Vermont Legislature SmartTranscripts:

[Speaker 0]: Use all you want.

[Rep. Alyssa Black (Chair)]: Hi, welcome to Washington D. Is April 16. This is House Healthcare, and we have in with us some representatives from two of our designated agencies to talk with us about some things that are happening around residential services that we thought we should get an update on and should be aware of.

[Unidentified Committee Member (House Health Care)]: Wonderful. Wonderful. Well, good

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: morning, Chair Black and members of the House Committee on Healthcare. My name is Melanie Gidney. I'm the Executive Director of Clara Martin Center. We serve Orange County and the Upper Windsor County territory area and currently serve as co President of the VCP board. In addition, with me today is Sandy McGuire, the CEO of Howard Center in Chittenden County and Christie Everett, our Director of Operations at Clara Martin Center. We're testifying on behalf of Vermont Care Partners, the statewide association representing Vermont's designated agencies. The private nonprofit community mental health and developmental services organizations that serve every region of the state. Thank you so much for this opportunity to speak with you today on a matter that feels of really urgent concern for us. We're here to address a crisis unfolding in real time. Vermont's adult mental health residential programs are at risk of closure and the people living in them face displacement with nowhere to go. We want to be clear both about the problem we're facing and trying to solve and the solutions we believe may be available to us with the assistance of this committee. So I think we covered. I think people are most familiar with the, our, the DA system. So assuming that I'll move forward. How we got here, a system built by Vermont for Vermonters. The residential programs now at risk did not emerge by accident. They were built deliberately over decades in direct response to crises and in partnership with the state. The closure of the Vermont State Hospital. The Vermont State Hospital in Waterbury was the state's centralized psychiatric facility for over one hundred and twenty years. By 2003, it lost federal Medicaid certification following patient deaths and documented care failures. When tropical storm Irene flooded the campus in August 2011, the state made the decision not to rebuild. Governor Stremlin announced that Vermont would instead build a decentralized community based system of care. The result was Act 79, passed in 2012, which was landmark legislation that charged designated agencies across the state with expanding community residential capacity, crisis beds, and step down care to replace the institutional model that had been left behind. Programs were built at the request of the state. So over the years that followed, designated agencies developed residential programs in response to direct requests from the state to expand capacity, keep people in their home communities, and prevent the psychiatric emergency department backlog that had become a defining crisis the post Irene transition. Howard senders 54 residential beds, Copley House, 4 Highland, which we all is in Clara Martin Center, we also call it safe haven, which might be of confusion. But just to clarify, and programs like them were not independent ventures. They were answers to a state call for building the community based care system. Safe Haven and Peer Supported Housing. Programs like Clara Martin Center Safe Haven, in operation since 1998, have long provided housing and affiliated services for homeless individuals with severe and persistent mental illness across Orange County, Washington and Windsor as well, filling a gap that no other system was equipped to address. This history matters. Vermont asked its designated agencies to build this infrastructure. The agencies did so in good faith and individuals and communities came depend on it. And I'd also add, I really feel like we'll talk a little bit more that we've had to close one of our programs and the outpouring of support and the positive outcomes that our community has experienced. I think they're also cost effective, treat people with dignity and strength, keep them in their homes and just really positive outcomes and saves money overall. Any questions? Okay. We wanted to identify who lives in these programs and these residential services that we're referencing. Across Vermont's designated agency network, there are currently well over 100 adults in mental health residential programs. These are not transitional residents waiting to move on. They are people with lifelong serious mental illness who require ongoing structured support to remain safe and stable. We think it's under, it's important to understand who they are understanding who they are is essential to understanding what is at stake. I think we all know that we have an aging population, and we have aging adults with severe and persistent mental illness with incredibly complex medical issues. Many residents have lived in programs for years, in these programs for years and even decades. They're aging, managing chronic multiple health conditions alongside serious mental illness. Some came directly from the Vermont State Hospital around the year 2000, when Vermont made its community care commitment. Some have been with us long enough, had the state hospital remained open, that they would have spent their whole lives there. Other folks are not eligible for other systems. These individuals are frequently ineligible for choices for care, Vermont's Medicaid long term care program. Nursing homes are often unwilling or ill equipped to accept individuals with serious mental illness, particularly those with behavioral complexity. Though in some cases nursing home placement has been pursued, there is simply no other system specifically designed to serve this population. High risk if displaced. Without residential support, these individuals face homelessness, repeat psychiatric hospitalization, prolonged emergency department boarding, and serious deterioration in their health and safety. For the most medically fragile residents, displacement from a stable long term setting carries significant risk of rapid decompensation. These are not theoretical outcomes, they are the predictable consequences of removers removing structured support from people have required it in some cases for decades. Some residents do not meet the new rehabilitative criteria, which is a current issue that's been going on within the state for the past year with some changes in Medicaid regs. In some programs, a number of current residential clients do not meet the new rehabilitative criteria, not because they're well, but because their needs are long term stabilizing and habilitative rather than acutely treatment focused. It's important to note that at Howard Center, all current residents are clinically eligible for this level of care, yet those individuals still face housing instability due to the lease based funding conflict that we'll describe below.

