Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons (Chair)]: Hello. All right, good morning everyone. This is Senate Health and Welfare on Wednesday, January 7. This morning we're going to take some time just to talk amongst ourselves about our interests and topics, topical priorities, what we would like to see on the table and work with. We've got a lot of bills and so we'll go through the bills in a couple of days. We'll take some time to sort out which ones rise to the surface for us and then do what we can do. But I'm really interested in what your interests are. I know some of them. I don't know all of them. I'm gonna start with old guard today. I guess you guys are Yeah. Visualized. Guard. Watch the board. Okay. That's not the experience. Experience. That's what I didn't think of. I think of experience. I'm sorry. No. I would be sensitive to that too. Alright. Senator Cummings. Okay.

[Senator Ann Cummings (Member)]: Experienced judge. I don't know what the bills say because I don't know that anyone had time to get a bill out as things were breaking in DC. I'm very concerned since I've spent an awful lot of time in this building trying to get all the marchers to have health insurance. I wanna make sure that we do the least amount of harm possible. First, to people, and secondly, that we don't do so much harm to the health insurance market that it's going to end up in distress for the years to come, depending on if people stay in it, if people leave it. I'm very concerned about if people either leave or don't have adequate insurance, that showing up at the emergency room will further stress our hospitals and their finances. I just got brought home to me the other day. I read an article and apparently Jim Henson of the Muppets died from a strep throat. He did. He had pneumonia as a result. Yep. Yep. Musions in his lungs. Three days.

[Senator John Morley III (Member)]: Right. Yeah.

[Senator Ann Cummings (Member)]: Dad Wow. Points out, can you mandate that schools test for strep throat like they used to? Sure, write the bill. When the Commissioner of Health comes in and asks him that question, you see insurance companies, I

[Senator John Morley III (Member)]: know, it's not

[Senator Ann Cummings (Member)]: a health commission. Exactly. But if if you don't have the money, you're more inclined to say it's just a sore throat gargle with lemon and honey or something and, yeah, tough it out. Yeah. Sometimes that can be absolutely deadly.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. Thank you. Senator Feuer. Oh, thank you, Chair Lyons. Well, oh boy, having spent most of my summer on the redistricting committee, It switched.

[Senator Martine Larocque Gulick (Vice Chair)]: Yeah. No, it's okay. I mean, there's a lot of overlap in there. There's a lot of overlap. It was brought home yet again that one of the biggest, if not the biggest, cost drivers that we are grappling with in the state is healthcare costs. So, I am committed and excited to continue the work of bringing down the cost of healthcare in the state of Vermont. I think it should be our number one priority. Creating bigger school districts is the answer, but bringing down the cost drivers. That is the answer to our problems. And in that vein, I think we should continue the work of taking services and taking care out of hospitals and making it more accessible and more available to people, especially in rural parts of the state. I spent a big chunk of the summer driving on little roads all over the state, and it made me appreciate even more the challenges that folks in rural parts of the state are facing, whether it be access to education or access to healthcare. This is real and we can't abandon those folks. So last year, we passed the birthing center bill, which is exciting. We worked really hard on the certificate of weed thresholds. Those are important to, again, disseminating care around the state in a way that folks can access it. So, all of that and keeping the quality high is critically important. I do have a bunch of bills that I would gladly share with all of you. I'm really excited about the one that really put strong guardrails around AI therapy. We've heard over and over again about the dangers that folks are facing, especially young people when they seek help from an AI bot when it comes to mental health. So I'm hoping that we can work on that. And then I have some other other bills I'll share with you, but priorities are around cost, access, and quality. Cool, yeah, that's good. There's a lot resonating in restaurants. It's great. Okay, that's it.

[Senator Virginia "Ginny" Lyons (Chair)]: Just those little tiny easily achievable. Alright, so what are we going to do third week? It was like he was busy for a while. Yeah. This will. Thank you. Thank you. I I like the way you've taken your work this summer and moved it into what you, you know your observations of what's needed. Great. Alright. So I'm gonna move over to the side of the table to save myself. Senator Benson.

[Senator John Benson (Member)]: Yes. Well, I would mimic many of the same things that Senator Benson just mentioned, I mean, cost, access, as I mentioned yesterday, concerned about some of our smaller hospitals or medical facilities. Access is critical for people, and if we lose all the smaller ones, and they have to travel long distances, that's not providing quality care, but at the same time, you're trying to balance cost. I also, as I mentioned to chair Wyatt this morning before we really started, I have gotten a couple of notes from constituents about S60 OR, and so the chair said we would be discussing that at some point, so that's how I care. Yes. Yeah. Just

[Senator Virginia "Ginny" Lyons (Chair)]: a few notes. Yeah, just

[Senator John Benson (Member)]: a few notes. So, but really, it's those essential pieces of cost balanced with quality and access.

[Senator John Morley III (Member)]: Difficult because you want better quality, more access, different costs go up. This is a duller sword. Within Yeah. The Northeast Kingdom. So, you know, rural communities, and I'm already starting to hear, so I didn't know it was gonna be on this committee yesterday. So now now people are starting to talk. And, of course, we have North Country Hospital, and you also have an NDRH, and, you know, people like, Senator Benson said, they're critically important to the Northeast States, and traveling long distances will be an issue. I also am really curious to hear your folks' perspective on I keep hearing that all this money that's coming from the federal government, we're rural hospitals since 'seventy eight, And then there's gotta be guardrails attached to that, I'm guessing.

[Senator Virginia "Ginny" Lyons (Chair)]: And we're gonna hear about that on Friday. Okay. Next Wednesday, next Wednesday. Schedule, right? Yeah, this is

[Senator John Morley III (Member)]: true. And I don't know how that works. I'll be curious to see how it works. I also hear that UVM did really well. I think

[Senator John Benson (Member)]: I read an article or

[Senator Virginia "Ginny" Lyons (Chair)]: was it what? No. No. It's well I don't It's very expensive.

[Speaker 3]: Very

[Senator Virginia "Ginny" Lyons (Chair)]: expensive. Spent a lot of time on why it was very expensive. This is one of the main drivers.

[Senator John Morley III (Member)]: Okay. Okay. And so I'll be this I I think I understand there's 14 hospitals in the state of Vermont.

[Speaker 3]: Yep. And

[Senator John Morley III (Member)]: some of them are linked together. Guess, I think, you know, must have some.

[Speaker 3]: I got Dartmouth has a few Yeah.

[Senator John Morley III (Member)]: In the state.

[Senator Virginia "Ginny" Lyons (Chair)]: With the Scott name. Yep.

[Senator John Morley III (Member)]: And it sounds like to me, Newport and NBRH are starting to collaborate more together, which is great. That is different. Yep. So those are, you know, for me and my district, those are gonna be some of the things I'll be thinking about, listening to, trying to understand. I know it's very complicated, but I'll do, let's go again, so I'll be looking into the rural hospitals. Your predecessor was a big supporter of your hospital. Okay.

[Senator Virginia "Ginny" Lyons (Chair)]: This is important to hear, say, because we get so used to it here, or at least I do, I mean I went up and I talked with the rural hospitals some time in the fall. Some of our first snowstorm, of course, right? And they were talking about the relationship that they have and how it's saving dollars and improving access. So it sounds to me like that's a good place for us to have some testimony. We get some of those folks in because they are doing really good work. I'm glad to hear that. So so we'll do that.

[Senator John Morley III (Member)]: I'm also hearing that it's hard to attract good doctors, especially in the rural areas. So I'm guessing that's I don't know if it's location or money or both.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah.

[Senator John Morley III (Member)]: So I I'm hearing issues surrounding that. I went with a primary care physician for three years. I couldn't get one.

[Senator Virginia "Ginny" Lyons (Chair)]: Just couldn't get one.

[Senator John Morley III (Member)]: So if you can't get one, then what do you do?

[Senator Virginia "Ginny" Lyons (Chair)]: You can't get one here.

[Senator John Morley III (Member)]: You can't get one here either.

[Senator Virginia "Ginny" Lyons (Chair)]: Well, primary care doesn't get you. Yeah.

[Senator John Morley III (Member)]: And so I finally got one now, and then they offer you nurse practitioners versus a doctor.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, that's my primary care provider.

[Senator John Morley III (Member)]: And how that works. Then I hear things about Blue Cross Blue Shield and that happens. So I'm hearing this, but my primary goal is just looking out for the rural communities.

