 It is 8.30 and everybody is here. We've done our sound checks. So I'm gonna kick us off. So good morning to everybody who's listening. My name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain Care Board. Today's day five of our hospital budget review process. So we're gonna be hearing from North Country and Gifford today. Just as a reminder to arrive at decisions for every hospital, we look to our statute, we look to our hospital budget rule for guiding principles. We have to balance several competing factors. On the one hand, we need to work to slow the growth and healthcare expenditures. On the other hand, we need to ensure that our hospitals have the resources that they need to recruit and retain healthcare workers and to provide the care that we expect in our communities, high quality care. So as we attempt to balance that cost containment, access quality and health system sustainability, we have to be mindful of this year's significant headwinds. We have historically high inflation rates. We have workforce shortages. We have provider burnout and we're still facing the impacts of COVID-19 at all of our institutions. We've been hearing a lot about that through all the budget hearings that we've had so far. So both nationally and in Vermont, we know that hospitals are facing unprecedented financial challenges as our businesses, families and individuals. So over the next few weeks, the board is gonna be working to approve fiscal year 23 hospital budgets for the 14 community hospitals that we regulate. But I just wanna remind everybody who is online today that the board is working very closely with the agency of human services to begin the work that's outlined in Act 167, which really aims to move us closer to a sustainable hospital system that ensures that remoders have access to high quality, affordable care. That work is gonna involve extensive data analysis and community hospital engagement. But the hope is that the end result is a more sustainable path forward. So as we turn back to the hearing today, I just wanna extend a thank you to both North Country team and the Gifford team for the time and effort that they've taken to submit the documents for our review. We know it takes a lot of time and we appreciate the effort there to help us understand your budgets. There's a few housekeeping notes about the hearings today. This presentation is a public meeting. It's being recorded and transcribed. So there will be a publicly available record. If at any time a hospital's leadership team believes there's some confidential information that the Green Mountain Care Board should consider, either as part of your presentation or in response to board or staff questions, just let us know, because if needed, we can go into an executive session and review confidential information from hospitals. Executive sessions will be limited in scope as defined by the open meeting law and limited to information such as contracts and information that will be considered confidential under the Public Records Act. So if an issue of possible confidentiality arises, I will call on our legal counsel to determine the scope of what could be discussed in that executive session. And then if it's deemed appropriate and at the appropriate time, I'll just ask a board member for a motion to go into executive session. All right, well, then it looks like everybody is here and everybody's audio works and our court reporter is transcribing. So good afternoon, Gifford. Welcome to our day five afternoon of hospital budget hearings. Before we begin, and I'm gonna turn it over to you in a quick second, I'm gonna ask Russ McCracken to just swear in anyone planning on speaking at all today, either presenting or answering questions. Russ, you could do that for us. Great, yeah, thanks, Chair Holmes. For the Gifford team, anybody who is planning on speaking or presenting today, if you could raise your right hand and I will swear you in. I do solemnly swear that the evidence you shall give relative to the cause now under consideration shall be the whole truth and nothing but the truth. So help you God. I do. I do. Thank you. Great, thank you, you're sworn in. I'll turn it back to you, Chair Holmes. Wonderful, thank you so much. And it looks like you have your presentation, we can see it. So feel free, Dan, to take it away. All right, well, thank you very much and a good afternoon to everybody. Thank you for the opportunity today to discuss Gifford Medical Center and our fiscal year 2023 budget. I'm Dan Bennett, I'm the CEO at Gifford and I'm joined today in presentation roles by our Chief Financial Officer, Jim Bertrand and also by our Vice Chair of our Board of Trustees, Vic Roboto, Rebecca O'Berry, Giffords, Vice President of Operations and Joe Markowski, our Vice President of Nursing. We're also here and maybe helping us out as we get into the question portion of the hearing. So I wanna start today in talking about the current state of healthcare as it relates to Gifford. Next slide, thank you. Like all of Vermont's hospitals, a Gifford Medical Center faces a difficult reality. And first and foremost, we're experiencing widespread workforce challenges. During fiscal year 2022, we significantly increased our reliance on traveling staff due to numerous vacancies in nursing, radiology and lab positions. We also experienced difficulty in other non-clinical positions, including environmental services, nutrition services, accounting and other business functions. And it wasn't possible and it's not possible to obtain temporary staffing in many of these non-clinical areas. So in those areas, unlike the clinical areas where we have travelers, we're forced to spread the work amongst fewer people. During this past fiscal year in 2022, we've taken numerous steps in response to these workforce challenges. We've enacted an organization-wide market-based compensation analysis. The result of that were wage increases for staff at Gifford that totaled over a million dollars. We also established a $15 an hour minimum wage for different employees. And both of these moves were reflective of the wage inflation that we've seen in the economy. We've also continued with numerous activities that emphasize Gifford's positive organizational culture. Some of these include having Gifford's behavioral health team providing in-house support for employees. And this is in addition to our regular employee assistance program. For many years, Gifford has offered a childcare program and in recent years, specifically for children of our employees, this is something that we continue to do. It's a tremendous benefit to our employees and one that does require a subsidy from Gifford. I said for many years, I just on a personal note, my son's in his mid-20s and he went to that many, many years ago. So it's definitely something that's ingrained in the Gifford culture. One of the things we've learned in the pandemic is the value of remote work where that's applicable and we have in a number of areas expanded remote work activities for our staff. We also this year reinstated a temporary wellness time off benefit that we first initiated as part of our employee pandemic support response in 2021. And we did it again this year. We also created some additional employee recognition programs this year. And we continue to invest in training programs both in-house here at Gifford and also with our area educational partners such as Vermont Technical College, Norwich University, Randolph Technical Career Center and Stafford Technical Center. From these efforts and others, we have seen some success in retaining and recruiting staff, including in our support services areas and also with new graduate hires in nursing. And our expectation is that we will be able to reduce some of our traveler usage in fiscal year 2023, but I wanna be clear that this does remain a significant risk. As you've heard from other hospitals and in your hearings the last couple of weeks, Gifford also experiences barriers to providing access at the appropriate level of care. We continue to see extended wait times for patients in our emergency department seeking mental health treatment. But I do wanna pause for a minute here and say thanks to Vermont's Agency of Human Services who has begun providing some Medicaid funding while we have patients who are waiting placement for mental health treatment. So I wanna thank them for doing that. But the conclusion here in current state is that after two and a half years of a global pandemic and at a time when we are seeing troubling increases in verbal and physical violence against healthcare workers coupled with high rates of inflation, lack of housing and childcare services, among other issues our healthcare workers are stressed and they're stretched. Next slide please. So you've already heard a few of the concerns and risks gotten in the previous slide. All of these issues, all these risks impact the sustainability of our healthcare system here in Vermont. At Gifford, something that is both a risk and an opportunity is our electronic health record implementation project. And we anticipate that we'll be able to go live with our new electronic health record system in July of 2023. We expect to derive tremendous benefit from this project including significant upgrade in our capacity to support our population health activities, efficiency gains by different system users. Those users now will be able to access patient information from one system as opposed to multiple and also increased access to clinical, operational and financial analytical tools. However, we are taking this project on at a time when our system is strained and our resources are reduced. And I won't repeat the workforce challenges that I noted in the previous section but that obviously is a huge risk not only to this project but in general. It's also taking longer than usual to recruit providers as it is with other staff members. This is also a situation that's worsened by the lack of available housing for people who want to move to our area in Vermont in general. Gifford has also deferred investments in our physical plan and it's