SmartTranscript of House Healthcare - 2025-1-29 - 9:00 AM

[Chair Alyssa Black ]: Twenty ninth, Wednesday. And, today is mental health advocacy day. So we're gonna have a full day of, talking with our partners, Realm, FATE, in this realm, and we're going to start it off with Vermont Care Partners. Thank you. Go ahead. [Simone Rishmeier ]: Good. My name is Simone Rishmeier. I'm the executive director of Vermont Care Partners. [Melanie Gidney ]: My name is Melanie Gidney. I'm the executive director at Clara Martin Center, and I'm president of the Vermont Care Network. [Kelsey Stetsup ]: My name is Kelsey Stetsup, and I'm the executive director of Orange Institute of Human Services, and I'm president of, the Vermont Care Partners Council. [Chair Alyssa Black ]: Thanks for joining us today. Yep. [Kelsey Stetsup ]: Thanks for having us. [Simone Rishmeier ]: Thank you for having us, and, thank you for taking all the testimony today for mental health advocacy day. Important day at the state house for sure. So I'd like to just start by saying if there's anything that we talk about that you already know about and you don't and you're, you know, feel free to move us on and or just interrupt and ask questions as we go. So Vermont Care Partners is a statewide network of sixteen hundred states designated in specialized service agencies that we are every part of the state and designated by statute to provide services to Vermonters. How much we want to go into the details [Speaker 4 ]: of that, but we are [Simone Rishmeier ]: a vital component of Vermont's health care system and of its and the safety net for Vermonters. We had last year, we served approximately thirty five thousand people, as clients and up to about fifty thousand in total. Our network has should have approximately six thousand staff. We have a vacancy rate of about twelve point five percent. So right now, we're lower than that, but it is a large part of Vermont's economy and very important to the managers. [Chair Alyssa Black ]: Leslie, I'm sorry. Do you have any slides? [Speaker 5 ]: Yes. I believe they are [Chair Alyssa Black ]: listed under Simone. Yep. Designated and specialized service agencies is the name of the organization. Sorry, didn't show up. No, go ahead. So [Simone Rishmeier ]: we just wanted to give a sense of how Vermonters enter our system of care. And there are obviously, this looks a little chaotic because there are lots of different ways that people enter and receive services. Last year, approximately sixty three percent of our services were provided in the community. So I think that's a really big difference and important to note that, it is not all office based. We're in homes. We're in schools and, partnering and integrated with hospitals, primary care, and others. [Kelsey Stetsup ]: Yeah. And just to emphasize the fact you know, I think we talk about ourselves from community based services, which is really important, and I'll speak for NKHS. But, you know, we covered two thousand square miles two million miles last year, driving around to get people and getting people to and from essential services. So not only are are the referral pathways from our partners, specifically for us, so twenty five percent came from our local primary care, North Country Hospital, NVH, Prattleboro, and Probation and Parole rounded out. Basically, our major referral sources, and so not only are we supports for Vermonters that live in the areas of the DAs and SSAs, but we're also vital supports to other institutions that feel the pressures, and look to us for the expertise and refer out to us, when they can't provide those services. [Melanie Gidney ]: If I can just add in, I would speak on behalf of Clara Martin Center that we felt that accessibility is key. I think we all know that Vermonters are struggling with mental health, substance use, developmental disabilities, and having accessibility when they need it, is something that we've been focused on. So we work towards the same day access model so that people can come into our catchment area in Orange County four days a week and walk in and get an assessment, a full clinical assessment. So we've been able to reduce our wait list through that so that we no longer have a wait list. And then they leave with a follow-up appointment. So the goal is within ten days, but we prefer to have it within five. And so far, our data is proving that out. And I think a shift too to have right person at the right place and the right time, we've tried to shift as much clinical administrative work to, support folks and just let clinicians, licensed master's level clinicians just do the care. So that's been a system change that we've been, in within the past year, that we've had success with. And, and it's really reduced the no show rates, the high no show rates, thirty percent no show rates that we were experiencing just because people moved on. They they got somebody else. They decided they didn't need care, and we lost that moment with them. So just accessibility, I think, for our whole network, is something that we're all trying to focus on to be much more responsive and meet them where they're at when they need it. [Chair Alyssa Black ]: Can I ask, has it had an effect on your vacancy rates? [Melanie Gidney ]: On we our vacancy rates are lower than they happen. So I would say, you know, it's been a transition for staff. So staff changed staff morale because it we also implemented centralized scheduling. So we could plug people right into their schedule versus going through the clinicians. So they've responded really well, and I think they see the the value to the clinical experience being much more positive and more responsive, and they bought into that. But, you know, there's staff morale, turnover is a very complicated puzzle. But we're stabilized post COVID, I would say. It still remains an issue, and I think we'll talk about that down the road with the salary and benefits, the wellness of our staff, the burnout of our staff, the lack of practitioners licensed masters level clinicians to do the therapy work, has been really a challenge for us to pay a competitive rate. So but in terms of the accessibility, the change in that process, I'm really proud of them and the buy in that they've had to adapt their themselves to meet clients when they walk in with not always a lot of information. So [Kelsey Stetsup ]: I can add to that too. I think, you know, when I look back at the last three years, I think coming out of COVID, so there's been investments. There's also been innovations in what we're doing. So some of what Melanie is referring to is same day access and some of the urgent care programs. So we do have the opportunity through new programming investments to see people the same day, to get them to a physical location if needed, if the community is not enough. And then the investments, you know, I can speak for NCHS, but, over the last three years, we've gone from four hundred and forty five staff to five hundred and thirty now. And so we've been able to recruit and retain folks, and so we've reduced our adult waiting list. There is no waiting list in our children's waiting list from one year to three months. So, you know, I think that's been a big case. And to Millie's point, like, it's not all the pain investments, although that is what we see as the number one driver of people either staying or leaving, but also the culture and other innovative work that people are enjoying and are attracted to from a professional standpoint. So I think that speaks to the access in the rural and being that dependable partner in our community is when our partners are depending on us to take folks in that they can't serve. We've been able to do that and improve access over the last few years. [Chair Alyssa Black ]: Leslie, did you have a question? I do. It's fantastic that you've reduced the access, you know, wait from one year to three months. Although, I was struck by three months sounds like a long time for a person who wants to get to their, like, savings in the moment. But I understand your staffing. But if you had your way, what would you want for access? Weeks. Same day. Same day. [Kelsey Stetsup ]: So we do that for a model. Property. That would be [Marie Lennon ]: the same day would be a different model. Right? [Simone Rishmeier ]: Or Yeah. Yeah. And and we do. [Melanie Gidney ]: It's it's a different model. We got consultation from the National Council of Well-being on how to go through that process. So it is a national model that I think is getting embraced, that we've had success with. But, ultimately, you wanna meet with that person when they they feel like they need services. They they're ready for services, and that window can be really small. Right. So we have to be responsive and flexible to meet that need. Mhmm. And that's what we've embraced. I don't think everybody's there yet, but I think that's what our our our system of care is working towards. [Chair Alyssa Black ]: Yeah. You were gonna celebrate. Sorry. Three months is a celebration from twelve months, but is it would you have a narrower window or maybe you're maybe that works. I'm I'm just asking. [Kelsey Stetsup ]: I I'll I'll clarify what I'm saying. So I think to Meli's point, like, when you the and we have other examples we can talk about through here where if you're building out the continuum. So we do have same day access. So you can be seen the same day. You're not guaranteed to see that same therapist again, and I think when you're looking for more long term supports and services, there is a little bit of a wait time in some programs. And that varies across the state agency to agencies, so I'm speaking for NKHS on those. But you can be seen same day, and we have examples of that. So our urgent care is called the front porch, but, you know, the story is saying, someone looked up, we're gonna get mental health support on Google. They found the front porch. They came in. They were seen for a couple hours. They went home. They felt better. Like, there is access. You can call mobile crisis. They will come out to you within an hour. So from an acute standpoint, you can be seen from a, you know, longer term. I want a therapist I'm gonna see every month. That varies and can be harder to get into, and we see that not only with, you know, our agencies, but any private therapist, anybody that's just saying, look. We're don't have enough space for the need that's out there currently. [Chair Alyssa Black ]: So what would be the time frame between being seen acutely and then getting into a long term relationship? Is there a gap? How does that work? Does that make sense? [Speaker 7 ]: I'm sorry. It's a valid question, and [Melanie Gidney ]: I think by agency, you might get slight variations. Mhmm. Because every all DAs offer, emergency services Mhmm. With need to respond within an hour. If not, you know, six minutes is what we can do seconds. It could be [Chair Alyssa Black ]: a phone. System is really working [Melanie Gidney ]: well. For us, it's for clinical services that you come in. We try to keep people with the same clinician. That's not always the case because it also comes down to personal choice. Mhmm. So you may come in and we have a a male clinician and they want a female, or they need a certain person with a specialty. So there may there's no guarantee who they come in and meet with. They'll see long term, but we try to keep it consistent where we can, but give flexibility to meet what