[Senator Virginia "Ginny" Lyons (Chair)]: Good, well and what happens in the rural parts of the state because we're all rural, literally, everyone looks at Chittenden County as dense population, but the reality is we also have primary care access problems there as well. So it doesn't matter where you go in the state. There might be a shorter wait time.

[Senator John Benson (Member)]: Yeah, dental is another issue.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, I'm glad you brought that up. So last year, we gave her this to Michael Costa. They were going for grants to train or do internships here. The Maple Mountain? Yeah. Uh-huh. I believe I read they've done their federal I'm gonna yep. Through the Rural Health Transformation Grant, they were written in and so they will be funded in the first, as far as I know, in the first process. Might be good to hear from you. Right. So, will, let me share with you when I finish my thing and then I'll share with you what I'm hearing you say and we need, and that was one of them, and it dovetails with what you were saying. You know what like about this? We're all on the same page. We are. I mean, I think we see a problem, the problems that exist. Last year was really good at emphasizing solutions, some of the bigger solutions. Now we have to start to get down into the details. So I mean, for me, as I have said before, it's primary care. We looked at hospitals, we're gonna continue that, looking at hospital transformation. We're going to hear about the transformation process as early as tomorrow and the next day, and the general begin to help go through what's happened and what's going on. I do want to have the hospitals come in, in particular Michael Costa, because when I met with the group in the fall, what he presented was outstanding. Some of the work the hospitals, Just the rural hospitals are doing is outstanding. And so I will just say, I'll just say, preface before I go to primary care, just one thing. One of the good things that our legislation has done is it has put everyone in the room together. So it isn't a single hospital making a decision about what needs to go and what needs to stay. But it's more of a collaborative process regionally and that's what you were talking about and you're talking about how can we regionalize and that's what the administration is now talking about, identifying our legislation, laws have said, go identify the gaps and then come back together and say, how are we gonna work together to fill the gaps? So that's what was so refreshing to hear. Now obviously each hospital has its own financial sustainability problems, know, and there's a lot of tension and competition going on. Nevertheless, there's also an understanding that if we don't do something and it's us and it's them, we don't do something, where it's going to fall. So, is good to hear what you're saying because I think it resonates pretty much with where we are. Primary care for me is absolutely critically important because it leads to prevention of all those chronic diseases and acute care needs that we see when people have to get out of the hospital. And then, so I've said this before, primary care, we need primary care docs. We put significant funds into loan repayment and we'll continue to think about those workforce dollars needed to keep people in the state, to draw people in the state. It's for nurses, it's for docs, and all the way down to the LPNs. We still have an LPN program that's ongoing. There's money that's being expended for that. The federal dollars that we got from ARBOC, we heard about that a little bit yesterday in a PROS. So there's a lot that we are doing but we wanna make sure it's ongoing and that we have an investment in the services that we need, everything from primary care and mental health counselors to hospital based services. So when I think of primary care, one of the things I'm learning from the advisory committee that we put in place. We have a primary care advisory committee that is participating in the state transformation plan and they're a very robust committee. And when I talked with the chair of that committee, and she shared it to the doc, and she said, One of the best things that you can do is exactly what Senator Gulick said, and that is there are things that are happening in a hospital that could happen less expensively and closer to home with primary care. We So can't do that. We can't pick out those things and move, but what we can do is to have policies in place that help that especially. So that's a piece of that primary care discussion. And as we go through the bill, we'll talk about other things. Obviously, this is important. Equal pay for equal work, affiliated versus independent docs, the whole issue around how do we pay people, what's the payment process look like, that's a lot of work. We need to think creatively about how we're going to do that to keep people in the Northeast Kingdom and then to attract them in and keep them at home. There's a huge differential between affiliated and independent, I'll just say salary wise, it's huge. So the cost of living isn't that much different. So those are some of the things, so the workforce, the primary care, and then I'm interested in all the things that you guys have talked about. I think it's awesome, really, and including the AI therapy guidelines, wonderful guardrails, and then the recovery substance use disorder continues to be a huge problem. Know, needless So, to say, I think we're all interested in all of this. Let's not overwhelm ourselves because it is and it's complicated. Will there are some very thoughtful bills that come in both from the administration, from the regulatory body, the Green Mountain Care Board, from us. We'll look at those bills and we'll try to take all of the things that we care about and see if there are pieces that can move from one bill to another and consolidate. Like I don't know, there's a lot of redundant thinking. That's a good thing. That means that people are on the same page. It's good. I'm So I don't know where I am. I'm I'm all over the place where to start, so I it. Should

[Senator John Morley III (Member)]: It's a while for policy for me. So let's say we form a bill and we do some of the things we're talking about here today. How do we know what the cost of that policy change is?

[Senator Virginia "Ginny" Lyons (Chair)]: So this is why we take testimony. We're going to have to take testimony and listen. So you'll hear one thing from the hospital, if you do this, you're going to destroy us. You'll hear the same thing from the insurance company, and you're going to hear the independent physician say the same thing. So, ultimately we have to try to fit all those things together and then listen to the Green Mountain Care Board and Department of Financial Regulation and what do they say? Well, yeah, we can balance this or we can help with that. And then finally come up with a decision and our joint fiscal office says, oh this is way over the top, or yes you're within this area. So it's not a simple process and I think we're at a stage now where we've heard a lot about the financial sustainability of each of the groups. Okay. I said, well, I think we won't make a really obtuse decision. You know, I I do. I think we'll be okay. One thing we might wanna check on, Martine mentioned the birthing centers. So, yes, see them. We want them in. Well, Gifford is our latest hospital. That's it. Colson's birthing center. Yes. Or Colson's upstairs. Colson's, yeah. So the birthing center can't go there because they need a hospital with obstetrics for those rare cases where there's an issue. So, the birthing center may end up in Waterbury, is not that close to Cobbling, but is ten minutes from my car, so if you're in an ambulance with a siren, it's a lot less than that from CDH and not much farther from UPN. So we have we set them up. And we just said, oh, well, yeah, they have to be here at hospital, but that somehow is causing some issues because it's they're trying to replace a hospital birthing center, and then that hospital doesn't have the facilities, can't be sure they can't get insurance to be there. So you bring up a real good point and we'll have folks in on that. We'll ask questions about that. We can do that as we're going through a discussion on transformation. One of the things that the Green Mountain Care Board is establishing criteria for closure and it's really, it has been based on budget but it's also based on proximity to like similar services. So, yes, you raise big I mean, I think what Senator Cummings is talking about here is regionalization, right? If we're looking at a regional, if we're looking at a region. Yep. And we have like a coherent plan for that region, then there won't be this sort of, like, haphazard Yeah. Closures and openings. And they're all connected. You need a really good ambulance service, but you're inclined to have first time Barrack town to go over Montpelier's one of the towns. They went to the wrong address.

[Senator John Morley III (Member)]: Oh, so that's a whole dispatching issue.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, right. I involved

[Senator John Morley III (Member)]: with all that

[Senator Virginia "Ginny" Lyons (Chair)]: I tried, Sam, buying a ladder truck over thirty years ago. We bought three, I think they're up to $3,000,000 now, with ladder trucks.

[Senator John Morley III (Member)]: Within

[Senator Virginia "Ginny" Lyons (Chair)]: thirty years of miles, don't think, was it thirty years ago? Yeah, at least thirty years ago, I tried to regionalize dispatch for police and fire in Chittenden County, and boy was that a

[Speaker 3]: fun time.

[Senator John Benson (Member)]: Yeah. And I participated in all of that with nine one one system, and I think the state dropped them all when they, you know, take it to the next step, which is to actually set up the dispatch centers. So they did the call centers, but they did not take it to the next level, which is they have the actual dispatch centers. And I know personally, I dealt with that. The little dispatch center in Randolph closed. And then from 'eight, we found our ability to go down to Hartford. And then we've been in four different places. We're now in Barrie City, but it was difficult

[Speaker 3]: Yeah.

[Senator John Benson (Member)]: To find a a service.

[Senator Virginia "Ginny" Lyons (Chair)]: Yep. Yeah. I think down your way, the Orange County sheriff stopped doing dispatch, and there were sections What's left the

[Senator John Benson (Member)]: office down the sheriff.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. Yeah.

