within the mental health system.

[Alyssa Black (Chair)]: I think I'm confused by you talk about the rigor. Take your time while I formulate a thought. I'm thinking about the immense training that providers within an emergency department have in every type of emergency situation. So, a physician assistant working within an emergency department,

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: do you

[Alyssa Black (Chair)]: have a problem with them making assessment on whether or not somebody has voluntarily decided to admit themselves for psychiatric

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: care? Yeah, I think it depends on the situation, but there is certainly a difference when somebody's rights are being taken away in an involuntary setting and being able to have your highest trained individual taking a look at that circumstance and said that person is in.

[Alyssa Black (Chair)]: Talk about taking rights away. As designed, no one is taking anyone's rights away. They are just simply starting the process where an individual can be evaluated by someone who No, someone who actually is qualified to make that determination, be as an actual psychiatrist, physician level trained in psychiatry. I'm with a medical background. With a medical background. I mean, seems to me that if we're okay with a nurse practitioner or even a physician trained in emergency medicine, They're actually not making the determination to involuntarily remove someone's rights. All they're doing is making an assessment on whether or not this person

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Is a person in need of involuntary treatment.

[Alyssa Black (Chair)]: Is a person in need who then

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: might can be in need,

[Alyssa Black (Chair)]: who can then get to the next level of care. And I know we've talked about, I haven't allowed you to answer a question yet. That's okay. I don't know if I have a question in it. It's more I'm confounded. I'm continuing my stream of consciousness because you and I have actually had this conversation before and I think one of the I think one of the coolest things that we do in terms of how we still treat mental healthcare differently than healthcare is by not providing the access and the immediacy. I find it cruel that we would make somebody sit in an emergency department through a night shift waiting for a physician to get in. I find that cruel. I

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: can hear that. And can I respond to that? Possibly also subjected to involuntary restraint or involuntary medication. But yeah, please respond. Involuntary restraint and involuntary medication is something that emergency departments can do and do do 20 fourseven if the need arises. And so that's not necessarily I don't think you're looking to solve that with this bill. No, I'm saying

[Alyssa Black (Chair)]: that the time that somebody would be in the emergency department would make them more susceptible to being subjected to that. And also, are you saying that you think that it's okay for a physician assistant to order involuntary restraint or?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: No, I'm not. What I'm saying is that five seventy three is looking to change for people experiencing a mental health challenge, why narrow it? Why is it just about someone experiencing a mental health challenge?

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: I'll answer that as the Bill's lead sponsor and someone else has probably done a lot of questioning folks, including yourself, on this issue. I am loath to see anyone involuntarily placed However, I understand that you oversee a system that is responsible for keeping folks in a very restrictive setting. And I trust the work that you do for folks who need that very much. I just absolutely respect your work. However, the need for this bill comes out of listening to folks who work in ERs, listening to folks who have presented in ERs seeking inpatient mental health care. And this is often the only way that they can get to it, voluntarily or involuntarily. And as much as I don't like to support that process, this is, in essence, a harm reduction step. Because I have heard from people who have experienced this that waiting twelve hours for a physician who's on their rounds to make it to them to sign off on something, a physician who hasn't spent more than five minutes looking at them, maybe it's someone who's new on shift, hasn't even seen the person. And you know who's going to inform them? You do. It's a PA. So that is, you know, I'm trying to, with this bill, web the reality of who is closest to the person who's seeking care and how can we get them to appropriate care. Not to inpatient care, but to the psychiatrist who can release them back to the community to respite, to wherever your team determines they need to go. But they do not need to be sitting in a hallway waiting for a physician to come on staff and sign the paper. So that is the reason for this bill.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: And that paints a very powerful picture. There's also people in that hallway who are experiencing other healthcare weights for placement. So from a parity perspective, we're looking at changing something specifically for people with mental illness. And that is not something that the department supports. What would be the parity?