they're seeking. I'm just flipping ahead [Chair Alyssa Black ]: on those slides, and I'm seeing that maybe we might address this. Any questions on this slide here? [Leslie Goldman ]: So my municipality, Winooski, is very grateful for the street outreach. And I know that that's a regional program, and I know there's been some changes recently in the funding proposed for it. We're a little concerned about that, because it has proven to be one of the most effective programs as far as helping folks who are either in crisis or just simply unable have been unable to connect with care that they really need. And these are our neighbors. I just wanna remind you, there are neighbors that are really deeply in need of help. So thank you to Howard Centers, who wouldn't be working with. Where do those folks fall? Are those considered self referrals or crisis supports? [Simone Rishmeier ]: I think that's more in the crisis supports can be self referral, but primarily in the crisis supports. And I think that what's important to note is that there's not one solution. There's not one door, there's not one solution. [Speaker 4 ]: When they look at this slide and [Simone Rishmeier ]: they look at schools, for example, we're in over sixty percent of the schools. That's that's in a lot of ways immediate access too. Right? So you're you're there. You're getting the supports. At other times, we're in people's homes with community supports. It's not only about therapy. And I think that, as a state, as a nation, if we if we are only focused on therapy, we're going to you know, there aren't enough people in the workforce for that to to work. And so, yeah, street outreach is essential. Being in schools is essential. Being in emergency departments, in primary care, having mobile crisis. And it's yes. [Chair Alyssa Black ]: It's a possibility. [Kelsey Stetsup ]: Street outreach is a really great example of, like, a model we wanna replicate. But based on the funding and how that works, it's so hard to stand up models like that because, you know, we we the state works really hard to leverage Medicaid, which is great because that brings a lot of federal dollars that allows to do programming. But when you look at street outreach, that's a capacity, program in my mind and saying, look. We need people who can proactively go build relationships, which I think is preventative care and getting people in the pipeline to get the services they need so they alleviate the pressure on those more acute, and it's also our neighbors, and it's just hard to do. But we're not funded to just stand people up to be available to go out saying, how many hits did you have? And we always talk about this as a firehouse model, but if you know, we like to make the comparison to the fire station saying, if they had to do a fee for service, you'd either be wishing for more fires so you can get paid or you'd be cutting services. And so if we want more opportunities to be proactive to build relationships, which is really the foundation of what we do, You can't plug and play people when you're dealing with the most vulnerable. People don't wanna repeat their stories, and so the retention piece of what we do is so vital, which comes into other things we'll talk about. But I think street outreach is such a great program. It's just really hard to fund. It's really kind of saying, do we have extra funds we can pay people to do because a lot of the work they're doing isn't technically billable under Medicaid standards, and it just makes it so difficult to stand those programs up. We find the same thing with, mobile crisis for us. Look. We're fully staffed. It's a really popular program, but we know the need is there. And sometimes you see ten people in a day, and sometimes you don't see any people based on if they're calling. Are we working closely with our partners, which we are? But if you're not getting the right amount of hits to draw down the right amount of money, you just can't have people available when you need them. It's a it's a resource constraint. So I think street outreach is that kind of ideal. Let's go be proactive in the long term outcomes from that. It's like, you're gonna see the reduction in the is anybody better off that we're really trying to go for, but the model is not set up to support that type of work, honestly. [Leslie Goldman ]: Yes. On the ground, I mean, that is what I'm hearing is that it is those relationships and the continuity of the relationships that really helps folks just get over that little hump. And then, you know, they're well until they can get really into that month three months later appointment or whatever or same day. The other thing I wanted to comment on is Leslie's question around same day access and whatnot. And you were doing consultation with National Council. I'm assuming that was actually with MTM services and the same day access. Was that part of your work? Yes. And we'll get into that more later. [Melanie Gidney ]: We were awarded a grant separate from CCBHC to put to to work with them, and it was very helpful. Yeah. And just to close on that, I would just say no wrong door with that street out work outreach worker. It could be an acute need that they connect to or connect into multiple different services. But that I think we're trying to embrace that whoever they come in contact, that person's responsibility to do a warm handoff to the appropriate next level within that agency system of care. And, Catherine, did you? [Speaker 9 ]: I got a part of my question. Yes. I I I guess I wanna know one thing. If a person is in crisis, are they gonna be able to be seen at that point? [Melanie Gidney ]: Yes. Yes. [Speaker 9 ]: The answer is yes. [Kelsey Stetsup ]: Right. [Speaker 9 ]: And that that's statewide, do you know? [Simone Rishmeier ]: Statewide, we have the two on one enhanced mobile crisis. So we go out and two people go out and and make sure that that person is safe and that they are referred and [Speaker 9 ]: So instead of going on, as an example Yes. If I call the number, I'm gonna somebody is gonna deal with me. Mhmm. [Kelsey Stetsup ]: And so you can call nine eight eight that we so in KHS and then CSS runs call centers twenty four seven. So the, you know, answer rate on that is quick to count seconds. And then mobile crisis will come to you if needed. So the standard is an hour to get to you. And then there are regional well, there's a slide on this, urgent care facilities. So, like, if the community can go to you and you need a physical place to go, we can take you there. And then, so that's the crisis continuum here, and it's meant to, you know, address those acute needs that you're talking about, just to be responsive in the moment right away and then send somebody to you and then go somewhere therapeutic to meet your needs if that's necessary. [Speaker 9 ]: And and the same thing goes for if I'm in the hospital and I'm gonna use Central Vermont as an example and Central Vermont no longer deals with it. I wouldn't be able to be that. [Kelsey Stetsup ]: So I think that's probably a topic we can pick up in more depth. But so most of our programs, we don't do involuntary treatment. We will assess folks. We can recommend EE or involuntary treatment, work with, DMH and the judiciary, but then we do need to refer out to Brattleboro or CBMC as the last resort for inpatient psychiatric treatment. So that is not something that we do, is involuntary treatment. Or inpatient. Or inpatient. [Chair Alyssa Black ]: Yeah. [Speaker 5 ]: Alright. Let's [Chair Alyssa Black ]: okay. Let's move on. Move on to [Simone Rishmeier ]: next slide. So that I'm sorry. [Speaker 9 ]: Did you have something you wanted? [Marie Lennon ]: I wanted to if if it's okay Okay. I'd like to elaborate on your question Okay. About deep mobile Yes. [Speaker 9 ]: I already have [Marie Lennon ]: about the practice of intervention. [Chair Alyssa Black ]: Can you [Brian Cina ]: say who you are for [Leslie Goldman ]: the record? [Chair Alyssa Black ]: Say who you are for the record. [Marie Lennon ]: I am Marie Lennon. I am on the board of directors for the counseling services of Madison County. When I first came to Vermont in two thousand sixteen, I was at the lowest point in my life. I went through CSAC, and, unfortunately, at unfortunately, at that time, I needed thirty nine waiting list for councils. But CSAC has what they call an e team, which is all on twenty four seven. Okay? You can call the e teams. Somebody from the e team will call you back and talk to you on the phone. [Speaker 9 ]: Did that happen to you? [Marie Lennon ]: Yes. Okay. More than once. [Speaker 11 ]: Okay. [Marie Lennon ]: More than once. And there were a couple of times when I ended up going to the emergency room and was in crisis. Yeah. And one of the eighteen members from CSEC came to the hospital to talk to me. [Speaker 9 ]: So what you are doing is substantiating [Chair Alyssa Black ]: Yeah. What they said. Yeah. Thank you. Thank you. Thank you for sharing your experience. [Speaker 5 ]: Thank you. [Marie Lennon ]: And let me just say, two years ago, I would not have been able to do this. Oh. That's awesome. [Simone Rishmeier ]: So this slide is a DMH slide, Vermont's crisis continuum vision, and we have added in some components of where the BCP agencies are at within this. But all of this is up and running. Some of it, it's newer than other components of it. I think we have we've talked about some pieces of it. Nine eighty eight, run by MKHS and and CSS, then we and the mobile crisis, the enhanced mobile crisis. We can talk we'll talk more about that. And all ten designated agencies, are a part of that. And then alternatives to the emergency department, many of those, it's I think it's actually extremely exciting. And over the past year and a half, two years, we've stood up about we have how many do we have now? Six, seven, in the state, which is wonderful. And I think it was in in a really a response to that that urgent need of where do we go? And it it started with pocket, the United Counseling Services, and focusing on kids. And now we have, a number that focus on kids and a number that are adults and some that are for everybody. So, working closely with DMH to figure out what sustain those and, think about how we meet the needs statewide. They've popped up because of innovation, because of funding, because of need, but, again, we do wanna make sure that every Vermonter has access to our urgent care centers. So this, yeah, this this is their vision of how people enter, and really the, goal is to re you know, reduce utilization in emergency department and support people in crisis wherever they, can be supported. In addition to nine eight eight, there are total crisis lines, and which we are moving more in the direction of utilizing nine eight eight, primarily. But for folks who are in the community and know that crisis line number, it's important that those still exist. [Chair Alyssa Black ]: We can go to the next. [Kelsey Stetsup ]: The only thing I would add in here that's not on this list is that, you know, we've also talked about the Vermont State Police embedded programming, and so, you know, that's part of kind of a crisis response in the work. So that's not represented here, but I think is considered in the conversation when we're responding to issues in the community. And we do have [Simone Rishmeier ]: you wanna talk about ninety eight? [Kelsey Stetsup ]: Sure. So I think just a little more in-depth, folks are aware