[Senator John Morley III (Member)]: I mean,

[Senator John Benson (Member)]: we have

[Senator Virginia "Ginny" Lyons (Chair)]: No other issues. This is not the judiciary committee. But

[Senator John Benson (Member)]: I would, Madam Chair, just go back to a comment that Senator Cummings made, and that is it would be great if the hospitals themselves would get together to do exactly what you're saying as opposed to us dictating where things come from and say, hey, we got this. How do we all work together where this hospital provides these services in the region here, so that they all basically survive when we all provide that quality service to the constituents? But it's not us kinda saying, you do this and and this. So

[Senator Virginia "Ginny" Lyons (Chair)]: I would like to say thank you for that comment, and I think that the work that we did in here last year in particular, but the work that we've done on 01/1967 and Act 68 last year and Act 51, the work that we've done there has been a really gradual transition to bringing folks together outside of this building and to have things happen because there's no way that I do not want to tell a hospital that you should or should not close the children's beds As you know, that's not my job. At the same token, we're making the decision independently and without the regional discussion to a large extent. So now we've got a stage where folks understand what well, we're responsible, but we're also responsible for engaging our community members. You're right. Top down doesn't always work, but it also mean but we also know that things have to happen. So there's a way you can get the crowbar out. Any anyway. I had just a couple one more so you've identified the other thing and that is the criteria for closures and access and how do we build that in here. And you can have a really good policy that says you go do this, but it is gonna work if the people who you're telling you do it are unwilling. That's part of the problem and we try to work together as much as possible. My other concern that I have seen as we've gone through all of this transformation work is who's in charge of what. So, Preman Care Board, Agency of Human Services, Department of Financial Regulation. So at some point I'm gonna bring, I think Jen will help us understand what each organization is responsible for when we can sort out what makes sense given where we are just by listing the votes. We're good. One more comment. The frustration comes in. 300, what, sixty, seventy small towns. Mhmm. We haven't done centralized dispatch from Barry Montpelier, Washington County yet. Five years of trying, and that's been twenty years of other trauma. We're in a crisis with our hospitals. And it's something it is very difficult for what was an independent we make our own decisions. We are our towns or our region's hospital to give up that power of. But sometimes they need

[Senator John Morley III (Member)]: encouragement. A loving nudge.

[Senator Virginia "Ginny" Lyons (Chair)]: A loving nudge. Or a big stick and a nice carrot. Yeah. Or what hits you know, you're at this point where we can't, oh, the carrot sticks to something bad, we'll have them here.

[Senator John Morley III (Member)]: Question is, do you try to do a great big thing all at once or a little bit at a time? Exactly. Hopefully a little bit at a time works better.

[Senator Virginia "Ginny" Lyons (Chair)]: But we, in health care now, we have reached and is doing away with the tax subsidies is Yeah. Doing away with the tax subsidies is cruel. It's It is absolutely cool. I'm looking into with a family plan costing $3,645,000 dollars a year. I would reach the tipping point where single payer, I've told a candidate 17% surcharge on your income tax, we pay from the previous employer. That's not the horrible number that it was the last two times the legislature looked at. That's why I mean payment reform is so very important and I'm having discussions with some of the chambers about how to do that. Keep her fingers in close. So, oh, this has been really fun. Seriously, it's good. I love hearing your perspective and I think we're all on line with you. We've got some very specific concerns. The birthing center is one, hospital's another. We're gonna bring folks in on those things. And we have lots of bills that don't get us going on regionalization. We have with us this morning Doctor. Rick Hildebrandt, who is the new Commissioner of Health. So Doctor. Hildebrandt, why don't you come up to see you again? Yes, ma'am. You brought a team.

[Dr. Rick Hildebrandt (Commissioner of Health)]: I did.

[Senator Virginia "Ginny" Lyons (Chair)]: And what I'm gonna ask of you is, as we get started, just we're gonna introduce ourselves first, then have you introduce yourself or give us a little bit of your background and we're going to try to consider this your confirmation hearing as well as a report and update on some of the work that's going on including recovery centers. And if that doesn't work out for committee members, we'll bring you back in and Okay. Let's start over here.

[Senator John Morley III (Member)]: Senator John Morley, Orleans. Nice to meet you.

[Senator John Benson (Member)]: John Benson from Orange District.

[Senator Virginia "Ginny" Lyons (Chair)]: Ginny Lyons, Chittenden, Southeast. Martine Larocque with Burlington, Chittenden Central. Ann Cummings, District. To meet you. Welcome. So

[Dr. Rick Hildebrandt (Commissioner of Health)]: I do have some slides,

[Senator Virginia "Ginny" Lyons (Chair)]: You may wanna introduce yourself for the record first. Absolutely.

[Dr. Rick Hildebrandt (Commissioner of Health)]: Thanks for the brand, and I'm sharing the floor with the public. Interesting. And again, the slides are light on content and, you

[Senator John Benson (Member)]: know, just a

[Dr. Rick Hildebrandt (Commissioner of Health)]: visual thing there, but I really want to focus on the conversation more than anything else. So I did want to give a little bit of my background. So as you may know, I'm a physician, I practice in the hospital, in the inpatient unit, and have done so for thirteen years down in Rutland. I started that, I came there right after my residency training in Darvin. When I came to Rutland, a few things were immediately apparent to me. One was that there was a lot of folks that were making decisions in the hospital, hospital administration and others, without any clinicians at the table. And it wasn't because they were excluded, was because people weren't gonna be raising their hands to say, Hey, I would like to be part of this discussion. The physicians really wanted to do clinical work. So I started inviting myself to a number of meetings, which found me on a leadership track, which was not in my plan at all. And saw a series of promotions over the years.

[Senator Virginia "Ginny" Lyons (Chair)]: Volunteer. Yeah, exactly. Because of me, really.

[Dr. Rick Hildebrandt (Commissioner of Health)]: And found myself in a number of medical director of the group and into the executive leadership over time. But the other thing that was very clear was that I can't solve the problems of my patients in the four walls of the hospital. They're too big and they require more people than we have here. It's not just medications, therapeutics, nurses and doctors, but it's coordination across the system. So I reached out to our community partners. We have a structure in Rutland that ultimately turned into something called our community collaborative, where we have all our local area healthcare stakeholders meet once a month. We talk about issues, challenges, come up with plans about how to address them. And initially it was really focused on very manageable hospital things, like readmission rates, some ED visits, I mean, trying to look at those. We were very successful, we looked at some these specific diseases. Although over time, it still wasn't really changing much. I mean, I'm still seeing repeat patients come in again and again and again. And even with the best coordination of care, it was the social drivers of health that really were driving a lot of these issues. Lack of financial resources, transportation, adequate food nutrition, access to health care, but all of the same social drivers that we see across the state. And that led me to look at different boards and commissions around the community and around the state. I joined the local investment agencies board. At that time, was in a local chief medical information officer, which is this really interesting intersection between EMRs and physicians. Challenging work at times, but I have a bit of a tech focus, so joined Vitals Board, which was really interesting and had a great perspective around the state. I joined the Board of Medical Practice and served as their chair for four years as sort of a regulator, which is also very, very interesting to me. But more and more my interest lied outside of the hospital and more of the systems that we practice in and work in. I was the COVID czar for COVID at our hospital and when Mark had announced his retirement, had thought to myself for a while, hey, know, maybe when he decides to retire, I'll bring my Adolin. Six, eight months later, I found myself in the position and it's really been great. The health department has really blown me away. I've learned a lot in my almost three months there. I've learned that I have a lot to learn. But what really struck me was the caliber of the individuals that work there are just amazing. And I don't know what I was expecting, but these are, like, the best of the best people that we have there. It's really been quite nice to see that. Really caring people who work very hard with their needs. So the next slide is, this is our mission of vision and our values, and I put this up here, a, to remind us of what it is. But also, the other reason that I felt I wanted to pursue this this role was I felt a calling to do so. There's an attack on science and on public health around our nation right now, and this really spoke to me and I felt like if I had the ability to do something, ought to do something. That was really driven by the position of the Department of Health. Public health can be something that's challenging to define. When public health is doing its job, nothing bad is happening, right? And we use this scheme of detect, connect, and respond as a way to think about public health. As a very tangible example, a number of weeks ago we had a outbreak of pertussis, a moving cough in a Washington County school. So we detected that. There was this thing going on. We responded by giving the school and community resources that they need, whether it was an education or access to vaccination or whatever they needed to protect themselves and their families. And we alerted that area of health care providers that, hey, this is going on, how to how prevent the spread. And that was sort of a good example of what happens here. But it happens in infectious disease, happens in so many other different ways that I was never aware of before taking on this role, whether it's in environmental health or chronic disease management. So many different, weather emergencies, either hot or cold, there's so many different ways that the health department will get involved in this sort of response when things happen to try and prevent them from distress. This is our organizational structure, and I don't expect people to digest all this, but the health department consists of about 600 positions, and we have 12 district offices in each of our communities that help serve to connect with Vermonters and with the local area of resources that are there. I oftentimes refer to this to remind myself of all the places we we touch, all the people we touch, And to remind myself that we range in what we do from very, very concrete clinical services like the Office of the Chief Medical Examiner, so nursing home visits, bridging families, lab testing, to more community based work, like chronic disease prevention, health production, environmental health, looking at air quality, soil quality. It's really nice to have experts in these fields because there is so much information to know that there's no way one person could, but we have experts in all these fields that are incredibly helpful to us.

