Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome everyone. It is May 5. This is House Healthcare and we are starting off this afternoon with S-one 193, which is obviously, if you recall, a bill that we don't actually have possession of, but we've been asked to make recommendations on for the forensic facility. I will say, I am kind of going to turn things over to facilitate to Representative Debra Powers. She's done a lot of great work on this and working with the elected council and various stakeholders and has some things to present. So take it away, Daisy. Hopefully, the help of meeting Ms. Glenn,

[Daisy Berbeco (Ranking Member)]: who I just met with, to share a document that I've emailed out to the committee. I'll just bring in us hard copies in a minute. But what I've done is sat in on House Human Services on Friday afternoon.

[Alyssa Black (Chair)]: They were

[Daisy Berbeco (Ranking Member)]: discussing the language that House Corrections and Institutions has. I think it's in their committee draft 2.1. And took into consideration the direction that Human Services was moving, but also tried to create a framework for this committee to speak to the things that would really be within our jurisdiction should there be people with mental illnesses in a forensic facility. So in the documents that I sent around, you'll see I put some recommendations. And these recommendations are drawn from best practices in other states that do this. They're drawn from testimony by Vermont Care Partners and others. And the goal is to, again, give us a framework to react and weigh in on this. And then Katie, during our meeting at noon, is lifting up some of these points and saying, well, this one could actually go in the existing language potentially, or this one wouldn't be relevant until further in the process. So I think maybe just reviewing it and maybe with Katie's guidance, we can lift up some things and see if there's alignment.

[Alyssa Black (Chair)]: Can you just tell me, you said you sent out language, just remind us what time and the timestamps to find it.

[Daisy Berbeco (Ranking Member)]: About five minutes ago.

[Brian Cina (Member)]: I was looking through my email and then I refreshed and it appeared at the top.

[Alyssa Black (Chair)]: We'll have copy when Tasha gets a minute. We'll have Tasha post. She's going to hand out hard copies to us.

[Brian Cina (Member)]: So these are recommendations that you've compiled for us to review based on the And information based on our discussion and your research.

[Daisy Berbeco (Ranking Member)]: Yes, and testimony from people in And health and then the conversation that's going on in human services, corrections and institutions. I haven't listened in on judiciary.

[Allen “Penny” Demar (Member)]: So who has jurisdiction on this one?

[Alyssa Black (Chair)]: On this document that you're looking at, I'm showing us where we have jurisdiction over this. So the jurisdiction, the official jurisdiction of this bill is in the House judiciary right now.

[Allen “Penny” Demar (Member)]: And all we're doing is showing our concerns and suggestions.

[Alyssa Black (Chair)]: Yes, that's what we're doing. And we're sharing our concerns and suggestions with House Judiciary and House Corrections and Institutions. And I believe Corrections and Institutions is not going to take At this point, they're not going to take possession of the bill, but they're working on stuff. I'm not sure at this point.

[Katie (Legislative Counsel)]: Yeah, I've heard.

[Brian Cina (Member)]: I heard it might go advance. So I don't know.

[Alyssa Black (Chair)]: Leslie, do you want to go ahead? Just a question, looking it

[Daisy Berbeco (Ranking Member)]: over quickly. And I see

[Alyssa Black (Chair)]: the clinical model required discharge planning and transition. I'm wondering where the victim fits into this, that we did have some testimony from victims.

[Daisy Berbeco (Ranking Member)]: I think we'll start at the top.

[Alyssa Black (Chair)]: Yeah, sure. Let's start at the top. Can just enter

[Rep. Debra Powers (Member) [time-bounded override]]: the points, would you rather I

[Katie (Legislative Counsel)]: Either way is fine. I can go through them, recognizing they didn't come from me. And then I guess what I'm thinking is as we go through each one, I'm just going to try to take notes about where it might be integrated and then I'll sort of have marching orders by the time I walk out the door, it goes after me. Okay, so this is the governance and ownership. The first bullet is require the forensic facility to be established, licensed, operated, and clinically governed by a DMH or a DMH contracted provider. This is one of the tricky ones. I'll say this several times because we know that there might be multiple departments with jurisdiction. And so figuring out how that cooperation will work, whether it be sort of hybrid operation of a forensic facility? How will it be licensed? One thing Representative Berbeco and I just talked about was how Human Services was concerned with the Corrections and Institutions proposed amendment of licensing a forensic facility as a therapeutic community residence, a TCR, because some aspects of the TCR are not applicable to the forensic facility. And the conversation we had twenty minutes ago was that this could be an appropriate addition to the forensic facility plan report that's coming back, specifically asking the administration to look at the TCR rules and identifying which aspects of the TCR rules would have to be waived in order to license the facility as a TCR. So that is something I could potentially add.

[Alyssa Black (Chair)]: And this will be the feasibility study. Okay.

[Daisy Berbeco (Ranking Member)]: And if

[Brian Cina (Member)]: you're a

[Daisy Berbeco (Ranking Member)]: TC, I sent around on Friday, I sent around the therapeutic community residents licensing requirements and guidelines. So you all have those. You can see in the body of the email, I just cut

[Alyssa Black (Chair)]: and paste the

[Daisy Berbeco (Ranking Member)]: top line of it. And you'll see that I think some of what Brian was noting in his vision for caring for this population in terms of being community based and least restrictive setting, it speaks to that, that there are definitely things that wouldn't allow this facility to be a TCR. So I think that was a good recommendation, Katie's idea, to have the feasibility study look at what would need to be adjusted from the TCR licensing to make this carry some of those components forward, but not obviously all of them. Brian?

