Vermont Legislature SmartTranscripts:

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: Okay.

[Sen. Virginia "Ginny" Lyons, Chair]: We're back live, and this is and welfare. And someday we're going to just have that COVID show. Ask myself Nolan will definitely be invited. To work. The incidental discussion.

[Amy Johnson, Director, Vermont Care Partners]: So,

[Sen. Virginia "Ginny" Lyons, Chair]: here There we is language in the big bill, in the budget, and tell you what page it's on. We don't need to look at that necessarily, but the language in the budget is a study, it's on page one hundred and sixty and sixty one of the big bill, and so one of the things that we do during the budget process is to resolve language issues and that this committee gives recommendations to appropriations or we at least look at it and review it and that's usually that's my job and I'll do that. And one of the things that I'm doing with respect to that language is listening to the Vermont Care Partners and listening to Dale, listening to both, and each one is very interested in having the language go forward as a way of analyzing the relationship that the administration has with our designated agencies. And so the contractual relationships, what's required, what's not required, what the payment process and so on. So I know I'm going out on a huge limb here when I do this and have folks in for this conversation, I think it's really important in a couple of ways. This is one of the things that continues to concern me that we have that ongoing debate. It was brought up during the conflict free resolution discussion and it's been going on for many years. I'm sure it's not going to end today. We could get us to a better place, and that's what I'm hoping we can do. So I understand in talking with Dale, I'll go back in a minute, that the language in the budget is fine. I didn't understand that earlier. I heard previously it wasn't, but now, you know, we need to stop that. And I've also heard from my care partners, they'd like to have it slightly different. And so I'm trying to put together something that both groups and both the administration and the care partners can support so that we can get information back that both groups are willingly participating together and bringing us what we need. That's really the goal here. I'm going to ask, we have an order of of presenting here that begins with Simone Rushmeyer of the Vermont Care Partners. You're here. And then we also have and Department of Mental Health as well as Department of Aging and Independent Living. So I think both departments are involved in the negotiation and the contract development and so on. So we'll hear from both. Correction for the record. Are gonna be in charge of the record.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: It's Department of Disabilities, Aging and Independent. I oh,

[Sen. Virginia "Ginny" Lyons, Chair]: what did I say?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Department of Aging and Independent. We can set Disabilities off of the thing, which is

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: And I also have a correction, if you don't mind. Actually thought Jill will be Doctor. Bowen will be speaking for both departments.

[Sen. Virginia "Ginny" Lyons, Chair]: Perfect. Okay. That's good to know. Ginny. And then go ahead. I just We're not there yet. Oh, no. Go ahead. That somebody it would be helpful We're getting if somebody could tell us what the issue was with the conflict. That's exactly what we're going to do. Great. Okay. We're gonna start with the Ground Floor. Was just weren't here when it happened. Oh, yeah. Okay. It's it's always wonderful. So on admission. Yes. And I do understand that commissioner Bowen will be speaking for the agency. We've you had told me that one. But you have a lot of backup people here, and that's a good thing. And and then so I'm only be speaking for the care partners. So or will Amy? Both of us. Both of us will be. Okay. This is so good. I I hope to get into a dialogue and, know, the ultimate goal is to have you go out in the hallway and come back with a solution, but we'll I don't know. Yeah. Okay. So I don't know that we need to go terribly deep into conflict free case management to get to what we need to be talking about here. I think really what we're talking about is the relationship between Dale, IHS, and the care partners. And one of my concerns has always been, and I dearly love my DAs, no question about that, and the work that they do. They're critically important to the state. But sometimes we see that our DAs will begin to do things that are not written into the contract and then that becomes something that they need to support and they get supported in different ways. And sometimes I also hear that the agency doesn't support the work of the VA, so I don't know how that all sugars are. So what I'm going to ask is for Simone, if you you can begin, and then we'll go to Dale and and go from there. You can explain what the problem is from your perspective, and that would help me.

[Amy Johnson, Director, Vermont Care Partners]: Were you so we're not talking about the Conflict free case? No. I mean, the the one ninety four lane.

[Sen. Virginia "Ginny" Lyons, Chair]: That's what

[Amy Johnson, Director, Vermont Care Partners]: we're talking about. Okay.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. Absolutely what we're talking about. Well, you

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: can't think we can understand what we're that

[Sen. Virginia "Ginny" Lyons, Chair]: we need to understand. We need to understand what problem we're trying to solve, the language that's in the budget. That's what I'm trying to sort out here.

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: Madam Chair, for background, I have asked a list of the totals of my issue brief on the case management for background for the folks in the community who don't know what we're talking about. What? The 101 plus is gonna post it.

[Sen. Virginia "Ginny" Lyons, Chair]: We were gonna get a 101 on what DAs even are, similar on that, if possible.

[Amy Johnson, Director, Vermont Care Partners]: Just a, like, a refresher because not everyone has been

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: in this community. No. We can do that.

[Sen. Virginia "Ginny" Lyons, Chair]: We need to know what a DA is.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: Just journey.

[Sen. Virginia "Ginny" Lyons, Chair]: Can you very briefly explain what designated agencies do for us in our district? And and commissioner, we'll do the same thing. It's all in the door. I'll shines. I hear shines. I know. That's amazing. So pleasant.