[Senator Virginia "Ginny" Lyons (Chair)]: Highly educated. Yes. And experienced.

[Dr. Rick Hildebrandt (Commissioner of Health)]: So one thing that I felt is very important to me to do in taking on this role is to preserve the trust in public health. We exited the pandemic with a very good reputation, and that was not true in every state of America. There's some state health departments that had a really tarnished reputation for effective and penlighting, and I credit the health department, I credit Doctor. Levine for doing that. But, you know, there's a tap on public health right now, and it's my job, it's our job to make sure people see us as the solid authority to give accurate information to the public. And that's something that's very important to me. There's so much misinformation out right now. It's been challenging to be fair. And our comms team has been working very hard to ensure that people have that knowledge, but that is a very important piece to me. The other piece though is it's not just about sort of central office communications. It's about those connections with communities. That's really how we have built and maintained that trust. People know other people in communities, in our district offices, with their health care providers, patients, school nurses, you name it. Those connections matter so much because when you have a personal connection with somebody that works for the farm and health and real estate, it really helps build that trust. I suspect there will be more of this discussion in the coming year as there has been just in the last week, but, you know, that is, again, a big plus. So speaking of immunizations a little bit, there's been a lot of false claims and falsehoods around immunizations in recent news. We just had a big announcement from HHS this week that dramatically changes the immunization schedule, which is a big concern of mine. And it does so based on I can't find any medical knowledge to support the changes that I made, which is of significant uncertainty. So we have a large group of stakeholders that has been working on this for a long time, since the first phase of being missed, including the health department, Department of Vermont Health Access, OPR, and the Department of Financial Privilege, and many, many more to ensure that Vermonters have access to vaccines if they would like to continue having vaccines. And that information is available to both patients and to medical providers about what the recommendations are for vaccine. So that's been a big piece of work. We'll continue on that work all year long, I suspect. And you may see me in some new media around that particular stuff. Thing that has been a real focus of mine, this is again, just in a few months, has come up a number of times around access. I know you guys were having a conversation just before I joined about health care access. I care about this not only as a provider and someone who has worked in the hospital for quite some time, but it's also a public health insurance. If you don't have access to, as an example, maternity care across our state, that's a public health institution.

[Senator Virginia "Ginny" Lyons (Chair)]: I just want go back to the previous slide, because we brought up the immunization bill that we have in committee, that the House also has in committee, and the House is going to take the bill up first, and know that you're, I think you're testifying in there.

[Dr. Rick Hildebrandt (Commissioner of Health)]: Yesterday.

[Senator Virginia "Ginny" Lyons (Chair)]: Yesterday. Yeah. I'm behind. It's okay. But, so, yes, and so that's a really important, I'm not sure that we heard the emphasis you placed on fast track.

[Senator John Benson (Member)]: Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: And it's an important bill to have happen quickly. Correct. So, we'll hear your testimony when we come in on that. Yeah. Thank you for the work you're doing. Absolutely. Absolutely. Madam Chair, can

[Senator John Benson (Member)]: I just follow-up to your comments? So that Yeah. Up to speed on all the bills is the connection between what comes out of the Department of Health in terms of recommendations versus what the insurance companies are going to cover for both. And if those two don't jive together, that creates, obviously, a hole in the system.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. So Part of the bill. That's part of the bill.

[Dr. Rick Hildebrandt (Commissioner of Health)]: Part of the bill. And I agree with you entirely, but the good news too is that people like Blue Cross Blue Shield, they see this as a money saving measure. I mean, vaccines prevent illnesses and very expensive hospitalizations. It's not a cost to them and see this, you know, this is something they want to So that's the good news, but yes, it's part of the problem. So again, back to access, Obstetric care is, there's been lots of discussions around obstetric care. There was a discussion in Gretlin about pediatric care. Transportation to services has been a real challenge, and there's much needed change in our EMS system to allow for, regionalization efforts to occur. You know, current reimbursement structures for EMS do not support hospital placements. They don't. They support bringing people to ER, which is not always what we want. We may want them to treat someone in the field and then not bring them to the ER or treat them in the field and send them to an alternative site or give substance use disorder treatment. So we would like to help with all of those things to try and reduce the burden on our health care system and EMS has been part of that. Good question.

[Senator John Morley III (Member)]: It's just funny, I do listen to the ambulance service, and so I think you're talking about. I see it again, prefilzation coming to deploy here to

[Senator John Benson (Member)]: some of them. I even went to

[Senator John Morley III (Member)]: the back and say, why doesn't the hospital stay over the ambulance departments? And because they work so closely with them, but I didn't get much traction. And then you hear about the Medicaid and the Medicare reimbursements and all that stuff.

[Dr. Rick Hildebrandt (Commissioner of Health)]: That's been a discussion, I'll tell you, in Rutland for a long time. And the reality is, ambulance services do better at emergency services than hospitals do in most cases unless you're very, very big. We shouldn't be running a transportation services hospital, which might hospital to hospital. That being said, the human services need more resources to do what we're asking them to do, which will save the system money that they need to be able to, as an example, build insurance for delivering care that doesn't report it.

[Senator John Morley III (Member)]: Well, so underfunded, we're going to the communities that we serve and requesting funds in order to operate. So that's how bad, in certain regions, are worse than others. Correct.

[Senator John Benson (Member)]: Hear that. Madam Chair, can I just follow-up? My is my understanding, is unless they transport, they do not get reimbursed. Your comment about treating on-site is a whole different animal that would have

[Dr. Rick Hildebrandt (Commissioner of Health)]: to be addressed in the process. Agreed. That's something that I hope to do, because it can't be just state funded. That that doesn't that's not sustainable. It needs to be we developed a system that allows the ambulance services to bill an insurer of providing the medic necessary services that's gonna save us all money.

[Senator John Benson (Member)]: Exactly. Right? That's what I was just gonna say. Yeah. It's certainly a lot cheaper if they were to administer air than bringing them to the ER and then Right. All those costs.

[Senator Virginia "Ginny" Lyons (Chair)]: Right on track.

[Senator John Morley III (Member)]: So we we talked about one time doing it county wide. Yeah. And, you know, I do the the the the courts, and things of that nature, so that everyone within that county, at least, make that part of the county budget. I lost that one too.

[Senator Virginia "Ginny" Lyons (Chair)]: You may win it, should learn.

[Dr. Rick Hildebrandt (Commissioner of Health)]: The thing I would say is I think that the EMS systems are ready for change. Now there's been some resistance to change, and medicine in general, because it seems to change, just to be completely transparent. Okay. I've been working on for decades. There's financial challenges, there's quality concerns. I think there's a reckoning for change for it hasn't been. So, this might be a burning platform or opportunity to start. The last item that around access that has been on my radar is around reproductive health, and we wanna make sure we have access to the services, despite any federal changes that come up. We did in our BAA touch on this briefly as they're concerned about some potential title factors, but it's part of our constitution and protected, and we want to ensure that we have access to services that's really important

[Senator Virginia "Ginny" Lyons (Chair)]: to us.

[Dr. Rick Hildebrandt (Commissioner of Health)]: Alright, and then the last focus area for me, and part of reason you're here, is substance use disorder, something that very clearly was something I was discussing and talking about and addressing from very early on. Substance use disorder is not a big problem. It's a continuing problem that has evolved over time. And I think Vermont has done a lot of excellent work in this space. And we're a leader in substance use disorder treatment in many ways. Our public scope model has been very successful. More and more patients that I see on the inpatient unit, there's less of them that are actively using IV drugs, more of them that are in some form of recovery. Now they may have had a relapse, but many, many, many more are receiving that new treatment, and these treatment options available that were not there. However, the field has changed. We're seeing a change from oblique use disorder to stimulant use disorder, which is an entirely different word, and polysubstance use. Within the stimulant field, cocaine is the number one drug we're seeing of abuse, but there's an increased slight increase in that, which is something I'm very, very concerned with. Amphetamines are probably the worst drug in history we've ever invented as humans. And my colleagues across the country who have population populations with high meth use, it's scary, the stories that they tell. This drug can possibly become violent. It's very hard to recover from. It takes years. It takes years for drug recovery in any instance, but it takes longer with methane.