[Brian Cina (Member)]: Yeah, it's just related to that. So in statute, there's a definition and criteria for a TCR, therapeutic mini resonance.

[Katie (Legislative Counsel)]: I don't know what is in statute. I know that TCRs themselves have rules where it's defined and all of the operational specifications are there. I'll look right now and see what we have in statute for TCRs. Before you

[Brian Cina (Member)]: look further, let me ask another related question because then we can wrap fold the neck, which is, I might get the term wrong. In statute, I believe it's called a secure recovery residence.

[Katie (Legislative Counsel)]: Secure residential recovery facility? Yeah, is that a TCR? I believe it is licensed as a TCR.

[Alyssa Black (Chair)]: Do we have, Because that's a

[Brian Cina (Member)]: high invention for our forensic, if we have a forensic audit, something like River Battle. So I just think that out there, thank you.

[Alyssa Black (Chair)]: That's not a question.

[Katie (Legislative Counsel)]: Community residents didn't come up in my word search, but sometimes they were up in a few. Anyway, first question, not seeing it in statute.

[Alyssa Black (Chair)]: So the current proposal from corrections institutions is that it be licensed, operated, governed by AHS, correct? AHS, but not the agency. What about the

[Katie (Legislative Counsel)]: state Human that was in

[Alyssa Black (Chair)]: service I think I have to step

[Katie (Legislative Counsel)]: far back. So the proposal you got from Senate said they had DOC in charge of the facility. A house judiciary changed their draft to say secretary of human services. Since then, this committee and human services had both sort of had conversations that the departments of jurisdiction should be in charge of their own the folks that they have the most expertise on. But that said, as I'm sure you know, human services is not inclined to have individuals within Dale's custody in the forensic facility, and they are looking at possibly expanding current x two forty eight population to see if they could address some of the individuals that are currently picked up in this proposal that aren't currently under active duty, like people with dementia or people with CBI.

[Alyssa Black (Chair)]: Okay, if however somebody within their population is at risk of safety to themselves or others, where would they be held?

[Katie (Legislative Counsel)]: Say that again. I'm sorry. Are

[Alyssa Black (Chair)]: they thinking of expanding two forty eight to include that someone could be in a forensic facility

[Daisy Berbeco (Ranking Member)]: in the custody of them?

[Katie (Legislative Counsel)]: I don't think they envision anyone in Dale's custody being in the forensic facility. I interpreted it as they were going to expand x two forty eight residential placements. That's what they're interested in. I don't think they're necessarily thinking that the language will be changed this year to do that, but that it's something they want to ask the administration for more information about as to if that is appropriate.

[Alyssa Black (Chair)]: What about somebody with co occurring?

[Katie (Legislative Counsel)]: I think it depends what their predominant diagnosis is.

[Alyssa Black (Chair)]: Leslie had a question. I don't know if this is the time you might talk about it. When I read the stuff you sent out on Friday about therapeutic community residents, I wasn't sure how it applied to people with violent potential. And that's what worries me about, and I need to understand how that intersects, the potential for violence is worrisome to me in the community. How do we think about that? I think that's why we need

[Daisy Berbeco (Ranking Member)]: a feasibility study. Because the TOPR does not apply to that population.

[Katie (Legislative Counsel)]: Nothing in our state does right now.

[Alyssa Black (Chair)]: Okay, so what you sent doesn't really apply to that population? No.

[Daisy Berbeco (Ranking Member)]: Okay, so that was what confused me. That's a proposal. That was the human services proposal is that it'd be licensed as a TCR.

[Alyssa Black (Chair)]: The forensic facility get licensed as a TCR. So it uses those principles, let's say, but then takes in that potential for violence. This issue with dementia and TBI, I don't know enough. I mean, I have really basically no knowledge about that kind of population.

[Daisy Berbeco (Ranking Member)]: Well, they're not our jurisdiction anyway, so we don't have to weigh in on that. Truly, but if we say they could

[Alyssa Black (Chair)]: be in the community and there's a potential for violence, I think that that's worrisome to me. And maybe we just say we have no voice, I get that, but that's pretty worrisome to me. Yeah, I

[Daisy Berbeco (Ranking Member)]: think, correct me if I'm wrong, Katie, but I think we should focus on the mental health population. And then hopefully as the process of coordinating with the other committees evolves, we'll work through Ledge Council and the chairs to find some language where we all can agree on what the path is. And then what we don't know, the people who are actually the experts on caring for these folks will figure it out through the feasibility study process. Okay, just so

[Alyssa Black (Chair)]: I understand, I'm sorry, but you're suggesting that we just work with the feasibility study right now and that's what we want to have come out of this conversation? No,

[Daisy Berbeco (Ranking Member)]: I think that we don't have to resolve right now what the pathway is for every population. I think we should focus on what we want our recommendations to be for the folks who are in there with a primary diagnosis of a mental illness. And look at these recommendations, see whether or not we want to take them forward, and Katie can advise us on what the best means and time for taking them forward is, or whether or not we want to.

[Katie (Legislative Counsel)]: Thank you. Can I just correct myself quickly? The therapeutic community residence definition is at 33 VSA seven 102, if anyone wants to look at that. And then more specifications about the license type is in 7103, 7105. So that's where you'll find it in Title 33.

[Alyssa Black (Chair)]: Okay. Let's move on to the 2nd Floor.

