Vermont Legislature SmartTranscripts:

[Chair Martin LaLonde]: Committee this Thursday afternoon, January 29, and we have some witnesses here on Mental Health Advocacy Day. We deal with issues involving the intersection of mental health and also substance use disorder and the criminal justice system in this committee. There is one bill that we have looked at having to do with victim notification in the forensics system. We anticipate seeing a bill from the Senate related to forensic facility and also to competency restoration. But generally, is an important issue that is for us here, I'll turn it over to witnesses in a moment, we're kind of at the end of the line. And this is actually where I think other parts of our systems have failed or have not been able to help individuals. And so it's really the upstream from the criminal justice system in this committee is where we love to see most of the work being done to address issues related to mental health, substance use, disabilities, and the like. But when it doesn't happen, it comes to us. But anyway, so I have Kelsey Stabbsen. Is Kelsey? Yes. Kelsey, sorry, sorry. I'm not looking around at the right place. So if you could just join us and please weigh in. We have about a half an hour total from the three witnesses, really appreciate you being here today. Appreciate all of you being here today. Thank you.

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: And Sima is my colleague, and I'll do a little bit of an overview of my intention, and then Sima's going weigh in with some more specific examples and some data and information here.

[Chair Martin LaLonde]: Yes, thank you for being here as well, Doctor. Rutland. Is it Radhun?

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: That's right. Thank you so much for having me. Ravin, semi Ravin.

[Chair Martin LaLonde]: Ravin, thank you very much. Thank you, doctor. Thank you.

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: So for the record, my name is Kelsey Stabsef. I'm the executive director of Northeast Kingdom Human Services, which is the designated agency that covers the three counties of the Northeast Kingdom. And I'm also a co president of the board of Vermont Care Partners, which is the association of 16 specialized service agencies and designated agencies that cover the whole state. And so I don't want to go too deeply into that, but just want to give a brief overview on what's the intersection with mental health substance use and developmental disabilities co occurring that intersects with the judiciary. And so I'll talk in broad strokes and then can answer some specific questions in a moment. So a couple of things I want to note is that the designated agencies focus specifically on serious mental illness or severe emotional disturbance when it comes to kids. And so that's the most acute intense things we see. And we often, not often, but with some frequency intersect with law enforcement, with the criminal justice system, and so are looked to as what I would describe as being specialty providers with expertise in mental health with substance use, and it's our look to do some of the most intense services in the community. And so we really are focused on community based supports and everything up to until we get to inpatient. And so we will do screenings in the hospital too for mental health to determine if someone needs involuntary treatment in a place like Ruttleboro Treat. And so before we get to inpatient or talking about specialty care, like a forensic unit, we have the state has in partnership with the designated agencies really built out a robust crisis system. So we have 988, which is the lifeline call center that's operating 20 fourseven. We have mobile crisis, so we have people that will respond. You call them, they'll go out wherever. That's a statewide program. We have folks who are embedded with Vermont State Police operating out of the barracks and will still respond with folks. You know, that helps support law enforcement saying, you know, call 911, people show up. It's awesome. But sometimes it's not criminally focused. And so can we take the pressure off of law enforcement and respond with a community based response? And then we do have several urgent care facilities around the state. And as an example, Northeast Kingdom runs a 20 urgent care that does mental health, substance use. It's walk in and we also have four beds for two to ten day crisis stabilization stay, which can be a step up or step down. So if people are stepping out of inpatient, they can come down. So one thing I want to emphasize is that the designated agency system and the community based system is robust. It does really intense work. So one part of talking about forensics or specialty care beyond outpatient community base is that you still need to invest in the outpatient community base. We think that is best for folks, keep them in their community for long term sustainability. It is really important to have a strong community based provider system. One other thing I want to note is that sequential intercept model, which has to do with the judiciary, is something that's been invested in, I think more from a time than other resource. But that is really about working with the judiciary to divert folks who do have mental health and substance use challenges out of the criminal justice system when appropriate. So there's a lot of focus and energy put on upstream and intercepting folks before they get to the criminal justice system. I will say that two years ago, the forensic facility came up and nine out of the 10 or all but one of the designated workplace service agencies were generally in favor of a forensic unit. And so this was for mixed health and developmental disabilities. And there were a lot of caveats that I would put into that saying like any forensic facility needs to be done thoughtfully. It needs to be built intentionally, because when you talk about involuntary placement, involuntary treatment, any restriction of liberty, I think cuts across a lot of the Vermont values that we hold dearly. And sometimes the acute nature of the situations we face are beyond the community response. And so there are examples that, we can name a few, and I think Doctor. Robin's gonna speak to that a little bit of saying, we're putting the people who need support at risk, we're putting our staff at risk, we're putting the community at risk when we leave some of these situations in limbo. And so again, having a forensic facility, talking about competency restoration and talking about involuntary treatment is something that with a lot of caveats, we'd be generally supportive of. As the bill comes forward, I'm sure we can have more testimony on what that would look like. What would we need to do if that was going to become a thing? And so I'm not going to weigh in on a yes or no on that yet, but can speak to saying we do need more intensive supports for a very small sliver of instances that rise beyond the community based supports that we do provide. You want to speak to some of your experience, Doctor?