[Senator Virginia "Ginny" Lyons (Chair)]: So at some point it would be good to have you folks come in and just talk about the different substances and what you're seeing from your colonists across the country. And methamphetamine being one that's been on our radar for a while.

[Dr. Rick Hildebrandt (Commissioner of Health)]: Think it would be good

[Senator Virginia "Ginny" Lyons (Chair)]: because it leads into some of the behavioral health issues that we see and how we deal with those in community services or in the judicial system if we do that. And

[Dr. Rick Hildebrandt (Commissioner of Health)]: in the treatment space, one place that very clearly came up first is the amount of public housing. There's a housing challenges across our entire system. I don't care what type of housing we have, shortage of it. Right? Recovery housing has a real shortage within our system. It's something that we're working on increasing, as you'll hear more about in little while. And we also, I feel strongly prevention is so important as well. We are increasing our work in prevention to try and decrease the amount of opiate abuse that we're seeing, not just helping folks from the treatment and recovery, but preventing seizures from the beginning of the which is really challenging, but a very, very important one. This is a number of highlights in the substance use continuum. I will touch briefly on all these. The point I want to make here is there has been a lot of movement in a very short period of time in this space, and that's been really remarkable to me. How many things have happened just in over the last, I don't know, six, eight months in this space. In terms of community driven planning, so back a year ago, in December '24, we published our statewide community informed needs assessment. Then in April, we published the health department's community informed strategic plan. October and November, we did a number of listening sessions in the 12 districts to find out what's the challenges people are dealing with. There are a lot of common themes, and housing and transportation being probably number one and two. Okay? But that has really helped to identify gaps we can come to address again. Improved access to housing, BT Helping is now twenty four seven five. We have phone, online chat, and Spanish language, and we have outreach workers engaging with people early and involve transportation services, so they have access to treatment recovery and deployment. Our crisis response has been strengthened, so our mobile crisis teams respond to both mental health and substance use disorder crises in communities, and we have integrated crisis events in our virtual public and media screening to reduce the pressure on our emergency department. Again, trying to help treat people in the community as opposed to all bringing them to the ER every single time we have them. Prevention work, as I had said, we have a multi decade funding base, which is in a million and 26, we're gonna be utilizing new funding from the Substance Use Prevention Special Fund, which is an additional 2,000,000 in supporting these additional districts and supervisory units with the capacity in this space. There's a lot I can go into in the prevention work, I'll leave just it at that because this probably deserves a sound game time.

[Senator Virginia "Ginny" Lyons (Chair)]: Right, we'll be discussing this. I know that there is, you and I have talked a lot about nicotine access in schools and prevention efforts there. It would be helpful at some point to have that conversation, I think, the whole committee. We were talking about it before you came in. Yes. And the levels of nicotine that kids are exposed to is not measured, not disclosed. It's scary. It is scary.

[Dr. Rick Hildebrandt (Commissioner of Health)]: Potency matters for all these, all substances. And you see that not just in nicotine, but in marijuana too. I mean, people are having huge amounts of problems because they've used marijuana for thirty years. So it's not the same thing nowadays than people are eating in the hospital with either recurrent vomiting or psychiatric conditions. Expanded treatment options, a lot of moving in this facility opened, well, this, we have the work that Validus did, opened some low intensity residential treatment services just recently. And we have a new hub that's opened in Paddington. I've had a chance to visit it, It was was a great facility. And then we're going to be implementing a number of CCBHCs to help expand access to non maligned substance use disorder and then co occurring disease, which is really a huge need that was happening. We have, and then the last thing I'll just say is support for long term recovery. So recovery coaching in our emergency departments and in our correctional facilities to allow immediate access to these services and certification of recovery centers and recovery kits are being implemented as well. Expanded recovery housing is proposed. It's in alignment with our recovery housing assessment report that we recently released, and is sort of central to a lot of this work and is really an important piece of the puzzle that we need for treatment of substance use. So here's our three key takeaways. I won't read them off the list. I do welcome any sessions that you all have and I look forward to talking all of you in the future.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you. This is a really good overview. I think number one on your list that's so critical right now when we're seeing such changes at the federal level and it does influence people when they try to sort out who's the expert and the megaphone from Washington is much greater than the megaphone and the ability to communicate in this small state. Thank you for your work and for being here. Questions to me for the patient.

[Senator John Benson (Member)]: But it was a very thorough presentation. Yes.

[Senator Virginia "Ginny" Lyons (Chair)]: Doesn't sound like you're gonna have a lot of pushback in here, Ross. I'm sure we'll have heated discussions, which is good.

[Speaker 3]: I love having discussions.

[Senator Virginia "Ginny" Lyons (Chair)]: Always a thing. Will. I know we will. As confirmation? Do you have any specific questions to understand the role that this commissioner will play at So we have someone here, Emily Tudor. Alright. To talk about the recovery report that we got. This is an important one for us and I will say I'm glad that you hit on prevention and recovery prevention for substance use disorders because we do have a bill in here for recovery residences and we'll be hearing about the bill more specifically. This is really to get set the groundwork with the report that's come to us. So I'm gonna let you introduce yourself and then give us the update that they hold. Good morning, everyone. My name is Emily Chittenden. I am the Health Department's Division Director for Southeast District. I've been with the department for about thirty two years. It's my thirtieth year in Southeast District.

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: So you are our expert, Ann. I've said a lot of that in the financial and operational realm. A lot has happened to at Ausmelt. That's a long way. I am currently the division director. It happened for about two and a half years now. Thank you for having us this morning. I definitely want to reiterate some of the things that our new commissioner had to say, especially in regards to our system at large. Substance use is currently one of the toughest public health things that we are currently facing in Vermont. Obviously it's not one of several, but it certainly is a priority for at least the work that I do on a daily basis and a lot of our wonderful community partners and systems that are out there. We have a lot of people working every day, working in this moment, working to help people improve their lives and seek recovery. The landscape is constantly changing. Can hear the commissioner speak about stimulant use disorder, the changing of the drug supply that is out there currently being used. I do need to take a moment to talk about alcohol. All the other substances that are out there are an issue and we need to focus on that and polysubstances is definitely part of the mix, but alcohol still is a bigger driver for health impacts than all the other ones in the body. So I do just want to put that back down and see what's more. Thank you. Let me ask you a question about that. Frequently what we hear is, oh these are the gateway drugs too, you know, of opioids or whatever. Where does alcohol fall in that hierarchy or is it just alcohol perpetually? It's everywhere. Would say it can be a gateway, know, as part of it's obviously it's a legal substance, it's part of the mix, it's part of our society and our societal norms. It is complicated across the board, it's an issue in every state that's not unique to Vermont. It's health outcomes, I think because it can be, feel longer term, maybe not have a suddenness that some of the other substances do, that doesn't necessarily always get the high profile book that it should. But there's, I think it's, and I'll make sure in our follow-up information, it's four out of five deaths are alcohol attributable and I believe it's in the twenty five to forty five Will do. Yeah. Because this is like, we know about our, that seniors are trying to use alcohol more to relax at home and they're like, oh yeah, think so. Even though you've just said twenty five to forty five, somehow. Thank you for allowing me to take the time about that. I'm here for me to talk specifically about recovered housing. We were fired last year to perform an assessment and provide a report to the legislature about recovered housing. Lot of wonderful information this morning to share. As part of that, we know as part of our needs assessment and our strategic plan, that recovered housing is absolutely a priority as part of that continuum and wraparound services. So we're excited to talk about that work this morning and we're looking forward to the future. Do you want to double down also on prevention? Prevention is the surefire way to the long term outcomes everybody's looking forward to, so I look forward to those continued conversations throughout the session. I don't want to interrupt, I'm not getting interrupted, everyone. You know, one of the real confounding things that happens is we all know prevention is the way to go. We know that, right? And so then we try to explain how much money it saves later on and how to measure that. Any help you can give us there would be great. That is one of my number one goals with this particular discussion is to make it tangible and to understand how the financial impacts Yeah. Epic Rewards on the other side. So I look forward to those conversations. Terrific. So,