[Rep. Daisy Berbeco (Ranking Member)]: Questions so far? I'm starting to get a little bit lost in terms of I'm following the thread of the individual story, but I wonder, you mentioned something about a change in Medicaid. Are you going to queue up what that change has been that disrupted people after decades of being housed?

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: Yes. Yes. Yes. So the problem we're trying to solve. When asked to speak to the committee today, we were asked to clearly define the problem from our perspective. So here it is. Vermont is changing how adult mental health residential services are funded under Medicaid, moving from a habilitative model, which is long term support to help people remain stable, to a rehabilitative model focused on short term treatment and discharge. While this transition is intended to align with federal Medicaid requirements, its implementation has created two intersecting crises that if unresolved will result in the loss of residential beds and the displacements of highly vulnerable Vermonters. So problem number one, no funding pathway for habilitative care. Many current residential clients do not meet the new rehabilitative criteria. They require long term stabilizing support, not short term treatment toward independent living. Under the new framework, there is no Medicaid pathway to fund their care. Programs cannot serve individuals they cannot bill for. Without a solution, providers face an impossible choice: keep beds open and absorb the cost or close the program.

[Unidentified Committee Member (House Health Care)]: Leslie, did you have a question? I'm sorry. No. When you say Medicaid, this is Vermont driven, not federal. I'm just trying

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: to understand. No, it is a change with CMS that they changed. The medical DMH is applying the federal legislation. Thank you. That basically within the criteria,

[Unidentified Committee Member (House Health Care)]: formerly CRT went away and it was moving from.

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: It was formerly CRT to now this TPL 63 certification. Do folks understand that here?

[Rep. Daisy Berbeco (Ranking Member)]: No, we haven't got an introduction to that.

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: Yeah. And then so we can loop back on that and further explain that for, but it narrowly defined who was eligible for this Medicaid insurance level of support. So it's at the crux of this. So we'll circle back on that. But the people that were eligible for residential care that's supported by Medicaid changed, that people needed to be supported to recover, get well, get better, transition back to a higher level of care, transition out into the community. We know that debilitated people, we know that there's 100 people that don't meet that criteria. But if you take away the housing and the supports they currently have, they're going to decompensate. So there's this gap for people that are long term care. They've been in our system for a long time. They need the supports, the wraparound services that we provide, but they don't meet that degree level of certification. They're not eligible to stay in these residential settings.

[Rep. Daisy Berbeco (Ranking Member)]: These are people who may have a lifelong mental illness, a really deep mental illness that is not going to be cured. Thank you.

[Sandy McGuire (CEO, Howard Center)]: A couple of things to add that might be helpful, and our state partners could verify or correct this if I'm misstating. But my understanding is part of this change in funding came about because of the conflict free case management component that the state was out of compliance with. And so in the developmental services world, where services are debilitated long term, there was one route that mental health services were able to avoid some of the fallout of what was changing or needed to change to get into compliance by, I think it got pulled out of the waiver and maybe as in the state plan, this is where you definitely like, I think this is what it was, that is what made this shift to the rehabilitative. So it was fixing some compliance pieces, but it shifted some of the eligibility for services and what the Medicaid, that stream of Medicaid could pay for. And so that's that crux of the the rehabilitative versus the rehabilitative piece. So many of our folks in these beds might still qualify for the, even at the new level of criteria for rehabilitative, and yet they'll likely need to be there long term. Others don't qualify for the new higher eligibility that's there. And I think one piece to note, was just looking at some data for Howard Center, over sixty percent of the folks in our residential beds, we have fifty four. The primary diagnosis is schizophrenia, which is one of the most complex, one of the worst as far as behaviors and symptoms of mental illness, and also one with the worst side effects of medications, which is really challenging for individuals. So as I've

[Unidentified Witness (Vermont Care Partners/advocacy staff)]: been exploring and better

[Sandy McGuire (CEO, Howard Center)]: understanding what we're facing both as an organization, but as a state, that was an interesting piece as we think about just your question, Daisy, are these going to be able to come and go in shorter term treatment, which is what this is geared up. And just one other piece, I just wanna note that we will still serve these individuals, right? They're still eligible for services at designated agencies and we'll all still be serving them with all of services that they're eligible for. But many of them are no longer eligible for the residential program, which in many cases leaves them without a home.

[Unidentified Committee Member (House Health Care)]: Yeah, that's where I went. Was like, they're likely to be homeless. Yes, It's really worrisome. I'm confused about how the system is evolving towards that. Just, Debra,

[Rep. Daisy Berbeco (Ranking Member)]: you noted conflict free case management. If you could just boil that down in simplest terms, in terms

[Unidentified Committee Member (House Health Care)]: of

[Rep. Daisy Berbeco (Ranking Member)]: like, because I think this is a really important piece when we get to what are the solutions, because there is that federal component that we have to comply with. But it is a state decision on what compliance looks like, whether it's providing more case managers in order to create that firewall payment and treatment plan. I don't know if one of you might be able to boil that down in really simple terms for us.