[Amy Johnson, Director, Vermont Care Partners]: It is. Pleasant. Further record, Amy Johnson Vermont Care Partners. I'm a director of Vermont Care Partners. So I'll try and make this brief about what DAs and essays are because I have like an hour presentation that talks about it, but I'll try and condense that into a couple minutes or one minute. So, the designated and specialized service agencies are agencies that are written into state statutes. They provide mental health, substance use supports, and supports for individuals with intellectual and developmental disabilities. So the difference between the two, it's fun to do this with the commissioner sitting behind and my boss. So, the designated agencies have specific catchment areas that they work within and the specialized service agencies do not. There's administrative rules that guide what they do, what they're supposed to look like. The designation process happens every three years. But I think kind of the most important thing is that we're written in the state statute. We provide services on behalf of the state of Vermont and there's specific mandated services that we provide. Again, DAs have specific catchment areas whereas specialized service agencies are supporting kind of a specific specialty service, which could be, so some people often think that specialized service agencies are the ones that only provide developmental services. That's not true, because we have some SSAs that only do children and youth mental health, that would be NFI. So, NFI, it's been talked about in this committee, there's specialized services at stage. There's probably more that I'm missing, like that's the like high level overview and I'll boot it to you to fill in all the things that I've Yeah, think that's, that's general. There are also, so for my care partners, it says 16 of the states 18 designated specialized service agencies as part of the network. So, there's also pathways and their peer support housing for a series of challenges and another single service development agency. So just to make that clear. I think, did you say that SSAs can be statewide? Yeah. They don't have a specific Yeah. And the other big piece is that DAs sort of have a no reject policy, if you will, so they need to be able to support people regardless, and SSAs can have more choice than that. So, that's a big difference as well. Yeah, and not every DA, so we do have a DA that provides only services to folks with intellectual and developmental disabilities. And then some, DAs provide mental health, substance use support, and IDD work, where some don't provide substance support. Those are called preferred providers. So, some of our DAs are preferred providers, so that network is much larger and that's a whole other topic and I won't go down that road, but just so that you're aware.

[Sen. Virginia "Ginny" Lyons, Chair]: And so your five zero one C3 organizations? Private nonprofit. Private nonprofit, but you're independent. Yes. But the state contracts with you to do certain level of work on behalf of the state. Exactly. And then you also have other grants and funding sources that allow for you to go and do other things, or it might help you combine some of your resources so that you're doing things for the state and helping out in the community in that way. Yeah, that's absolutely true.

[Amy Johnson, Director, Vermont Care Partners]: I don't know the latest percentage, but it's about 94% in aggregate Medicaid funded, The agencies are. Yeah. They vary, obviously. Yeah. Okay. Alright.

[Sen. Virginia "Ginny" Lyons, Chair]: Howard Center, Washington County Mental Health. Oh, we could split the map up and look

[Amy Johnson, Director, Vermont Care Partners]: Northeast at all of Kingdom Human Services. Yeah. Home Health Organization.

[Sen. Virginia "Ginny" Lyons, Chair]: Are home health organizations part of that? No, no,

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: they are not. No, they are not.

[Amy Johnson, Director, Vermont Care Partners]: We partner with them, but they are not part of

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. Partner strongly with FQHCs and home health and other organizations. So you have relationships with other organizations including hospitals? Absolutely.

[Amy Johnson, Director, Vermont Care Partners]: Yeah. And embedded positions in some of those as well. There's so much more to say. This

[Sen. Virginia "Ginny" Lyons, Chair]: is is really helpful so that people can now ask the questions about, well do you do this? We can, that's helpful.

[Amy Johnson, Director, Vermont Care Partners]: And it spans the continuum of prevention of interventions, crisis, but also the age span. So, yeah. Prenatal to end of life care. Also, I think one of the things that people don't often realize, they think mental health agency or, you know, providing adult inpatient or adult in office care, and 65% of our services are happening in the home community. I think that's noteworthy. So, when we talk about home and community providers, that is a big chunk of the work that we do. I think just lastly, This is why what happens, you could just keep talking. I just wanna say this last thing and that that is that, you know, I think as a state, we've made a lot of intentional policy decisions to move away from institutionalization that towards community based care, and that is really what separates us in large part from a number of other states that we have a firm intention and belief in where our work is grounded in the values of community based care and enabling people to live in their communities and be supported there. Yeah, really honoring that promise that was made to Vermonters when the Brandville Training School closed. Right. Oh, yeah. Yes.

[Sen. Virginia "Ginny" Lyons, Chair]: Make making sure that the services are available locally. Yeah. Exactly. Okay. No, this is great. Very good. Quick questions to anyone. Alright. And I know you just came out with a report. Yeah, our interim report. Love that. This one. How do you feel about it? 22. Can pass it around.

[Amy Johnson, Director, Vermont Care Partners]: I have some in my bag for you all too.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: Oh, so.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I

[Sen. Virginia "Ginny" Lyons, Chair]: know that I've been in communication with Amy quite a bit regarding the language and what to sort out. And have a strong interest in this. I have had for several years now about how to look at the relationship between the DAs and the states. Things are changing, and so this might be an appropriate time to have that analysis. So from your perspective, do you have language that you sent us that we have on our webpage? Don't have our testimony sent to Calista yet.