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: Hi, thank you so much for having me for the opportunity to talk with you. I'm going to focus today, first I'll introduce myself, I'm Simi Ravin, I'm Chief Medical Officer at Howard Center, Vermont's largest designated agency. To give you a little bit of a sense of my professional background, I'm a forensic psychiatrist, so I've trained in adult psychiatry and completed additional training in forensic psychiatry, which is the field of psychiatry that focuses on the intersection of criminal justice and mental health. In addition to my work at Howard Center, I serve on faculty at the Division of Law and Psychiatry at Yale University School of Medicine. Really appreciate this opportunity to talk with you about some areas of concern that I and my colleagues have at the intersection of criminal justice and mental health, and I've identified a few places where we have real opportunity to improve our system and support safety in our community and support the individuals whom we serve. Let's see, I want to make sure to highlight a few areas specifically, and then I'm glad to answer any questions. One of the areas that we encounter fairly frequently is that there are limited mechanisms for meaningful community oversight of individuals who are on orders of non hospitalization, and a lot of those individuals on orders of non hospitalization are on those orders out of criminal court, meaning that they have had criminal charges that are resolved in an order of non hospitalization. And therefore a range of seriousness of criminal charges, and not infrequently for criminal charges, for really serious violent acts or violent incidents, and then are mandated to treatment with designated agencies. And when these individuals are mandated to treatment with our designated agencies and don't engage, don't come to appointments, or adhere to those orders. We really have limited mechanisms to support the safety of our community and to support those individuals. I'll just share with you, I was talking about this discussion with one of my colleagues this morning in supervision. And he said, Oh, yes, and gave me an example of an individual whom he works with, who was on an order of non hospitalization from a resolution of a criminal charge. And this individual had been charged with attempting to and threatening to harm a neighbor with a knife, and then was mandated to treatment with our team, but didn't engage with his care manager or the medical staff member either by phone or and my colleague tried to reach out to him in the community, and we were left with a great deal of concern about this individual safety in the community. So that's that just gives an example.

[Chair Martin LaLonde]: Let me ask you a question about that. I mean, area has come up multiple times and I continue to try to understand what can be done about it. And I am continuing to do that. It seems in the statute that the answer is if somebody's not engaging in the order of non hospitalization, that's one of the factors that could weigh into having an order of hospitalization. But that doesn't seem to ever or hardly ever be happening. And do you have any insight on that? Number one. And number two, since that isn't working, any other recommendations of what we can look at to address this issue?

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: I think you might have read my notes that I'm going to get to, but that is exactly the issue. And I think that that concern applies to individuals on orders of non hospitalization out of criminal court, be they resolution of criminal charges for individuals who have been found not competent to stand trial, and on the rare occasion when someone is found is their criminal charges are resolved and not guilty by reason of insanity finding, those individuals are often under the care mandated care of designated agencies. And so one of the areas of tension that we encounter is when our clinical teams have concern about an individual's significant non adherence to an order of non hospitalization where our significant we have significant concern about that individual's safety for themselves or those around them. We would then complete an application for revocation of that order of non hospitalization to the Department of Mental Health clinical team, and often that results that pathway can result in an order of hospitalization. It's for hospitalization for that individual. What we have experienced often is that our clinical team and our concern, we're not always in agreement and more often than not we are in disagreement with the clinical team at the Department of Mental Health about whether that revocation order, whether that petition for revocation should go forward to the court for consideration for revocation. So that is the sort of rate limiting step that we are experiencing and respectfully a resolution to that or a solution to that would be for designated agencies to be able to inform the relevant court directly of concerning non adherence to orders of non hospitalization.