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: Is there a form for people who are there with a broken leg? There is no parallel to involuntary procedures and removing someone's rights. So do not frame this as a parody issue. This is about parity. And

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: we certainly open to agree to disagree. I believe it's a parity issue, and I believe that we should not be singling out individuals with mental illness. I hear that it's a path to have somebody be seen by a psychiatrist. During that time, they don't have rights to leave. They do It not have We have multiple emergency rooms that function very differently across this state. And I understand that this is a particularly challenging issue for hospitals in more rural areas, which I assume are also challenged from a physical healthcare perspective, and getting the right specialists to evaluate someone for that next step. I imagine they call for consult. I imagine they're doing various forms of telemedicine for that. And the department does not support moving forward with this as a treatment. I'm sorry, I'm going to interject. I'm very

[Alyssa Black (Chair)]: confused by the parity issue. There is not someone sitting in an emergency department right now waiting for an inpatient bed for any type of health condition, a broken leg, a cardiac event, there is not one person sitting in a hallway who doesn't at least have an order that when that bed opens up, they're the first to get it. That is an access issue. That is not a provider can't even make the order for inpatient status. This is not about, I mean, if we want to have a conversation about the parity, then we can talk about the time period between when this is ordered and when a psychiatrist is able to perform their examination. That is a different conversation. There is no parity situation where a physician assistant in staffing an emergency department is unable to order inpatient status or a CAT scan or any type of service. This is withholding medical care. This is about withholding someone's care. You can't give me another situation that we would say, we're just going to withhold care for this person and make them hang out here and wait it out until shift is over and somebody can come round on. Find me any situation other than this one particular process that we do this to people.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Do we have any data on individuals who are waiting for that assessment for the first certification for that time?

[Alyssa Black (Chair)]: We have anecdotal evidence. We have anecdotal from hospitals in our rural settings. And if you want to talk about parity, that means that Vermonters in a rural setting are not receiving the same care that Vermonters in, say, Chittenden County are getting. So, no, do we have

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Like, when it comes to ED, you get checked in.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: Why are you asking us if we have the data? That's your department.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: I don't have I do once there's a first cert and the second cert. There are so many complexities that happen when somebody comes in. And I think representative Donahue spoke a little bit about this during her testimony that folks can present for an emergency room visit for a variety of reasons. And those reasons can look like someone experiencing a mental health condition, but it may be that their thyroid is not leveled. And we still do have a health system. And although there's been shifts in that, that oftentimes will somebody comes in and they're experiencing challenges that look like mental health or substance use. And instead of doing a full medical and mental health workup, they go to involuntary care. Zach, do you

[Alyssa Black (Chair)]: have data on that?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah. The hospital system would have data on that. We don't have data on that because if somebody comes in and they're voluntary, they also go under that same process of making sure, hopefully, that their physical conditions are identified and addressed to determine how and if they're interacting with someone's mental health condition. And when somebody is a PA, they do have a lower level of training. And these are folks who can be incredibly complex and kids and older Vermonters. And so there's no question this is a very challenging issue to solve.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: It is. And thank you for your patience, as clearly we're frustrated because, one, you sort of changed your opinion on supporting the bill, and that's frustrating. And two, I find the letter that you read or testimony that you read to be, frankly, insulting. This bill is not perpetuating stigma. You know the intent it was created in. It was created by someone who openly lives with a mental illness, who has a strong career for a legislator. So people with mental illnesses do not often have someone sitting in this seat in the legislature creating legislation. So to receive testimony like you just gave to me is incredibly insulting. I respect your work very, very much, but let's do better together. I think Brian has a question. Brian, you have a question, and then

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: I think we're going to

[Alyssa Black (Chair)]: move on to our next witness.

[Brian Cina (Member)]: Can you hear me okay through the AirPods? Yep. Okay. So so I understand the witness commissioner, this is a question for you, so it's not common. But I understand your point. You can't see me. Sorry. It'll start glitching, it'll start glitching. So I understand your point about people's rights. I don't dispute that at all because the moment the process is initiated, people's rights start to be impacted. Like the moment someone questions their sanity or questions their competency, that happens. People start treating them differently and things quickly escalate for a person and their rights become increasingly restricted. But I also see my committee members points that in that same situation, delaying the process can also impact their rights. What I'm wondering is I'm still I'm really trying to understand the parity piece. Is it that like I'm trying to understand like that. What we'd be adding a provider type who could provide a service. We're not taking something away. So I'm like wondering like are are people not able to get treatment because PAs can't do things that doctors can do, so they're waiting for the PA. And so the concern is if we let PAs feed people in a mental crisis, but we don't let them treat a certain health condition, that's not parity That we should be rethinking what they treat in general if we're going to add them for this?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yes. So I'll take the APRN for an example because

[Brian Cina (Member)]: Okay, thank you.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah, that's a good question. So we do have and allow, because it's in statute, that APRNs have the same abilities as physicians. What's not in statute under that same is physician assistants, and the APRNs were shifted for all of health care. So we do have APRNs who do that first cert, because in the statute, it allows for that for all of healthcare.