[Sandy McGuire (CEO, Howard Center)]: I can do it really simply because I think that's the level I understand it at. It's that this conflict free case management, the stapling out of compliance is what triggered this change in the Medicaid. So I think how we were paying for these services across adult mental health overall changed and went under a different Medicaid is not Medicaid is not Medicaid. There's lots of different streams and rules. And so it changed to a different stream that then requires damage to apply different rules, different criteria, what can be funded, what can't be funded, which we'll talk about a little bit more in the previous funding. Again, I think it was all under the waiver. We were able to pay for room and board Under this new stream, room and board cannot be covered anymore, which is another concern of ours that could potentially shift to the clients. So I'm not sure I know what conflict

[Unidentified Committee Member (House Health Care)]: free is. That seems like what's

[Rep. Daisy Berbeco (Ranking Member)]: generating The the person who is designing the treatment plan cannot be from the entity that is going to be

[Rep. Alyssa Black (Chair)]: collecting the payment. Oh, so it's conflict of interest. Okay. I was

[Unidentified Committee Member (House Health Care)]: in conflict interest. It.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah. So there has to be Medicaid, there has to be like a firewall. So that person has to be somewhere else. But because of the limited workforce we have in Vermont, it's really difficult to do that. We would have to create a whole new workforce of people doing just treatment plans. Okay, doesn't make sense.

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: Okay, I didn't understand. And developmental services went in one direction and DMH went in a different direction in terms of meeting those guidelines. And my understanding is it did take the Medicaid out of the waiver and put it into the state plan. And by doing that, this rehabilitative versus habilitative came into play. The reality is not everybody meets those rehabilitative criteria. And this it's not necessarily a small group. The ones that don't still have very high needs and are incredibly at risk and medically fragile if they did not have the stable housing with the supports that they've had in place. So that is our concern. For us, we'll speak a little bit more about Clara Martin Center's experience. When this change to residents needing to meet TPL 63 certification, it eliminated a lot of people that had access. We were at full capacity prior to July 1, and when that change went into place, our numbers are significantly lower. So we just can't we don't have the referrals that are eligible to fill our beds. So yet there's people that still need this level, but they don't meet the threshold, through the assessment process with DMH through our programs. So we're left with where do these people go? And we know they still need the supports. That, but we'll talk. And I think the other thing for me to mention is that just because somebody isn't rehabilitative, that they really are in that maintenance, they've kind of peaked at their level of need and care, and it's clear they need this for life, that they didn't fail. That's just the reality of their illness and their progression and the effectiveness, I think, of our supports to keep them stable in our residences and out of the hospital. So I'll speak a bit about the police conflict that's coming out from a housing perspective. So in addition to rehabilitative and habilitative changes, several residential programs were developed using federal HUD money, which by law requires the residents to have leases. The states indicated that settings where residents hold leases may be considered permanent housing and therefore may not meet criteria for residential treatment reimbursement. No final policy determination has been issued. This creates a direct conflict between two federal requirements: CUD indictates the pieces, Medicaid now penalizes them. At Howard Center, all 13 effective individuals in leased based settings are fully clinical eligible for this level of residential care, meaning they meet that TPL 63. The issue is not clinical need, it's in the housing structure that Vermont and the federal government deliberately built. We do not yet have a final policy answer on how or whether this conflict can be resolved. So this comes back, I think, to some of those new Medicaid requirements. These were programs that for two particular facilities, HUD has a program, I think it's eight eleven, that is specifically designed to provide or support stable housing for populations with serious mental illness. And so these were established quite a

[Sandy McGuire (CEO, Howard Center)]: while ago and the federal government actually pays for the building itself. And if you use it for those intended purposes for a certain amount of time, it might be forty years. Ultimately, the organization would own that property if they continue it with that use. So it reduces the cost significantly on that. But a HUD requirement, and we vetted this with legal counsel, is that there are individual leases with the state. And so the interpretation as DMH has worked through this is that is actually permanent housing, which is at odds with rehabilitative treatment if it's permanent housing. And therefore, believe, and we haven't heard a final decision yet for what'll happen July 1, but that our understanding is that they won't be able to fund programs that are in these, which essentially means, okay, well, so we give up that property, give it back to the government, go buy or lease another property that then we need to find the dollars for and have all these folks move into that property to be able to maintain the same services. Again, these folks are all eligible. They do meet that higher bar for these services, but the actual building itself is the problem.

[Rep. Alyssa Black (Chair)]: All right.