of ninety eight eight. So NKHS and NCSS separate the duties. So, NCSS is, doing daytime during the week, and NKHS does nights and weekends. That's how we cover it. So we, get to, twenty four seven coverage. And so the important thing that I do wanna highlight back nine eight is, like, if you call, you will get somebody. And so, you know, the hope is and where we're headed a little bit is, like, geotagging. So right now, it's based off of area code. So if you had an eight zero two number and you were in California and you called it, you'd actually get us. And so I think they're trying to sort out, like, you wanna be connected to where you are physically. And so I think they're sorting that out but close to getting that online. But the important part is, you know, if you don't get us, then it rolls over to our headrest partners in New Hampshire. And, you know, the headrest will go national, but you will get somebody who will pick up the phone. And so you can see some of our data here. We have seen, a large increase almost, I would say, threefold over the last three years in need. And so I think that's one awareness. I think the need has been there, but making sure to divert folks from nine one one to nine eight eight. And on a previous slide, it said about ninety five percent of all calls are resolved on the phone. So it's a great intervention. I think it diverts folks to a better level of care, and then, obviously, they're calling from somewhere where they're safe and it's most often resolved. And then the rest of the continuum partners nicely with this if we do need to send somebody out. But, the ninety eight program has been a great partnership across the VAs and with DMH and I think to, great success. [Chair Alyssa Black ]: I'm sorry, Brian. You see you over there. Yes. [Brian Cina ]: Yeah. I'm sitting I just I didn't wanna interrupt the table because I have to leave in a little bit to go to this. Okay. [Chair Alyssa Black ]: Do you have a question? [Brian Cina ]: Yes. When I just it's it's it's not a super important question, but but but when someone calls nine eighty eight, what happens in between nine eighty eight and, like, when I'm working at first call, the phone rings there? Because, like, I'm often curious what the experience of the person is. Like, is it it it does it go right does some computer patch it right to the local phone, or is there a person, like, that unplugs something and plugs it in here? Like, no. I'm kidding. And how does that what's the per the process? Because I'm just asking to understand. I said it's not that important because it's not, like, life or death right now. But when someone's, like, trying to call, what is your experience like, you know, that's really what I'm getting at, like, in terms of waiting for someone to actually because I know when you call our crisis line directly, sometimes it goes to the pager and then they page us, and then there's this delay. And so if you could just speak a little bit about the chain of communication from dialing nine eight eight to talking to a person. [Speaker 9 ]: Yeah. [Kelsey Stetsup ]: And so you can see here. So right here, the average speed to answer, you know, was originally twenty five seconds when we started in twenty twenty one. Now that was six seconds, so someone's gonna pick up. And so, I know we have our own call center. It's dedicated. It's not someone doing multiple positions. I know NCSS is moving in that direction. And, we've also implemented technology. So it's hard if eight people call all at once, we don't have eight people on, and that's when you roll, and so it can take longer. It's like forty five seconds. But going back to it's like you will get a person on the phone. It's not gonna go to a pager. Someone's not gonna call you back. Like, you may have to wait longer if it's a high volume time. One other thing we've implemented with technology is the ability if we are seeing high volume or if someone's out that we have the technology to tap somebody who's on call to work anywhere so they can work from home as long as they have Internet connection. So that has, helped to increase our answer rate. And so for a few months there, we're at a hundred percent. But just based on when people call, you might get a couple that roll over it, so you're not always gonna hit a hundred percent. But the point of ninety days, you're always gonna get a live person fairly quickly, and for us, it's very quickly. [Brian Cina ]: Does a computer do that, like, the the rolling over process? [Speaker 9 ]: I'm not [Kelsey Stetsup ]: sure, like, the technical behind the scenes, but we it's I I just wanna say it's simple. I don't know. That's like It's like It's like Yeah. I think there's, like, some way to process it. Like, if it rings a bunch of times, there's a a cutoff where I'll get rolled to something else and then pick that up. So I think that is digitized. I'll do it. Yes. Yeah. Oh, yeah. Sorry. I get what you're saying. No one's like, oh, wait. Headrest, New Hampshire, like that one, like the call center. No. No. No. You're right. That's the back end digital. Thank you for clarifying that. [Melanie Gidney ]: Just speak to your question a little bit on our emergency line. We are trying to do better of making sure we have a live person to person hand off, and that's not taking messages. And not every I I'm not speaking for the whole network, but I know through mobile crisis, we are trying to make sure that people don't get lost in those cracks and that you keep the person on the phone until you have that live person that you can pass them. And that that handoff is done much more with intention to make sure somebody doesn't follow the practice and we can't reach them again. [Speaker 11 ]: That's kind of an understanding. Yeah. [Speaker 5 ]: Yeah. It's [Brian Cina ]: like nine one one, you wait on the phone with them and then they put you through to the next person. But sometimes people call the crisis service, and they get a pager. And then they Okay. Somebody answers, but they're, like, answering service, and then you wait. And, like, that fifteen minutes, like, we try to answer those calls quickly, but I worry sometimes what happens to people who they you call them back and they don't ever call you. [Speaker 5 ]: Right? You know? Sure. [Melanie Gidney ]: I I don't wanna say that's guaranteed, but we're moving in that direction to eliminate that gap. This is just curiosity on my part. [Chair Alyssa Black ]: We've got three years of data now. Are we tracking, like, times, days, months, like, where call volume, like, our Yeah. [Kelsey Stetsup ]: We have our [Chair Alyssa Black ]: holidays, especially. Or [Kelsey Stetsup ]: We have a we'd be happy to come back and do that detail, but there is so much data. It's actually a really good example of, like, how we wanna kind of approach other services, but we can slice and dice the data pretty intensely to saying, like, these are when the majority of the calls come in. And so we can certainly come back and speak to that. We'd love to. And the the last thing I wanted to do thing with? To Brian's point is saying, you know, as an example of the importance, I think, of having a local system of care that is statewide is that we did receive a call with someone. And so they don't have to say their name, where they are. And so we did have someone who called and was actively suicidal and gave just enough information. And because there was a DA, we were able to call the local DA somewhere else, and they were able to go do a wellness check and intervene and save a person's life who said, you know, I'm just taking much pills and I'm gonna kill myself. And so that connection between the designated agencies was essential to saving that person's life. And so having nine eight eight be local and answered by folks who are connected to other people is a pretty central part of the crisis continuum. [Chair Alyssa Black ]: Thanks. What do you need to do? [Speaker 12 ]: Yes. I was just continuing with your question. I'd be interested in knowing the amount of time spent on the telephone with these individuals. And, also, what's the age group for these phone calls? [Kelsey Stetsup ]: Yeah. We should rate that down for sure. Yep. [Speaker 4 ]: K. Thanks. [Simone Rishmeier ]: Right, writing down the questions so we can get back to you. So we talked about the mental health urgent care programs, a little bit before, this data is from, twenty twenty four and we are closer to about five hundred people across the state at this point in time. And so, as you can see, counseling services, Addison County, Unencounseling Services, Healthcare, HCRs, Washington County Mental Health services, Northeast Kingdom, Howard Center, and Memorial all have programs. We are working with BOS as well to cross map our data to determine the impact on emergency departments. So we're getting some of that initial data currently and, had a bit of a setback with the flood and the system, but we're back and up and running. So, we we will get that information to you as well. But that's been really helpful just to see what the impact is, of these programs on ED utilization. Not that that's the only metric. Obviously, the most important thing is are people better off. But we are doing that as well. [Chair Alyssa Black ]: Actually, do we have data yet available on, like people entering the system of care? As far as people who are visiting urgent care programs, are they do they have sort of preexisting relationships with the designated agencies or in the continuum of care, or are they sort of possibly new people who are feeling, like, safer Yeah. With, you know, a different model of receiving emergent care? I'd I'd be curious about that. [Speaker 5 ]: That's a [Simone Rishmeier ]: good question. We don't have the numbers right now, but I would say that it's definitely both. And I know that Washington County speak to NPHs. Washington County and the Howard Center, a lot of the folks who are going to their urgent care models are new to are are not current clients. And then it's really a matter of what their need is and whether they need that follow-up care as to whether or not they get enrolled in programs. [Kelsey Stetsup ]: And I can speak to NCHS, but, yeah, over fifty percent are not associated Mhmm. With, the organization. [Chair Alyssa Black ]: Okay. Just wondering if we're reaching people. Where are they? Yeah. [Speaker 5 ]: Yep. We are. [Simone Rishmeier ]: And it's part of I mean, it is also part of the challenge of sustainability, because if they're non clients, we can't bill Medicaid. So And [Kelsey Stetsup ]: I would say, you know, one of the nice things over the last few years is the continuum being built out. And so, again, as we see nine ninety eight, I think there's good research that said it takes about two years to build models to fidelity. And so we have seen as we trend it, like, an increase in utilization every month, essentially, and it's trending upward. But just like with mobile prices, which started a year ago, we need that time. One is behavior change. We're still seeing people. The great thing about nine one one in the hospital is, like, you go there, you get seen, you call nine one one, someone comes. And so diverting folks, making sure it just takes time to build that up, and so we are seeing increased utilization over time [Melanie Gidney ]: at these programs. And I'm not sure it needs to be said. What a much more therapeutic, better environment this is, especially