[Amy Johnson, Director, Vermont Care Partners]: That's okay. We will send that I just want to start really quickly with, I know that Nolan sent in the conflict of interest free case management and DSPR firm information. That is one thing of many reform efforts and changes that are happening within the DASSA system of care. And so, this study and or the community engagement process that's in the big bill currently are not necessarily speaking just to COI, DSP and our form. This is really looking at the DASSA system at large, not just connected to COI and DSP, although that is one big thing that they're working in collaboration with the agency. But just want to put that out there that this study language isn't specific to that. It's really wanting to take a deep dive on the full system of care.

[Sen. Virginia "Ginny" Lyons, Chair]: So,

[Amy Johnson, Director, Vermont Care Partners]: I want to thank the committee for allowing us to provide feedback on S-one 194 connected to the study of our system of care. We appreciate the committee's attention to our network and to the work of this study. And we're very encouraged and appreciative of the agency, many folks in the room from the different departments. We're encouraged by the administration's support for moving the study forward. We do hope that we can just walk out in the hall and come up with a plan and come back in. That's a great goal. Taking a thoughtful, comprehensive look at the D. A. And S. A. System is timely and necessary based on everything that's going on and everything that's happened with COVID and kind of

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: the world that we live

[Amy Johnson, Director, Vermont Care Partners]: in today. Particularly as we navigate broader healthcare reform and increasing community need. Like I said, there's a lot going on in the world right now and there's

[Sen. Virginia "Ginny" Lyons, Chair]: a lot of shifts and changes.

[Amy Johnson, Director, Vermont Care Partners]: We see this study as an important opportunity to grab future policy decisions in a clear understanding of how this system operates, what it delivers, and why it matters. So, I'll pass it over to my gentleman right here. Okay, thank you. Appreciate the opportunity. I just wanna say first in response to what you said in the quarter, are the issues? I just I just wanna say at large, I think that we we all have the same goals in mind, and we're coming at it from different perspectives and lenses, and we do work together a lot trying to move policy and policy implementation forward, and we're going to disagree on things. It is we've needed to look at the systems for a while, and so I am too very appreciative about this process. And I appreciate the intent behind the study and the recognition that the designated and specialized service agencies are a critical and essential part of the larger healthcare services delivery system. As we were just talking about, it's a system that has evolved over decades to meet the needs of Vermonters. And I think as we, I I feel like we've been doing healthcare reform for decades, but we're at a different stage of it now. As we continue that work and continue to try to meet the shifting and increasing needs of our communities, it is essential to do a deep dive into our system, into the services that agencies provide. As you mentioned, they're funded in different ways and meeting the needs of different communities in different ways, but looking at the savings they create and the tremendous benefit that they provide to individuals, families, and communities at large is important. At its core, we want this study to really strengthen the system, and we want to do that by clarifying expectations, aligning responsibilities with resources, and supporting long term sustainability, aligning that and intersecting that with healthcare reform at large. The services of the DAs and SSAs impact the outcomes of people, individuals, and communities, and also the roles and responsibilities of hospitals and FQHCs, home health and others. It's important to look at that intersection. We're particularly supportive of the inclusion of language that clearly identifies the essential and specialty services delivered on behalf of the state, examines how responsibilities have examined over time through state prioritized initiatives and required systems transformation. Some of what we do is meeting the needs directly as a result of community needs assessments. Some of it is, there are ideas from the state's perspective, some from the system, some both, some are federally required. So it's a mix of different responsibilities. We're also supportive of inclusion of language that establishes a more defined process for implementing new or expanded responsibilities with prior agreement on funding, staffing, and operational feasibility. Right now is a very good example of how over the years the system has taken on significant additional responsibilities and changes in response to community needs and federal and state priorities. Without always having the corresponding infrastructure or resources necessary and without sometimes, I think, enough adequate planning for implementation. This has real implications for agencies and most importantly for access to services for Vermonters. As the work moves forward, we would encourage careful attention to a few key principles. One that the study meaningfully accounts for the importance of local service delivery and community responsiveness. The strength of the VA system lies in its ability to meet people where they're at, with incredible expertise and deep knowledge of local needs and of their partnerships. Another is that any recommendations emerging from this process are grounded in operational feasibility and sustainability, stability of the system. This includes a clear alignment between expectations, workforce funding, and administrative capacity required to meet those expectations. And third, that the process reinforces what I know to be true that we can do, a transparent and collaborative framework between the state and community providers when considering changes to our roles, responsibilities, or its programmatic service design. So

[Sen. Virginia "Ginny" Lyons, Chair]: I don't know if we're walking. No. Not walking through.

[Amy Johnson, Director, Vermont Care Partners]: I wouldn't have heard for advice. What doing am here? Yeah, I mean, generally speaking, that's welcome. Any questions?

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: I guess I really haven't

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: heard the big issue. Can feel it in here. Is it a contractual issue going on? Is that between the administration, AHS and the DAs?