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: So problem number three, the implementation timelines already past the point of adequate notice. The Medicaid transition was originally scheduled for 01/01/2026. Recognizing the scope and complexity, DMH extended the deadline to 07/01/2026, A decision we definitely appreciated. However, as of today, April 16, providers across the state still do not have the following. Final rules or policy guidance on the lease based lease based housing conflict which Sandy just spoke to. Service rates under the new model most agencies have not received these yet or any guidance on how room and board will be covered. DMH has indicated this cost would fall on residents and or agencies, but no formal policy or amount has been established. The last point deserves emphasis. Medicaid does not cover room and board. Under the current framework,

[Speaker 0]: suggested the burden of covering those costs would be borne by residents, many of them who live on fixed SSI, SSDI income, and by the agencies themselves. Neither is viable. Agencies cannot absorb an unfunded

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: cover room and and board gap and the residents on fixed incomes can't afford it either. There's less than seventy five days until July 1. There's not sufficient lead time remaining for providers to plan, notify residents, adjust staffing, or determine whether they can remain financially viable. For many, the window for an orderly transition has already closed. So what does this look like at the statewide picture? Across our member designated agencies, the impact is significant. So, for Clara Martin Center, the agency I represent, for 4 Highland, also known as Safe Haven, Clara Martin Center's only staffed residential program of four beds that were integrated with two crisis beds is closing 06/30/2026. In DMH's proposed FY twenty seven budget, a cut was made to Safe Haven as it wasn't considered an outlier in the system on how it was built historically. Trying to get remove the outlier funding, that's one offs, and that one off was an agency, our program at our agency. When that proposal came out, we were already six months in. We were one of the first agencies that actually got a rate. We are the only agency that got a rate for July 1. And it was clear with the change in TPL, we did not have capacity, the appropriate referrals for us to remain viable. So when that funding cut, that was really for uninsured, underinsured Vermonters, it kind of was the final seal for us. And we'll talk about that process a little bit further. In Lemoyle County, Copley House has 15 beds and Johnson Group Home has seven beds. Copley House is a residential care home serving individuals who largely transitioned from the state hospital around the year 2000. Many have lifelong mental illness and would have been institutionalized for most of their lives without this program. If Copley House closes, 15 people face homelessness, placement in settings ill suited to their needs or rapid decompensation. The Johnson Group Home has at least one client who will never be able to manage independent living. Howard Center has 54 beds across seven sites in Chittenden County. 21 beds are at definite risk due to the unresolved lease based housing conflict. All individuals in those sites are clinically eligible for this level of care, but the housing structure currently disqualifies the reimbursement. All 54 beds are potentially at risk if service rates prove insufficient or room and board costs are not addressed as agencies cannot absorb the unfunded operational gap. CSAC has 15 to 16 beds with no viable pathway to sustain DMH funding under new guidelines that have been identified. Closure remains possible. There are no alternative placements. NCSS has a six bed TCR. Four of the six TCR clients do not meet the new rehabilitative criteria. They also do not qualify for long term choices for care supports and cannot manage independent living. There's no residential program in Vermont specifically designed for this population, and that's the complex medical needs. Washington County and other agencies' programs anticipate significant changes to the nature of residential care and increasing acuity of residents as requirements shift without corresponding increases in staffing or funding. The total number of beds at risk across the state is not small. These are not duplicative or redundant programs. Vermont's residential mental health capacity was already limited before these changes. So every bed lost makes the entire system more brittle. I think we wanted to speak a little bit about some of you may have heard the process that Clara Martin Center has been through to come to the termination that it needed to close its Safe Haven program. I thought I would ask Christie Everett to speak to that process and how we arrived at that decision.