for our youth, to be treated in these programs than be in an ER with all the Yeah. The stimulation and just not right place, right time. So that's been, huge. [Simone Rishmeier ]: A lot of focus on the escalation for sure. We can talk about enhanced mobile crisis, a little bit. So these numbers actually, I just, gave HCRs a call this morning to see if you had updated numbers because these are from, first six months. But so, in as of now, two thousand eight hundred and thirty seven people have been seen through the mobile crisis program, with a hundred one thousand five hundred and thirty one follow ups, which is a significant increase even as you can see from our first six months of of data. So, again, to Kelsey's point, it takes a while to build programs and for people to, feel comfortable calling and to change the attitude of, I'm just gonna go to the emergency department because I know it can be seen there. Right? So, but we are really trying to meet people where they're at in the community and provide the supports that they need. Just a couple [Chair Alyssa Black ]: of questions. This is a relatively new program, the embedded commissions with the state police. So we're in all the state police barracks now. So they're employed by the designated agencies. They're paid through the designated agencies. It's coming out of the DMH budget or DPS? Bulk. And they're embedded. Are they available for other services if they're not being utilized? Because they're within the designated agencies, are they strictly only available so if they are in if they're in the barracks, are they only available for that time or anything that, you know, perhaps the state police would need them for? [Kelsey Stetsup ]: Oh, yeah. I can speak to that for our folks. So we've so there was an expansion last year, so we went from two because we cover Saint Johns, Grandin ports. We have two people, and then we have four. We've also found that these positions are really enticing to folks. Like, when we put out application to get fifteen, twenty, thirty people apply, which is, like, not typical of every position we put out. And when we talk to our partners at BSP, specifically, Lieutenant Wynne and Saint Johns, you know, so this is, like, one of the best things that's happened to their barracks. And so I think if I'm gonna paraphrase some of the things that they do appreciate is, one, when they get a call, they respond immediately. Some we've had recent conversations. St. John's Bridge has been selected to be the, next round for public safety enhancement team, and some of EMS and local PD are saying, look. We love the program, but with an hour response time based on your catchment area, like, sometimes it's just too long. And so, like, we need someone there to relieve us because this isn't a criminal issue. It's not a medical issue. It's more of a social issue and saying, like, there's this tension in timing. And so I think the embedded, BSP program is meant to be able to respond with them, but they can also respond without them. They can do work and follow ups from the barracks, but connected to work that BSP is doing. And so we found it's alleviating a lot of the social service aspect that police get roped into because they now call nine one one, and they're getting responded to calls that saying, this isn't really criminal. Someone needs help. We are here And knowing that the staffing crisis is urgent, especially in our area with BSP, there feel the alleviation of some of the calls that are related to the criminal aspects that they really do need to prioritize. So, to your question, yes, people will work on things without the police, but they are really focused on, connecting to calls that come into the barracks and alleviate some of the adjacent, work that police are called to. [Chair Alyssa Black ]: I I think one of the things that I'm confused about about this parvo program is how it either plays with or, intersects with mobile crisis units. I mean, isn't that sort of the intention of the mobile crisis units? And do these are these competing or or do they do they play well with each other? I Yeah. [Simone Rishmeier ]: It's a good it's a good question. I don't I don't see them as competing. I see them more as, again, sort of that any door to Melanie's point before, that we can meet people where they're at. And sometimes that is with law enforcement. Sometimes it's not. We try with the enhanced mobile crisis to not be going out with law enforcement. And so there's I think they they they play off of each other and different people come through different avenues and different doors. We also I mean, we've talked a bit too about, whether they could you know, if they're not busy at the barracks, could they then go out to a call? But the funding mechanisms, the funding streams are different, and so we can't can't sort of swap people in the same way that we'd like to, going back to Kelsey's point out of buyer house model, that we don't have. So it's really about some of it is the constraints of the funding streams. K. So the these positions are not billable? [Kelsey Stetsup ]: They're paid out of the grant. It's a much simpler drawdown for just, like, if you work to get paid. [Chair Alyssa Black ]: Right. [Kelsey Stetsup ]: And so it is a really nice thing. We do collect data. We have a good amount of data we can present on, but it is different than the mobile crisis where you're getting insurance data and making sure you're billing down. The only way you get paid is if you do it. So mobile crisis looks a little more fee for service rather than the VSP model, which is just you get paid if you have an employee there, which is very [Chair Alyssa Black ]: Which means we can't draw down federal funds [Kelsey Stetsup ]: for free. [Chair Alyssa Black ]: Yeah. Okay. [Kelsey Stetsup ]: And that's always the the flex and the challenge, which is, like, you wanna draw down more funds. But if you don't get the hits, you don't get the money. And then, you know, I will say that that creates strain on the system of saying, like, this is how many people we actually need to employ to be responsive within the hour or to you know, a lot of the frustrations people have is, like, can you come quicker? We need you now and saying, well, if we have two people to cover two thousand square miles, what's a realistic response time in the northeast kingdom if you were just called away to Canaan and you need to go to Hardwick? That's a two hour drive. And so, it is the tension between the firehouse and the deeper service model, [Speaker 9 ]: which makes it challenging. [Chair Alyssa Black ]: Thank you. Oh, I [Speaker 5 ]: I think Can I add an example? My name is Eric. I'm the director of mental health assistance services from our care partners. I used to work in a residential program and I have an example of a pretty intense crisis that we had where we called mobile crisis. It turned out we still needed a police and EMT response and the individual was really we were all struggling in the moment it was it was pretty hectic and so the police were able to respond with the embedded social worker and that social worker played a really pivotal role in helping the individual calm down and explaining to to them what was going to happen moving forward because they were going to need to go to the hospital and they were able to come in and offer a complimentary service. They were able to start fresh and develop a new form for the individual whereas the mobile crisis since I was had been working with with them for about an hour at that point. And it's sometimes just a fresh base is really helpful and sometimes having the authority in coming with the police is also a really nice alternative. And in other instances having someone with the police who's not an authority figure is also is alternative. So I see it as really complimentary. [Chair Alyssa Black ]: Are are the embedded, clinicians with local police, are they also grant funded, or are they are are they able to bill for their services? [Simone Rishmeier ]: I believe those are grant funded too, right? Yep. Okay. [Leslie Goldman ]: I'm sorry, Daisy? How do the pay rates of the embedded clinicians compare with those of your clinicians who are providing services under the roof of one of your regular facilities? [Kelsey Stetsup ]: So the embedded positions are necessary licensed clinicians. They don't need to be. So they're called mental health crisis specialists. And so that is not a required master's license eligible position, and so that can fit into a different pay band. I think we try to make those fairly competitive. And so I think that they are I think they're paid less than the licensed clinical folks that we would have for mobile prices. You can need a, at least a roster clinician with that. So there is a slight, tiered, to the pay, but it's still competitive enough at least for us to fulfill that. [Leslie Goldman ]: I'm just trying to figure out why, those positions are receiving such a high volume of applicants. [Kelsey Stetsup ]: So I'll speak for NTHS. That's for us. And so it might be demographic. I know some other folks haven't had as much success as we had as hiring those, but it does help when you can have a bachelor's and you're not required to have a licensure to do that. There is robust training, but it is slightly different requirements, which does open the applicant pool as opposed to looking for clinicians who are master level and or licensed just really narrows the people. And, also, I think the market rates for licensed clinical people is also something that weighs on the designated agencies both to pay, and what you can get for private primary care hospitals like we are, is at a detriment when recruiting for those specialized therapeutic physicians. [Speaker 12 ]: Yeah. Great. So what is the type of training that one has to go through to be embedded with the state models? [Kelsey Stetsup ]: And so, again, happy to come back and speak in-depth, but it is robust. And so that's a collaboration, and I don't have all the trainings off hand, but it is intentionally bust. It's in a lot of different dynamic situations, sometimes wearing a bulletproof vest. So there are things that you need [Speaker 9 ]: to be aware of and [Kelsey Stetsup ]: so but happy to come back and speak in-depth about. [Chair Alyssa Black ]: Thank you. Yep. Good talk there. [Simone Rishmeier ]: I was talking now because he's controlling back there. [Kelsey Stetsup ]: Bring Bring up two different slides here. [Speaker 5 ]: Yeah. [Simone Rishmeier ]: Yeah. So, I mean, I think as you all know, there, the designated agencies are required to provide certain services, through statute, community rehabilitation treatment services for adults with serious mental illness, children, youth, and family services, twenty four seven emergency services, and the CS waiver services. [Leslie Goldman ]: We if you wanna just go [Simone Rishmeier ]: to the next slide. The We try to these are examples. It gets small. There's a lot. But the purpose of this slide is really to talk through how so many of the services that we do support those populations that we are mandated to serve through statute. And so we bucketed it into upstream supports for prevention and stabilization, holistic supports, effective intervention, and then community crisis response. We've talked quite a bit about community crisis response, and I think that's in large part, because we know that a lot of, folks are in crisis right now, and we have