imperative that we maintain an operating margin that's sufficient for us to be able to address not only our facility but also our equipment and our technology needs. And like everybody else, we've also felt the impacts of inflation and supply chain disruptions. Next slide please. Gifford is focused on advancing our population health strategies. We embrace the philosophy that our mission includes providing care when people need it and engaging our community members to improve overall population health which will reduce the need for more costly healthcare interventions over time. Our status as a federally qualified health center and a critical access hospital provides a unique opportunity for us to accomplish our population health strategies. To that end, we've invested resources in psychiatry and counseling services, community-wide dental programs and support for transportation and food security programs. Our chronic disease management programs include our diabetes clinic that is making a significant difference in people's lives through individualized programs and coordination with multiple providers. Gifford has championed food security initiatives in our communities. In addition to participating with the Vermont Food Bank along with other hospitals in the Veggie Van Gogh program, we also provide food drops in harder-to-reach towns throughout our service area. By partnering with individuals and organizations in these towns, we ensure that people who lack transportation or are homebound also have access to healthy food. As I noted earlier, our planned investment in a new integrated electronic health record system will advance our population health capabilities significantly. Next, I'm going to turn the mic over to Gifford Medical Center Board of Trustees, Vice Chair, Vic Roboto, and he's going to discuss our strategic planning process and our governing practices. Next slide, please, and then over to you, Vic. Thank you, Dan, and good afternoon, everyone. I'm Vic Roboto, and I'm happy to participate here in the hearing today, give a perspective from the Gifford Board. First of all, I just wanted to note that we take strategic planning seriously, that we know that the environment is constantly changing and that we need to adapt to remain effective. Every three years, we set aside time to take stock of the issues impacting the people we serve and how well Gifford is positioned to meet these challenges. The board, medical staff, and management work together to establish priority goals to become accomplished over the forthcoming three-year plan period. We undertook that process in 2021 for the present 2022 to 24 plan period. So this slide describes the priorities, kind of boiled it down to one page, a lot of work to one page that resulted from the process. And we've titled them as people in culture, population health, infrastructure, and governance. Under each title, you see our primary goal and key objectives. What you don't see is a list of, I don't know, 50 or 60 tasks and projects that are tracked and progress is reported to the board on a quarterly basis. So under, I just want to talk a little bit about each of these four priority areas. People in culture, it's about investing in our workforce. They are at the heart of what we do and we can do nothing without them. So we're focused on recruitment, retention, training and development and developing staff to grow with us. In population health, we recognize that our mission is not only to treat illness and injury but to help people improve their health status and avoid acute illness. That takes engaging with the community and moving our processes and systems more directly in line with that approach. Infrastructure, we're installing the analytical capabilities to better support operational and clinical decision-making as well as creating master facility and technology plans. And then governance. These are indeed challenging times and the board is focused on Giffords financial stability. Therefore, good governance has to be a priority. To be sure, we are focused on the, to be sure that we are focused on the right issues that we hold management accountable, that we represent the community's best interests, that we formally evaluate our own performance as a board each year and always seek to do better. And we view these four priorities as mutually supportive of each other. Next slide, please. So here's some tangible examples of what we mean by exhibiting good governance. We do provide oversight via several standing committees such as finance, quality, personnel and compensation. They meet regularly. We engage with management and meaningful conversations and we get our questions answered. We review strategic plan progress, as I mentioned before at the board meetings. We know that the healthcare system in Vermont is in trouble. Gifford will continue to work with our state governmental agencies and other providers to seek solutions that address the needs of our communities. Then finally, we are committed to providing access to important clinical services and to making sure that Giffords is sustainable and will be there over the long term. That is what our communities expect of their board and their institution. Next slide, please. We get feedback from our community in a variety of ways. This includes the community health needs assessment, patient satisfaction surveys, community representation on the board and just conversations on the sidewalk with friends and neighbors. But a survey only gives you so much and we are going out to hear the voice of the community in a more structured way, not just assume we know what they think. So this year, we had what we call the listening tour to our means of getting community feedback. This is something we had planned to do several years ago but we're delayed by the pandemic. We arranged the structured meetings open to the public in Rochester where I live, Bethel, Randolph and Chelsea. Board management and medical staff leaders visited with community members to hear their concerns directly and their ideas about healthcare and wellbeing in the community. It was very informative and a wonderful experience, quite honestly. The general themes we heard include issues around access to various types of care, things that are listed here, transportation, medication affordability, food insecurity. In some cases, Gifford can address these issues directly. I can addiction medicine services provide. And in other situations, we work with partner organizations like the Food Bank to produce the monthly free food distribution as Dan mentioned earlier. So we're very pleased with the way these community conversations have been going and look forward to continuing them. And I'll turn it back over to Dan. Thank you, Beck. Gifford has a unique organizational structure and I thought it'd be worthwhile spend a couple of minutes reviewing that with you today. We're one of only two organizations in the country where a federally qualified health center or a FQHC is the parent organization for a hospital. In our case, there's a second subsidiary corporation as well, Gifford Retirement Community. And they're represented on this chart that's on the screen. FQHCs are regulated on the federal level by HRSA. At our board meetings, we find people a dollar if they don't spell out the acronyms, but I'm gonna assume that you know what HRSA is, but I can spell it out a few more. And like with other hospitals, like with hospitals, the regulatory environment for FQHCs can be complicated. One key regulatory principle for FQHCs, and I wanna note that I'm greatly simplifying this for brevity, but one key regulatory principle is that FQHCs cannot be owned or controlled by another organization, such as a hospital. And our structure reflects that requirement. Gifford Medical Center is the largest component of our organization in terms of revenue, expense, and the number of employees, and the budget and other financial information that we present to the board is solely for the hospital Gifford Medical Center. In terms of our financial reporting structure, we have several divisions under Gifford Medical Center, including obviously the hospital departments with all the clinical and direct support departments in there. Our childcare center, which is called the Robbins Nest, and our administrative and support services that serve the entirety of Gifford's programs. These Gifford shared services are allocated out to our three corporations utilizing appropriate accounting practices. Next slide, please. Next, I wanna show you some examples of what resides in the hospital and then what resides within the FQHC. At the hospital, that includes all of our inpatient, medical, surgical care, as you know, we're a 25-bed critical access hospital. Our surgical and specialty care practices are located within the hospital structure. And you'll see some examples of those specialties here under the second bullet in green, these services that fall within Gifford Medical Center. All of our ancillary services fall within the hospital, including our laboratory and our radiology services, among others. The hospital contains our 24-7 emergency department, our operating room, our surgical services, and our renowned birthing center. It also includes our rehab services, physical therapy, occupational therapy speech. They also fall within the hospital structure. Next slide, please. So on the screen now are the services that are contained within our federally qualified health center, Gifford HealthCare. It contains all of our primary care services and those are located across six sites. That includes our family internal medicine practices, pediatrics, behavioral health. It does include our OBGYN and midwifery practice. As I noted, the birthing center itself is within the hospital. But the practice and the providers who practice there are included under the federally qualified health center. That is something that's probably quite different from what you see usually on the board. It also, as Vic noted, we have a number of other programs, our addiction medicine program. We contract out with another nonprofit to