[Sandy McGuire (CEO, Howard Center)]: Yeah, so there is

[Christie Everett (Director of Operations, Clara Martin Center)]: a slide included. There's a lot of information. It is small. So I'll try and walk through some of it just to understand the pathways of how we've had to change our program over the years to really meet different criteria and cost and shifting everything else like that. So our Safe Haven program was opened in 1998. We're really proud. It was the first program in the state for a community mental health agency and a peer program with Vermont psychiatric survivors and non New Vermont. And that was a six bed transitional living shelter funded by HUD. At that point, that was HUD's priority, was transitional living for the permanent housing. Homeless individuals who had a mental health challenge or a substance challenge could stay up to two years in that program. Historically, it had always been a full program. And we were able to transition people out to housing within three to six months under that model. In 2014, the federal policy shifted, and HUD no longer prioritized transitional housing. They prioritized permanent housing. The program, because it was funded by HUD dollars, we actually had a decrease in funding for that program. And we actually lost two of our beds. So from a six bed transitional to a four bed permanent, again, people could only stay up to two years. But again, lost capacity. And in Orange County, this is really the only staff housing program that we have. Around that same time, we had our Christmas Place two bed crisis program that was started under Tropical Storm Irene. We were able to actually move those two beds into our safe haven building, which was really helpful because individuals who were in crisis could also get that support and experience from people with lived experience. So for our program, it really was a model that worked really well. And we could have people there for a short term amount of time, three to fourteen days in our Christmas Place program, or longer term in our Safe Haven program if they were homeless, and provide all the services that we could, whether it was case management support, voc rehab support, any of those services in our outpatient clinic. In 2019, we had been working with the Department of Mental Health, Community Development Corporation, and some other community partners to really see how they could restore the two beds that we lost to the agency. We cobbled together some funding from different sources, and we were able to put online 28 South Main Street in Randolph as well. Again, that's another program that had DMH support around that. That created four permanent individual one bedroom apartments for folks who had mental health challenges, substance challenges on the campus of the Fair Martin Center. Folks who live there had easy access to our outpatient services as well, too. So we were able to restore those beds. They provided some operations support at that point for us to be able to serve individuals who were uninsured, underinsured as well. All of these programs came with the whole understanding that folks had to spend at least 30% of their income towards room and board as well. So whether it's the 28 South Main Street, whether it was Safe Haven, there was always that requirement to meet that. If individuals couldn't meet that, they didn't have any income, we would connect in general assistance and they would provide some of that resource to the room and board. But if people couldn't still afford that, we'd work on a sliding fee scale. So at least that issue was addressed as well. So we slowly built back some of that capacity in 28 South Main Street. It has been full since we opened it in 2019. So no turnover there. So as Melanie had mentioned last year, DMH transitioned individuals from what was CRT, the new rehabilitative treatment program, for folks who need this long term chronic health for stabilization of their mental health symptoms and everything else like that to now no longer being CRT. Their TPL 63 is an added insurance benefit. It's third party liability. So folks who meet a criteria for what was previously CRT are eligible now for TPL 63, which allows them enhanced services and everything else like that. What happened, though, at Safe Haven is Safe Haven then was pared down to we could only admit people who had TPL 63. We could no longer admit transition age youth who might have been homeless with a mental health or substance challenge. We could not admit regular, normal, basic adult profiles of individuals who do not have chronic mental health challenges, if they did not qualify for TPL, they were no longer eligible to be considered for housing at Safe Haven. So as that changed, while we had four beds, our occupancy rate went down to about 25%. We had available beds that we could have served homeless individuals that could not access that care. So beds set empty. And I think we're dealing with individuals who are homeless across the state who could have qualified. We could not serve them. Sorry,

[Rep. Daisy Berbeco (Ranking Member)]: Christy. I am just looking at the clock and we have a few minutes left, I feel like we probably have lots of questions. So my first question is what can we do to help as a committee? I know, you said Yeah.

[Unidentified Committee Member (House Health Care)]: There's

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: been a lot of questions about what happened for us and why we came to the decision to close, Because we are an outlier, and that we did make that decision to close effective June 30. So didn't know if people here had questions, but some of the other legislators have had that. So you know that if you wanted to know about that, but let's go fast forward. To propose solutions to what can the legislature do right now. We understand there's still time this session to move on something or do include provisions in a germane bill. The homeless continuum bill currently in the Senate includes supportive housing initiatives, including ideas around voucher plus care that could provide meaningful support to our residential system. We're actively engaged there and would welcome the committee's support for housing type service provisions. Additionally, a study requiring AHS to work transparently with DAs on federal and state requirements is moving forward, And that kind of structural accountability would help prevent the situation we're in now. For the immediate July 1 crisis, the most important lever the legislature holds is to direct DMH to issue final rules, issue rates, and room and board guidance without further delay, and to make clear that a further extension is on the table if that guidance cannot be issued in time or resources are insufficient. And then we talked about the next biennium and more long term planning, really requiring all of the state agencies to come together to work with us as a DA system to look at the ongoing issue of housing. We know without housing, without stable housing, this very at risk population becomes destabilized and there's a higher cost on the system on the other end. And it's a life and death matter. So you know, I think we need action. The VCP network needs answers on their program going forward as of July 1. And as of April 16, they still don't have their rates. And the rates that we did get with the change in the TPL does not have our program being sustainable. So I worry that our experience, there's others on the cusp of that same situation of having

[Rep. Daisy Berbeco (Ranking Member)]: to close programs. When did people submit their cost sheets to DMH to get their rates?

[Rep. Alyssa Black (Chair)]: I don't remember

[Sandy McGuire (CEO, Howard Center)]: what the date was. There was a deadline that was set that agencies met and provided that information for. Yeah. I mean, I think, hopefully what's coming across is our concern and urgency of the situation, both to we don't want to be forced to have programs that we can't sustain, both for the organization's financial health, but most importantly for our neighbors, for our Vermonters that are living in these and our staff as well for something that might potentially happen July 1 and not having that information to understand how to plan. We're hopeful, maybe it's all gonna be great and be sustainable. That would be a wonderful outcome. However, it does leave the concern for many communities about the habilitative individuals that aren't meeting that new higher bar for this level of care. That is something that it has immediate impact, but also feels like it has a

[Rep. Daisy Berbeco (Ranking Member)]: little bit longer runway to be able

[Sandy McGuire (CEO, Howard Center)]: to figure out some solutions to that in the coming months or over the summer, whatever that might look like with the agency. But again, I think we're concerned about the potential immediate impact and some very unintended consequences, I think for all of us across the state,

[Rep. Alyssa Black (Chair)]: if there's a way to avoid that. So is HS, I mean, human services? So in the Senate, what is, you're working with a bill in

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: the Senate? Yes, it's the homeless continuum bill that we're aware of currently in the Senate around supportive housing initiatives and vouchers plus care. So I don't know more about that specific language. But are there other bills that we can tap into to address this need from this funding gap? Johnson.