been as a state investing in that. And that is essential. I think all of us would probably agree that, if we're going to change the trajectory five to ten years out, we also have to invest in the upstream supports, and the prevention and early intervention. So this is an these are examples of some of the work we do around housing, employment services, food assistance, the community based services from Perinatal across the age continuum. We have an increase of peer, supports throughout our programs that will be increasing even more with, CCBHC as we implement that. We have the school based services that we talked about, elder care. So they're they're it's robust. It's diverse, but all of these programs and supports are really necessary to care for the folks who we are, mandated to support through statute. [Chair Alyssa Black ]: Are we gonna talk about, school based services I had in the because I do have a question since you brought it up. But but [Speaker 4 ]: We can talk about that. Let's talk about that now because I don't think we [Chair Alyssa Black ]: have a separate Really, my really, my question was just, are we are we seeing a bounce back of success beyond six from where we got down to? When because, of course, this is really important for education funding. [Melanie Gidney ]: Yeah. I'll speak about it ourselves. Just at Clara Martin Center, we are at our highest level of clinicians in the schools and clinicians being we have behavioral interventionists. We have BCBA's behavior specialists and then master's level clinicians doing therapy in the schools. And we have branched out. You know, we had one or two supervisor units. We're a small rural catchment area, but we're tapped into each district now. And the demand is increasing that I'm beyond, you know, approaching what DMH's limit is that I can have. So, the, the, I, whether this, the, the need is there, the schools, I also think we've done a better job at relationship building, and meeting the school's needs and being flexible where we can. But, yes, we have just exponential in the past two years, that I've just hired another cohort of a BCBA, a supervisor, and a a sub. So it's it's, I think you gave a number at [Chair Alyssa Black ]: the beginning of your presentation that what percentage was it that [Simone Rishmeier ]: It's over sixty percent. I can double check it. Sixty three. Sixty three, but I can provide it. Exact number. I think it really varies around the state as to whether contracts are increasing or or decreasing. And a lot of that has to do with, our ability to have the workforce necessary to to meet the contract and relationships with schools. And I and and I would also say that there's sort of this a lot of it's also maybe about education. Right? So if you're if you're in a school and you're saying, I just want control over this person. I want them in the school when I need them, wherever they are, versus thinking a bit more broadly about it to think about how, if you're contracting with a designated agency, really benefiting from all the services that they provide. It's not just that one person in the school. And so I think there's more education to be done there and also about the funding mechanism. And I'm not the person to talk about that, but, we do have people in the room who can. But it's also about the funding mechanism because I do believe that it does really save, our system dollars and it saves the state dollars and taxpayers as well. [Chair Alyssa Black ]: So to Laurel. I think Laurel's been in today. So Yeah. [Kelsey Stetsup ]: And and the only thing I would add, you know, just to echo what Melanie said, we are seeing increase in requests. And and what we saw come through in our area with some schools was ESSER funds through COVID, and those are ending. And so they're saying, how do we afford to keep these people? What can we do? Can we work with you? And so we have had more outreach to saying, can we have that? And, you know, tied to these upstream supports and holistic supports. And I do wanna add some of the visioning that we're trying to talk about, which is, like, yes, kids are struggling in school, and so that tends to draw our focus. But when you zoom out a little bit, which is what we're trying to do, it's a family systems support. We're seeing social determinants of health. And, really, what we're trying to do is saying, look, it's really hard, and we see this with PCPs. We see this with private therapists. They're saying, I do this one targeted specialty thing. I'm a therapist in a school for nine and a half months, but in the summer, go to the DA. The private therapist in the community turn off their phones and say, call the DA after five because I'm not available. And so we are the backup, and so we get stuck into these webs of other people's services. And what we're really trying to say and especially with schools, like, I think we need a little bit more of a holistic approach, and, that's some of our pitch saying, like, we need to do family system work. We need to be twelve months out of the year and, to really effectively address some of the acute issues that we're seeing, especially in schools. [Melanie Gidney ]: I would say what's unique for us too is we've actually been able to fill those contracts. So we might have had the interest before, but not the ability to fill them. So not I'm not confident it's gonna sustain, but for this period of time, we've been able to fill a much higher percent of those open positions. [Simone Rishmeier ]: And if [Kelsey Stetsup ]: we're talking about the funding, SuccessMeOn six is, like, one of our only noncavitated funding sources, and so it gives us more flexibility to contract directly with schools and leverage the Medicaid drawdown. Yes. We're overall capped by the state saying, hey. If you're gonna have this many positions, like, this is the allocation of dollars, but there's more flexibility in some ways with the funding than with our adult and children's case rates that is capped and really puts that downward pressure on recruitment abilities with staffing and how we're able to pay or not market rates. [Simone Rishmeier ]: Heidi, did you wanna? [Speaker 7 ]: Yeah. I I just wanted to put, you know, [Simone Rishmeier ]: just say who you texted [Speaker 7 ]: for the record. Call. I am the CEO of Washington County. And I just wanted to kind of note that I'm excited for ClearMark Center and your increase in your contracts. That is not the situation in Washington County. I don't believe it's in two new county either. So we are actually experiencing about we have about thirty unfilled referrals. We are having extreme statin crisis in our in that particular area. So, so our experience is not the same [Speaker 9 ]: at all. [Leslie Goldman ]: For school based. For school based. Yeah. [Speaker 7 ]: We are in every super we are in every area, every store. We are not, financials. [Chair Alyssa Black ]: Okay. Okay. [Speaker 9 ]: You have extra people that have applied for your jobs? In schools or [Kelsey Stetsup ]: in other positions? Not schools. I mean, we're doing better than we have in the past recruiting. We still have couple openings not to the extent of other designated agencies, but I would say on comparison, you know, we're have been smaller historically, and and some of the changes that have been happening in our area has led to more referrals, which we have been doing a better government billing, but we don't have a giant surplus of folks who are applying to the school based positions. [Speaker 5 ]: Yeah. Any? [Speaker 11 ]: Yes. Yep. [Speaker 9 ]: Maybe what you wanna do is [Kelsey Stetsup ]: Not enough to share. I think we're just it's it I you know, in the and we have tried to do that in recruiting saying, look. The good part about designated agencies is, like, yes. We have programs, but, I had mentioned we had a surplus in the BSP or mobile crisis applications. We have been saying, look. If someone feels like they have, transferable skills, we should be passing those folks along. So we are trying to say, hey. We have a lot of people applying for one specific position, but would they be good somewhere else? And so if that's the case, we will share based on, geography if it's close to another joining, designated agency, but mostly internally saying, hey. I think you might be good for this position too. Absolutely. [Chair Alyssa Black ]: Could the designated agencies work together to align their pay scales? [Kelsey Stetsup ]: I don't think so. You might run into some legal issues there with, like, some might be in trouble with some, like, wage fixing and stuff like that and possibly collusion if you're talking about that to it cuts across kind of the competitive environment. We do use I think a lot of people have done market studies. And so I would say that our competition is less between designated agencies because we're based in catchment areas, and who we're really competing against would be, like, primary care and hospitals and private therapists, obviously. [Chair Alyssa Black ]: And that was the gist of my question is, at a certain point, aren't you just competing with each other for a limited number of peep of people, and are they just moving from one to the next based upon, you know, pay rates. [Kelsey Stetsup ]: I don't I don't find a lot of, like, switching in between designated agencies. [Chair Alyssa Black ]: Okay. [Kelsey Stetsup ]: Some but usually, I can think of a few just kind of anecdotal, examples, but usually that's more based on, like, life circumstances saying you pay so much more. I think you would find that it's probably close ish. I mean, you can find Indeed postings and look it up and saying, hey. How are you doing? But there's no formal conversation about wage setting, but I I don't see a lot of, like, transfer between designated and at least Fliershop. [Melanie Gidney ]: Mhmm. And if I can just clarify with the schools because, Heidi, I don't disagree with you. Behavioral interventionists, we've been able to hire. It's bachelor's level. If I'm looking for a BCBA, I mean, there's just not enough in the state. So this is a new position for me. I should probably clarify that. I just, up until this point, had been successful at filling more than I have historically, so I'm really happy about that. But there are certain positions that are extremely difficult. [Chair Alyssa Black ]: Alright. Let's move on a little bit. We're we're I think we're running low. Yeah. We're not right. We have a half an hour still, but I know that you have an amazing amount of information to we [Kelsey Stetsup ]: do have to [Simone Rishmeier ]: talk about. Talk about. So, we can kind of whip through some of this. We did wanna just a little bit talk about the strengths and actually to your point about whether we share information. I did wanna just touch upon how the agencies really work extremely robustly together. And I'll just take a second to talk about that. The workforce, first of all, the committed and dedicated staff at the agencies is really remarkable. And we have, through the Vermont Care Partners Network, we have over thirty different working groups, where staff from those agencies all come together and really work through, talk about best practice, talk about some of the challenges, meet with state folks and other stakeholders who are coming in, talk about policy, the impact, how we can improve. And, so that's really important. And to and getting to the financial piece, the CFOs actually meet