[Sen. Virginia "Ginny" Lyons, Chair]: I think that's a hard question for them to answer, but I'll try to answer what I think we need. We need the data and the understanding of what are the requirements for services today, and moving forward with the healthcare transformation plan, what's going to be needed in the future, and what resources are available to support the services that are being asked, of what's being asked of the DAs today. Yeah. This is

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: a funding issue.

[Sen. Virginia "Ginny" Lyons, Chair]: It it it no. Well, it may be a funding issue. It could be a resource issue. It is a matter of recalibrating where we are now because we're in the middle of strategic planning. Okay. That's really it. And so it's trying to move this process forward in a way, in an equitable way, so that the designated agencies are part of that and that Dale is a significant part of that. So that's all it is. Okay.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: And this isn't appropriations? This is

[Sen. Virginia "Ginny" Lyons, Chair]: There was language placed. S one ninety four was a bill that we were taking up in here, which didn't have time for, and so we're looking at language that House Human Services put in as a placeholder for us to consider that was reflective of the work we might have done in 01/1994. So this is part of the way we negotiate through the appropriations process. I'm perfectly happy to go ahead and try and do it myself, but I think that this is an important piece for the committee just to be aware of and to have input on. That's it. I don't want to I sincerely don't want to put anyone on the spot, whether it's the DAs or whether it's the agency, period.

[Amy Johnson, Director, Vermont Care Partners]: I appreciate that. Can I say one other thing? Just in response. I think it's healthy to do. You know, we Right. Like, as we're looking at our health delivery system and our human services continuum, you know, what what's really needed and how do we fund that adequately and how do we make sure we can support for Monters instead that needs to be a collaborative process between not only honestly between providers and the state, but also those receiving services. Yeah.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. No. I mean, and honestly, as the agency is going out and doing the needs assessment and looking for gaps out in the community, coming back, looking at what community services are available, what's needed, and that's all going to have implications for these folks.

[Amy Johnson, Director, Vermont Care Partners]: And we had recommended a stakeholder working group. We want to make sure that we're doing this in collaboration, that isn't one entity or another kind of doing something and then bringing forth information, but that we're working on this collaboratively. That's inclusive of a lot of different departments under AHS because we are funded in a variety of ways and are supported by Dale, Department of Mental Health, Vermont Department of Health, Department of Children and Families. We also have people with lived experience, families with lived experience, people from state standing communities. There's a variety of folks that we have recommended to be part of this kind of work group experience. Then I know at the big bill, there's the community engagement process that kind of goes broader than that. But it is really important that we're working with all stakeholders and the various departments within the agency.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, questions? I think we're good. I think what we'd like to do now is to hear from Dale. Thank you. Thank you. We do have the language that you brought to us, and it's on our web page, and Dale has sent us the language from the budget, page 160 of page nine fifty four. You wanted to make me up here, or you're happy right there.

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: I think

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I can take it if she's happy right there.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Nobody wants to sit at the end of the table.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I don't know. There's two of them. No. We get it. I'm like I

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: think I'm happy to, like, sit

[Sen. Virginia "Ginny" Lyons, Chair]: on the floor with you.

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: No. You're gonna pull that chair over.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Okay. So I'm I'm back by Orange Del Bow and commissioner for apartment disability independent living, which we really should say detail because

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: everybody

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: gets that wrong. It's a

[Sen. Virginia "Ginny" Lyons, Chair]: It's so much easier.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I know, right? I'm gonna say it right. And I am maybe she just got

[Amy Johnson, Director, Vermont Care Partners]: a bath. She's got my bath.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Okay. So I really appreciate Simone and Amy's testimony. I want to say that we really appreciate the designated agency system. The providers are amazing. They do very, very difficult work and serve a large population. There's nearly 3,500 people that we serve in the disability community. I believe, I've been here not quite two years yet, that there is a strong relationship between the DCP, the designated agencies, and the department, not just Yale, but also the Department of Mental Health. The Agency of Human Services has worked very hard to work together. You highlighted, Chittenden highlighted that they stand as a business, each of the agencies in its five zero one T3 capacity. We also understand from a business model that they have all of us not, I mean, the theme of what I'm going to say today is that we have to integrate, not look at things as silos so much. We want to not fragment the work that we're doing because I'm a systems person, and I think that anything that we do that we do in a collaborative, coordinated, and integrated way is more successful. So if we're going to go forward, we need to do it in that vein. That will lead us to just a little bit perhaps difference in the language and how we are approaching this in terms of study, deep dive, what I call transformation, and what many call transformations in the midst of the changes that are happening with healthcare reform and also specifically for the designated agencies. I will add that the designation rules, we have links for you. There's a lot that's clear in the current state about what the expectations, rules, responsibilities are, what the role of the commissioners are. I also just want to be clear that in the designated agency system, there are three service lines. One being the developmental disability service line, and that has its own designation that is essentially my responsibility. Then it's the mental health service line, and that is Commissioner Hawes' responsibility. Those are separate designations. The rules are very similar, but they are separate designation lines. Then there's a non designated service line, which is the substance use line, into some things like preferred providers, etcetera. So just to give it more clarity, but there's also a lot of information available in the state system of care plan, we have a link for you on that, and in some of the work that was done to clarify the roles and the changing roles with some of the activities that have been happening under conflict free case management. So that's my piece of it. I want to say again in terms of the relationship, really have appreciated the Vermont Care Partners. We attend their board meetings. We have very, very regular meetings with them. Our person back here, Jennifer Harabeden, is the developmental disability division lead, and she's actively engaged very frequently. Maybe she's right next to my knee. And she's also, for the record,

[Amy Johnson, Director, Vermont Care Partners]: don't know.