[Katie (Legislative Counsel)]: Limit DOC involvement to external security only if necessary. Think that the proposals that you've seen from House Corrections and Institutions sort of says that as well. So I don't know that you need any additional language to do that. Governance models similar to mental health agency oversight models used in other states. So I think you could ask as part of the plan to have more information about models for competency restoration or forensic facilities in other states. It sounds like also there are a lot of ideas of how you want it to function, and maybe that would be a preliminary step and you're maybe past that step at this point. I don't know. But if you wanted to ask for more information about that, potentially, the feasibility plan would be the place to ask it. The plan, at least as how Corrections and Institutions envisions it, is not a report back on, is this give us more information so we can make up our mind. It's more, we've made up our mind. This is what we want. Now how do we get from point A to point B? So it's assuming that we're sort of along in the process and a decision has been made to have a forensic facility. These are the elements we want in the forensic facility now. How do we do it? If that's helpful. Very. Number two is the facility purpose. So defined as a secure treatment facility, not a correctional institution. I might just read all of these together and then talk about them. Clarify the placement for competency restoration, evaluation stabilization, and treatment, not for punishment or detention. Ensure sessitory language distinguishes this facility from a correctional facility. So I think this could maybe go somewhere right in the language itself. I don't know if this would be part of the feasibility study, but if you want language that this placement is competency restoration evaluation, stabilization and treatment, we could use those words maybe in the definition, maybe somewhere else. I think

[Daisy Berbeco (Ranking Member)]: they're already in there too.

[Katie (Legislative Counsel)]: I think a variation of this, I don't Do you want me to look into that or leave it?

[Alyssa Black (Chair)]: What else is in there currently?

[Katie (Legislative Counsel)]: Well, have that section Hold on. You have section 4B that has a list of different clinical aspects. Right now, have in the definition section that it provides for the secure, valued treatment and care. And you're looking at language competency restoration, evaluation, stabilization and treatment. And then you say it again, secure evaluation, treatment and care. So that could be replaced.

[Alyssa Black (Chair)]: Sort of worry about losing care.

[Katie (Legislative Counsel)]: Add it.

[Alyssa Black (Chair)]: What if somebody not actively What if somebody is not actively engaged in competency restoration or evaluation or stabilization or treatment? What if they are just a danger for the public?

[Daisy Berbeco (Ranking Member)]: And they don't have a clinical reason to be there? Yet to be determined.

[Alyssa Black (Chair)]: Well, mean, it kind of goes back to sort of our discussion that we had around what's happening with the designated agencies and the designation change, CRT designation change, in that if you're not actively working towards restoration or working on treatments, What if you've just gotten to the point where you are stable where you are and yet you still pose a danger. Which it seems to me like the word care encompasses.

[Daisy Berbeco (Ranking Member)]: Can you tell me what page you're

[Alyssa Black (Chair)]: on, sir? It's on page two, line, well, I don't know the line that's on this draft, but it's section Z three. I'm looking at the language that Katie gave us last week. Corrections and institutions. It's not 3.1,

[Daisy Berbeco (Ranking Member)]: is it?

[Katie (Legislative Counsel)]: Well, there's language there, too, that I just read from. If there was a document from corrections and institutions that I gave you last week, you don't have a hard copy of it.

[Alyssa Black (Chair)]: I'm just putting it out there for discussion. All it It

[Katie (Legislative Counsel)]: could be easy enough to add with your list, or with a list on this document if you wanted it to say everything. Brian, what do you think?

[Brian Cina (Member)]: I'm thinking about what, I'm wondering, I guess, what, and I guess this is a study, but I'm wondering what are the evidence based practices for competency restoration, what's considered the best? I'm also wondering, I mean, you asked, so this is what was kind going on my head, is there a place for looking at emerging treatments? For example, imagine if a person, when they're asked to do competency restoration, there's a menu and they get to choose what they want to do to restore their competency versus just one size fits all. Because that menu could include emerging treatments like neurofeedback, for example, which I think should be offered in all correctional facilities right now because of its potential to address criminogenic behavior. But there's emerging treatments. So what would be interesting is for this feasibility study to say, here's not only the infrastructure, but here's all the different programming options and what they cost, and here's how And maybe some of this programming can be used for competency restoration and more. That's the other thing, we're going to invest all this resources in six beds to provide a very specific niche of treatment for a very specific population, is it possible that that investment might serve others in the system of care, whether they be people who need secure, like what you were just saying, what about people who are just unsafe? To help them become safe again, wherever they are.

[Alyssa Black (Chair)]: I'm not really talking about the competency restoration because if you're engaged in competency restoration, that is inclusive in here. And once you've had your competency restored, you then move back into the criminal justice system and face Yeah. So I'm not worried about that. Because as long as it takes to restore competency, they will be there. There will be placement for them. And if they're being evaluated, there's placement for them. And if they're trying to be stabilization, there's placement for them. And if they're actively receiving treatment, there's a place for them. I'm worried about once all of that has been determined to happen and they're not actively receiving treatments. Maybe I'm getting to I think of treatment as like trying to get to something. What if you get to something and you are now stabilized and yet you still remain a danger for the public.

[Brian Cina (Member)]: This is what I was saying the other day. It's like, I'm concerned about the lack of aftercare because we restore someone's competency, but then if we throw them back into a cell with another person who has schizophrenia, which we did, and one of them killed the other one in Vermont, this was all in the news, they put two people with active schizophrenia in a cell and they fought and one of them killed the other. So we stabilize a person, but if we just throw them back in a cell with another person who's not stable I stop

[Alyssa Black (Chair)]: that process. Competency restoration is a criminal process and it's a legal process. It's not- But

[Brian Cina (Member)]: it is treatment. What I'm saying is what the treatment we're offering in the correction system isn't going to support maintenance of competency. Is, I feel like our thing, that if we're not providing healthcare in our correctional facilities that promotes recovery, then what are we doing in our correctional facilities? And so we spend all this money to recover someone to have them stand trial, but then we throw them back into a place where they're not getting healthcare. Do you see what I'm saying? Then we're not keeping them safe.