weekly at this point because there's so much change going on. So there's a lot of collaborative sharing of information. Also enhanced training opportunities. We, are working a lot on the mobile crisis trainings, and, we have a BCP Leadership Academy now where we're trying to really think about the out years and growth in our leaders, throughout the network. And we serve as a training ground. I think it's really important to note that there's so many people who come in and do their internships, get their start at the designated, and specialized service agencies. And some stay and some leave. We're actually working we, we'll be working even more closely with colleges and universities to make that a much more formalized, internship program. So that's exciting. And then the depth and breadth of programming we talked about, quite a bit already and our focus on quality and quality assurance, quality improvement, and data. That is a increasing focus of ours over the years. So and then just quickly, the shared services. We are having a lot of conversations about doing even more of this. But right now, we're we do quite a lot together. The agencies do quite a lot together. Some agencies share in IT services. Some agencies share in staff. We have the Vermont Care Partners data repository, our unified electronic medical record, financial services some folks share. So there's really quite a lot. And then also in terms of coverage of schools or coverage of, for crisis, agencies do support one another in that as well. And then lastly, community education and involvement. There's a lot there that we do. Mental health first aid. We currently have three different mental health first aid grants, three focusing on schools, but also our SAMHSA grant, see what happens with that, is also, allows us to do adult mental health first aid trainings. And that is a very robust program, but there's also mental health CPR and others that, across the state. Okay. I whipped through strengths. I'm trying to go quickly so that we can get to some of the other components. Did you wanna talk about challenges? You don't want to. Sure. [Kelsey Stetsup ]: I mean, I think we've touched on a lot of it. One thing I will say when I kind of think about I would say that going to one of our strengths that we are experts in mental health and substance use. We do recruit folks with, like, deep knowledge, and the folks that we can't keep have long institutional histories and great trainings related to more long term care, so serious mental illness and severe emotional disturbance, we're talking about kids. We do take on the most acute, and so that creates, you know, some of the you know, Mel was talking about, acute care, the crisis, the burnout, like, the most intense, and we do get that a lot. And so some of our challenges, I would say, come back to retention, recruitment, keeping folks to do this hard work. When I think about it, I think we're like a specialty service. That's how we're looked at it. And usually when you get referred out to a cardiologist, that costs a lot more. It's the opposite. We're paid like generalists, expected to be specialists. And when you can make more money and do less intense work at the FQHCs or the hospitals or in private care, why wouldn't you go do that? And to Simone's point, we are training ground. We're really proud of it. We license people, and then they say, I got my license. Thanks. I'm gonna go do something else. Not all the time. We try to incentivize people to stay, and those who do are great, but it puts a lot of pressure on our ability to fall through on what we're supposed to be doing. We have seen an increase in referrals, I think, across the state, and so you can see the crisis continuum. The need for that is higher, which means that the follow-up and aftercare and more long term supports is also increasing. And then I would say just, you know, going back to the acuity, we talk about you know, there's some data saying, you know, CRT is down, adult outpatient is up in terms of that, but I would say that the acuity overall is going up, and that has more to do with eligibility standards than anything else. It's saying, like, the people we are serving have more intense needs. And then I think the kind of, like, social determinant, Jason, issues that we're facing is saying, yes. There's underlying mental health or substance use issues, but if you're not housed, if you don't have a physical place to go, it makes it very challenging to have positive outcomes, with folks. And then saying housing, you know, how fast can we build housing, affordable housing? And I think folks that we pay and have done a good job of increasing their pay still struggle, and it it does feel, agonizing and, really frustrating to know that people who are providing supports to our most vulnerable are also vulnerable people in Vermont who, you know, we had our legislative panel and say, I have to go to the food shelf as a single parent to feed my kids, and I work at a social service agency. So I think that is challenging when we ask people to do that hard work and and they're struggling themselves. Okay. I've seen that. [Speaker 9 ]: Chris, are there any efforts at this point in time to deal with the situation where their services are not reimbursable by the insurance companies? [Kelsey Stetsup ]: Yes. I would say, you know, with DMH and others trying to bring private insurers to the table, is an ongoing challenge. I think I think a lot of, you know, our mandate have those serving underinsured or not insured folks and, a lot of Medicaid, which allows us to draw that down. We can see private payers. Like, I don't know if you wanna speak to that. I think your payer mix [Leslie Goldman ]: is a little more. [Melanie Gidney ]: I was just gonna add on. So topper, we have a our payer mix is about fifty fifty, fifty percent Medicaid, fifty percent Medicare and third party insurance, which is a significant change for our rural area. You know, it used to be seventy five, eighty percent Medicaid. So we don't fully understand that shift of where those Medicaid folks, are, or what's happened in that regard. But in terms of the Medicare, we know that we have an aging population. We know that our older adults, have significant mental health substance use needs. They're isolated at home. Getting them connected to community supports is essential, but Medicare does not cover that. And Medicare only will reco will only be reimbursed by a licensed, clinical mental health counselor or an LICSW. So Medicare doesn't even reimburse a licensed alcohol drug counselor to do substance use work. So that's a federal level that we're advocating for that change because it is significant and it's only gonna get more significant with our aging population. We've been lucky to have some grants, prior to CCBHC, but with our CCBHC grant, our focus was on older Vermonters, and we've just hit barrier after barrier, because what they really they don't necessarily just need therapy, which is what Medicare covers. They really need those community supports and connections. And so that's been frustrating for us. In terms of third party, kind of the same situation. So increase in Blue Cross Blue Shield, Cigna, Tri [Simone Rishmeier ]: Tri. Tri. Tri. [Melanie Gidney ]: Tri. Tri. And, you know, they pay for therapy. They pay for psychiatric services, but not our full continuum of care that is really successful at supporting people. So case management services supports in the community peer work. We do have individual contracts with Blue Cross, that I think we're all trying to negotiate and have discussions to get a broader, but it's just increases the cost of health care. And we know the challenges there, but it is a significant barrier to treat all payers the same and offer the same services. So significant barrier for us that we've been trying to work through, trying to find some roots to provide that continued care that we know is essential. Transition age youth was our other end that we also were trying to address, like, with our older that just hit into roadblocks. Medicaid is wonderful. You know, it covers our full continuum for the most part, and the flexibility to meet them, at that person centered level of what they're looking for and what's most helpful. [Speaker 9 ]: So third party and Medicare are the problem? [Melanie Gidney ]: From my perspective, yes. And the reimbursement rates vary. [Kelsey Stetsup ]: And one thing I would just add that fits in kind of the strength and the challenges. So we laid out our core services. There is talk with that. The MAHHS says, you know, focus on your core service. At the same time, they say, do this thing. Do flood recovery and CCP. Go to the homeless shelters. Go to the hotels. We need you to be responsible for this. Do the crisis continue. And so there are two tensions saying, like, focus on your scope and then expand your scope. And saying, it is one of the best things about the DAs. We're flexible. We can be responsive. We're very creative. We go out with the community, which, not a lot of other folks do. And so it gives us a lot of ability to meet people where they are, right place, right time, in a therapeutic way with our expertise, but also strains us under the funding system when they're saying the DA will do it. And there is an expectation in narrative in our community saying, like, why isn't the DA doing more? I think it's really harmful to us actually. And, you know, one thing we try to talk about is, like, when things go wrong, we always want to talk about, you know, why and who's supposed to be doing what, and it does become nuanced. But, you know, one request for this place and anybody is saying, like, we do a lot of good work and need help sharing that information too and saying, like, the investments over the years have increased our access, our outcomes, and saying, like, we do good work when we're asked to do it. And there's also a lot of work to be done and a lot of struggling folks who, there's just more to serve than we can possibly. Do. [Chair Alyssa Black ]: I Thank you. Excuse me. Yes. We're going [Speaker 9 ]: to that slide. Can you go back to [Chair Alyssa Black ]: the There was a lot on that. Yeah. There's a lot. [Speaker 9 ]: I know that the paperwork problem is is a major problem. And I also know that it's being worked on. So can you just tell us where you are with that? Because I know people that have left their job because of that. [Simone Rishmeier ]: That is absolutely true. People have left their job because of the administrative burden. Yeah. You know, I think we continue to work with the state on streamlining as much as we can and to work on our IT systems in house to, you know, automate as much as we can. And yet there are more and more demands both from the federal and state government just about people wanna know what you know, they want to know the information, and we have to be responsible to taxpayers and taxpayer dollars. So we completely understand that there it still needs to be reined in. It you know? And I think also on the education front, there needs to be a lot more work around. If you're going into this field, you actually are going to also have to be collecting information and documenting because that is part of the job. [Chair Alyssa Black ]: I think that Melanie had mentioned something at the top of your presentation of shifting some of the paperwork towards more of the administrative staff and away from and freeing up the clinical