[Rep. Thomas Burditt (Vice Chair)]: So, just can I

[Chair Martin LaLonde]: put an

[Rep. Thomas Burditt (Vice Chair)]: attempt to put a finer point on that so that I know I'm understanding correctly? So, the designated agency is tasked with, charged with oversight of this individual who on an ONH. Yes. But then when there is evidence of an inability to comply or an unwillingness to comply with the ONH, and you as the designated agency sort of plead that case to DMH, you you don't have the influence that you would like or might need in terms of a a change in status for that individual.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: The current process, as practiced, though I'm not an attorney that I've reviewed the statute, the current practice is we then complete an application for revocation of the ONH and then submit that to the clinical team at the Department of Mental Health. They then review the information we've given them. Sometimes they have additional interviews, and then they decide whether to go forward and and request a hearing to petition the relevant court for revocation. And it is more often than not that we are not in agreement on we are often more concerned about community safety and the safety of our client because of our proximity to them. And we find this as a real

[Rep. Thomas Burditt (Vice Chair)]: You're responsible for them.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: Yes, yes, we're both responsible for their care and hold a significant responsibility for their safety in the community and to report and share their non adherence to the order of non hospitalization. That's right.

[Rep. Thomas Burditt (Vice Chair)]: And just a quick follow-up on that, how is there a typical or prescribed length of time that this might, this process might take from the time you reach out to DMH and then they, their decision process and petition the court?

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: I actually, I don't know if there's a time limit. I've found that they are usually pretty prompt in responding to us. And the process for if on the rare occasion that we do go forward, that they do elect to go forward to request that hearing, that that is a long process. And it can take my colleagues have, say two two weeks, my experience as little as two weeks, my experience has been more like four or six weeks and often that individual is hospitalized emergently while awaiting the hearing.

[Rep. Thomas Burditt (Vice Chair)]: Okay, gotcha. Thank you very much.

[Rep. Barbara Rachelson (Member)]: Barbara Linkert. Thank you. I'm wondering to follow-up on Representative Bartima's questions. There's no sort of like, if there's not agreement, yet another body can help review that.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: That is a great question, and we do not have a process like that of appeal or another level of review.

[Rep. Barbara Rachelson (Member)]: And is this the process that's used in other states or is there

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: So that's a great question. I am familiar with processes primarily in Connecticut and Massachusetts, and I had the opportunity recently at the American Academy of Psychiatry and Law to discuss processes with colleagues from other states. We seem fairly unique in this, though, as my colleagues reminded me, each state has sort of developed their own process, so we're all unique. But I don't think that other states have similar processes.

[Chair Martin LaLonde]: Thank you.

[Rep. Thomas Burditt (Vice Chair)]: Just to clarify, wondering if this is in statute or if this is I'm assuming as a dedicated agency, do you have like an MOU or a contract with the Department of Health? How has that worked? So that's why I'm trying to understand. Is this a statute thing that we need to work out? Or is it more this is just the agreement that you and the Department of Health have navigated and that needs to be updated?

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: Well, arguably both, but I think there's opportunity in clarifying the statute to, from my perspective, have the designated agency have more voice about clinical status of people on orders of non hospitalization. So I think that there is opportunity in the statute.

[Rep. Thomas Burditt (Vice Chair)]: And has it been explored within the contract or MOU? Again, I don't know the right word, but the agreement between you and the Department of Health.