[Alyssa Black (Chair)]: Can I totally see your point? But we're not dealing with the correction system. I mean, that's why we have recommended that this not be under the Department of Corrections. So I'm just trying to think about the aspect of if we are going to have a forensic facility, what is it going to be used for? Who is going to be there? And are we ensuring that any language that we have allows the correct ability to protect the public with those individuals that are there. I can't deal with corrections. And I get all your points.

[Daisy Berbeco (Ranking Member)]: Can we go through because everything I think will be addressed. We have a clinical model section coming up. There's something about patient rights. There's also time limits and transition to appropriate levels of care. So what happens when folks are no longer in need of treatment? And I think those cases are under different circumstances.

[Alyssa Black (Chair)]: Okay. So I'm going ask an absurd question.

[Katie (Legislative Counsel)]: Can people go in and out of competency?

[Alyssa Black (Chair)]: Yes. So that's another thing that worries me. Yes, today you're competent, but maybe not next week. And I don't understand how to deal with that.

[Daisy Berbeco (Ranking Member)]: Let's go through the sections, please, because we only have

[Emily Brown (Executive Director, Green Mountain Care Board)]: to wait for another twenty five minutes.

[Alyssa Black (Chair)]: I want everyone at least plan

[Emily Brown (Executive Director, Green Mountain Care Board)]: the heading so you know where we're going.

[Katie (Legislative Counsel)]: Does the clinical model require individual evidence informed competency restoration plans? I think you could put that in section 4B, but I think you might also want to think about what's being done to people who aren't there for competency restoration. What about people who are not guilty by reason of insanity? So maybe individualized clinical plans, for lack of a better word. But some type of individualized You're making

[Alyssa Black (Chair)]: sure that we're capturing both populations.

[Katie (Legislative Counsel)]: Include psychiatric care, med management, legal skills, education, habilitation, and trauma informed care. I'm assuming, is that for everyone? Is that part of competency restoration? That's part of competency restoration, like the court procedures, education, and legal skills. I think you can

[Alyssa Black (Chair)]: put that into 4B.

[Katie (Legislative Counsel)]: Require discharge planning and transition support to begin at admission. I don't know if this is the right place to talk about it. No, you have it somewhere else. Oh, to so me, this bullet and the last bullet and four kind of go together, slab, chicatunium, outpatient, community based inpatient and secure So treatment I think what those are both getting at is that what happens to somebody after they leave a forensic facility. I definitely heard in human services, and I'm hearing it a little bit here that there is an interest in seeing type of, like, a plan in which a person is followed after they leave a correctional facility and have services for that person that are may well, in human services, they said residential, clinical and case management services to monitor and ensure that person has what they need to be successful in the community. So if that sounds right and you want to see that, I could put that as part of the forensic plan, Not the forensic plan, the forensic facility plan, feasibility plan. But that would be something that they would have to, the administration would have to report back what is a plan for after somebody leaves and here are the elements. You'd want to see what would this look like.

[Daisy Berbeco (Ranking Member)]: Yeah, and where is this facility on this continuum of when folks are not guilty by reason of insanity, where do they go? Do they go to River Valley? And I think that's the intent of those bullets, is making sure that everyone has a plan. People aren't just going to reside here forever. And that there's a plan first for restoring competency, if that is their issue. And second, that once it's restored, where is the next appropriate place that's the least restrictive place, but also best for public safety if they're a person that's danger to the public.

[Katie (Legislative Counsel)]: In the feasibility plan, I Debra has a

[Unidentified Committee Member]: see, and I agree, that we can safely meet the individual needs. But how about the community? I think there's some people, a lot of people who actually are concerned about putting them in a community base, and they still are a danger potentially to the public. Is that out of the Is that in the language of the actual bill? Yeah.

[Daisy Berbeco (Ranking Member)]: And I think my way of approaching these recommendations is that we're looking at folks with mental illnesses. We're not looking at the overall public safety. Public safety is in judicial committee. And I mean, obviously, I care about the safety of the community, but I feel like it's harder for us to determine that with the expertise that's in our jurisdiction.

[Unidentified Committee Member]: Well, with the level of care and the follow-up, hopefully that will prevent it.

[Alyssa Black (Chair)]: Exactly. Can

[Katie (Legislative Counsel)]: I comment

[Alyssa Black (Chair)]: on that? Yeah, can I just say something? First of all, Brian, I apologize. I think I might've just connected the dots that I wasn't connecting. Yeah, so you're talking about competency has been restored and yet the legal process has not come to a conclusion. You're talking about the interim. I thought you went forever and ever and ever, even after sentencing. Again, I apologize. I don't think it

[Brian Cina (Member)]: was. Will say that I feel like when it's sentenced, we should be wrapping them in every possible service to rehabilitate them, including evidence based practices for changing criminogenic behavior, instead of putting them in a setting that drives criminogenic behavior.

[Alyssa Black (Chair)]: I agree. And I guess I thought that you were just talking about that piece.