[Brian Cina (Member)]: I actually get it now, what you're saying. I just needed you to kinda articulate that a little further. Yeah. And and let me just make sure I'm getting it. Because APRNs and MDs, I think would be the right way to say it, MDs and APRNs, can treat all health conditions as equals. Correct. Then it's okay, but we'd be making a carve out in one procedure for physician's assistant that they do not do in any other part of healthcare. And even though our intent may be to increase access or speed up the process, it's creating an imparity or whatever the word would be, an inequity.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: That's correct.

[Brian Cina (Member)]: I I get your argument now. That's I I need to process it more, but I I needed to I was try I've been really trying to understand it and now at least get I under I see what you're saying now. Thank for through that with me.

[Alyssa Black (Chair)]: Leslie, and then we're gonna move on to our

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: next witness. So we heard testimony about the training that you provide to the hospital in the emergency room that was comprehensive and well designed. So you're saying that PAs who are also well trained in many arenas and might have training in mental health issues as part of their generalist training, that that training is not sufficient to help them do the first serve. We're just talking about the first serve. I understand that requiring sometimes if someone's in the ER and the PA can't sleep, they require someone to come off the floor to an APRN or whoever who's doing other work to come down.

[Leslie Goldman (Member)]: So it delays care basically everywhere. So we're just talking as I see the first cert, And how does having a PA who is trained in your world, trained by your materials, not capable of just starting the process? Sure. So the current training for first certifications that happens in for MDs and APRNs is a great training. And it is also geared towards individuals who have a substantial amount of training, not saying that PAs don't.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: From my perspective, the conversation is still the same, and that we're looking to change something specific to people with mental illness. But sometimes people need specific things. You come in with a broken leg, you need an orthopedist. You come in with your heart dying, you need a cardiologist. So in this case, you need someone who people are concerned may do harm to themselves or others need psychiatric help. And trying to start the process to get them to psychiatric help in a more efficient way seems reasonable to me. And I'm really worried about rural areas. We heard testimony from Grace Cottage. They have PAs in their ER all the time at night without access. We need to be able to start that process. No. In the rural areas, no. No, I feel like I have answered that question really quickly today.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: Thank you. Thank you.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah, thank you.

[Alyssa Black (Chair)]: Thank you for coming in.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Well, thank you. Good morning, madam chair, members of the committee. Thank you for having me. I appreciate the opportunity. My name is Jack McCullough. I'm an attorney at Vermont Legal Aid, where I've worked since 1983, and I'm the director of our mental health law project since 1994, '95, something like that. And at the Mental Health Law Project, we represent everybody in the state of Vermont who is subject to any kind of involuntary mental health proceeding. And that includes both the criminal proceedings for someone who's been found incompetent to stand trial or not guilty by reason of insanity, but also all the civil proceedings under Title 18, including cases that start out with these emergency exam applications that you've been talking about here. And it's clear that the intent of the bill and what you've heard in support of this bill is that this is a bill in favor of that is designed to provide health care for people. What I would say is that this is not the right way to be looking at the question. What this bill is doing, I think the right way to look at the question is if this bill is about taking away a person's liberty without providing them adequate due process. And, it's vital to recognize what's at stake in these cases. The Supreme Court has held that involuntary hospitalization for purposes of psychiatric treatment is a massive curtailment of liberty, and it justifies the most stringent protection of the person's rights. If an can be held, if an involuntary hold can be initiated without any examination or evaluation by a psychiatrist or other physician, people are at risk of losing their liberty without an adequate justification for their detention. We oppose this. We believe that an examined by a licensed physician is essential to the protection of people at the very beginning of the commitment process. And I've heard members say, well, it's just the first cert. It is a certification by a physician that the person who's being detained has a mental illness and as a result of mental illness is a danger to him or herself or others. And to talk about that, it might be worth talking about how the emergency exam process works.