[Senator John Benson (Member)]: I am

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: on the timeline slide, John. Okay. So, I really want to give a brief history. That was part of the research that was done about recovery residences, state of Vermont. So, back in the late 80s, early 90s, we had the beginnings of really peer run recovery residences. Oxford House is a type of recovery residence that's a model that's used across the country, and it's definitely very independent from state government, from funding sources, independent space for individuals looking for a sort

[Speaker 3]: of a living

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: environment. Indeed, and I apologize, this is very funny, right? In the early 2000s, the legislature began providing funding for community based recovery center organizations. So we have 12 recovery centers across the state, provide a variety of things from recovery coaching. They have programs like AA and NA and other things like that in their programs around communities everywhere, each engage individuals in the pursuit of recovery. We then moved into the mid-2000s when the legislature created the Vermont Recovery Network. The Vermont Recovery Network was bringing those recovery centers together, developed policies and procedures, sort of have a policy place and position, and gave them a unified space for advocacy across the state. There is a current entity known as Recovery Partners of Vermont. There's been an evolution of our times to get into the current entity's social network. In the early response candidates, in 2011, a National Alliance for Recovery Residences was established. We refer to that as NAR. NAR helps set the stage and their definitions for different levels of recovery housing and their goals. In 2016, the Vermont Alliance for Recovery Residences was founded, and then they were then recognized as a NARA chapter. You have a Vermont body that is currently helping us implement those MARA standards and bringing those associated MARA. They're also currently working as our certification body. In 2021, this is an important note just because of resources. Phoenix House of New England did close and with that we lost 58 events across the state. That was That's because of the pandemic? No, it was pre pandemic. Was kind of financial. They're a large organization, but I do not believe the pandemic was the, they may have an impact, that's the sole issue there. The 2024, F-one hundred sixty two, which is part of the reason why I'm here today, requires recovery residence certification recommendations and the systemic assessment of recovery residences, which is some of what I'll talk about today, including temporary memoir tenant loss. In 2025, we inventoried 145 beds and four zero four community recovery resources, which we'll talk about a little bit more in-depth here in a second. And then you'll see in our time up, I realize it's not 2030 yet, we do have some hopes and dreams. In our landscape, we're looking for, to increase our overall capacity to 400 beds across the state, so that would be about a two fifty bed increase. We're looking for geographic equity. We do have spaces within the state of Vermont where we do not currently have beds. In some spaces where we do have beds, we don't have enough to serve the population or the needs there. We also need to support specific populations. For example, individuals that are justice involved. We may be looking for programs for couples or more individuals with dependence or individuals leaving out with pets as part of the mix. Then here's some of the other spaces around housing. And then, big part of this bill was ongoing monitoring assessment and data collection. And so we find a way to streamline that, try to reduce the administrative burden so programs can do the work they do but still provide us with the data that we need and develop short and long term outcomes that we can measure and adapt as we determine what those outcomes are. Thank you. Next we'll move on to the report itself. There is a link available in this. I do probably say that can identify if you enjoy the read. But the report itself required us to assess the four following categories. So we were asked to create a comprehensive inventory of all recovery residences in Vermont, including assessments of proximity to employment, recovery, and other community resources. We were asked to assess the current capacity, knowledge, and ability of recovery residences to inform data collection and improve outcomes for residents. We were asked to assess recovery residence's potential for future data collection capacity and assess the types of data systems that are currently in use in the state of Hawaii. A big part of that, which we were excited about, which doesn't get talked about a lot, is evaluation. We put a lot of wonderful programming out there. A lot of people are very interested, but if you don't have the data and an evaluation plan behind that, you don't know if your investment is making the impact that you're voting for. We're excited that this particular report included those types of questions. It may be helpful. I am going just for the group of saying there's some new individuals, I'm going to give you the definition of recovery housing. Oh, it's good for all of us. Okay. And you'll find it in the report itself. Act 163 defines a recovery residence as a shared living residence supporting persons recovering from a substance use disorder that provides tenants with peer support and assistance accessing support services and community resources. The next slide speaks to the recovery resident certification. Are looking at what, again, talked about NARA, which is the national level. And we've adopted that in the state of Vermont through an organization that we call VTAR. And VTAR is our current certifying body and they certified four different levels of recovery housing. That level one, peer one, that when I was talking about Oxley House, the individual assessment is really just individuals come together and they're going set up a SOPA vetting environment. Level two, which is a large volume of our current inventory, is a managed environment and those include house rules and there are designated leaders in the house. So they have some internal governance. Level three is a supervised environment. We have a few of these in the State of Vermont. John is promised being one of those for who are familiar with that particular space. This is a supervised environment and they have staffing on-site and they have a large focus on life skills programming. The highest level, or the next level up, is a level four, which offers clinical treatment services in house. For the state of Vermont, Doctor. Hillbring talked a little bit about some of our treatment capacity expansion, one of those being the New Virginia facility, which is what we call a low intensity clinically managed treatment program, is very, very similar to Level four in this space. They're not necessarily interchangeable because one is driven from a treatment perspective, the other from a recovery perspective, but in the state of Vermont we do have, though we don't have any certified as level fours, the 3.1 that is currently happening in Virginia Ginny Grace House in Rotman, Vermont through Recovery House Inc, are serving some aspects in that manner because there's still a large component where employment is part of the mix engaging in their communities. I wanted to put that out there to serve their education. So if we have a patient who's coming in with acute needs or recovery needs and sort of decox, that person would start at level four. No, they would start at an even higher level than level four. They have Valley Vista and Recovery House have medically managed high intensity treatment, which includes that detox piece that you're talking about. So they may go to that high intensity piece, and from that, as a result of their treatment plan, may step down to that 3.1 bed or that level four level after they've done that high intensity. I was just trying to get that in place. And then, so we're moving, instead of walking up the levels, we're walking down the levels until we get to the pierce or through.

[Senator John Morley III (Member)]: So is that how it normally works?

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: That's how it normally works.

[Senator John Morley III (Member)]: So they immediately go right to the Yeah, it depends. They don't usually start at level one, they go to

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: This is housing, this sort of comes when an individual has really developed their recovery plan and what are their needs as an individual. Each individual's journey is that, it's unique. Some people never touch the treatment system, go solely to the recovery space. They may find it through AA, they may find it through NA, others may, depending on what they need, start at that highest level of clinical, medically managed treatment, and you know, walk a traditional harshness at different levels. Sometimes people have a recurrence of use and go back up for a second, and you can go stabilization. Gotcha. So it's a very living, breathing space, and meeting the people where they're at in their recovery journey. Which is one of the things that makes it really complicated. It does, yeah. Humans are called a kid. Or hotly, Ned. That's self included. So yes, meant to be living and breathing and moving with the person as they continue to pursue their recovery goals. Our goal is to provide a comprehensive system that has every level that possibly would be needed, including that co occurring space with mental health and physical health care to be ready when it's needed. Next, we're onto the recovery residents inventory. I just wanted to give you a brief inventory of the state. Currently, per the research, only partnered with Fletcher Group, an outside entity of private events. We need inventory to eight organizations across the state that have housing in 29 locations for a total of 145 beds. 26 of those locations, making up 137 beds, are B type certified. Certified using those national standards that we've adopted at the state level. 23 locations and 121 beds are at that NAR level two, which has house rules and has leaders identified within the actual residence. We then have three locations, a total of 16 beds that certified with neuro level three. Speaking to some of Genesis Promise locations in that particular space, which brings that life skills component, whether that be finance, employment, some of those other things to the emergency. We do have about a fiftyfifty mix of those 145 beds identified for men and for women. Within that, there is a subset that we have 20 beds available for women with children and we have six beds available for men with children. In eight counties, I'll try something else to be available afterwards. Bennington, Caledonia, Chittenden, Franklin, Memorial, Rutland, Washington, and Windsor have at least one recovery residence or transitional housing program within them. While six counties, so Addison, Essex, Grand Isle, Orange, Orleans, and Wyndham currently do not. As far as that gets tossed. So, mean, just thinking about this, if you're a person who needs level three and you live somewhere far away, that's a problem. It's sort of a mixed part. Some people are able, want to actually be their community of residents, or they're in active use and want to go somewhere else. To, They need to remove themselves from that particular space. Others do not. There's a mixed bag there of understanding of where, I think no matter what you need statewide geographic equity, it doesn't necessarily mean that the individuals in Brattleboro are seeking services in Brattleboro, they may be seeking them elsewhere and are moving across the state, part of the statewide access. It doesn't necessarily mean that that individual's access needs to happen

[Speaker 3]: in their community because that may not be

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: the healthiest chance for them.

[Senator John Benson (Member)]: So you may be getting to this, but what percentage of these beds on average are fit?