[Brian Cina (Member)]: Okay. Well, thanks

[Alyssa Black (Chair)]: for reflecting on Frederick. No, was looking at No, that's what he was talking about. So I don't want to go back, should it be for competency restoration and maintaining restoration?

[Katie (Legislative Counsel)]: In our hands away trial?

[Alyssa Black (Chair)]: Yeah.

[Katie (Legislative Counsel)]: I don't exactly know where to put that yet, but it should be in statute or in the feasibility plan, but I'll write it down and figure out a home for it as I go.

[Brian Cina (Member)]: I throw her on the freeze out there? Probably where your lesson must.

[Alyssa Black (Chair)]: Well, placement is for competency restoration, but also that the placement is for maintaining competency throughout the legal process.

[Brian Cina (Member)]: The feasibility study would be looking Can at I throw out one other phrase, and if it gets shot down, so be it? So you said maintaining competency, and I would add and promoting recovery. And the reason I say that is because they go hand in hand, and I just think we should be recovery focused in general, but people don't want to complicate it, but I don't think it complicates it that much to tie them together.

[Alyssa Black (Chair)]: Leslie, sorry. Understand that you're thinking that public safety is not in our jurisdiction, But I would feel more comfortable if we would connect something that included in the plan considering public safety, or at least something that acknowledges that we're aware that we need, that that's part of our grief as well. That would be important to me.

[Daisy Berbeco (Ranking Member)]: Where do you suggest putting something? Do you want to get through and see if that's I something would like leave

[Alyssa Black (Chair)]: that up to Katie to think about where but we I just think I really care about that.

[Brian Cina (Member)]: Maybe we should like, I'm no one's in charge, but I'm noticing that we keep getting stuck. Maybe we should really try to hold questions till we get through all Daisy's stuff. It might save time. I'll personally try to do that. I've been trying to be quiet.

[Katie (Legislative Counsel)]: Okay, so four. We kind of skipped over the first two bullets. So require a DMH clinical review for admission and require documented clinical findings that no less restrictive alternative can safely be met on the individual's needs. So this is sort of looking at the court process. I think I will double check the work that House Judiciary is doing, and maybe we can integrate something about this restrictive setting.

[Alyssa Black (Chair)]: That protects public safety, or I mean, I'm sorry, but it's just

[Katie (Legislative Counsel)]: least restrictive setting. That's already part of the work that Houghton judiciaries do. Get it, but I think it should be our case. Okay, Section five, Patient Rights Embedsment Oversight applied amongst mental health patient rights protections rather than correctional disciplinary frameworks. The conversation we had around that is that while there is something very structured around individuals with mental health, I don't know that we have something that's built out as much around substance use disorder. We do to some degree for individuals with intellectual disability. I'm not sure about dementia or TBI. I don't know if they have these kinds of protections blurred out in statute as much. I know your focus is on mental illness, and I'm just trying to think of the big picture, we would ensure these protections for the whole population that would be at the forensic facility. So I'm kind of flagging this for more Ensure access to counsel, grievance procedures, advocacy, and interpreters. The counsel is covered in the work of a house judiciary, but access to interpreters and grievance procedures with the processes at the forensic facility could be built into section 4B. Require independent oversight, including review by mental health care ombudsman. That's easy enough to add to the jurisdiction of the mental health care ombudsman, if you would like to see that. I missed that.

[Brian Cina (Member)]: It's like the healthcare advocate.

[Alyssa Black (Chair)]: Yeah.

[Brian Cina (Member)]: It's just a different word.

[Alyssa Black (Chair)]: And our mental health testified on this. Ricky testified on Zoom, Jack McCullough.

[Katie (Legislative Counsel)]: She's at the mental health care, No, but Rights Vermont is the designated ombudsman. It's a federal designation. Oh, okay. So that office, for example, gets, I think they get their reports of seclusion and restraint. Is that right? Yes, I'm getting that. So a slightly different office, but I can add that to their statute. Staffing standards require staffing to meet clinical needs and best practices for forensic psychiatrists, psychologists, nurses, social workers, and peer support specialists. So we already have language in 4B about staffing. So do you want to list that these are the types of people who will staff the forensic facility? I'm not quite sure what the goal is here, that they meet best practices. Let me see what we have before we go.

[Daisy Berbeco (Ranking Member)]: My goal was to recommend that in contemplating the design of a facility, the group or the feasibility study group would consider these best practices around staffing with regard to these license types for folks with mental illnesses?

[Katie (Legislative Counsel)]: So right now, what we have in the bill is that the forensic facility shall implement staff qualifications, licensure training and supervision requirements that are sufficient to ensure that persons transferred to the forensic facility have access to clinically appropriate care and treatment services and supports consistent with individual needs and with applicable professional standards. Does that meet that? Is that

[Daisy Berbeco (Ranking Member)]: what you're I'd want to be more specific. Okay. How so? Can we get the feasibility study? I don't know. I just feel like if we're going to look at different types of folks that are in there, I feel like it should become a smorgasbord. And maybe we need to look a little more closely. Peers are supposed to be provided at every level of care in our mental health continuum. Is this on that level, on the continuum? I don't know. I feel like we need

[Katie (Legislative Counsel)]: to have a deeper dive into that aspect of staffing, for example. The feasibility plan to address the types of professionals that will be working in the forensic facility. Yeah.

[Daisy Berbeco (Ranking Member)]: What are best practices for staffing?

[Alyssa Black (Chair)]: Can we not prescribe certain

[Unidentified Committee Member]: job descriptions?