[Alyssa Black (Chair)]: May I interrupt for just a moment? Am I understanding that your testimony is that you'd like us to strike that APRNs are Well, also able to do

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: I actually do think that the role of the reliance on APRNs has been a degradation in services that our clients receive. But for purposes of today's testimony, my purpose is to come here and oppose the bill.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: You speak to what's a degradation? Mean, degradation is a pretty heavy word. Can you speak to that? Sure.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: The education and training provided, even for an APRN or a PA, is nowhere comparable to the education and training that a physician, particularly a psychiatrist, receives. This is not to disparage APRNs or PAs, but just to say that they are not the same as doctors.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: I don't think anyone's saying that APRNs or PAs are the same as such psychiatrists. But if there are no psychiatrists available, what happens to the individual who is in need of help?

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Well, we don't know whether the person's in need of help. You're going beyond the initial question, which is, is there a determination, is there a valid determination made that the person's in need of hospital level care and evaluation? And so I don't think we can assume that just because someone has made a call that that guarantees that the person is in need of inpatient psychiatric treatment.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Well, think we could assume that medical explanations for perhaps behavior have been ruled out in the emergency room by someone trained to do that. And once those are ruled out, then we have to think about potential psychiatric contribution and then start the process.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Well, except I think this gets us to how the process works. We refer to it as an application for emergency examination. But nobody's really applying to anyone to make it happen. As soon as the qualified mental health professional signs the application and the doctor signs the physician certificate, those two acts, those two things are all it takes to provide the authority for the person to be taken into custody and admitted to a hospital. They don't have to apply to anyone to do that. There's no judicial oversight of any kind at that stage in the process. And many people I talked to are really surprised that you're not ordered into the hospital by a judge. It's the screener and the doctor together who make that determination to deprive the person of liberty, to put them in the hospital and hold

[Alyssa Black (Chair)]: them.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: For twenty four hours.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Twenty four hours, yes. And what happens in a lot of these cases, I remember, I've been doing this a long time, I remember when it was very common for the screener and the psychiatrist from the community mental health center to meet with the person where they were. Meet with the person if there's some incident yeah. And they're go out to the person's home. Go out to the laundromat or the side of the road, you know, wherever the person is experiencing crisis. And so then they would have the ability to, in real time, in person, evaluate what's going on. Now, often when a person gets to the hospital, they still might not get to see a doctor. The second certification that you're aware of is required to be done within twenty four hours, Very, very often happens by video. So the person who's being held still hasn't met with a doctor.

[Alyssa Black (Chair)]: Oh, I'm sorry. You said you've been around for a long time. You were remembering when they were done on the side of the road. Were you part I don't know when this legislation came about, but were you part of helping craft this legislation originally?

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: It's been in existence before I came to this practice. But we've got situations now where under this bill, with no requirement for a physician certificate, someone might be picked up on a Friday, taken to a hospital, might not have the opportunity to actually meet with a psychiatrist until Monday.

[Alyssa Black (Chair)]: But this bill doesn't have anything to do with that, no?

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: It absolutely does, because it removes the necessity for the person to be seen by a doctor. Now you're right, I don't think an APR and is adequate either, as Commissioner Hawes says, this reduces the threshold, reduces the level of clinical training and expertise that would be required to deprive a person of their liberty.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: We'll hear them from, I think, I just want to speak.

[Alyssa Black (Chair)]: Yeah, Allison, I'm trying to ask a question for a while, so

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: let's We keep hearing physicians on levels of clinical expertise. I just want the committee to know we're going to hear from folks that oversee these various levels of clinicians. And so just be aware, we're going to hear more from the folks that are actually in charge of that. Go ahead, Thank you for coming. And please excuse. I don't mean any disrespect. I am learning how to word my questions.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: I used to be disagreed with, so. Well,

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: you've obviously been doing this for a long time. I'm curious of your medical background, if you have. Do you have any medical background?

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Oh, I have no medical background. I've learned quite a lot in my many years of doing this, but I'm not a doctor. So that's where we are.

[Alyssa Black (Chair)]: Brian, I'm sorry, Brian.

[Brian Cina (Member)]: I know you can't see, that's why I buttered

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: off. You can't see.

[Brian Cina (Member)]: Yeah, and I don't know if there's more you wanted to say before I ask my question or

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Go right ahead.