provide mobile dental care in the area and nutritional counseling and other services are also fall within the FQHC. So I hope this was helpful to give you a little bit more information on what's in the hospital, what's in the FQHC. I know it does get a little bit convoluted with us because we are a little bit different. We kind of like being different, but it is good to explain that sometimes for people. And so with that, I'm gonna turn it back over to Jen Bertrand. She's gonna take you through the next several slides. Jen, next slide, please. Thank you, Dan. Good afternoon, everyone. My name's Jen Bertrand. I'm the chief financial officer here at Gifford. And I just wanted to take a moment to thank the board. We do recognize that this is not an easy budget cycle for any of us. And it's good to see you, it's been a while. I also wanna take a moment to really think and acknowledge Sarah and the staff. We know that there is a considerable amount of work that goes into this process and it is not unnoticed. And we really appreciate the partnership with Sarah and the team. And with that, we'll dive into the financial portion of our presentation. So normally we don't lead the financial section of our presentation with our margin discussion. However, in recognition that it does stand out and also dovetails quite nicely off of Dan's last few slides, I did figure we should start here. And noticeably our margin does appear quite favorable. However, as Dan mentioned, our corporate and divisional structure is truly a factor when evaluating our margin. We've really extended the services under the Gifford healthcare umbrella beyond what a basic footprint would be for a small healthcare organization. So as an example, not many critical access hospitals have an onsite daycare for its employees and that is subsidized. But it is really critical for us in terms of recruitment and retention efforts in our area, especially when childcare resources here are very scarce. Also, most FQHCs, as Dan mentioned, do not incorporate the professional side of obstetrics and gynecology into its footprint, even though it is allowed under an FQHC structure. So I just wanna be clear there, it's not a normal footprint that you would see. And it is one that does tend to require a subsidy, especially in the case of our current situation where we are shouldering a larger subsidy, honestly, as we've experienced some considerable provider vacancies for this particular service line. And normally those locum expenses would be recognized in the hospital because of our structure, they are being incurred by the FQHC instead. So in turn, that would have had an impact on our margin and bringing that margin to a more reduced standpoint. Our nursing home, of course, is an extension of our hospital. And if you've heard other hospitals mention, we certainly have a systemic issue with the availability of skilled nursing beds. Our nursing home actually consistently runs at a 98% capacity on average. But again, this service does operate at a significant subsidy as well. But all of these much needed services are truly essential to our community. But again, they do rely on that subsidization from our anchor, which is the hospital. So as a result, the hospital's margin is diminished after we account for the support that we do provide for those services. And just to touch on one other thing as we're on this slide, as Dan mentioned in FY23, we will be implementing a new EMR. This did require us to scale back investments in capital. This is gonna have a considerable impact as with any implementation on cash flow. So we need to be responsible. So our budgeted margin and day's cash position is going to allow us to really reserve for that future impact of the EMR implementation. And inherently with any EMR implementation, there is a delay in receipts that's gonna require us to dip in what I call dipping into our savings, so to speak, in order to float that difference in the cash flow. So it is gonna be a bit significant. We're probably looking at the duration of about six months for Gifford for the longer lasting impacts of that implementation and delayed receipts. Next slide, please. As it pertains to net revenue and our fixed perspective payments, our budget is yielding a 7% increase when it's compared to the FY22 budget. And a portion of that net revenue increase is attributed to some volume increases that we've been seeing in various outpatient service lines, but also one item I wanna mention that certainly having an impact on our net revenue is related to one of the accounting changes that's involving our contractual allowances and the reclassification of those adjustments which is contributing to the increase in NPR. And I'll talk about that a bit further in the next few slides, but I just wanted to acknowledge that is creating a swing. We've also incorporated an estimate, excuse me, for our Medicare Cost Report Settlement and that is taking into account the increases in budgeted expenses as well as the budgeted cost report settlement factors that we're going to see inherent to another accounting change with the creation of a management contract methodology and I'll touch on that in a couple slides as well. I do wanna mention that we feel Gifford is in compliance with GMCB's budget guidelines. It does fall below the two year cap of the 8.6%. So I did wanna mention that and then also just mentioned from a fixed perspective payment standpoint, RFY 23 budget does include our participation in Medicaid and MVP as we continue that participation. We have been participating in those two payers here for quite some time. So we are gonna continue that participation. And if you could go to the next slide, I'll talk about the future state of where we might go with this. So obviously we're gonna consider future participation in Medicare as well as the Blue Cross program and any commercial, other commercial programs after we've been able to implement and stabilize the new EMR. And as Dan said, again, that's slated for July of 23. So some of the things that we've been doing in terms of our investments in healthcare reform, we have listed here on the slide, but it is important to note that those investments that we do have listed in the narrative as well as what you see in front of you right here on the slide, they're actually included in our FQHC's budget. But certainly to be transparent, the investments that we made recently under the FQHC do primarily fall into these three areas. So behavioral health care coordination and diabetes management. And frankly, those investments have largely involved the hiring of additional staff to support the ongoing work in those three particular areas. So I did wanna mention that about what our investments are in healthcare reform. Next slide, please. So I'm gonna spend a little time on our commercial rate increase. Our budget does incorporate a 3.65% rate increase at the aggregate level. We applied a 3% increase to our inpatient charges, a 3.28% increase to our outpatient charges and a 15% increase for our professional charges. And the marginal rate increase that we are proposing is really going to cover the commercial portion of inflation and some of the cost shift factors. And we've really tried to outline the methodology of how we arrived at the rate increase in this bottom section that you see here in the slide. I'll walk you through that. So on the left hand side, we have a calculated inflationary impact of 931,000 that we've incorporated into the budget. That's then translated to a calculation of the commercial components that constitute the rate we've incorporated. So then on the right hand side there, we first apply the commercial mix of unique patients, which in our case, you can see at that top section is 34%. That comprises 316,000 of the 679,000 that we're requesting. We then layer on the historical impact of our annual payer policy changes, which for Gefford has historically been about $70,000 annually. We do calculate a cost shift factor for Medicare. Now keep in mind, the only applicable cost shift impact is related to the clinical, not the administrative, but the clinical portion of provider salaries, fringe, as well as benefits. The rest is mostly, and I'm gonna say that on purpose, mostly covered under our cost-based reimbursement methodology. And then lastly, the calculation and the applicable Medicaid cost shift amount, that is again based on our Medicaid mix. And so all of those components comprise the $679,000 that we're proposing for our modest rate increase. And you're gonna hear me say this again, and I'll talk a little bit further about this in our expenses that we have not passed along the wage inflation that we did incur in FY22. We recognize that the 3.65% does stand out, but we were really trying to ensure we minimize the impact on our community and maintain a level of affordability for our patients that we do serve here in RHSA. Next slide, please. So I'm gonna spend a little time because for this year's accounting changes, we have quite a few, we have four to be exact. The first accounting change that we have listed here on the slide is really pertaining to our professional anesthesia services. We did transition this to a purchase service model. So essentially this is going to reduce our net revenue for those professional services on the NPR line, but essentially increase the expenses pertaining to the contracted professional services. The second accounting change that we have listed is really related to what you've heard me mention before, our adoption of a management contract methodology. And we did this at the beginning of FY22. And we really like the use of management contracts is really a way of discreetly identifying all the administrative and overhead expenses that are allocated to all of the divisions under the corporate umbrella. And Dan alluded to that earlier when we refer to that as Gifford shared services. Historically though, those expenses have actually been embedded in the individual expense lines and that includes salaries when you look at the face of the hospital's financial statements. So the reduction