[Alyssa Black (Chair)]: I mean, right now I'm looking at forensic psychiatrists. What if you are a psychiatrist but not a forensic psychiatrist? Can you not work in there? Well, that's why we're asking feasibility study That's to work what I'm saying is, can you read the feasibility study to figure out what the and not prescribe?

[Brian Cina (Member)]: What the multidisciplinary team should be.

[Alyssa Black (Chair)]: Yeah, that's right. Okay. Thanks. I think it's too specific.

[Brian Cina (Member)]: It would be ironic if they came back and said, Just correctional officers. Sorry. So heavy.

[Katie (Legislative Counsel)]: So then you have a 20 fourseven clinical coverage and in Subdivision 6 Of B, you have ensured a registered licensed nurse or a physician is available to provide care to transferred persons twenty four hours a day, seven days a week. So does the point on this draft Does the language in the draft get you what you want? And if not, how can we change it? So this says, Is it available So to provide that is fairly loose language. That doesn't mean that somebody is on the premise of the forensic facility to provide that care. That could look like telehealth, that could look like somebody's on call. Maybe that is your intent, or maybe it's not. Does it have to be a nurse or a physician? So I guess I'm looking to see what your policy preference is on that.

[Brian Cina (Member)]: Correct. My preference would be for it to align with the evidence based practices for competency restoration. Since I don't know what those are, I feel like the feasibility study should come back and say, Here's the recommended multidisciplinary team and staffing strategies that and maybe we ask for a few, maybe we say, Don't just come with one so that we're cornered in, but what are some options? I don't know. I'm trying to have us stay open minded and not box us in too much to want something. Because I feel like we were given a very specific proposal and it would be good to have more of choice. But in terms of policy decision, if we hear that there doesn't need to be in the therapy, I'm just gonna use this as an example, in a therapeutic community residence, there needs to be like an on call physician 20 fourseven, but they don't have to be on-site, then I'm okay with that. But if we hear like in this kind of facility, need an ophthalmologist on call at all times, then I would want it, but sorry, too soon. Yeah, I was trying to pick a random example and it wasn't random. You know what saying, a surgeon, I'll say, a surgeon on hand, but I don't think we're gonna need a surgeon on-site for a forensic facility because they could take them to the emergency room, anyway.

[Alyssa Black (Chair)]: If we're requiring that staffing meets clinical needs and best practices, and then we're just requiring 20 fourseven clinical coverage, aren't we already saying that all the staff, mean, the staff is going to have, they must meet clinical needs. So therefore, there would automatically be 20 fourseven clinical coverage.

[Brian Cina (Member)]: Yeah, but I mean, what that is, does that mean, for example, is there a nurse on duty 20, but no doctor available till the morning? Or is there a doctor on call for the nurse to call, or does the doctor have to be on-site? Those are the things I don't know how it should be, and I'd like to hear in the feasibility study, to do this right, here is the right staffing mix. I'm guessing, from experience, that a doctor has to always be a medical there has to be a medical person on call at all times, and that you can have other kinds of care staff that have other kinds of training. Like my guess is there's going to have to be a nursing person on duty, but probably not a social worker overnight or something like that. I don't know.

[Daisy Berbeco (Ranking Member)]: I'm sorry, but we have Katie for ten and more we still have a few sections to go. So hold your questions. Okay. So where we

[Katie (Legislative Counsel)]: are right now is I hear that you're interested in possibly removing B6 from the list and instead in the feasibility plan, ask the administration to address the types of professionals to form a multidisciplinary team for the forensic facility based on best practices and to supply some staffing strategies for the fracing facility.

[Unidentified Committee Member]: Staffing strategies.

[Alyssa Black (Chair)]: Well, you're good. Yeah, you're good.

[Katie (Legislative Counsel)]: Section seven, separation from fractional. Section seven is the collocation with sentence in general correctional populations. I think that's covered in the draft now. No use of correctional uniform segregation or disciplinary sanctions. I could put that into section 4B. I got a quick question.

[Alyssa Black (Chair)]: No, go ahead, Allen.

[Allen “Penny” Demar (Member)]: Okay. No use of correctional uniform segregation to this virus. Thank you. There might be some situation where you've got to call in corrections or police letters off. To put that down, I think you're a can of worms. In another situation, if a person is pretty much competent to stay at trial, somebody's going to transfer that person to the court system. Probably going to be a uniformed officer. So it's something to consider.

[Alyssa Black (Chair)]: Yeah, and also if we say no use of correctional uniforms or segregation or disciplinary sanctions, are we essentially banning seclusion and restraint from this facility?

[Katie (Legislative Counsel)]: Well, segregation Does would

[Alyssa Black (Chair)]: that seem wide? Can we discuss that after we get through all of these? Okay, thanks. I will flag it in my opinion. I will pass off

[Katie (Legislative Counsel)]: my list for now. Ensure safety through therapeutic design and clinical supervision. Maybe that is sort of part of the instructions on the feasibility plan. A is the court review and time limits. So require regular court review of competency that is in progress. So it sounds like you've had conversations and testimony about the right time frame. So I think there's already regular reviews built into the work that the House Judiciary is doing. I don't know if that is the timeframe that this committee would recommend, but I will flag that, that if six months, I think it's six months in the bill, If that is not the policy decision that this committee makes, I could flag that for the other committee. The second bullet is established limits to prevent indefinite detention. Right now, there are some off ramps out of the frenzy facility and the work that house judiciary is doing. I think you'd have to review that to see if they're sufficient for you, but that concept is being discussed downstairs. Require timely discharge of transition to appropriate level of care when restoration is achieved or unlikely. So we talked a little bit about keeping somebody whose competency has been restored in a forensic facility throughout their pending trial and trial. And we talked a little bit about discharge and transition and what that outpatient system might look like and what you wanna hear back. So maybe we'll just pause on that. Let's see. Subdivision 9, independent quality oversight, require public reporting to legislative committees and various data. The recommendation I'm making here, so in the bill that came over from the Senate, it does have an annual report. House Corrections and Institutions wants to take it out, thinking that sort of it's putting the cart before the horse and that we don't know what this forensic facility totally looks like until we have a feasibility plan and the legislature decides on a course of action. So maybe at that point in time is when you require an annual report. But at this point, you could ask for data metric, the metrics, reporting metrics as part of the feasibility plan. Has that worked?