[Sen. Virginia "Ginny" Lyons, Chair]: They've learned all the relationships in this drama. It's Vermont. It is. It is.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Think in some ways I agree that we have the same goals. Those who are working directly, the providers on the ground providing services, and those at the Agency of Human Services and in the departments have the same goals in terms of service provision, you know, access and quality and choice. And I think sometimes we will disagree, as Simone said, but I also think that sometimes we're both willing to dance together. It's sometimes we like different dances, but not. So I I think that any of the tension at all, it's just a natural tension. It doesn't really get to the it doesn't really impact the core of our sort of relationship and in it together sort of approach. I do want to say with regard to the language, so what we liked about the language that was in the House is that it's integrated with healthcare reform, and we want to be careful that we don't pull something out of the umbrella of healthcare reform. It was embedded in legislation last year. Again, I know that you said that the Lyons had a big role ensuring that that was in there, but the idea in healthcare reform of having the community providers as part of the system change is absolutely essential. It's not just the hospitals that will be able to reform the system, it has to be the whole continuum. The designated specialized services agencies will pop out, called specifically in there with appropriations, etcetera, and so this study that we're talking about needs to fall under that umbrella, needs to be part of that system. The notion of having engagement and having all the different stakeholders that Amy and Simone referred to is part of the overall plan. I think we're looking at current state and making sure we understand it. That's where some of the links will come in to clarify answer some of those questions, roles, responsibilities. I also think that what we're focusing now is what will the future state look like, and making sure that there's inclusion designing that future state. That was always the intent. It's fine to have it specific in the language. We added some language that we pulled from what was penned into our recommendation, pulling in the section about, you know, into the statewide healthcare delivery strategic plans that identifies essential services, aligns expectations with resources, strengthens the long term stability of the designated specialized service agency system, and that comes from that. So what we tried to do was say, I think we've got a lot already in this, but we do want to make sure we're not siloing off many different studies. We have a lot already baked into legislation. In this past year's BAA, we have a convening that includes the chairs of our committee's jurisdiction plus appropriations, and that's happening this Monday in Waterbury. All the designated agencies have been there, the case management organizations and others, where we will be going through what was in that BAA and we'll be discussing together some of the ideas and strategies and what is currently happening now and where we see us going. The other is that we came together with VCP and planned sort of a three part approach to how we can proceed in the future. One was around the immediate concerns, and there have already been five or so work group sessions on immediate concerns with appropriate folks from designated agency system. Sometimes it's the CFOs that we're talking about, the fiscal issues. Different people have been in the room depending on what the topic was, There have been five of them. They've been on liability issues, budget calculators, some of the other high concern issues, solution focused. Then the middle section is stability. So to your point about why are we pressing here, I think stability and sustainability is the name of the game, not just in this sector, but across the board. We do have fragility in our systems. Some of that is financial, but it's not the only driver, but it can be connected to others, workforce, etcetera. We have that as our second tier in the work that we're currently engaged in. That fiscal stability right now for the designated agencies who are most at risk fiscally, We have an expert team that is looking at, they have submitted their financial information, and the goal of that is to do that deep dive in finances and see what suggestions come out for improvement in what areas. It is meant to be a helpful tool to help us really understand where we can support around fiscal stability. Then the third part is sustainability, and that's also baked into BAA, with the designated agencies to each provide a sustainability program next year. So it would be something we would be working on now. I want to make sure that with the healthcare reform legislation, the BAA legislation and other places where this is embedded in healthcare reform, that we honor that and make sure that we are staying within that umbrella. That's when we talk about integration. So not another study that's over here by itself, because again that won't be as successful unless it's integrated, but in terms of specificity and who would be engaged and all that, that certainly can happen under that umbrella.

[Amy Johnson, Director, Vermont Care Partners]: So open for questions or if we

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: wanna just ask if any of this team has something further they want to say.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. We've so the the cloud is clearing. So it it the language in the budget for me is is very much about the work transformation work that's going on next.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: And for the future? Well,

[Sen. Virginia "Ginny" Lyons, Chair]: yeah. Okay. Work you're doing. Yeah. For the future. Our action plan. Strategic action plan at '68, at '51, at 01/1967. So you're a baby. They're like marital babies on this committee. And what I'm hearing from the DAs is, yes, that's all well and good, but we wanna know where we stand with respect to the agency, to the department, to the sort of the relationship that's there. I don't see that there's a reason why we can't do both somehow in here. And because the process that you've described or that's here in the budget is a process that is more of a community engagement process, bringing everyone together and talking about what do we need and how we go forward. And I think what I'm hearing from the designated agencies is we wanna know our place in this world and how we're going forward. So and I think both of those perspectives are legitimate. No question about that. And and the proposal that we had from the designated agencies had a list of a working group that are going to get this done and that is more of the administrative work that needs to happen once they can understand what's required of them going forward and what isn't. Trying to sort out the best way to pull those two things together. So the language

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: that we added, you you have, right, a copy?