[Unidentified Witness (Vermont Care Partners/advocacy staff)]: So we're following the housing continuum bill and there is work in there around permanent supportive housing and shelter plus care bridge programming that would potentially support this population. So that is a potential supportive program, but we're not sure what that'll look

[Unidentified Committee Member (House Health Care)]: like when that'll be able

[Unidentified Witness (Vermont Care Partners/advocacy staff)]: to support this specific population. The other thing that we're working on in the budget bill is language around a study slash work group that would focus on this kind of state federal mandates and the process by which these things happen, because what we're seeing pretty consistently is that changes are made. They're not necessarily happening as like a full group effort where everybody's talking about, this is what's happening, this is what we need to do, how are we gonna enact that? What does this look like on the ground? What does this mean for agencies? Changes happen and then things shift and then it has this detrimental impact to the agencies and most notably the people that we serve. And so we're really looking to establish a clear transparent process by which state and federal mandates and requirements are happening to the DA and SSA network. So that is being worked on with the Senate for the Senate version of the budget. There is something in the house version of the budget that looks like a community engagement process akin to act 167. And so we're trying to enhance the language to add that as a lever that we can pull to support kind of the broader systemic issue around this. But in terms of what's happening right now for the rehabilitative population, there still isn't an answer.

[Rep. Alyssa Black (Chair)]: So one of your now before July 1 for us to direct DMH to do this and also delay, are you suggesting we try to move legislation that could be Or are you just saying, like, send an email to them? Actually, two part of that. I'm certain that you have conveyed to them that this timeline is not working very well for you. What has their response been? They're working on it.

[Christie Everett (Director of Operations, Clara Martin Center)]: And I think part of the decision making that went into our decision to close Safe Haven because it's co located with our crisis beds, the mandate that all our crisis beds become integrated PIP beds was not brought to the agencies prior. Was DMH proposed that to legislatures without discussing it with the system as well. We had a very short window to put that into place. The cost to put that into place would cost our agency post, I think is what we figured out, about $400,000 which is unfunded. There is no funding attached to this integration whatsoever. And it goes to why it's really important. If these mandates come down, the system and the providers are involved in that and not just make these decisions without the input of people who are providing this care as well, too. So that was one of the things that really led into why we needed to make this decision to close. And when we discussed that with the Department of Mental Health, we talked to the commissioner, we talked to the director of mental health services. We've been talking to them for a couple of months prior to making this decision. The response we got was, well, just look to your regional partners and work with Washington County or someone else, which we work really well as a system of care. Think folks know that the Vermont Care Partner System and all the agencies, we collaborate very well. The problem is individuals who are in crisis, individuals who are connected with their outpatient services, they are better served that they stay in their community of care. Taking someone from RAND UP, where we have our systems built in our agencies, a lot of our services are within walking distance, taking someone who's in crisis and sending them to White River Junction, where they're apart from their psychiatrist, they're apart from their case manager, doesn't really work for individuals as well. So I think there can be some things that are regional, but agencies and communities need to have those services locally as much as possible.

[Rep. Alyssa Black (Chair)]: Any questions? For you, should we have DMH come in? I think that, so I'm looking at DMH, I'm assuming that DMH is watchability, watching.

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: Think the takeaway I would add to is just bringing to your attention that there is this housing. There's already a housing problem in the state. This raises for a high risk population more vulnerability and instability. And some of it is as Rachel with federal government, but what are we going to do? And an experience like we went through with Clara Martin Center, there's a lot of other agencies that are on the cusp of that. And yes, we will continue working with DMH, but time is of the essence.

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

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: Thank you for your time.

[Rep. Daisy Berbeco (Ranking Member)]: You clearly have urgent things that you each could be doing. And I think that just underscores the urgency of sharing this information with us, the fact that you took time to

[Rep. Alyssa Black (Chair)]: come in here. And it's wonderful to see all your faces. The story is distressing.

[Melanie Gidney (Executive Director, Clara Martin Center; Co‑President, Vermont Care Partners Board)]: It is very. And I think there's we feel a level of urgency, responsibility and accountability to those that we're serving. And it's that runway. I mean, we knew that with our decision, needed at least ninety days, both from the client experience and the staff to do something safely and properly and communicating with all the proper people. I think that more time goes by that runway just moves that out even further. And we'll continue pursuing the clarity and working with DMH in partnership around this, but it is getting to a tipping point.

[Rep. Alyssa Black (Chair)]: Thank you. Thanks for paying it to our attention. Okay.