staff to be able to provide clinical services. Is is that something that's being done across all the designated agencies? Is it just Clara Martin? I would say you can Go ahead. [Melanie Gidney ]: I feel like we're doing it at many different levels. I think DMH and DSU is working together to look at all of their requirements from the federal and state level. We're looking at it across the board within the DA system. Many of us share EHRs and how can we streamline that information. [Leslie Goldman ]: I don't want to interrupt. Go ahead. [Melanie Gidney ]: So, there's that work, as the broad VCP network and then cohorts within VCP. And then it's an absolute constant within each of our organizations around how do we manage this because the experience isn't just on the clinician and it is still after pay, probably the reason people are leaving. It's the biggest stressor and burden people people are experiencing. That's my train of thought. [Speaker 4 ]: It's also a word for [Melanie Gidney ]: the For the clients. Yes. It's what I wanted to say. You know, to come in when people do walk in and they wanna be seen, they wanna tell their story. They don't want to get literally ten pages of screenings and assessments and, consents. And, I mean, it is a packet. Mhmm. And so we did. We moved it, to our front end admin assistants, and then we have, access clinicians that meet and do fee agreements, all those wait consents and waivers and informed, of what they're they're participating. But I often wonder when they leave that appointment, even when they leave with another appointment in hand, was that a positive experience, and were they able to tell their story? Because if we can put that paperwork aside and just listen, that's what people came into this field for. That's what we're experts in. But I think each of us are trying to manage it. And as much as the e EHR is helpful, I actually think it's it's more pressure from a clinician's perspective. We absolutely hear that. [Kelsey Stetsup ]: And I think the tension on both sides of that is one. You know, they're always asking, well, how much of your time is spent on direct service, and we wanna see the most of that. But it's so compliance heavy that you just have to hire admin staff. Like, you said, if we're offloading administrative burden to other staff, they're not seeing people. They're doing paperwork. And so, like, that's, again, the tension on both sides saying limited administrative, you know, costs. You don't wanna see those too high, but it's compliance state of, like, the regulations, which is more prove it saying, show us you're doing the work, but that requires a whole. Or we have people that aren't doing direct services. So [Chair Alyssa Black ]: But, also, it leads to better job satisfaction for those actually providing clinical services, which is the mission. [Leslie Goldman ]: I just want to put in a plug because I see that one of your challenges is and we long know reimbursement rates is a problem. And it's a problem that impacts everyone that lives in Vermont because it impacts access, right, and availability of care. It relates to the documentation problem and administrative problem. Right? Because I think a lot of and I don't want to offend anyone, but I think a lot of our providers don't really know the true cost of delivering care, right? Because it's just infinite the amount of things like your electric bill, the amount of things that go into delivering one for two minute service, every minute service. Right? And if you've worked with MTM, you know, because Scott Lloyd will hammer this home. And I personally would love to invest in all of our DAs. Calculating that out. I think it's one of the most valuable investments we could make because then you can leverage that true number to negotiate what it truly takes you to deliver that care. And I think, you know, equipping yourselves and us with an accurate number, of what it takes is is so priceless. Right? And I think it also, helps you assess whether the administrative burden is truly what is required. MTM has a service that they actually have narrowed down documentation requirements and you know, turned thousands of pages of CMS requirements and state regulatory, and joint commission requirements into, like, you know, two hundred pages instead of a thousand. So just I I'm glad you're working with MTM because they're the experts in that stuff, and I would be really happy to entertain requests like more work with them because it's it's invaluable to our system. [Melanie Gidney ]: They were part of the right person, right place, right time, and matching the expertise with the work. And filling out forms can be done by a case manager. It can be done by somebody else. Doesn't have to be that master's licensed level clinician. Right. [Speaker 4 ]: And we have to be great [Leslie Goldman ]: that the forms are still required because I know our federal and state requirements change frequently, and sometimes the burden can be lessened. Great information. [Chair Alyssa Black ]: And I know there is some great information coming up, [Speaker 5 ]: and I want to get to it. So [Simone Rishmeier ]: Thank you. So we were just talking about what we should skip through. You know, there's there's a lot here. There there are opportunities. There's more information on our vacancy rates. I will just say that there's, as you all know, a lot of state and federal changes, that we're all embarking on and involved in, which, a lot of which is really exciting. CCBHC, for example, which I think really helps the state and all of us get to a more integrated, our vision of an integrated delivery system. It's also it's also pretty taxing and nerve wracking because of the unknowns around it. DS payment reform and conflict of interest, free case management and what how that impacts our CRT population. It's just a lot. So, we can come back and talk about all those different components, but, just to say that there it is, I think, both an opportunity and a threat to be implementing all of this at the same time. I would we've talked a lot about the workforce barriers and challenges. I do want to take the opportunity to say thank you for the tuition assistance and loan repayment. It has been invaluable to to the workers and and to our staff at the agencies. We're in we just started our second year of this this round, and we are collecting robust data. We will have more of that available to you. [Leslie Goldman ]: Can you remind us [Chair Alyssa Black ]: what the work requirement is for that? Is it one year to one year or Six months to one year. It depends if it's switching to either tuition systems or loan forgiveness and depending on which path you take. Okay. Six hundred one. Okay. [Simone Rishmeier ]: Do we wanna we only have we only have ten minutes. We really wanted to talk about the CCBHC and the financial component. So I guess it's more up to you all about that. [Chair Alyssa Black ]: Yeah. I really wanted to hear about CCBHC. I finally got that acronym right. [Leslie Goldman ]: I I struggle This is not everyone. [Chair Alyssa Black ]: Even though I have a mental brain blocked around this acronym. [Simone Rishmeier ]: Yes. Yep. I think a lot of people do. That's fair. So we have two agencies that are, going through the certification process right now, Claire Martin Center and Rutland Mental Health. And then we have, four more who will be going through it in a year or so, maybe a little less Northeast kingdom, HCS, and CSS, and Howard. And then the remaining organizations will apply through. We are hopeful that all will become certified community behavioral health centers. [Chair Alyssa Black ]: Oh, not Can you really quickly explain what that is? [Simone Rishmeier ]: What CCBHC is and how it differs from Yes. What we currently do? Yeah. So there are a number of core services, and and, Melanie and Christy, you can get to the detail of those. I'm gonna talk about how the way I see it really differing from what we do now is an expansion. It's, a formalization of co occurring with substance use and mental health. It's increased coordination and integration with primary care. It's increased access, especially with veterans. And I think another piece is our the requirement for a robust needs assessment. And I think that's what that's really showing is we've always known a lot of the needs in our communities, but this is even a deeper dive. And so getting a sense of some of the more marginalized populations and what their needs are and how we can afford to, meet them where they're at as well. Part of you you were talking about cost based reimbursement. Part of what agencies have to do is fill out a a cost report, and CFOs have been working quite a lot on that. And our hope had been that we could do sort of a template across the system to get at what you were you were exactly saying. What is the actual cost here and now, and what is what will it be with CCBHC? And we're still in the works on that. You So that is a long process. It's extremely detailed, and then it is not just a financial one. You need to get every I know a lot of folks in your agencies involved in that because you're looking at what is what is the appropriate staffing pattern? What is the appropriate pay? What is that based on? We look at bureau of labor statistics, etcetera. So, I I think it's a I think it's an exciting opportunity, for Vermont. And, it was started in large part at the federal level, right, to provide a bit more parity between FQHCs and community mental health centers, both in funding and in, and incentivizing working more closely together. And I think that that is, hopefully what it will result in. I think the [Melanie Gidney ]: only thing I would add, Simone, is it also helped us develop our peers, and people hiring people with lived experience. And I've been so impressed by the effectiveness of peers and the the the experience that clients have had. And then mobile crisis was part of that before we got the grant, as well. So having a two person response that went out into the community, that we had started that through the CCBHC process. You know, Christy, you know, you've really been at the heart of this, effort for Clara Martin Center. I'm not sure if you have something to add as well. [Speaker 4 ]: Yeah. So I'm Christy Everett. I'm the director of operations at the Clara Martin Center. I think, you know, we've been dealing the longest with CCBHC at the state level since we got our grant in twenty twenty one. And I think it's really looking at our system of care under the umbrella of CCBHC and every team that will fit under that continuum in some way other than like a residential services and some school space services. But the real focus of the work has been trying to kind of what's been said, meet the needs of the community, identify what they are, and then bring services to bear and develop that, really focused on sort of full force of care. What does someone need? It's not just mental health. It's not just substance. It could be assistance with primary care services and the and the how that intersects their mental mental needs with their mental health needs. Making sure that we can help people receive those services if not through us that we can help them connect the services in the community. And how do we address those needs on a more global scale. I think it's been transformational in helping to support staff that are doing this work. Working on the administrative burden, very