[Sen. Virginia "Ginny" Lyons, Chair]: I have I think I have language extracted from h nine fifty one that Rebecca sent.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I don't think And then there's there's an addition the added language into that. Yeah.

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: Can tell me look at that? I was looking at that.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah. And it it it comes from what Amy had written, and it just sort of summarizes that It is that the plan will identify essential services, will align expectations with resources. That's the green and the black Yeah, number Will strengthen the long term stability of the designated specialized service agency system, so it's specific to them and captures just in some of it is the direct language. Also the language itself around the study and all of that that's in here already, it would include the people that are Those are our stakeholders too. Those are the folks that are included in an engagement process. This is not healthcare reform is not something that happens in a corner or in a closet. It's something that But happens in

[Sen. Virginia "Ginny" Lyons, Chair]: the think the difference here is that there's concern on the part of agencies, and I don't know whether this true or false or indifferent from us anywhere, but I think the agencies are concerned about losing their place as the designated workers for the agency. Mean, want some This is me talking. Want some? I'm sorry.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I hadn't heard that before.

[Sen. Virginia "Ginny" Lyons, Chair]: Well, it's me. That's why I'm You're like a therapist. It's good. Don't tell my daughter that, please. She is a

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: therapist. I am as well,

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: so maybe that's Well,

[Sen. Virginia "Ginny" Lyons, Chair]: so I'm trying to sort out here that I think some definitive answers about direct contractual relationships is what I see in the language from the DAs, and I don't see that in here. I see may do this or may identify, that kind of stuff.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Okay, can I? Yeah. Okay, because we're having a slightly more informal conversation, I appreciate that. The designation rules are in statute. It's not something that would just That's gonna be my question. Yeah, they're in statute. So I think that

[Sen. Virginia "Ginny" Lyons, Chair]: they're pretty firm.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I mean, is some latitude on things like attachment areas about what areas are designated. Not sure, since we're having conversation, I hadn't heard that concern before.

[Sen. Virginia "Ginny" Lyons, Chair]: I'm just Good. That's good because that's me. That's not them.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I don't know.

[Amy Johnson, Director, Vermont Care Partners]: I don't know how informal or formal this

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: would be.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. No. Look. Please.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: You need someone to join me. I don't have

[Amy Johnson, Director, Vermont Care Partners]: a Nice to Jennifer behind you. I got your back. I guess I would say I I think the work in the BAA and the work on the health care strategic planning and this can all fit together. This is this study, I see anyway, this study less about that the deep dive that's going on around sustainability and stability that's in the BAA language And more around we started some work quite a while ago around identifying essential services and how they're resourced and what the needs of the communities are. And it to me, this is more of a study around that and making sure that we are meeting the needs of Vermonters and we're and we're doing so together in a transparent way and looking at those services against available resources. So I think they fit

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: I all together in

[Sen. Virginia "Ginny" Lyons, Chair]: hear you. It's the core services thing that is

[Amy Johnson, Director, Vermont Care Partners]: Well, yeah. And also though, would say that it's also it is important to elevate the DA and SSA system and mental health substance use and IDD services as they relate to and intersect with the larger health delivery system. We're part of a lot of groups, but it's often really about hospitals and primary care. And it is essential to be looking at it the full continuum. I think this helps that. And I think it would help also with what are the parameters? Like at what point do we sort of stop saying, oh, and can you, you know, can you as agencies do this without the resources necessary? And can you do the you know, I think there are federal mandates, there's state mandates, there's community need. How do we look at that all together knowing that the resources in our state are not as expansive as we'd love to be

[Sen. Virginia "Ginny" Lyons, Chair]: able to. And I'm thinking as you're talking and thinking about the strategic planning process that's going on that there's a sequence of steps in that. And the sequence is identify the needs out there and then say how are we going to meet those needs and that's where your comments come in.

[Amy Johnson, Director, Vermont Care Partners]: Yeah, how do we meet those needs and how do we establish processes moving forward that allow us to really make sure that before we start implementing something we have right structures.

[Sen. Virginia "Ginny" Lyons, Chair]: Everyone needs to be on

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: the page. So let me say that that's why we added the align align expectations with resources that we added that to the language.

[Sen. Virginia "Ginny" Lyons, Chair]: Well, but expectations are one thing. I'm I'm thinking that once you have the way that the action plan is put in place is that there's transformation discussion going on and the independent organizations, the hospitals and others are making decisions about what they can support and what they can't support. And then there's also that negotiated piece about how much is available in terms of resources, and that's where the discussion needs to be very firm. So you can't say, well, we need more resources or on the other side, we're just taking away the resources. So it has to be some some dialogue. Well, that's what

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: we meant by aligning expectations with resources. Yeah. I get it. Can You say that more clearly. We need to. I think that, first of all, identifying the needs of communities is a current state thing. It's not just the future state, a current state thing. Yeah,