in the overall expenses is really primarily related to that particular adjustment and now we're doing that appropriate allocation and recognition of those expenses between the divisions. And it's also a component of that reduction leads me into the next point of one of our accounting changes which applies to our daycare operations. Historically the expenses and other revenue associated with this particular division have been included in the reporting of the hospital's budget. But as Dan mentioned, we made the decision to break this out as its own division. So that did result in us removing all of the associated expenses as well as the other revenues for that particular service line from the hospital's reporting. So this did increase the margin when you compare that to prior years. But again, it is important to mention that it is a subsidized program and it does support our recruitment and retention efforts. We did just make the decision to break that out as its own division. And then lastly, at the end of FY 2021, we did conduct a very thorough assessment of our current revenue cycle processes so that we could identify areas of improvement. And one of those specific areas was the classification of our contractual adjustments between payers. We had several factors that were contributing to our need to make this correction. And I'll give you a few examples. One is, we have payer classes that were not designated to the correct patient location. We did have some adjustments that were not classified based on how payers reimburse. We did not have distinct breakouts for workers' clump or Medicare Advantage. Those did not exist in our system, they do now. And then our general ledger structure, it didn't support the needed distinction by payer and patient location. And then another example is we had a lot of, actually all of our adjustment codes, they were hitting one corporation instead of being designated to the appropriate corporation. So therefore we did find it crucial to make these necessary changes to correct the contractual structure. Next slide, please, Penny. Just to touch on other operating and non-operating revenue, I wanna take a moment and talk about 340B. So obviously as some hospitals are mentioning, 340B funding does continue to be an area of concern and risk. Now, I wanna point out that the majority of our 340B funding is actually recognized under the FQHC. So therefore on the face of the financial statements, the hospital's funding does look very minimal because the majority of it is in the FQHC. But I did wanna say that originally the FQHC was actually exempted when all the manufacturers were actually going through their process and not granting that 340B funding. However, in the last several, well, it's been almost a year now, the FQHC is now being negatively impacted by that as well. So we are actively trying to explore some of the available alternative solutions to the reduction we're gonna work with and we've already reached out and have been working with, I should say, our third party administrator as well as some of our FQHC partners so that we could try to find a solution for that funding. Another item to mention when it comes to other operating revenue, the budget does assume a decrease when you compare that to the prior year's budget. And again, that is related to the daycare revenue. Daycare revenue is recognized in other revenue. So I did just wanna mention that. And then lastly, our budgeted 2023 non-operating revenue, I'll admit that is an identified risk. Market returns, as we know, they're unpredictable. We did assume a gain for the budget. So obviously our total margin would be negatively impacted if we weren't able to recognize those gains. So I did want to acknowledge that. Next slide, please. So candidly, we've got a bit of minutiae occurring with our expenses as we've implemented some best practices in accounting. And overall, our expenses are decreasing when you compare them to the 22 budget as well as our 22 projection. The two primary contributing factors were the ones I've already mentioned. It's the change in the management contracts as well as the daycare expenses. But also in reducing costs, we've really focused on cost saving initiatives in our organization. And we've really tried to challenge ourselves. We know this becomes more and more difficult, but we're really trying to challenge ourselves and our staff to find offsetting savings, especially in consideration of the fact that we're going to incur the expense of operating two EMR solutions in this next fiscal year. So we needed to be very cognizant of our expense growth in this year's budget. Some of those cost saving initiatives that we have incorporated are continuing to improve on our staffing control process. That way we're limiting FTE growth within our organization. We're also going to be integrating staff benchmarking into our process that same process. We've certainly continued our efforts when it comes to our agreements with service contracts and purchase service agreements. We're constantly trying to reduce costs there. We were able to achieve some savings with some recent changes that we've done to our contracted arrangement for professional anesthesia services. So when we first entered into this contract, the provider compliment was 100% MD and in partnership with our vendor, we were able to shift a good portion of those positions through attrition to CRNAs, which do come at a much lower expense. And the other piece of that with our contracted negotiation with our regional third party for this particular service, we've been able to mitigate the utilization of locals to cover any planned or unplanned time off, which we weren't able to do in the past. So that's another area. We're certainly challenging ourselves in trying to find cost saving initiatives. We engage our teams and our staff and really try to encourage them to be part of the process where they feel that they have ownership. They're able to accept ownership of this and be part of the process and really be financial stewards within the organization. And I did wanna touch on some of the other challenges though, because we realize that our budget is reflecting a decrease in expense because of all the things that I was just mentioning, but we're certainly feeling the same impacts as other hospitals when it comes to the unprecedented workforce challenges. And like most, both in our state as well as nationally, our recruitment and retention efforts are being challenged constantly by the inflationary pressures, wage compression, workforce availability, it's constant. And it really does continue to impact that balance that we try to strike between financial liability and adequately supporting the needs of our workforce. As Dan mentioned, we're really feeling the impacts of staffing vacancies. And again, not only in clinical areas, but in support areas. And as Dan mentioned, we just don't have the temporary labor options to fill those positions and they're critical, especially in environmental services in our dietary positions. You know, it is systemic. We're feeling this throughout the organization. We've got vacancies in billing, coding, patient access. I'll be honest with you, I sat into other hearings and it was interesting to hear another hospital have the same issue that we do in accounting. We've had a vacancy in our department for nearly a year at this point. So it is systemic. It's not just in one particular area. And then of course, the increases in labor expense in order for us to keep pace with the market right now, they're just significant. And as Dan mentioned, for the hospital alone, we did invest over a million dollars in FY22 toward permanent market adjustments that we did for our staff and that wasn't budgeted. We did increase our minimum wage here to $15 an hour. Again, that was not budgeted. And we really tried to be responsible and we absorbed those unbudgeted wage increases and we did not carry them forward into our 23 wage inflation that we did use to substantiate our rate proposal. We did absorb that. But like everyone, we're continuing to fill the pressure. We're getting competition from retailers, the restaurant industry, and they just continue to keep ratcheting up that $15 floor and it's crazy because we're competing for the same workforce. And I don't really like to use this term that much, but it really is true. We're really battling wage war and we're not just doing it with each other. We're doing this with other industries and it's really impactful. And I do just wanna mention that we acknowledge that we do have some risks in our budget. And especially when it comes to the potential for another COVID surge, we did not incorporate any COVID related impacts into our budget. There's also risk in budgeting a minimal amount for travelers which is what we did for 23. Obviously it's with the hope that we can counteract that reliance that we needed in fiscal year 22 with the recent increases in our wages. That's our hope. And lastly, with the modest wage increase that we did build into the budget, there does continue to be a significant risk with the market pressure for wages. And I did just wanna acknowledge that. Next slide, please. So you heard me mention this earlier, but as a result of our EMR implementation and our consolidated operating margin performance, we've really limited our capital spending to approximately 100% of depreciation which is really resulting in a target spend of about 3.9 million for our capital budget in fiscal year 23. And obviously I wanna acknowledge and we recognize that that's not a long-term solution, especially with our age of plant which is exceeding 16 years. Frankly, we recognize that we've been caught in this perpetual deferral cycle so to speak because since the onset of COVID we've really deferred about it's north of $6 million in capital investments. So that is certainly not a sustainable model, but our goal post implementation and stabilization of our EMR is really to achieve a reinvestment of about 120 to 140% of depreciation. Next slide, please. The board had requested as part of our