thankful for the work with MDM. We do have some potential additional options that we are looking at with them as well. But as we address sort of the pay increase needs, we've also been able to support staff to get training in, like, evidence based practices and identify, like, what needs are out there? What is our community saying? Our trends that we have, including what services we face around the world. And I think it's I think I said it before, there's no part of our agency who's not been touched in a positive way by CCBHC. I think we've been really thankful to have the support of the VCPU network, support DMH and DSU to really do this collaboratively so we might have a grant at Clara Market Center full of working with the other agencies to share best practice what we're we're learning through CCBHC, learning what FTM has shared with us on same day access, and how other people can sort of benefit from that knowledge as well. I think the biggest thing that we're working with right now as we go through certification is trying to help support our state agencies and their alignment efforts. We will go through certification. We also are going through designation at the same time. So those two processes are still gonna happen, but the state, is trying to sort of align those into one process. So we have one set of criteria, one manual to follow, one reporting mechanism, but it will serve different parts and pieces of that. So I think it's been a great collaboration with our state partners as well as we've explored this and tried to build it out. But when we look at sort of that administrative burden, some of it is larger than us and how do we sort of help support them in the state levels of burden things, and to a better alignment. [Chair Alyssa Black ]: And this is funded by a federal grant? [Speaker 4 ]: Currently, we're funded by a federal stamp set of grant. We got our first grant in twenty twenty one. We got a second grant, in twenty twenty two. Now as the state was accepting demonstration, we're working with states through that, but our federal grant ends in September twenty twenty six. [Chair Alyssa Black ]: K. Great. [Simone Rishmeier ]: We just have a few minutes, and I would love to just touch upon CPI. And I don't know if, Heidi, whether you wanna join in on this conversation. It's it's an important one and, really quite striking when you look over the years. [Chair Alyssa Black ]: So do you wanna talk to that? [Speaker 11 ]: So, actually, Manili, the chief financial officer at the Howard Center, do this in two minutes. So it's three slides there. There's a lot of information, and we'll get all that information in two minutes. We're gonna go through it really quick. So what you're looking at right here, the left column is our CPI since two thousand and eight. The second column over is the increase, from Dan mentioned Dale. Fourth column over is our, inflationary increase from DSU. And the the red columns, as you can see, the third and second column is our our shortfall, in comparison to CPI from those net gain increases. I'll also put this in context that this is assuming that they're funded in two thousand eight. And I think there could be some arguments maybe that we were maybe short in two thousand eight, and it's just been compounded since then. I've got a slide forward to the next slide. This is our days and cash on hand. You can see the green bars on the hospital system, the blue bars out of the VA system. So you can see we we we had some cash come in and opened, and it was it was nice. It helped us get through that. That's all kinda gone away. We're basically back down to pre COVID levels of cash. We'll also say that that sixty three number is our system average, not Not the floor. There is some that nine zero one. You know, we've our center in the twenties most times, and that that too is not the floor. You know, the the swings when we have to pay payroll or if we don't quite get as much or payments are held up, you know, we we get lower than twenty, which is not where we wanna be. So we are I know there's a lot of news about the hospital for agility. You guys are very plugged into that. We are gradual as well. Just wanted to show that, make sure you understood that. [Chair Alyssa Black ]: Can you give us an idea of what a healthy days on hand would be? [Speaker 11 ]: You know, the state says sixty they want us to be at. I think we wanna be closer to a hundred. [Speaker 5 ]: Ninety. Ninety. [Speaker 11 ]: Okay. Ninety. That's good. Yeah. I'd like to be closer to a hundred. I would feel more comfortable. Three months, you know, would be would be more comfortable. Yeah. So if you wanna go to the next slide. So this is our payer mixes, our system versus the hospital system. I just want you to to really understand. We're gonna do as much as we can to impact that seven percent slice. You know, it's easy to know if we've talked to, you know, some of your constituents at Wednesday. We're doing what we can on that seven percent, but we need some help with that ninety percent as well. So just do the sequence to this legislative session, I guess that would be our ask, you know, to help us out. Okay. You can do it on that. I need to [Speaker 4 ]: I think that's the [Speaker 7 ]: the difference that you're really gonna see is that the designated agencies don't have a place to cost shift. Right? They aren't able to shoot to the private payers. It's such a very, very small piece of that. [Chair Alyssa Black ]: K. And then I can go to [Simone Rishmeier ]: the next slide. We won't get into the details, but just to let you all know. Amy will be here to do this part. No. But to let you all know that we are you will, a six point two percent Medicaid rate increase. And we, our CFOs have worked diligently to really give, to, to have that be a strong number and to have it be based on a number of different factors, including what you see here. So the four point eight percent salary increase based on US Bureau of Labor, average projected health insurance increase at thirteen point five, which is average. It is so much higher for for some. An average projected increase of six point two percent for other fringe, and then the general liability auto, others, six point five, and then all other operating projected to increase three point three percent based on the new annual CPI. So, this will be our ask is our ask. And, you know, I would say that this is to keep the lights on. And, while we are investing in our crisis continuum, and while we are hoping to have an increased investment in prevention and early intervention in upstream services, especially given the impacts of, closing of hospital beds and other and acuity within the community, this will be essential. [Chair Alyssa Black ]: I have not seen the budget yet. Is this in the governor's recommend? We have not seen it yet either. Thank you. Connor just said it's stuck. Yeah, you said summer. Yeah. Casey. One, I just want [Leslie Goldman ]: to commend you for, taking an incredibly underfunded and overworked system that's so critical to everyone in this state. And, really, bravely, Christy and Clara Martin jumping in and taking initiative with the CCBHC model. I just wanna make sure everybody understands that that model is federal model. It was born out of the FQHC model, which, you know, they analyzed all the successes of the FQHC system and, said, how can we even do even better? And that's what the CCBHC model is. And funding for the CCBHCs, although it is federal, it has over the last, four years been increasing very steadily. And I know right now federal funding is, really wacky, but, the trajectory, even through the last administration, was pretty consistent. And I am just really thrilled that the whole system, it sounds like, has a really good understanding of the benefits of the model. What are the threats to our entire system adopting that model? [Simone Rishmeier ]: I think well, I think some of them are unknown. Right? We don't know what we don't know about the about the new model. I worry about the cost. It is increase in services and moving to cost based reimbursement. So what does that really look like and how do we fund that? I do think there are, some of the outcomes and the data requirements are more medical than we, I think, typically would support, wrap our wrap our arms around. And so I think that shift will be a harder one. There there is actually, in some ways, more data collection necessary. We are looking at how we can find some efficiencies across the network, in in doing the data collection and the data analytics around that. [Melanie Gidney ]: I leave it to I think my concern is just the current state of the federal funding and the investment going forward. [Chair Alyssa Black ]: Mhmm. [Speaker 11 ]: You [Melanie Gidney ]: know, up until the change administration, I think all TVs were the federal government was this was the route to go. Our experience clinically is it's the and from a community perspective, is it's the route to go? I think the concern now is feels like is the carpet gonna be pulled out from and under us, just in terms of the federal funding and investment to continue it and at what level. I also get concerned about the DEIB. You know, that's been a big component of CCBHC to date and just where our environment is related to that. And, you know, it's part of our core strategic mission, to support marginalized populations in all of our communities. So I worry about that angle as well and what the impact that I hear may have in terms of our ability, to accept things, and we'll figure it out. But that's my as of today. Yeah. [Chair Alyssa Black ]: Yeah. And I sorry. Did you have a question? I'm sorry. Leslie, did you have a question? I do. I just need help understanding the very looking for support your very last time, where you say six point two percent Medicaid rate, but it's a five point two percent increase overall. What's that difference? [Speaker 7 ]: So our overall, our expenses are gonna be increasing by five point two percent. But as we pointed out on our other slide, Medicaid does not fund all our entire program. So in order for to generate enough revenue to have, like, a five point two percent increase, we would need a six point two percent increase on Medicare rates. [Chair Alyssa Black ]: Okay. So that five point two is your increased expenses overall. Yes. Got it. Yep. [Simone Rishmeier ]: You know, and that is a concern for, CCBHC too. The areas of the state that have, more private insurers and or help client, right, coming into your agency, that's we worry about how financially viable the CCBHC will be with that. And that's a deeper, longer conversation, but it is a concern because it is it's Medicaid funded. And so we do really need to be working more with our, private insurers, Blue Cross and others, to, get them to invest in the CCBHC model as well. [Chair Alyssa Black ]: And I know. I think in the interest of time, I think we're gonna end. But thank you so much for coming in. And there is, I know, so much information. Luckily, we could spend hours and hours on this. [Speaker 9 ]: Thank you [Simone Rishmeier ]: for having us. And and reach out if any questions I mean, Amy's here too, obviously, a lot. And but anytime you want us back to provide more information, that's [Chair Alyssa Black ]: I think we're gonna take a fifteen or a ten minute break. Ten minutes. So let's be back here at ten forty five.

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