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: it is.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: We do community events. Right, and forever. Right, and so it's clear that the needs of the community is a driver, physical reality is a driver, workforce is a driver. We're, I think, all on the same page with that. That's where we always begin. We always begin there, and then we would need to get to a place where we are meeting together with all of the people and making sure we have everybody's input. So, that little section under five that we added, what's meant to do what it is, I think Simone was just trying to talk about what the decisions are. If there's particular situations where there would be a request, I mean, of that is contractual, right? The idea that there would be a request, you know, I think that that can be built. I mean, we're, we're at the sort of wrapping point of contract, right, where we are, and then each year there is a contract. I think that that is something that would have to be baked in if there's some kind of concern that there's a deliverable required that isn't expected. I mean, there's some latitude in terms of what is needed to buy the designated agency system.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: The That center. If, Dale said that the DAs, hey. We we need this done. We need a done. And the DA say, right now, we don't have the funds or the resources to be able to do that.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah. So we go back and we look for whether there's any possibility of finding additional funds. We do all the time.

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: Yes.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I don't know if you want to say more about that, because you're usually the person who does that work. Yeah.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: I'm just I'm just scared that there there could be more requirements put on VAs potentially.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I mean, that comes up with things like there's someone who's in public safety and a challenge. So sometimes for a particular agency, there's a challenge, and in that case, there are several things that the agency tries to do.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: I'm just envisioning you have Budget Adjustment Act. You also have the budget process. So every six months, you kinda get a crack in this thing, for additional funding or whatever.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: So

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: So as commissioner Rowan is saying, there's a variety of ways that we address that. So if it's an individual support plan, there are levers that we can pull and there's language in our contracts now

[Sen. Virginia "Ginny" Lyons, Chair]: to address

[Jennifer (last name unclear), Developmental Disabilities Services Division leader, DAIL]: If it's a program we're looking to start, that's a different process to say, we'd like to have the system develop a program for this. What would it take to do that? And what's the funding required to do that? How and then and then as a department, we look for the funding for it on a one time and ongoing basis. So, we try not to have unfunded mandates because that is not fair for our partners. We do that doesn't mean that there aren't times when there are federal requirements that there we as an agency feel is already included in the funding that is authorized to them because it's a shift in how services are offered as opposed to a new expect expectation.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Can

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: I add on to that real quick? Emily Hawes, Commissioner for the Department of Mental Health. And just adding on to what Jen stated around new initiatives and the picture of a system evolving. And part of that conversation that we have is, let's say we ask you to do this new thing because the system has evolved and this new thing is where we can bill and provide improved evidence based services to our community. Part of that conversation is how have we been delivering this service historically and allowing that historical service to evolve instead of creating two new things. And so those are conversations that happen across the system where we lay out, this is where we're going, this is how we're going to get there. And sometimes those are really challenging and sometimes they go very smoothly. In the end it's that too that we want to provide the communities the services that help our communities be healthy.

[Amy Johnson, Director, Vermont Care Partners]: Can you show an example?

[Sen. Virginia "Ginny" Lyons, Chair]: Sorry. Yeah, I just want to point something out here. Got the example.

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: I'm happy to do that.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, I'm looking at the language that came to us from the DAs and a number six is on the charge. It's online. It says number six is an examination of a process by which the designated and specialized agencies implement new or expanded responsibilities only with a prior agreement on funding staffing operational feasibility. I mean, that language might change a little bit at the end, but I I think what I see there is a a process. So if and it works in both directions. If the DA decides they're gonna go do something new and they're gonna use some of the monies that have come from the state to do that new thing and the state says, wait, wait, wait, wait. We have other plans for that. That's not a good thing. On the other hand, if the DAs are required to do something new and there hasn't been a process for implementation, then that's a bet. So what we're looking for is a process that everyone knows about. That's what I think we're talking about here, is having some predictability within those changes that are happening. And we're going to see some changes, you know, obviously with all the work that you're doing on transformation. So I'm trying to sort out how best to integrate some of the some of these, what I call, request bits in this proposal with what you're talking about. But I don't I think you're both trying to look at the same thing. And and we all have the same goal. We know that. We're trying to help people in our communities.

[Amy Johnson, Director, Vermont Care Partners]: Yeah. And

[Sen. Virginia "Ginny" Lyons, Chair]: and I Go ahead.

[Amy Johnson, Director, Vermont Care Partners]: Yeah. I I guess I would just add that there, I think as much as possible, we do try to collaborate. We do try to say, okay. This is what the system needs. And at times, there have been situations where ideas just pop up. Pop. And then the expectation is implemented. Mhmm. And the expectation is implemented with this funding model, which doesn't cover cost. And that is challenging. And I I think the most important piece, however, is before we like, we should be designing together and figuring out the implementation together because a design without full feedback from the providers and people receiving services is not going to work. Or it might work, but not as likely to work.

[Sen. Virginia "Ginny" Lyons, Chair]: I see both sides of this story. I do too. And they're both a gentleman. You were going to get an example. Sure.