[Alyssa Black (Chair)]: Yes. Reporting. Can I also ask the public reporting to this public report include that data that's in bullet number two of number nine? Because aren't we getting into confidentiality in some of this?

[Katie (Legislative Counsel)]: Let's see. Length of stay, outcomes. Think

[Alyssa Black (Chair)]: about safety incidents. Safety incidents.

[Daisy Berbeco (Ranking Member)]: Unless you report all this right now. It public? It's in DMH.

[Unidentified Committee Member]: Provided there's no names.

[Alyssa Black (Chair)]: Yeah. Well, know that if we have a forensic facility with like four people at this There's one person in here. So let's not put this

[Daisy Berbeco (Ranking Member)]: in statute. Let's recommend it for the study. That they look at what data to report. That's what PD and I discussed.

[Brian Cina (Member)]: Great.

[Katie (Legislative Counsel)]: Okay. 10 is implementation and rulemaking. Again, corrections and institutions is recommending taking out the rulemaking section from the bill, thinking that it is too premature, and instead waiting till the forensic facility comes back, having a sense of what it will be, and then putting rules in place. Okay, that's it. You made it through.

[Brian Cina (Member)]: Made it through. I saved my comments for the answer.

[Alyssa Black (Chair)]: Thank you, Bob.

[Brian Cina (Member)]: Okay. Thank

[Alyssa Black (Chair)]: you, Katie.

[Brian Cina (Member)]: I might've missed this, and that's why I was trying to check with you, but then we decided to keep moving. But when you were in section six, did you say anything about including language about the training of staff, like what they would recommend the training and approaches towards? Because I would like it, if they're gonna give a feasibility plan or study, for it to include their recommendations on approaches to trauma informed care, de escalation training. In other words, not just saying the words, but being like, here's examples of systems or programs or philosophies or trainings that we would implement to build a culture in the facility of recovery. I believe our staff are capable of this. I just like to see it, to see it articulated versus just having saying people are going to be trained in this thing. It's like, well, what if it's a feasibility study? What is the proposed approach? Other thing was, back to Penny, you mentioning the correctional uniforms and security, maybe there's language, and maybe you already wrote this, and I'm repeating it, but I didn't have a chance to check with you, so now I'm checking. From the clinical perspective, what is the approach to security? And how does that intersect with correctional facilities? Because it could be that the plan includes a variety of paraprofessionals who serve in a security role in the facility. And then if a person has to leave, they hand them off to someone, similar to how, like in a correctional facility now, they bring them to the or court or whatever they call it. I think that's actually what they call it. And then people like me or the EMTs will meet them in that area and there's a transition between providers there. They go, instead of the ambulance, maybe they go with a sheriff or something. But what I'm getting at is there would probably be an intake or a admissions or discharge area that could be where this So what I'm getting at is I'm not trying to control what it is. I'd like to hear what the best practices would be for security, and that would address that issue of the uniforms because instead of us just banning it outright, we ask them for the recommendations.

[Alyssa Black (Chair)]: Yeah,

[Allen “Penny” Demar (Member)]: you're right, but we're talking about their patient safety, we're talking about public safety, what about the public of the staff? I think most of these places, don't they have security people on the premises? Yeah. So you're saying they shouldn't be wearing a uniform?

[Brian Cina (Member)]: No, I'm saying we should ask the NIH or whoever does this study what they think is the best practice for running security there. If they say uniform, then we They say it, if they say no uniform, but they wear hospital gear, you know what I mean? But asking them how to navigate that versus banning it outright. But I don't

[Allen “Penny” Demar (Member)]: want to forget the staff safety at all costs.

[Daisy Berbeco (Ranking Member)]: I don't either. And I just want to make one thing clear with regard to public safety. This obviously is a lot about public safety. But in order to contain the discussion, the stuff in here doesn't speak specifically to public safety. My background is in behavioral health and mental health. And so the recommendations I lifted up are related to that. And I know that there's a lot of solid work being done in the other committees regarding public safety recommendations. I'm going to suggest that a way forward Katie, I know it's after two, but a way forward might be for me to take this document. And I've noted where Katie recommended things could go in a study or where there were significant questions from committee members that needed further discussion. So I would take this document, reorganize it into sections that I propose we put into the bill language now for the Katie referenced. And then the rest, I would put into a section that just says possible study. Does that make sense, Katie?

[Katie (Legislative Counsel)]: It feels like an extra step to me. If you want to do that, that's fine. I mean, it doesn't affect my time. But I think at this point, we're just working on a compressed time frame. I'm thinking it makes sense to ask representative Evans if she is ready to integrate your recommendations into hers, and then I just go and do it.

[Daisy Berbeco (Ranking Member)]: I just want the committee to be clear on what our recommendations

[Katie (Legislative Counsel)]: Oh, I see. I was thinking I could just highlight them in a different color. So it would be like, if you

[Daisy Berbeco (Ranking Member)]: want to do it, then I don't have to. That's great. Okay.