[Brian Cina (Member)]: Yeah. It's kind of like a question to check that I'm understanding. Think I get your point. That by adding this provider type at this stage of the process, we're not increasing access to care. We're actually speeding up a process that restricts people's rights and doesn't necessarily mean they're gonna get the care they need. So just because we're adding another provider type doesn't mean they're gonna get care. It just means that they might be detained longer than they need to be or they might get into the process quicker, but either way that's not giving them more care. It's not increasing access to care. That's what I thought I heard you saying. That this isn't about increasing care, it's more about having a lower threshold at the beginning of a process that could potentially violate human rights. Exactly.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Once we get into court, it's an adversary process. The Department of Mental Health is represented. The proposed patient is represented. And while the Department of Mental Health is there because they sincerely believe that the person requires the treatment that's needed and they'll have the doctors, whatever witnesses are there to test ify because they think that that's what's needed to provide treatment for the person. We're the only person there is there to say to a certain court what our client's intentions are, what our client's wishes are. And it's important for us to do that. It's we consider it important to defend the liberty interests that are raised by these cases.

[Brian Cina (Member)]: Based on your experience, do you have any suggestions of what would improve the process? Because I think that's the intent here, to help people get help if they need it or let them move on if they don't need it quicker and not be waiting or detained unnecessarily long. Do you have any suggestions of what could help?

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Yes, have two suggestions and one of them is the thing that I sort of made a rule for myself that I would say every time I come here to talk about mental health, I would talk about this. So thank you for that. The best thing, the most effective thing that that the legislature could do to improve the process is to greatly increase the resources provided to the community mental health system. Housing, clinical services, all of those things would get us to a point where people who are hospitalized now might not need to be hospitalized, people who are in hospitals will be able to get out of hospitals faster. So before we make any other changes in the system, what we should be doing is putting a lot more money into the community mental health center. Asking for more money is not always a winning argument in this building, but at any given time right now, there's probably a thousand vacancies in the community mental health system across the state.

[Alyssa Black (Chair)]: I don't think you're going to get any argument from this committee on that. But I am answering the system we live in.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: But I am answering the question. And then the other thing that could improve the process is that if you're going to allow a PA to certify mental illness at this first certification step, then the state should be required to limit the second cert to a circumstance where the person has actually met in person with the doctor, with a psychiatrist, because that's

[Alyssa Black (Chair)]: Thank you. We have two questions, well, three, and then we're going to move on to our next witness. Would you like Leslie to go next?

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: No, I'm to remember it. You spoke a bit about resources, which you're singing my song. What are your resources like, and how do they relate to these folks that we're talking about in this bill? We

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: have enough resources to do our job based on the money we get from the state. I can tell you a couple of things, is that we get, for many years, when someone's involuntarily admitted, EE to the hospital, we get copies of the paperwork from the department.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: The DMH from SACEPRA.

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: Yeah. We don't have the time, given our current staffing, to review every set of paperwork and reach out to the clients at that stage when they're just being detained. Our initial contact with We'll talk to them if they call, but our initial contact with the client is when the application for involuntary treatment is filed.

[Alyssa Black (Chair)]: Can I follow-up on that really quickly? Because this was the question I had for you. You receive notification every single time someone has been involuntarily Admitted. Do you receive that notification prior to the psychiatrist certification, the second certification, or do you receive that afterwards, after that psychiatrist has made the recommendation for involuntary admission? When do you receive that? Well, we typically get it. I should say that there seems to

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: have been some slippage. We don't always get the paperwork, but we often get it when the person's admitted. Okay, you said you don't get it? Before the second cert.

[Alyssa Black (Chair)]: Are you required to are they required to send it to you? No. My other question was do speaking of that, what have you seen a trajectory have you seen an increase in involuntary admissions over a number of years? Do you have any data on how many you're seeing and how many you're seeing that are inappropriate? I

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: don't think we have the data to answer that question. Okay, so we're I think the number of admissions probably in the possession of the Department of Mental Health, they could probably give you that answer more easily than we can.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: Act 114 has.