presentation process to just speak to the supplemental data monitoring. So I just wanna briefly touch on the three areas of focus and refer anyone to our submitted response for any further thoughts and details. But as it pertains to the market share report we did feel that when it came to evaluating net revenue it does omit certain components that we did list in our response but overall we did not feel that there were any material fluctuations in net revenue when we were evaluating that report. And then with regard to the reimbursement analysis admittedly we felt a little bit hampered by not having some of that detailed supporting information for the summary data so that we could further understand the analysis with regard to that particular report. And lastly, as it relates to the demographic report we do incorporate the demographic and population characteristics of RHSA into our budget process more so independently of the report but inherently we do incorporate those factors into our budget process. And before I hand it back to Dan I did just wanna say that we feel that budget we're proposing is thoughtful it's responsible and it does remain in compliance with the guidelines that the board has set forth and with that I will hand it back to Dan. All right, thank you, Jen. Sorry, I've got to reshuffle my screen here. So I'm gonna speak to our health equity efforts here at Gifford. One of the things that I find very redeeming about working in Vermont's healthcare sector is the way that people are willing to work together to solve problems. Think we all thought that was evident throughout the pandemic. And it's also true with all the efforts that people are making around to advance health equity in the state. Gifford's a small nonprofit healthcare organization that has far more priorities than resources available to accomplish the priorities. So we need to rely on our partners as they rely on us to both share information and resources. And many other, several other organizations around the state have offered assistance with health equity efforts including UVM Health Network, Vermont Association Hospitals and Health Centers, Health Systems, I should know that. And by state primary care association and we have been able to utilize some of those resources and benefit from them. We do have an internal diversity equity inclusion group at Gifford and that includes members from across our organization, providers, staff members, our leadership and human resource teams. Admittedly our process has been methodical and at times our progress has been impacted by our internal staffing resources. Our team has selected a number of initial priority areas for focus and have begun working on them. These include steps to ensure that our environment and our surroundings will be inclusive and welcome to all. Our team is developing organization-wide training on DEI that this will include individualized trainings to particular departments, but we'll also utilize our organizational employee education platform to ensure that we do have standardized training that all employees will receive. Our program is still in the early phases and we are working to create a process within our organization that we can then adapt moving forward as needs arise throughout our organization. Next slide, please. So the board did ask us as well to provide some data on wait times and visit lag and we have provided that. Some general comments. Obviously our goal is always to provide care at the time and the place of service that is needed by the patients. Many factors do include, do influence wait time. These include the availability of providers and other staff, patient choice and preference. One thing that we try to do at Gifford is if in particular for instance with primary care, if somebody calls for an acute visit and they call a particular practice or looking for a particular provider, if we're not able to get them in and the timeframe they're looking for, we will offer them another location and or another provider where they can receive that service. But sometimes they choose to wait. Sometimes they choose to go to a different, to an urgent care or another setting as well. But that does impact wait times. Our imaging numbers are impacted as well by the purpose for which a test is ordered. For instance, if a test is ordered to support a new patient appointment, so a person is going to a new provider and needs an imaging test for that appointment, they'll usually get that test just before their first appointment. So if their appointment with the provider has a wait to it, then their imaging test will also. I'd wanna point out that there is no wait for acute imaging needs for services included in this reporting. If somebody is coming to our emergency department or if a practice calls and says somebody needs to get in urgently, emergently, we get them in and they get done and there is no wait for that. Next slide, please. So it feels a little bit disconcerting two and a half years and still be talking about the impacts of COVID, but it is still relevant. We did include that in our narrative, you see it here on the slide. And they speak to some of the impacts as well as some of the things that we've learned over the last two and a half years. But the impact COVID really is long reaching in how it's affected our workforce. And it's really difficult to express. The stresses our staff have been under and I'm not just speaking to Gifford, obviously this is the situation everywhere. So not only the stresses they've been under, but also the sacrifices they've made. Ultimately, our budget presentation is focused on what we need to do in order to care for our communities, both in the traditional sense and also in the terms of the work that's required to fully implement a healthcare system based on population health improvement, but none of that is possible without a well-supported workforce. And as I noted earlier, our healthcare workers are struggling and this is a very difficult time for them. Next slide, please. So closing remarks, again, our purpose today was to provide you with a greater context to the many activities that our fiscal year 2023 budget supports while highlighting many ways that Gifford supports its communities and also is guided by our communities and all that we do. As Jen noted, our budget meets the guidelines set by the board and we ask your support in approving. We have included an appendix and that includes our income statement, our balance sheet and our cash flow statements. And we haven't, we're not gonna go over in detail on those, but obviously we can answer any questions you have about them. But I wanna thank you again for your time and your efforts in this process and repeat something Jen said, it is nice to see you all again. We took full advantage of the opportunity you provided last year for hospitals that fully met your guidance to not do a public hearing. That was not an indication of our not wanting to do it, but was something that we did take advantage of and it's nice to be back here in front of you and we'll turn it back over to you and for your questions. Well, thank you, Dan and team. It is nice to see you all back. Hopefully at some point we'll get in person again, but appreciate that both last year and this year that you submitted budgets that were within our guidelines. So I just wanna note that we really do acknowledge and see that and appreciate it. So at this point, actually I'm just gonna take, we're gonna take a 10 minute recess. We've been doing this just to give board members a chance to compile their thoughts and also people to stretch and take eye breaks. So we'll come back at 2.35 and we'll start in with some board questions. So I will see you all in about 10 minutes and thank you so much. I think we have everybody and the court reporter is always here whenever I ask. So I'm gonna see there's the laugh. The laugh of being here. Thank you, Lisa. Yes, I am here. Great, okay. Well, with that, thank you for the great presentation again, Gifford, very clear and thorough. I'm gonna kick it over to board member lunch. Thank you. It's good to see you both. I'm sorry, I'm glad you were not, you didn't have to come last year, but we always like to see your smiling faces and on the last. And thank you for submitting a very responsible budget. It's much appreciated. I had just a couple of small questions. I'll note that Jen, you anticipated a couple of my questions probably from having heard them earlier. So I don't need to ask them again and I appreciate that. So one follow-up on the EMR implementation. I know you spoke to making some assumptions when you were looking at your margin in terms of the revenue issues that come with EMR implementation. Did you also include assumptions on utilization specifically in your request? And could you just speak to that a little bit? Cause as I'm sure you know, often what we see is people are a little too optimistic in their assumptions before the EMR implementation resulting with a budget miss. So just wanted to get a little more detail about that. Absolutely. We honestly feel that the impact and keep in mind is only gonna be three months into our FY23 fiscal year, which will extend into FY24. But we really do feel that the impact will be budget neutral. And I say that because of the efficiencies that we're gonna gain by several things. One is we're gonna be adopting industry standard workflows with the EMR implementation. We're actually streamlining systems. Right now we have four EMRs that we're operating. We're gonna be streamlining three out of the four and as you can imagine because of our structure, the FQHC system isn't really talking to the hospital system well. So that's really gonna create an efficiency there. And then also this is a significant one. We're gonna be migrating away from manual processes and really shifting to a system driven process across the board. And so we really felt that that would create that budget neutrality for us versus what I've honestly experienced in my past going through a very large EMR implementation where you do anticipate some dips there in the