[Unidentified Committee Member (House Health Care)]: So

[Rep. Alyssa Black (Chair)]: we are moving back to everybody's had sort of overnight think about it. We're going back to H two thirty seven, which is the doctoral level, describing my doctoral level psychologist's bill and bill that we did last year. And I mean that three people in this committee actually worked here last year. And I wondered if anyone had any questions on it. Anyone have any concerns over what came from the Senate? Anyone needing any refresher on what the bill does?

[Speaker 0]: Can you refresh us?

[Unidentified Committee Member (House Health Care)]: I read the bill.

[Speaker 0]: You break the bill down.

[Rep. Alyssa Black (Chair)]: I can break the bill down. Second one. Hold on one second.

[Speaker 0]: Oh my

[Rep. Alyssa Black (Chair)]: god, breaking the bill down too. Well, section, I'm going start with section two, because section one is just definitions. Section two directs the board of psychological examiners, which is essentially OPR, within OPR, to adopt rules that would regulate doctoral level prescribing psychologist licenses, including clinical rotations, minimum requirements for a postdoctoral psychopharmacology program and prescriptive authority, and also the role to regulate collaborative practice agreements and what the collaborative practitioners qualifications and competency evaluations are. And it removes from the board's rulemaking authority, explaining complaint and appeal procedure because as Katie explained to us yesterday, it turns out that that's in another section of the statute that sort of encompasses everything. So it's not that we're getting rid of that. It's somewhere else. It lives somewhere else. She said that as they go through statue, they clean it up on various places.

[Speaker 0]: Let's see. I've question. Yeah. It says the powers of the board, the duties, the board is the board of psychological examiners. Yeah. What is that made up of?

[Rep. Alyssa Black (Chair)]: It's within OPR. I'm doing this by memory, so if I'm wrong. So, within OPR, they regulate lots and lots of professions, And within each of these professions, they have these boards, which are sort of experts on that profession. And so they do things like rulemaking, coming up with criteria that make somebody eligible for licensure. And there is a board of psychological examiners within both the office. They appear if you Google

[Unidentified Committee Member (House Health Care)]: They're right here, there are five. Three are professional, one of them I actually know personally, and he's very skilled, and then two are members of the public.

[Speaker 0]: Thank you, that helps. Section

[Rep. Alyssa Black (Chair)]: three essentially sets up the process in which somebody can apply for licensure to the board of psychological examiners for prescribing psychologist specialty and what their eligibilities are, that they have to obviously have a doctoral level licensed practice psychology, because this is only available to doctoral level You have to successfully complete a post doctoral level training in psychopharmacology, which I think it would be a bit too, it's like

[Unidentified Committee Member (House Health Care)]: a two year psychopharmacology is? What's that? I just want make

[Rep. Alyssa Black (Chair)]: sure everyone understands what psychopharmacology is. Essentially prescribing year mental illness. That makes sense. The American Psychological Association is the one that has the programs. So they have to receive postdoctoral training in that, and then they have to complete, as part of that training, they have to complete these clinical rotations in five practice settings. And then they have to also then complete a national certifying exam. And then having met all the other requirements for obtaining the specialty as determined by the rule, which was in surgeon. And then in order for someone to actually then prescribe, they must have a written collaborative agreement with a collaborating practitioner, which would be essentially a psychiatrist, I believe, right? I think

[Speaker 0]: so. Psychologists.

[Unidentified Committee Member (House Health Care)]: So in line five, a written collaborative agreement is required for all prescribing psychologists practicing under a prescribing psychologist.

[Rep. Alyssa Black (Chair)]: Yeah, but there's rules in here who that person has to be. I'm sorry. I should really I know that there was something in here that Yeah. That who the who the actual person had to be that is the collab collaborateor. Katie is here, but I bet she's busy. It

[Unidentified Committee Member (House Health Care)]: says collaborating practitioner under definitions, so page two, line four.

[Rep. Alyssa Black (Chair)]: We should have gone out of section one. Definition 12.

[Unidentified Committee Member (House Health Care)]: Physician licensed to practice medicine pursuit after '23 or '33. We just learned that '23 was medicine and '33 was DOs, which we

[Rep. Alyssa Black (Chair)]: get as our other bill. So it has to be essentially, it has to be a physician. So the physician, the prescribing doctoral level psychologist has to work with a collaborative agreement with a physician, and then they have to receive issuance of prescriptive authority from a collaborating physician, which is limited only to prescription drugs for the treatment of mental health conditions that the collaborating practitioner provides in the normal course of practice. So while it does say that the collaborating provider needs to be a physician or a DO, it then requires that you can't prescribe anything that that collaborating provider wouldn't be prescribing in normal practice. You know, it can't be like, I'm going to pick on a specialty. It can't be like a urologist who doesn't, in normal practice, prescribe psychopharmaceuticals.

[Unidentified Committee Member (House Health Care)]: But even in this case, it might be that the collaborating physician doesn't treat schizophrenia with a certain drug that's experimental, which means that the psychologist could not do that.