[Alyssa Black (Chair)]: So, we're talking here about allowing physician assistants to start the process that then more expediently gets a psychiatric examination for a patient so that they can receive those services sooner, but we don't have any data that somehow this whole process has, you know, we're just involuntarily admitting everybody that comes through the doors. I'm trying to see where I'm trying to figure out what the problem is, and I think I'm a

[Jack McCullough (Director, Mental Health Law Project, Vermont Legal Aid)]: little confused. Okay. Well, I can tell you a couple of things. One is that in my office, we only see one side of the story. We see the cases where the person's been screened into the hospital. If a person is seen, seen with the screener, sees the doctor, and they decide the person doesn't need to be hospitalized, We never see that. So there may be records somewhere of how many screenings take place that do not result in an involuntary admission. I know what those statistics are or what they would show. I'm sure that not everybody who gets seen by the screeners winds up getting getting admitted. What I would say the problem is and I keep coming back to the same answer, really, which is that I know there's a desire to picture what's happening as accelerating a person getting care, but inherent in that provision of care is somebody is being somebody who at one moment is free to stay in their house and watch television or do whatever they want, free to walk to the store, free to do whatever they want. But as soon as the emergency exam application and the physician certificate are signed, and that person loses those freedoms and they are subject to being transported by the police to a hospital. And so they have, at that point, even though we may get them out of the hospital after that happens, eventually, at that point, they've lost the interview they had before. And that's a big deal. And I don't think we can pretend, I don't think we should pretend that it's not a good deal.

[Alyssa Black (Chair)]: Leslie, and then we're gonna finish and move on to the

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: I think I'm good. I don't think anyone here is saying this is not a big deal, clearly a big deal, but that's not the question on the table. The question is how to get this person care they need at that moment and expediting it. So thank you. Thank you. And thank you for the work that you do with Vermont. Yes, you. Liz, you want to come on up? Lindsay already went. Oh, yes.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: Sorry, Liz.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: She had people at nine She couldn't come in. Was awesome. We had. Hi. Thanks for joining us again.