utilization. Yes, yeah, absolutely. Okay, great, thank you. And in your narrative you had mentioned that you did not realize all of the full amount of your rate increase from commercial payers last year. And I wonder if it's possible for you to quantify that a little for us, if not now later in terms of what that impact was. Yes, I don't remember off of the top of my head robin what we had put forward last year, but we can certainly get that to you. That'd be great, thank you. In terms of the travelers, a lot of hospitals have been kind of giving us this information in terms of numbers and dollars per hour. So I'm wondering if it's possible for you to kind of translate your information into that kind of format just for comparison purposes so we can see how things are hitting apples to apples. Sure, so I'll speak to this and what we put in the budget versus what we might be seeing currently. So in the budget we did include the premium portion of that traveler pay for the equivalent of about three travelers and at the rate of about $140 an hour. Since then honestly, the rate has come down to be about more in line at $120 an hour. So there has been a little bit of a variance since we had done the projection to be honest with you, but that is really what we incorporated into the budget. Okay, and you said three travelers, how many do you have now? Oh, well, during the projection, we had 12 nursing travelers and two ancillary travelers. We now have, Dan, I believe it's 19 that we do currently have in house. We have quite a few though for those off the top of my head are an ancillary and the remainder in our nursing areas. And when I say ancillary, you heard this, it's radiology and lab. It's really where those are sitting. We really are hoping that we can buy that down with our wage increases and also, and Dan might wanna jump in. We've been really leveraging our relationships with some of the area educational institutions and we are going to be having some new grads starting, but Dan, I didn't know if you wanted to jump in on that at all. I actually will see if Joe wants to take a swing with that one since it's right in her wheelhouse. You're muted, so Joe, Joe. And I apologize, I can't remember. Was Jill Swarnand? She was. I was. Okay, great. Thank you, everyone. So we do, we have between 19 and I think soon to be 21 travelers, the majority of those in the nursing areas, MedSurg, OR, BC, ED, it's kind of across the whole board. We also have been very frugal in making sure that we are only utilizing travelers to get us to the point that we can continue to keep our beds open. We are not replacing travelers one-to-one with our vacancies. Our vacancies far exceed that. We are fairly lucky in that we have some really dedicated, committed folks and a lot of per diem staff that are really working full-time. In the MedSurg area, I have five per diem staff that are working full-time and without them that would be five more travelers. So, you know, we really are thankful. We started a new grad nurse residency program this year and we've had really great success with that so far. We had a couple more just on this call that I saw a couple more applications come through. So really excited that we can get them in and train them. And of course it's a matter of using our resources to train them and that sort of thing and stage it in because we can't take them all at once but working really hard to fill those vacancies, working really hard to give them capstone experiences here so they make a relationship with us, really working hard to stabilize our workforce because that's not sustainable for sure. Great. Thank you. Yeah, it's great. It's exciting to hear about the partnership with the educational institutions and growing your own because that does seem like it's been a very successful strategy around the state for hospitals. No, that's great. And I'm almost done. I just had a couple others which again can be followed up later in terms of, so when you're talking about your margin, you were talking about the different pressures because of the structure of your institution. I'm wondering if it's possible to quantify any of those pressures to just provide some more dollars sort of justification for the margin? If you don't mind, Robin, I can actually speak to it now. Great. Also, I'm fortunate enough to have a very adept Director of Revenue and Cycle Operations who told me that our 22 rate was $823,000 just so that we can put that to bed now, I guess. In terms of our margin, on the face of our financial statements, it appears that the hospital's margin is $6.7 million. And after we take into account the deficit for Robin's Nest, as well as the nursing home and the FQHC, it actually buys that margin down to $900,000 at a rate of 1.5%. Great. OK, that's my only question. I'm all set. Thank you, Jess. Thank you so much. And I just want to acknowledge that somebody has their hand raised using the hand raised function named guest. I don't know who you are, but I wanted to say that at this point in time, we're just doing board questions and we'll turn to the HCA after that. And then there's an opportunity for public comments. So just wanted to let whoever was waiting in the wings there know that. OK, with that, I'm going to turn it over to Tom Kellum. Well, this is going to be pretty quick. My first question was already answered precisely at $6.7 million down to $900,000. I do remember a couple of years ago when we were at the hospital, there was an issue with some of these retirement units. And they just weren't moving as fast as people had hoped. And my guess is with the real estate market now, they probably all moved pretty quickly. But if you could talk about that a little bit, because a couple of years ago, a year and a half ago, two years, that was a big deal. I mean, they were just doing what you said happens with margin when you have these other entities that look at the hospital's margin as their margin too. Yes, thank you. Really, in 2021, once people started to move about again, and as you noted, the real estate market got quite insane, we were able during 2021 to fill it. So we have 49 apartments. I believe it was in November of 2021. We filled it, and it remains full. And we have a program of a ready list, which is what it sounds like. People who are ready to move in. And I believe there's 14 people or 14 couples who are ready to move in once an apartment comes up. So once an apartment does come up, people are moving in right away. So the situation is completely different. Coming out of the pandemic, we were able to move quickly, and that is doing well. Well, that's very good news. I just remember it was a bit of a struggle back when, and now it's a blessing and a blessing. My next question is looking at the Medicaid numbers, budget to budget. I have two questions. It's a drop from $7.2 million to $4.3 million in NPR, budget to budget. And a lot of that was related to lower utilization and changes in accounting being the causes. So do you have any sense of the proportionality between changes in accounting and utilization? We do, Tom. So the change in accounting, if I remember off the top of my head, not looking at the appendix, right, was about $1.1 million shift, actually, from the Medicaid bucket into Medicare. And from a utilization standpoint, trying to think off the top of my head, I think is around $2.3 million if I recall on that particular lineup for the utilization shift. OK. And my last question is just if you could talk a little bit, and maybe this is for Jill, I don't know, but talk a little bit more about the anticipating the hiring of new grads in the next few months. So it sounds like the pipeline from the educational institutions into the hospital is getting developed or is developed. And I'm wondering, A, can you talk about that a little bit more? Because just to get a sense of whether you're ahead of other hospitals, every hospital is trying to pursue that. But secondly, I'm wondering if this is part of the state's workforce development program and that this effort is being done in collaboration with state entities. So it's a little bit of both. We've certainly been involved with the state workforce collaborative and looking at some formal partnerships with VTC where we would actually have, in fall of 23, have some of our staff here become actual clinical instructors. And then we would offset that with seats in the nursing programs. We haven't realized that yet. But we have really kind of marketed and gone out to many of the nursing schools. And I think Gifford offers something a little different than other places. I mean, entering health care as a graduate nurse in the middle of a pandemic when there is no resources, there's no support, there's no one who you can look to as a mentor, and that sort of thing is very scary. And there's a lot of folks that would want to come to a smaller hospital that has more resources and support and understands the workload and has those reassurances. So I do think that we have a little bit of an edge there. We have invested a ton of time with our nurse educator on our residency program and making sure that we're not just orienting them to the job, but onboarding them into the profession and continuing that through for the next full year with these folks and by doing some preceptor training as well so that we're really making sure that we're not just pairing them with nurses who know how to do the job, but nurses who know how to transition them from nursing school to practice, which is a huge leap. And it's really, we're kind of continuing to improve our process as we're doing that. We have also adopted another methodology for the way we're orienting them called T-SAM where we actually are maximizing their clinical experiences by having them partnered with a nurse and having full responsibility with the nurse for the whole assignment, but only to insert in tasks within that. And as they continue to develop that, they would gain more. It's an evidence-based practice model that I think is really, it reduces your orientation time by 18%. It increases their clinical exposures