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: Yeah, you're welcome. So, one more recent example is the implementation of Enhanced Mobile Crisis Response, which is our two person response 20 fourseven statewide for individuals experiencing a substance use and or mental health crisis. And that project was two years of discussion prior to implementation. Information provided directly from the system to help inform the implementation and that program also qualifies for enhanced federal match, which is helpful. And so part of the evolution of implementing a program like enhanced mobile crisis is looking at all of the programs that have been implemented to do very similar work, but not in an evidence based structured payment model. And that we're in that. We've implemented as a system, the enhanced mobile crisis response, and we're still working with the agency to transition the appropriate staff into those response teams, perhaps out of roles that were developed maybe twenty years ago. And we've moved on as a system from those programs, but those programs have a lot, you know, communities like them, but we need to do that culture shift. So I'll say that that didn't happen overnight. That was several years in the making. The go live, I think though, felt like it happened overnight from a system perspective. I think that that was really unfortunate, even though a lot

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: of

[Emily Hawes, Commissioner, Vermont Department of Mental Health]: conversation went into play. Maybe that's just go live for anything. You implement an EHR and a go live is shocking. And you've talked about it for a decade before that go live. So there is appropriate anxiety related to that, but I do think that that is an example of evolution and where those conversations and implementation processes have, know, there was some learning in that.

[Sen. Virginia "Ginny" Lyons, Chair]: But I

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: don't believe you do a lot of change or requests without working together on it. It's not what I

[Sen. Virginia "Ginny" Lyons, Chair]: have seen since outside the noon. She

[Amy Johnson, Director, Vermont Care Partners]: has slipped like her vent. Sorry. I realized I was doing that. Sorry.

[Unidentified Committee Member (likely Sen. John Morley III or Sen. John Benson)]: Sorry.

[Amy Johnson, Director, Vermont Care Partners]: No. I mean, I think that mobile that is a good example where we work together. I think implementation science shows that it takes at least two years just to get something going. Are 6,000 or 5,000 employees in the system, so change management takes a long time too. It's not gonna happen overnight. And I think that and there aren't I think it's more around the funding structures and just I'll give the example of we're sort of in the midst of this, so sorry I'm bringing it up, but, like, integrating public inebriate and mental crisis beds. Yeah. It was something that we really learned primarily through testimony here about it rather than, like, really thinking about what should happen. Now we're all talking about it, trying to figure out how to implement it. How to do it? The funding structures don't work. It's not really integrated. And we're still talking and trying to figure it out, but it's an example of, like, let's let's plan really well at the get go. You know, we're having a lot of problems with DS payment reform and conflict of interest. There have been a lot of there have been a lot of meetings. Got a lot. Gotten to know each other very well, but there's not there there significant, significant challenges there and real risk for the state and providers and people. And so, you know, I think it's really just about how can we do this better together? And what are the needs of our communities? We're doing we'll be doing lots of community needs assessments with CCBHC and others and digging in deep and trying to align those with hospital needs assess assessments and FQHC and other assessments. We're a small state. We can do that needs assessment in different ways. And and then really seeing, like, are we do we have what we need in place to meet the needs of some very, very vulnerable people?

[Sen. Virginia "Ginny" Lyons, Chair]: And and the two year period sounds like something that's needed. Time.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Sometimes you need that time, sometimes you have it, sometimes you don't have it. Right. It was ten years in planning together for conflict free, for example, and it's still a transition that happens. I think that we have to have flexible

[Unidentified Committee Member (likely Sen. Martine Larocque Gulick or Sen. Ann Cummings)]: work

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: on the ground, that people have to pivot to the realities of the changes at the federal level. I mean, this is the reality, the fiscal realities. We don't control a lot of that. So, we do need to be able to, you know, be able to maneuver quickly when we have to, at the same time that we plan together, when we do have the luxury of several years before something has to be implemented. Rural health transformation, for example, is a very rapid process, And

[Sen. Virginia "Ginny" Lyons, Chair]: great, it's a We didn't do that. We did not put that.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So, you know, I feel like this is what we can control, and this is what we can't control, and we have to be able to maneuver quickly together. So sometimes that's going to be possible and we can align with things like best practice implementation science, all that, and other times we have to act. And so I don't want to build in something that prevents us from responding appropriately when we need to, but we shouldn't be doing things, you know, that we can do more slowly too fast, but we can't do things that we have to do too fast too slowly either.

[Sen. Virginia "Ginny" Lyons, Chair]: This has been an informative discussion for me, and I hope for others in the room. And I'm looking, I have looked at the proposal that both such proposals have come to us on language and I would ask you honestly to get together and I look at that number six as the process piece seems to be pretty critical in decision making. And before you offer anything, I'm gonna ask you folks to we're gonna end, we're gonna go offline, and we're gonna allow for you to have a discussion on this. And, you know, ultimately, the decision is gonna happen probably down there.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I just want to thank you for the opportunity to have this conversation, for us to come together. I appreciate you and the whole committee's deep caring for the population that we serve, which we all we all are all there, and that's why we're here having this conversation. So really appreciate. No. I appreciate you coming in, and this is

[Sen. Virginia "Ginny" Lyons, Chair]: not an easy thing to do for for anyone, but I think it's really important. It's important. And the what I also heard in all of this is how sometimes the legislature can cause problems, and we wanna solve them, not cause them. And so so, you know, I'm asking you to get back to us with some some kind of agreed upon something or closely agreed upon something that we can take to our colleagues.