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: So designated agencies are written in state statute. We exist as We're private organizations, but essentially fulfill duties of the state. So we are tasked to take people into our care on behalf of commissioners. And so that's for the mental health commissioner and also the Dale commissioner. And so they are technically in the state's care, but we are designated to support them. So each year we negotiate a provider agreement, which has a lot of language in there that is fairly set. And then there are statutes that About hospitalization, involuntary. And so those go through BMH and then through the judiciary process with the judge and presenting that. So there are probably a couple of entrance points that would need to be amended to change how that happens. And again, you know, I think Vermont has a preference for community based options, which I think is a good thing. And to what we're speaking about, the sliver of folks that need more intensive level of care, there probably needs to be

[Rep. Thomas Burditt (Vice Chair)]: thought about differently to address this. Certainly appreciate those people, just wanting to understand the levels of that. And so is it that we need to start at the top or have things been addressed at other levels as well? Or do we need a comprehensive approach? Do

[Chair Martin LaLonde]: you have more, Doctor? You can continue.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: I think that through our discussion, I've covered the points I really wanted to emphasize on where there's opportunity to improve our processes. I think I'll just emphasize that this is a narrow group of individuals whom we serve. The vast majority, we serve effectively, safely, and in a client centered manner in the community. And when we have the responsibility to both serve and oversee the safety of individuals in the community who have history of serious violence and significant criminal charges, we have an opportunity to improve our processes.

[Chair Martin LaLonde]: And I

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: think that there's opportunity to improve that through the statutory language on orders of non hospitalization.

[Rep. Barbara Rachelson (Member)]: So I have two questions that are not exactly on this topic, but I think you two would be really well Can I ask one question on

[Chair Martin LaLonde]: the topic, and then I'll turn to you just real quick? And maybe this is a sensitive topic, we can't say much on this. But I'm curious to understand where there has been this difference of viewpoint where probably revocation of a bone age was sought and it didn't happen, and then something bad happened. I mean, you know, and then we've actually had to harm occur. Know, know yeah. And I I mean, I know of two situations that involve that my understanding, and it's really hard to get to the bottom of these situations. Like in Franklin County, there was somebody that at one point had been on an OMH and ended up killing his father. In a situation in Washington County, there was somebody that either was on an O and H or should have been, who did. So it's like and I'm I'm just reason I'm asking is it's hard to find out if there have been these bad situations that makes this salient, a little more salient and lights the fire under the legislature and the administration to actually do something about this?

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: I can give you, well, I'm gonna try to give you an example that gives enough salient information that you can see why this is of really profound importance without giving any kind of identifying information. I can tell you that this happens not infrequently, that an individual is on an order of non hospitalization and then we've had difficulty getting it revoked through the process that I've described and then there's harm to that individual or people around them. I will try to give an example without giving any identifying information of someone whom I have worked with. This is a woman in her early 30s who was on an order of non hospitalization out of a criminal court for a serious charge. I'm trying very hard not to give much, any identifying information, so please pardon the vagueness.

[Chair Martin LaLonde]: No, that's not offensive.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: Yeah. We became very she had a very serious charge that attracted a fair amount of public attention. And I left care with us, wouldn't come to appointments, wouldn't answer phone calls, wouldn't engage with our staff when they went to their residence where she was living. And we became increasingly concerned because of a history of violence towards others thankfully a history of violence towards others without serious injury. And because of the depth of our concern about the non adherence, we this was this is a few years back, just to give some context, completed an application for revocation. And one of the difficulties we ran into was we didn't have a lot of current information about her, how she was doing in her current state because she was taking a step back and not engaging with us despite that she had an order of non hospitalization and a mandate to do so, but we had pretty profound concern. Our colleagues in the clinical, team at Department of Mental Health said, we sympathize with you, but we don't have enough information to go forward to request revocation from the court. And so we continue to try to reach out to this individual in the community and to reach her in her residence in person by phone and so forth without success. And we petitioned a second time and were unsuccessful again a second time. We actually became concerned because the individual we learned may have obtained weapons, not firearms, but knives, and were very worried about the people immediately around her. Ultimately, our request did go forward. Our colleagues on the clinical team at Department of Mental Health said, yes, this is concerning. We understand you've not been able to connect with this person. We understand the level of risk and we'll go forward to have a hearing about this. While we were awaiting the hearing, this individual had assaultive behavior towards a number of individuals who were in their proximity, thankfully without serious injury.