by 62%. And it's really been very positive in its feedback. So I'm not sure if every other facility is using that model, but we've started it. We have seven new grads that we're in the process of kind of moving through. And like I said, I'm getting more all the time, but I do think that they are looking to start their practice in an environment that's gonna support them and not eat them up. Cause- I hear your phone ringing. I mean, the reason I asked that is just kind of a thought in the back of my mind that travelers are in, to some extent, kind of a one-time event, unless the pandemic comes back or something, but it's been a huge investment at a short period of time that as normal processes begin to unfold, maybe mitigated just over the next couple of years, which happened to be budget years 2003 and 2004. I'm just trying to get a sense of what we're building in the base of hospitals that may just kind of fall by the wayside over the next couple of years. So that's why I asked that question. And with that, all I'll say is I've known Jen a little bit on the board and everywhere she goes, there's these incredible operating margins. And so she's got the special sauce and don't let her go, Dan, because when you're looking at six and seven and eight percent margins, and I know you've got other draws on that, but you're the best margin person there is in the hospital business. So thank you for that. And back to Jess. Great. I agree with everything you said, Tom. Could I just add one thing to your statement, Tom, that I think was very optimistic about the workforce? I don't think the travelers are a one-time thing. It's projected that the nursing shortage is going to take us through 2030 at least with all the baby boomers that are leaving the profession and joining the actual care population. And so while I think we gained a little bit of ground here, I do not even begin to think that travelers are over or that we've solved it or anything. So I don't want to rain on your parade, but the numbers don't predict that quite as much. I fully agree with you that it is a risk. I mean, maybe it's a risk not worth taking, but there are some hospitals out here that have told us they're not like Southwestern. They're not hiring travelers at all. They just, they've basically taken the approach of investing in their impermanent staff. And I just, you know, I could be totally wrong. I know not presenting that as that was what I think. It's just kind of what I'm trying to explore. And that's why we have these hearing processes. So, thank you. Okay, great. Member Walsh. Thank you, Jess. And hello, Dan, Jennifer, Jill, and Vic. It's nice to meet you. Haven't had the chance in person, but it's nice to see this. This is very short. I wanted to just say thank you for submitting such a clear presentation, clear narrative, answering the questions about assumptions within the budget also very clearly. And I also thought it was worth calling out your in-house behavioral support. That's something that we haven't heard other places. That seems like a real sign of your commitment to your staff and the community listening tours. That's also not something that, you know, there are needs assessments, but a listening tour is another level of commitment. And I think that's worth noting. And so thank you for doing that. And with that, I'll go back to you, Jess. No further questions. Great, thank you. You're welcome to the board. Thank you, sir. Just a couple of clarifying, maybe one or two clarifying questions. One was when you talk about your 3.65%, you use the term commercial rate increase. And most people talk about a change in charge. And I've always asked all the hospitals, as I'm sure you know, what is the relationship between the change in charge and the commercial rate, the effective commercial rate? So when you use the term commercial rate increase, I guess I'm questioning, is that your change in charge or are you giving us the effective commercial rate? And if so, okay. No, go ahead, Jen, that's great. I think you know my question, so have at it. Yeah, no, that is the change in charge. But the, you know, effective commercial rate that we're actually going to be able to recognize is 2.92%. Okay. Is there a number that we ask you that you don't know? I'm sure there's gonna be one, I'm sure. There's a lot up here, but I'm sure. No, I appreciate that, I appreciate that. No, that's really helpful. And actually, let me just ask, you know, it was interesting about Gifford's choice with respect to how to apply those charges, you know, across inpatient, outpatient and professional. I noticed for most hospitals, they would apply it to inpatient and outpatient with nothing applied to professionals. So seeing the 15% applied to professional and the much lower, you know, applied to inpatient and outpatient, I wanted to ask a little bit about that decision and what that means really. So candidly, when we did that revenue cycle evaluation, a portion of our fee schedules on the professional side of our business are actually currently set below the Medicare fee schedule. And so when we evaluated those, we felt that we needed to bring that up as necessary. And so that's why you're seeing that larger percentage there because we are actually getting paid below the Medicare fee schedule. Okay, no, that's helpful. Thank you for that. And, you know, my other question was around a little bit around occupancy rates. And so thank you for sharing your occupancy rates and your average daily census. I see that it varies between 10 and 12. It says in here that you staff for 25, but I'm wondering do you, is that really what you're staffing for is 25 or that's typically, you know, if you're not coming close to 20, you know, in terms of an average daily census, or is your variance so wide that there are days when you're, you know, coming close to 20 and other days when you're at five. And how does that work? You're staffing, particularly in these workforce shortage areas. Jill, you wanna jump in on that? Sure. So the 25 is kind of our all in number for our med surge area and our birthing center. So in our birthing center, we have core staffing around the clock of two RNs. So that is a fixed number that you can't change. Same with our ED. We have our fixed staffing to kind of keep things open. On our med surge area, we really, while you might take a snapshot of time and you see a number of 10, you may see us be up at 17 or 18 throughout the day where we're discharging five or six, admitting five or six, and we're turning those patients over on a regular basis. We also have some longer term stay folks who are getting, well, some short-term rehab folks who are staying longer than the acute stay, you know, in getting some swing bed time as well, you know, using a lot of resources. So we are staffing our HP unit for a census of 15 to like 18 to give us that flex. But the 25 is our all in number with our birthing center, et cetera. Super helpful, that was great. Thank you for that clarification. I appreciate it. Let me save my other questions. The other ones were just for requests, actually not so much questions, but thank you for the data, you know, that you provided on the specialty weights. You aggregated it by, you know, all specialty, all in one. Really what we're trying to get at is information about different specialties where we can see where the bottlenecks are across the state in certain specialty areas. So, you know, this may not be possible for you now. I recognize that may be a bigger challenge, but my request is really as you move to a new EMR system, if you can, you know, try and incorporate tracking of both referral lags and visit lags by specialty, we're going to ask this, I assume we're going to ask this question again next year. So to the degree, I know you're going to be in transit in terms of an EMR next summer. So that may be a bit of a challenge for you, but if, you know, this is one of those issues where if we don't measure these metrics, we don't know there's a problem, we don't know where the problems are and we can't move to fix them. So that was just the one request. And then the other one was I'm asking every hospital, just if anything changes in the next week or two or since your submission about federal or state payments, relief funds, unexpected increases in Medicaid, Medicare, anything like that, if you could just let us know and let in particular Sarah, Sarah's team know. Okay, so I think that's it for me. And I've actually, I don't think our finance team has any questions, but I'll just throw it out there. Does our finance team have any questions at this time? I am not hearing any. So at this point, I think what I'm going to do is turn it over to our HCA. Thank you, Chair Holmes. Dan, you, with your comment about putting a dollar in the jar every time you use an acronym, it forced me to frantically rewrite things and I'm still going to use acronyms undoubtedly, but I'll find your jar. So, you know, I do want to echo the kind of laudable efforts you have done to speak with your patients and the community at large. And I think it, that's not necessarily an easy thing and the community listening tour, I think, both how it informs your strategic plan and how you put it front and center in your presentation. I think speaks volumes to your organizational culture. I also just wanted to say that I was very happy with to see the connections you made between your cost reduction strategies and your requested charge increase. I think you did a wonderful job outlining how those cost reduction strategies were specifically geared towards reducing your charge request. So you mentioned in the narrative, moving from an in-house anesthesiologist model to a contracted services model and how that affects GMC's finances. I'm curious about its impact, if any, on patients and specifically patients who may be, who are eligible for patient financial assistance or your financial assistance policy depended on what type of person you're talking. I mean, people use different terminology for it. Sure, I can speak to that, Eric. And really the way the contract is actually