[Rep. Alyssa Black (Chair)]: And you have to also have schedule of two and four controlled substance, issuance. And then section four is a new report. That's a new thing, and that just OPR is going to report to us and health and welfare on the number of psychologists who have taken this up, what the status of available collaborative practitioners are, and then whether or not there's any updates that need to be made. The reason they put this report in is, as Katie told us, essentially, if it wasn't working with the collaborating provider and there was a shortage or something, then they would come to us with ways that maybe we can address that. Alright. That was my really, really bad walkthrough up in

[Speaker 0]: the middle.

[Unidentified Committee Member (House Health Care)]: Good practice.

[Unidentified Witness (Vermont Care Partners/advocacy staff)]: Good enough. No, as I

[Rep. Alyssa Black (Chair)]: was doing that, I'm thinking I ought be on the floor. I can't even see straight.

[Speaker 0]: Question. We passed this in two twenty four or 2025

[Rep. Alyssa Black (Chair)]: last year.

[Speaker 0]: And it went to the Senate. Then it comes back. Now this ain't

[Rep. Alyssa Black (Chair)]: a strike call. It is a strike call. It is a strike call. It's a strike call, but it's basically, they struck everything out and then put everything back in except for those four red areas that Katie told us about, which were the only things that they did. No words. Here, you guys are allowing me to practice this because I'm doing this on the fly today. They added in section two the minimum number of requirements for the curriculum. And they added, or they changed in section three, the clinical rotations. It was eighteen months. They've reduced it to fourteen months. We had nine different specialty clinical rotations, and they have condensed those into five. They eliminated pediatrics, OBGYN, and surgical surgery, and they combined family medicine and internal medicine into one. And then they added neurology. It's just funny when she was telling us this, I remember us last year going through each of these specialties. The GYN? I know. Well, and the reason that they eliminated those is because they're not allowed ascribed to pregnant people anyways in the bill, or eight year olds or children. And why did he not have neurology in that? I know. What were we thinking? And then they added section four, which is just that report back. How's it working? And then they changed the dates. Have to change the dates obviously because it's a year later. They're supposed to go into a family home.

[Unidentified Committee Member (House Health Care)]: If wanted to embed it in their mental health provision, I don't know if that's important. I thought that was cool. Yes.

[Rep. Alyssa Black (Chair)]: They're currently working. They've been working for a couple of years now, aligning all the mental health professions sort of under, not under one thing, but, you know

[Unidentified Committee Member (House Health Care)]: Rules and organizing. Yeah. It's all over the place in statute if they want to put

[Rep. Alyssa Black (Chair)]: it together. Yeah. Okay. So unless there's any discussion on this, I'm going to straw poll this. I'm going to write down. Again, I remember I looked up last year, the committee vote on this was ten zero one. And health and welfare, I think was four one zero or four zero one. I'm not sure what. So all those in favor of the recommended amendment, approving the amendment as recommended by the Senate. Please raise your hand. One, two, three, four, five, six, seven, eight, nine, nine, 02. Thank you. I think Brian just drawed it. Okay. Thanks a lot. I will I know we'll cobble together. Spoiler alert. Worst bill report you will ever see is gonna be today on this.

[Unidentified Committee Member (House Health Care)]: I disagree. I you're well prepared at this point.

[Rep. Alyssa Black (Chair)]: I was gonna hack and cough my way through it.

[Unidentified Committee Member (House Health Care)]: Go go through the four points. I mean, it's a send in a minute. I I mean, it's pretty you know? Yeah. The problem was is that it was a strike

[Rep. Alyssa Black (Chair)]: to hull, which makes it

[Unidentified Committee Member (House Health Care)]: This is the poppers. This is yeah. And everyone will go, okay, actually. That is my bill report.

[Rep. Alyssa Black (Chair)]: It says this was the former member from Barrytown. And he will come after you if you don't. Honestly, I mean, Tupper worked on this bill for years and years and years before. And I don't know if you remember at crossover time last year, we were really hurried. We had all these things and, like one of the most important things we did was we got this bill through for topper because he really had spent many, many years on it and it was deeply personal to him, which is why I made him report it. Because I remember I sent it. I'm doing this live. I sent it to her. I said, Topper, you're going to report this bill. He's like, I don't report those. He's like, I've been here for twenty years. I don't report those. I mean, well, you're doing this one. So he did this one.

[Unidentified Committee Member (House Health Care)]: And he did the other one too.

[Unidentified Committee Member (House Health Care)]: And then he did the other one.

[Rep. Alyssa Black (Chair)]: It was perfect. And it was perfect. Okay. So he's going to go jail. And I'm pretty sure the only reason he resigned was because he wanted me to take over. He famously hated doing bill reports. Okay.

[Unidentified Committee Member (House Health Care)]: Movies not alone.

[Rep. Alyssa Black (Chair)]: We're waiting for Jen. Let's take a break.