[Liz (Emergency Department representative/nurse leader)]: Thank you for having me again. I do want to start by saying thank you to you guys for this continued conversation, for really making sure that you're investigating every avenue of this process and including the people from every aspect that touch these patients. Specifically, we continue to have these conversations of what it looks like because I'm sitting here representing the individuals that are in the setting that these patients are being brought to. So emergency departments is the only setting that patients can get to inpatient care. So whether it's under voluntary or involuntary, they can only have that through the emergency department. I want to thank Lindsay. You guys heard her testimony and saw her letter. I network with her a lot around how we can work together, which I think is really important on this, to make sure that patients' rights are protected in these settings, but to also appreciate what these settings actually look like. And I'm here to not talk to you about the perceptions of what's happening. I can talk to you about what is actually happening. And I network with all 14 hospitals across the state. BOSS coordinates with the emergency department directors and nurse managers to make sure that we're all The voice at the table is really the people that are having to do this work. And I've got to tell you, we are trained to deal with everything. We are now trained, a lot of us, to deal with OB emergencies and deliveries as we look at a nation that's becoming more and more OB desert. We're trained to deal with emergencies for pediatrics, traumas, TNCC, ENPC, CEN, PALS, BLS, all of the certifications behind my name to ensure that I can take care of any patient that walks into the ER needing care, to include de escalation for these patients specifically. So again, I really want to talk about what your goals with this bill is and really bring it back to that it's just talking about the first certification and ensuring that the right patient is seeing the right providers at the right time in the right setting and addressing the barriers to accessibility and the efficiency across the health care system currently while we continue to make changes to the larger system that is broken. And I think we would all agree that, myself included, we want the least restrictive means possible to these patients. It is really challenging to be in those situations when you are actually the one physically taking away someone's rights. So please think about how that is different for us as we are in those situations, and we have to manage them, and we have to train, and we have to support each other, And how, again, the reality of right now, this bill is supportive to these patients, but also still continues to protect the entire process. So as I mentioned, Title 18 is a person's, once a person is warranted and a certificate for emergency examination shall be evaluated as soon as possible after arrival to the hospital. You pointed out that currently, that includes that's a provider, a doctor, as well as an NP, but not a physician assistant. Emergency departments are staffed with physician assistants at all times of the day, not only at night, where that tends to be specifically in rural areas. And I've worked in our medical center as well. They are staffed throughout the day to support the needs and the census and the acuity of the hospital. Ensuring that we add people to that definition that are actually in front of the patient, again, allows this process to start sooner. And it actually improves some significant legal gaps, as I've had really great conversations around that. Because if a patient is brought in under a warrant so if a clinician, a qualified mental health clinician, sees a patient in the field, petitions a judge to get a warrant for an emergency eval, a judge signs that warrant and has the police bring a patient if they're not willing to be participatory in coming for their emergency eval, because we are the only place that can do it, they will be brought in for the eval. If that emergency department, because of whatever else is happening, does not have a doctor or an NP available in real time, that individual is in our department in almost this period of time that is legally very unsettling to us because it's really hard to determine, do we let them leave? Really sounds like what they were brought in under is incredibly challenging, and we need to support what their crisis is and their access to care. If we don't have a PA to certify that EE legally, can I hold them? No. Do I open the door and let them leave? That doesn't seem like right care either. So for us, we're stuck in this weird time frame where we can't get the right access because of this clause. I know Lindsay had mentioned really maybe clarifying that this is only emergency department physician assistants. I support that. Again, the bigger picture of if I could say, what do we do to improve the system? It would be access outside of the emergency department for patients before they're in a situation where they actually require involuntary treatment would be really helpful, as well as the outpatient resources that are needed along the way. But again, we're talking about this bill, which is right now. This doesn't lower the qualifications. Daisy mentioned you guys were going to have that But NPs and PAs are phenomenal in emergency departments. They are some of my favorite providers to work with. They are efficient. They are trained. They are certified. They hold all of the same certifications that we do to treat these patients. And as you talked before, right now, we're actually excluding mental health patients from getting access to care. And that is the only population in the emergency department that is sitting there without access to care. So PAs are able to see absolutely everyone else except for patients in this. So a PA can treat a STEMI, which is a life threatening heart attack when I have to get to the cath lab in thirty minutes. And they know and they are trained to do the protocol to get them out of our ED in sixty minutes or from the ED to the cath lab in sixty minutes to get to a balloon. They are trained to do that. And they do that really well because of what we see and what we do and how we feel about doing our job for our community members. Again, currently excluding these patients in acute crisis doesn't help them get that first certification. So they would continue to be qualified by the Department of Mental Health under the same standards and process that the NPs and the doctors do. They go through that same qualification process to be able to write EEs. And this is also, just as a side note, in coordination with the designated agencies assigned to those areas. So all of our EEs are done with our designated agency, a qualified mental health professional. So whether they're coming in from the field or they come into the hospital to assess us with the decision to do an EE, no matter who the provider it is that's signing off on that, it is done with qualified mental health professionals. So it continues to support us. The providers also continue to order appropriate labs. What this first cert does is it cleans up the gray zone of getting more work done and keeping that patient safely. So we continue to get the work up to appropriate. We collaborate with the Department of Mental Health and the inpatient facilities that actually the doctors do a doc to doc and they say, Hi, have you done this? Have you looked at labs? There's standard labs and protocols that we have for obtaining urine and blood samples to rule out medical things. And PAs, NPs, and providers are not bound by using order sets based on their licensure at this time. They use the same order set for every type of patient in the emergency department. So the workups don't change. We see these patients. We do the workups on all patients. And again, it's really about being able to sign off on that certification. Because as we mentioned, I agree with Emily. It's not great that a doctor that really doesn't see the patient comes down and signs the piece of paper. But that is the reality. So in addition, that's a barrier to care and it's an overuse of resources. So currently, in some facilities, I had a colleague who, like I mentioned, we continually talk about this on the ground, who said the other day that she was called down to complete an EE. She was a hospitalist, NP, complete an EE on an ED patient. The PA was down staffing the ED at that time. She came down, saw the patient, based on the information presented, from a hospitalist training into the emergency department world, where it's very different training on how we assess immediate emergent crisis and care versus the entire hospitalist world. So she comes down. She signs off because she is allowed to, and this is how the hospital has done that. And she goes upstairs and she writes a consult. And then she'll also charge the patient for a consult. So patient is getting duplicate charges for assessments and care, which again, we talk about how that's not efficient in our current system and really challenging, I'm sure, for the patient on the other end to see that you're getting duplicate charges in a system where we can just make sure that the right people in the right settings are seeing the right patients. Again, I'm not going to relay a lot that we've talked about here, but the delay of access is the hardest part. So again, someone's sitting there in this gray zone where we ask this is our verbiage can we let them leave? Well, they're allowed to leave until they try to leave. That's not good for the patient. So we're trying to hold patients there under this voluntary umbrella without being able to start the process of getting them appropriately assessed for their second certification. So again, the certification process isn't changing. There will always be that second certification, which I very much support because we've talked. There are situations where somebody's current situation has escalated to immediate acute crisis. And then once that situation resolves, their second certification, it doesn't warrant it. They're discharged. And I think that that process is working really well. I think it continues to protect having a dual certification process to ensure that there are two providers from two very different lenses. Again, an emergency department because that is the only place that they have access and can get to care, as well as a licensed psychiatrist. So again, I think what five seventy three really does is it's right providers, right time, right place, providing appropriate care to all patients with the same guardrails in place to protect them.