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: They're a hot commodity, so in general this is not a space where we have a lot of vacancies, so they're heavily sought after, if anything, there's a wait list mostly in most spaces. We definitely do have some vacancies right now. We definitely have a higher need than the capacity we currently have. I will say 40 of the beds of that 145, for example, are currently in Chittenden County. Obviously that's a large part of the population, but that's a long way from other spaces in The States. We have obviously some states that we found out. But recovery residents growth is definitely an area that we see as a gap and something that we need

[Speaker 3]: to work towards.

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: Yes, we're not paying for a lot of empty you have down there. The second part of the inventory was about a recovery resident doesn't act in isolation. It needs supports around it in its community to support the work that's happening there. We were asked to inventory community resources across the state. We identified 25 employment resources. Examples include Hirability, which is part of the Department of Disabilities, Aging and Living. My favorite kind of world. And Vermont JobLink. We identified 54 recovery resources, including mutual aid groups. Mutual aid groups are things like AA, Alphonse and Anonymous, and if you don't know this already, that is invented in the state of Vermont. It's one of our friends that I'm sleeping. And then we have 12 recovery centers across the state. We also identified three twenty five other community resources, including treatment providers, criminal justice, drug court and reintegration services, education, harm reduction, etcetera. I think that the most important part of all of this, again, some of the other, Vermont is a leader in regards to the amount of services and things we have there to wrap around, individuals seeking services. Have wide portfolio, we don't have enough. We know there's a huge issue in those different things. As far as the things we pursue to identify are listed deep and diverse. We are very thankful for it. I would say that one of the biggest things out there is medications for treatment or medications for opioid use disorder or medications for alcohol use disorder. We have one of the highest concentrations for 10,000 individuals in the country. For that specific space of treatment services, we have a lot of different things. This next one is a tough visual, so I want to recommend that you take a look at when you have the PowerPoint in your hand. This is to give you a map across the state with some pop outs that in particular areas, because when you look at the map itself, it can look like the clusters are on top and hard to read. The biggest points in this one, proximity to community resources is an important consideration when citing a recovery residence. Again, we want to have, we talked about transportation, we talked about employment, access to a recovery center, access to other life skills type of environments and education. Most counties in Vermont have higher recovery ecosystem index scores, that means the number of resources around it compared to The US average. The community resources that are available vary by county and city. The most widely available community resource, again, is medications to treat opioid use disorder. The counties with the most community resources per 10,000 residents, who have the most per their population, are Orange, Caledonia, and Essex. And the counties with the fewest resources per 10,000 are Grand Isle, Addison, Chittenden, and Orleans. Wow, I mean, it's the opposite of what It's really Yeah. Like that. It is. Integrative. Yeah. Well, but people are still like spread out in the a rural part. And it speaks to economy scale as well. Talk about resources. From a national perspective, Vermont is a leader in providing a recovery ecosystem that supports individuals in their recovery and with their families. Again, we have, Vermont has a higher index score than the country in general and that includes other parts of our work, everything from service programs to mental health treatment access across the country. Some of our smaller counties do have lower index scores across the entire service array, but we are still, in general, above the national average. Alright, again, a lot of the questions that were part this report were focused on data, so we're going shift a little bit to the data component. Recovery residences funded by the department. Again, we don't fund all of the recovery residences across the state. We currently collect and report robust outcomes data to the department. We can still live in the land of results based accountability, how much is somebody doing something, how low are they doing it and trying to build internal logic models? Are individuals better off as a result of that? Based on Survey feedback, from the number of appropriate organizations that participated in this, using data management systems specifically designed to manage the resident level data. And data collection in constant data systems are challenging for some recovery organizations. Indirect rates are a real thing. They're allowable with federal funds. There is organizations oftentimes really focus on the programmatic piece, so some of that infrastructure approach can be a real struggle within our organization, but we're doing support for them to try to build that structure. But funded organizations have been able to provide all the currently requested data, so they've been working very hard to get that information to us. Again, we receive that data from them on a quarterly basis. I think the important thing to note is they are currently reporting data to us. They are also currently reporting data to NITAR as the certifying body. So we're going be working closely with NITAR to dovetail that, try to reduce as much of the administrative burden as possible so they can focus on the work they're doing, but still give us the outcome data and the never served and things like that, so we're able to talk about this in a large universe in detail and how it can help it evolve and move forward. Again, we were actually quite pleasantly surprised that all four, of the four responding organizations, we do have one organization that has a large, B4 has a large portion of the image group, so we don't have 20 vendors across the state to provide us, but they, the fact that they were using a data management system and how our coordinating and supporting each other really was the same in the right direction. Some of the difficulties and barriers to selecting information is, number one, updating responses from residents, incomplete data, problems importing historical data into new systems, so for example, as they evolve or if they bring on something that looks, it's not an electronic health record, but it may feel a little bit like that. Sometimes that transition can be difficult. There's always data cleaning and analysis of any data space. The cost itself, there's FTE time, the systems themselves, things like that, and general comfort with data collection. We have a lot of people doing a lot of great work, passionate in the field, but maybe don't have a data background, or don't have that type of experience. We're trying to bring that technical assistance in those cases to our partners. The next phase we're moving to is the recovery resident's current state findings. I don't think a lot of these will necessarily be a surprise based on our presentation and your experience with this, but just to simply go through them. First and foremost is a lack of recovery residence capacity. The financial resources as a barrier to continued operation. The one thing I would say is, you're talking not just about services, you're talking about physical residence. Things cost different things in different counties, so the property values and portions of, in children may be different than Canaan, for example. The NSWR funding identified as a key barrier in general, lack of diversity among recovery residences with regards to the NARA levels, so again, when we're talking about levels 24, we do have a significant portion of our inventory sitting in Level 2. The state's current landlord tenant law as a barrier to operations. A need for recovery residences tailored to specific populations. We've talked a little bit more in one space we're looking at is couples. Often times people talk about individuals with dependence, but there's also a space for primary carers. Again, let's come up a lot, especially in some of the conversations around individuals experiencing homelessness as interest with their pets. Also do a shout out to my blog, Pets Matter. Various data collection, strengths of the state's, and again, this is sort of a mix of the strength of the state's current recovery ecosystem, Transportation, travel distance and stigma identified as barriers. Transportation is an issue across all of our services. We're not meeting that. Our partners at AHS all speak to the same thing. We're all state without public transportation. We're thankful to mitigate transportation and inform our job access, but still that is a significant barrier. Many challenges being faced by the recovery ecosystem itself. Workforce is a huge issue across the board. That's another area of concern for us for all levels of care, whether that be from prevention programming, all the way to working as part of the recovery residents. The presentation done at the national level that I last went to was that each generation may have a theme in an area where it may go to. We have about a ten year generational gap of people with a significant decrease in people pursuing jobs in this particular field. With that, it's not something that we can bridge, it's something we have to weather. And how do we weather that? It's part of the work, especially Vermont and aging states, that we don't have a population growth state, obviously it's like North Carolina. You brought up data a few times and it's here again on this slide. A few questions. Generally, barriers to data collection. I'm curious about what that looks like because we've heard over the years how for some folks seeking help in various forms, they've had to fill out a form over and over and over again. It actually becomes a barrier for them to receive care because of just the nature of the timelines of these forms. So, I'm curious about that. I experienced firsthand the weaknesses in our data collection in the state this summer around working with the AOE. So I'm curious about just generally data in our state agencies. But then I'm also now this sort of new threat, which is data being collected by the federal government to be used against people, and are there ways that you are protecting people's data? So that I know that's like a huge part of I just dropped. That think I did a couple of ways and I think that that would be something that's also good for continuing the conversation. I would say from a practical standpoint, I think one of the tenants of our system of care enhancement initiatives in general is reducing administrative burden. At the same time, we're working to do that. Part of this is talking about dovetailing data collection that happens as part of grant reporting, what VTAR is collecting as part of certification, and can those become the same data set? Can there be an 80% overlap and so there isn't redundancy and duplicative work? I think at the same space, I don't know how the changes in med paving and the burden of having to apply every six months, trying to also free up our organizations to support individuals and helping them to continue to pursue their health insurance coverage. So I think that we're going to do, that was one of the things that we've been focused on for a long time. I think right now we're even more focused because we have this external piece that's going to add a significant burden and we want to start to get out of the way to get the space for that to be able to happen. So in general, is key focus for us. And again, this report helps bring some of those ideas to life, especially in this particular type of programming. I don't want to say all around that I think it's going be a reduction because of what's coming from external sources, but it isn't a focus for us. In regards to protections, I don't know if I'm an expert to speak to that in particular, so