[Katie (Legislative Counsel)]: But I haven't been able I did reach out to representative Emmons, and I have not heard Jack. So am sort of waiting on that.

[Alyssa Black (Chair)]: And I had a three second passage in the hallway with Representative Emmons, and she indicated she'd like these recommendations by Thursday at the latest. So that's the time frame we're working in.

[Katie (Legislative Counsel)]: So I feel like maybe they're new speed. Well, I need more guidance, I guess, is what it comes down to. Because I'm walking through new language with human services and corrections and institutions tomorrow. I had thought maybe I would just include this language as part of it to keep us moving. But you wouldn't have a chance to sort of weigh in and look at what I've put together. So I don't know how you want to proceed that way. Should I hold on to that language and keep it separate and apart from what corrections and institutions are doing?

[Alyssa Black (Chair)]: Is there a time that we can meet before? Can we coordinate a time to meet before we meet with them? I know that your schedule is so tight to include right this minute. Could you do what you said and highlight that language so we we could review it before even if we had a minute with you, we could at least Yeah. See.

[Katie (Legislative Counsel)]: Let's see. I'm booked from nine to twelve, and I'm booked for most of lunch. Booked at here on the floor at one. If you get off the floor at two, then maybe I don't know how

[Alyssa Black (Chair)]: realistic that would be. For tomorrow? Yeah. Okay, so S-one hundred ninety. We don't have Jen yet. Jen will be here soon. If you recall, S-one 190 is the spill that we had on the wall, and we kept it on the wall because there's lots of people doing lots of things and trying to get us good information before I introduced it to the committee, because I didn't want to confuse everybody, frankly. So, and I just want to let you know, I actually have been working with Jen on some language, which I'm going to put forward to the committee for consideration. But I wanted to get some testimony prior to that from Green Mountain Care Board and DFR, and particularly around some of the decision making, like the bill that came over from the Senate has a cap on the QHP market, and we deal with, and then we've heard proposals from our financial regulation about possibly changing, putting caps on some other services for the whole market. And it dawned on me when we had the broker in the other day that we in this committee, because we don't have much control of any, almost, the ERISA market, I thought we should learn about the self funded market a little bit. So I've asked both the board and DFR to come in and talk about that, as well as some proposed language for 01/1990. So first up, we have Emily Brown. It was bad for a pretty person. That was good. I know.

[Brian Cina (Member)]: I'll save my questions now for the right person. You framed

[Alyssa Black (Chair)]: it. Now you guys save your questions. Good

[Emily Brown (Executive Director, Green Mountain Care Board)]: afternoon. My name is Emily Brown. I'm the executive director at the Green Mountain Care Board. So here to talk about S-one 190, and as the chair said, why we've chosen to identify the QHP market for this interim statutory cap, but then also putting it in the context of the rest of the commercial market. I think this committee heard a lot of testimony last week about wanting to spread the benefit of reference based pricing to the whole commercial market and not wanting to single out the QHP market. So I'm really here to talk about and respond to those points. So I think I'll start by level setting and saying the board last year was and is required to implement reference based pricing. We are currently and have identified a contractor who's going to start working with us to develop our reference based pricing plan, which will impact all commercial payers in Vermont. So I just wanted to start by saying that we are not saying we are only doing reference based pricing for QHP and no one else is going to get the benefit. We are taking a system wide approach to reference based pricing. We are already starting on that work, and that work when implemented largely through our and connected to our hospital budget process. Because remember, reference based pricing as identified last year and what the board's been asked to do is to do it from the hospital side. So we will be setting hospital prices and identifying hospital prices and lowering the prices on that side. And that way, all of the savings, all those savings are going to flow through to all commercial payers. In S-one hundred ninety, we have identified the QHP market as a market that needs immediate help to provide stabilization and to make sure that market stays available and accessible to all those who are now in it and all those who might have actually left the market and providing them maybe an option to reenter that market. So just to level set, S-one 190 was the interim statutory cap of 250% of Medicare. And as I said, over the last year, that market has seen significant declines in enrollment. I think this year alone, we've seen more than 5,000 individuals leave the individual QHP market. That's almost a 20% decline. That was largely attributed to the fact that the subsidies went away before when there were the enhanced subsidies. About over 90% of that market was receiving subsidies. I think that number is now at about 77%. So you have a large part of that market now that are not benefiting from any subsidy. And in reaction to that, many people and families are leaving that market. There are further actions that are coming down from the federal government that we expect will create further disturbance in the QHP market. One of those is a change to the federal administration's approach to silver loading. I won't get into the details of silver loading, but essentially it was a step that the board took to make up for the lack of CSR payments that the federal government decided not to make.

[Alyssa Black (Chair)]: On one second. Are we okay?

[Brian Cina (Member)]: Woah. It hasn't done that before in here.

[Alyssa Black (Chair)]: Hold on a second. CSR. She's been ripe.

[Emily Brown (Executive Director, Green Mountain Care Board)]: I should because

[Brian Cina (Member)]: the livestream has disrupted. Sorry. We can't talk about policy. We can only talk about other random things.

[Daisy Berbeco (Ranking Member)]: It's inaccurate. Tell me to try

[Alyssa Black (Chair)]: the hot button then starting up again. Yeah. I looked up and I'm like, well that's weird, why am I looking down if I'm weird being

[Daisy Berbeco (Ranking Member)]: serious?