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: Yes, please. I just want

[Unidentified Committee Member (female)]: to address the parity question. I have been with my mother in the ED for hours, and to me, the parity that you're treating this person or getting them evaluated and getting them out of the ED is actually a blessing. Like you're say that you're taking their rights away by treating them first, it seems like almost better to get them out, not only for the patient themselves. And I understand this is you've taken someone's rights away, the severity of it is intense, but it's also better for the other people who are great. I've been in the hallway at UVM for like eight hours, but

[Alyssa Black (Chair)]: my mother's heartbroken, heck, it

[Unidentified Committee Member (female)]: was terrible. I just, I'm not buying the parody part of this, that we're, it's going to happen anyways. And you're just removing them from something that seems like it's more intense than it would be, than it has to be, in my opinion.

[Liz (Emergency Department representative/nurse leader)]: Yeah. I agree. I think it's hard. I think that these conversations are hard. But again, I think what the goal here is as we continue to try to integrate what is going to be successful change on a larger scale, And again, that is more outpatient access as well as easier inpatient access because we call that the Intelli Loophole in the ED. If you want inpatient access, if you feel like my scale has been tipped and I need a little time in the right place and I want voluntary inpatient access, you have to go through the ED. But the system that supports voluntary access is not regulated and it is incredibly challenging. As Vas has reported out, the significant amount of data around patients sitting in the ED and EE involuntary versus voluntary doesn't include the voluntary patients that sit there. And the hospitals that we are trying to get them to and trying to get their care coordinated through send requests for private payment plans from a patient. So we'll accept you for voluntary patient if you can sign this patient payment plan. But we, as an emergency department, if you're considered and stating that you're a risk to yourself or a risk to others, safely. And I don't want to discharge you safely. That's not safe for you and it's not safe for our community. So again, there's so much to do to improve the system for our patients, for our hospitals, for every other patient in the emergency department that we are the funnel of health care right now. Again, really what this is doing is supporting what we currently have to ensure that the process is started. Not that the process is done right, but the process is started timely.

[Alyssa Black (Chair)]: Yeah, I mean, to me, it just seems like we have designed the system as it is currently. And that system maybe should not have been designed that way, or maybe we need to redesign how

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: it is. But in

[Alyssa Black (Chair)]: the meantime, that's what we've required. And it just feels to me like we've taken and we've tied the emergency department's hand behind their back. And then we're blaming the emergency department because of the system we designed.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Right. You can expand that to the whole system. Yeah.

[Liz (Emergency Department representative/nurse leader)]: I've had that great, interesting conversation with Lindsey around that. And it's true. And again, I welcome these conversations. I'm grateful to be sitting here. My colleagues at ANA, ENA, and BNPA are really engaging more than what we thought we would be doing. I run an emergency department. I'm a direct care clinical personnel that deals with patients daily. And I'm sitting here because this is important on my own time to represent all of our emergency departments in this state to ensure that those patients have the right access. And that health care, as we move forward and your committee presents bills like this, is really rooted in what happens at the bedside. Because we have ideal states, but if we're not starting at what's actually happening, we're never going

[Daisy Berbeco (Ranking Member; lead sponsor of H.573)]: to get there. Liz, thank you so And I really appreciate I don't know if the committee knows, but Liz has really helped me come up to speed with the many ways that folks experiencing mental health crises interact with her folks in the ED. And I just really can't thank you enough for helping me get up to speed on the issue and such a challenging issue and continuing to stick with it and make sure that we're centering the right voices. And that's another thing I would just point out to everyone's additional testimony under this bill folder. Mad Freedom is an organization that sent in a letter. I met with them twice, and then one of their staff was in for disability rights day. She testified a little bit about the bill, so you might want to go back and listen to her comments on it.

[Alyssa Black (Chair)]: Great.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Thank you. Thanks, Liz. Thank you. Thank you, Liz. I'm so

[Unidentified Committee Member (female)]: happy when she wants to. We

[Alyssa Black (Chair)]: should go off of live. We'll be back at 01:00.