[Rep. Barbara Rachelson (Member)]: Okay, all right. Well, appreciate that. Thanks for that. Yeah, finally. That actually brings up a third issue, is interesting to think about when you can't make contact with someone, if the failure to be able to make contact could trigger some action because we don't know. And that action might thoughtfully be something not necessarily hospitalization, but some way for somebody to figure out what's going on. Or just go into limbo.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: I think that's a really interesting point, and it's interesting when you look at what is allowed for revocation of an order of non hospitalization, what we typically the outcome when an order of non hospitalization is revoked is hospitalization, but a wide range of clinical interventions are allowed and that brings up the possibility of utilizing that more fully, the revocation mechanism more fully for other kinds of intervention or clinical care to support an individual that are not hospitalization.

[Rep. Barbara Rachelson (Member)]: So I will make this really quick. I know mental health, despite getting increases at times, things are tight and there's more demand than you can serve. I also get concerned when our state contracts out services and doesn't think to, it's not even Department of Mental Health, it's other departments that are contracting out mental health services. And I'm wondering if when the RFP is out for providing services in Corrections, if you have a right of first refusal or preferential treatment as a provider to bid on these things so that we're allowing our Vermont resources to have access first to these types of service opportunities.

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: It's certainly an interesting thought. We don't currently provide services in corrections, but we do when we have someone transitioning from corrections to the community, we do do in reach to have as little disruption in care as possible.

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: Yeah, we do have some programs that go into facilities for specific reasons, self use being one of them, but from a bidding perspective, I mean, we've seen those RFPs and saying like, what's the capacity and ability to do that, which I think is probably what you run up against. But I think it's been considered in the past, but I don't think there's any, inside track that the designated agencies have for an RFP.

[Rep. Barbara Rachelson (Member)]: And my last question is, when public inebriates, when we repeal the repeal to send them back to jail, I was told, Oh, the Howard Center doesn't want to do Act one anymore. And I said, Is it that the programs are not being adequately funded to do these programs? And so I guess I just wonder if designated agencies are looking to not be doing the kinds of programs that ACT one was doing. And I don't know if your four beds include.

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: I mean, Act one is Howard, so I'll defer to Howard on that. But from a public inebriate standpoint, know, NKHS has a contract for that. But the way it's funded required us to staff it through an on call procedure because crisis continuums are about being needed when the thing happens. If you fund it on a volume or if you have to say like, well, we're not going to pay for people to be there, then what happens is in effect the process reduces the efficacy. And so what we found was that for the police, they're like, well, we're not going wait half an hour for you get there. We'll go to hospital, we'll go to jail because we got other stuff to do because they're taxed. So you can't blame them, but to just have someone available 20 fourseven at a even, you know, just a fairly decent rate is going to cost you $100,000 And so that's just not available. And so what you get is people going to higher levels of care like the hospital emergency room, which is expensive and has a healthcare cost or jail, which again is like a fine holding place, but doesn't get to the root cause and you're probably gonna have recidivism. So we would argue that we are open to doing that. We're a preferred provider for substance use. The front porch is co occurring. We have people there that do clinical detox, that's intense and you need medical oversight for that. But in terms of social detox or public anemia program, we're certainly open to that. I would say that the entrance issue there is funding, very

[Chair Martin LaLonde]: limited. Good. I was

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: wondering if I know there's a third person to testify.

[Chair Martin LaLonde]: Toes? No, no, there is. There's not much time. So Lindsey, are you gonna be back the weekend of February 10 for isn't there a disability thing? Yeah. We have you on that day instead so we're not cutting into your time? Because I know I've already set aside that we're going to have some time on that day. So can we reschedule you for that instead? We're not rushing you. So thank you very much.

[Kelsey Stabsef (Executive Director, Northeast Kingdom Human Services)]: I'm gonna be happy to come back. Think when the bill put forward in there, I think there's more to talk about. Absolutely. There is. Very good. So I appreciate the time today.

[Chair Martin LaLonde]: Yeah. We need to see what what they're gonna do with the downstairs. Thank you. One minute. We'll send it side s 193. So Yeah. One minute. Thank you very much, everybody. And

[Dr. Simi Ravin (Chief Medical Officer, Howard Center)]: Thank you so much.

[Chair Martin LaLonde]: And we are