[Speaker 3]: I would be happy to refer other members over

[Emily Chittenden (Division Director, VT Department of Health – Southeast District)]: to them. Yeah, we've just sent a message to the department. That's a question you could get answered, and that'll be a more general question, I think, throughout our discussions with AHS overall. And then, so we have some report recommendations to close with, and they're sort of couched in four key areas. The first being addressing barriers to expanding capacity, which we talked a lot about. We talked about our vision for 2030 expanding to approximately one of those across the state with an array of NAR levels to support the needs of our lungs. Fact, it began with local shelving, couldn't it? All sorts of things. Anyway, again, that sort of covers areas one and two. So one is just inventory and number. The second is the service array and the different types of recovery residence levels that we have out there. Amending the landlord and tenant statute to reduce barriers and support the health and welfare of the recovery residence space in and itself. And then support for ongoing collection of outcome information for recovery residences and again, doing that in a coordinated and thoughtful way. One of the biggest things I am focused on is only collecting data that we use. There's things that we're required to, depending on the funding source that may be out there, but if we're not using it, we need to do an assessment of that and stop collecting it and things like that. So, those are the four key areas that are part of the report that we have already included as part of our work going forward. We're excited to partner with our community partners with each other and others to make those things up. Thank you for the, just good. Keep going. In the show. I think my final thing is, Ann, we look forward to working with you and parts of the legislature and other parts of government to continue moving this forward. I'm not coming to any space where there's any disagreement that recovery housing is important, That it's something you need to build upon or enhance. Was a very friendly topic for the first engagement of the legislature. Yeah, this is good. We started working on this, I think two sessions ago because this has been a two year report.

[Senator Virginia "Ginny" Lyons (Chair)]: It's a lot of work and just want to say, we very respect very much the work that you've done to complete this report. It's huge, and not simple. And I'm also very happy to see that you've identified some justice involved folks. I know you were at the summit in September, that was good, with the course. And I do have a question for you. We've got these recommendations, the barriers, I mean the barriers can go outside of our committee. So the landlord tenant statute that we dealt with in here, and then I know there are other committees, economic development committees interested in that as well. Could be gov ops interested in some of it, natural resources, if we're looking at some of the barriers that you talk about with respect to local zoning and community engagement, addressing the gaps, then we can find a place where we want it to go, but then we know we need to know that it can get there. So there's a lot here. One of the questions that I have is not a recommendation here and maybe it's already have it and that is is there a coordinated pathway for helping people get to where they need to get? I know because you've identified other, like needing a place for couples or people with pets or people with kids, is there a reference base? So I have a bill in judiciary that establishes the community justice centers as a reference base for identifying community services locally. Is there something like that for recovery residences for people or for those who are supporting people? We are actually, the 12 community forums that we posted across the state, that was an identified gap in need and resource, so we are currently meeting with a variety of communities, even my own company, have a resident in South Burlington, Hey. My South Brooklyn high school grad, but we are meeting with Jesse Baker in the city to talk about that. We're working with other sister departments at the Agency of Human Services to create things and resources for the judiciary, that when they're looking to refer individuals into the system, how can they look at it from a co occurring space and moving consent. We've also identified that as an issue in So is it a recommendation in here? It's a recommendation as part of our strategic plan. It's not necessarily in this particular, but it's overarching for the entire system as part of our strategic plan. Okay, it would be helpful to have it in this context. Peggy, why? Because now we've got a bill in there that is for justice involved people and obviously it goes to co occurring and other things but it would be good to have it in here as well so that we're not you know reproducing what do you call that when you're doing redundancy. The wheel. Thank you, Senator. Thank you, Senator. Yeah, so that's good. That was one thing that really popped up in my head as you were talking, to have that coordinated system and it links in with judicially involved and those who are not. And it does link in with what Senator Gulick is related, talking about with intake for all the other things, people who don't have homes or places to live. I'm glad you're working on that. Thank you for that. We'll have you, as we go through the bill that relates to this, maybe we'll pick this up again and see if there's language we can put in that dovetails with the plan process that you're doing. Sounds great. That's great. Thank you. Thank you so much. Questions for me? Ask my question.

[Senator John Morley III (Member)]: Madam Chair, One is, it sounds like you have a lot of demand. Yes. And over the last five, seven years, is the demand starting to curb and come down, or is it continuing iguana?

[Senator Virginia "Ginny" Lyons (Chair)]: It's interesting, so I would say the demand is going up, but for me that's a promising thing. That means people are interested in increasing engagement and recovery, I well towards want individuals to be aging more services, I want there to be an increase in demand because that means the number of individuals needing and not receiving could potentially be decreasing. The additional resources that were put out there were outreach and engagement workers as part of the opioid abatement settlement came through. We're putting individuals into our communities through our preferred provider network to meet them where they're at and try to even get an individual to contemplate a phase. They may still be in active use of working with To me, currently right now where I sit, an increase in seeking access to

[Senator John Morley III (Member)]: the positive. So I think he made a fantastic job, unbelievable. I met with law enforcement officials a while ago from the state police and sheriffs and new for the city PD. Some of these issues came up. Yeah. So That in some of that discussion, law enforcement is actually trying to help get the individual they left. Surprise to me was there are some people that don't want any help. Correct. And I was kind of I was kind of put back by that. They just don't want help. They're happy. They said that they're happy, and they just they they they're in this cycle, and that's what they become accustomed to and they don't want any problems. I was I was quite surprised by that.

[Senator Virginia "Ginny" Lyons (Chair)]: It is. It is amazing. That's where the outreach engagements, you know, they may not be in that moment, but at some point in time you may get that right moment and seeking that moment and trying to find your way into the system as quickly as possible to So they were saying,

[Senator John Morley III (Member)]: I was guessing after

[Speaker 3]: a while they became tired

[Senator John Morley III (Member)]: of it and actually wanted help. Were sick of it, the lifestyle or sick of them, and then they needed help.

[Senator Virginia "Ginny" Lyons (Chair)]: That was one of the biggest reasons for moving BT Health Link to 20365, with call, chat, anything else. Could think about it at 03:00 in the morning, because it's easily 09:00 in the morning, could be Sunday, it could be Monday, is trying to get as many avenues as possible. There is, we have other crisis lines across the state. Mobile crisis is certainly part of the work. You have to work with the CCBHC efforts within our designated agencies. There's multi pronged approaches trying to find a a space which we refer to as no wrong door. However they're willing to come in and access services, we want to make sure that

[Speaker 3]: we're able and there to take that out. Thank you. Questions?

[Senator Virginia "Ginny" Lyons (Chair)]: You've done it. Thank you for your work on this. So, the last slide, we will stay in touch. Absolutely, thank you. It'll be great, yeah. This is very good. There's a lot here and some of it is not easy. I know the landlord tenant issue is something that comes up and there's difficulty with that and other difficulties that we have to step across, I think we'll see what we can do. And you're working with the CCRPC acronym? Chittenden County Regional Planning Commission. But working with the planning commissions I think is great. I've been trying to move them into the healthcare sphere. It started with echos a few years ago, worked on that with them, now with healthcare becoming so prominent, it's great to see that they're helping you. We had wonderful participation as part of our community forums that did include legislators as well as wide array. We did engage with over three fifty promoters as part of that process in a thirty day gauntlet across the state That was very informative. It was reassuring because we were seeing some of the similar things. It was good to see that there was very common themes across the state because when there are common themes, you get that economy and see how it's easier to dive in and face change. Right. And people who live at the local level have a better sense of what and where and how. Thank you.

[Senator John Benson (Member)]: Thank you. Alright.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you very much. Thank you all. It's wonderful to be here. The Department of Health is a star in this you very much. So, Chittenden, I think where we are, I think we're a good place to stop for the day and tomorrow we're going to get, well this afternoon we have the governor's address on the state and state and then tomorrow we'll start to look at some of the background of transformation that we've been working on and you have not but it'll bring us all to one place. Jen will be coming in on that. We're trying to have get someone in from the administration to also talk about what's going on in the transformation world. Not a deep dive but kind of a picture of where things are, what's happening with hospitals and others. What else are we doing tomorrow? You've got the agenda in front of you. And then we'll start to look at some of the reports that have come in. We did this report because I think it's really key to a lot of the planning that's going on in the state and it's an important report for one of the bills that we'll be looking at. Then we're set. So we are gonna wrap