structured is kind of a net neutral type of relationship between us. So nothing increased in terms of our applied percent to charges or anything like that that would change the patient's obligation, so to speak. So I think that that really kind of levels out in the end, to be honest with you, it's just a change in the shift of how we're reporting that as an expense in terms instead of revenue, I should say. Okay, and I bring this up really because you may be aware of Act 119 and I think in an early draft of that bill, there was some talk and some language about having contractors adopt hospitals, patient financial assistance policy that was dropped. And so there are many aspects to the financial assistance policy, but really GMC stands out as, I think, at least having read all the PFA's, the patient financial assistance policies of all the Vermont hospitals, you stand out honestly as covering contractors also under that policy. And I think that bears noting. Thank you. So this is less about GMC, but really as you're, we're thinking about a new EMR, I was wondering were you offered, and this isn't about whether, I'm guessing it's unaffordable, were you offered a discounted license to Epic by the UVM Health Network? Dan, if you don't mind, I can take that one. The answer to that honestly, Eric is no one, but I can tell you some inherent, I happen to come from the larger health system here in Vermont, and I wanna make a couple of correlations to that here. So the way Epic was structured under the network would actually require a considerable amount of support by the UVM HN team to be involved in managing things, such as the Charge Master, how AR actually functions the way supplies function just to name a few things. It was really set up to be interrelated within the network, which is great, obviously for them, but in terms of trying to bring other organizations onto that platform, it would pose some challenges, I would say. And so the other thing I did just wanna mention too, just from a broader perspective for the smaller hospitals that you have here in Vermont, is it's not just, and you mentioned the cost, because everybody says that about Epic, of course, but it's not just the licensing cost with Epic, I'm gonna be very frank, that there are numerous what is referred to as Epic dependencies that require the purchase of quite a few Cadillac platforms, and those are very costly, and they can't be shared among the organizations, and they use Workday for payroll, that's a Cadillac platform. Cornerstone for their education platform, they use ServiceNow for their IT service ticket platform, so I can go on. But those dependencies really do come at a really high cost, especially for the smaller organizations. So I just thought I'd mention it if that was helpful. That is super helpful, and obviously Epic would cause lots of problems for small hospitals, and people have different opinions about the ROI on Epic, and I won't go into my personal opinions here. So I'm curious with implementing this new EMR, is it what value do you think it's gonna have for patient care, and what's the kind of return on investment, or are you hoping it will have? So I'll talk a little bit about some of our goals for patient care. I tried to specifically note in my comments, what we think it's going to do for us around population health. I think to the question before about wait times and our ability to be able to split out our wait time specifically by specialty, we have very little ability right now to be able to get data out of our systems in a way that assist us with decision-making, whether that's financial, whether that is statistical, but definitely as it relates to being able to design particular programs and outreach, and disease management, interactions with patients, we're limited in being able to do that right now with our current systems. So by going to the platform we're going to, it's going to greatly up our capabilities there, and I do think that that is going to directly benefit patients. I think it's gonna directly benefit our employees as well, because these are activities that they're chopping at the bit to be able to do, and there's a restraint there because of our systems. There's also, I'd say a corollary simple benefit that our patients are gonna have as well. Jen noted we have four electronic health records across our system. We have two patient portals as well. If you come to the hospital proper, there's one patient portal. If you go to our practices, there's a second patient portal. That is neither efficient, nor is it overall helpful at times for our patients. It's a struggle for me when I'm trying to figure out what I should be accessing as well. So that's gonna be a big improvement as well. So those are just two specific areas that we probably could talk for hours about this, but it's definitely going to have an impact, positive impact for our patient population and for our communities in regard to our community health activities. I hope it goes well. Oh, sorry, Eric. I was just gonna comment on two other things, if you don't mind. One is now we're gonna have one patient record also, so that's certainly gonna be a help for our patients. And with the new EMR, one of the things that we really took seriously and into consideration, especially around our financial assistance and what we can do for patients is it's gonna allow us to really expand upon our re-registration process. So that we're gonna be able to put our patient advocates in contact with the patients prior to them coming to the visit so that they're not so potentially stressed with having those bills when they come into a healthcare organization. So we're really adopting that practice when we roll out the new EMR as well. So I did just want to mention those two things. No, that would be great. And I was just gonna say, I wish you the best with the implementation process. I know it can be rather rocky at times. I'm gonna pass it off to my colleague, Charlie, if he's on. I am here. Hi, so this is Charles Becker, a new staff attorney with the HCA, but it looked like Jill, you had your hand up. Yeah, I was just gonna say that, with our four systems now, they are all these standalone systems where nothing flows forward for the patient. So when we're trying to embed evidence-based best practice and really looking at outcomes, our providers are having to re-enter data several times and our patients really aren't kind of appreciating that impact of what a truly integrated system could do. I really think our system is gonna definitely have direct impact on our patient outcomes. The patient portal, we didn't even talk about that, but their access to their own information in a seamless way and just having that all flow forward is gonna have a huge impact on them and the providers now spend three times the time trying to do something very simple and they could be spending that sitting down and having great conversations with patients. So it's huge for us. We're so excited about it. And like maybe some other places who don't want the change, we're ready for it, we need it, so. Perfect, thank you. So I just had one question. I was curious, and I should just introduce myself again. I'm Charles Becker, new staff attorney with the Office of the Healthcare Advocate. I haven't met any of you all before, so nice to meet you. I was just interested in hearing a little bit more about a couple of the public health initiatives that you mentioned, particularly as they relate to access to care. So I'm just down the road from you in Stockbridge, so I know that we're in one of the more rural areas of a very rural state and that the population here skews older and it's hard for some of our neighbors to get out and drive, the roads are rough even in good weather. Maybe some people can't even afford a vehicle. So I'm just curious to hear about the home visits program, how many people are you serving with that program who's a geared toward what types of visits are you able to make with that program? How much does it cost? And then also I was curious about the rides to wellness program mentioned in the narrative. I tried to do a little bit of research about that one ahead of time and I could only find a reference to something from the Agency of Transportation, a pilot program in Springfield in 2018. I was just wondering, is that the same program? Is it up and running in Gifford? How does it function? Is it volunteer based? Can I sign up? Great, well, Charles welcome and just state that if you're driving in Stockbridge on 107 and Jen comes behind you just let her go by. Oh, okay. Yeah. So I'll talk about the first one and Rebecca O'Berry who was sworn in as our Vice President of Operations. I'm gonna hopefully tag team her to talk about the rides to wellness program but the home visit program is it's still a pilot project if you will and our Chief Medical Officer, Dr. Josh White has been very active in pursuing this. Unfortunately, he was sick today so that he could tell you all about it. I can tell you some about it and Charles will be happy to if you wanna talk more about it in the future but this is a program, it's similar to a para professional program with para, yeah, I just totally lost the word but with EMT programs, yeah. So pairing with EMT programs this started over in Chelsea with their ambulance service and they actually had started themselves and then we got involved because we have a primary care practice in Chelsea and there's another nonprofit board that have provided some funding, basically grant funding to the ambulance service in Chelsea so that they could go out and do home visits basically wellness checks for people are homebound or really trying to target people that the ambulance service had been called out to a lot and the logic being that if we engaged with them proactively and the ambulance service went out and just did a check and visit looked at their home surroundings to see are there fall risks? Are they, do they understand what medications they have and are they taking them correctly? So having conversations about that. Taking a look around, do they have food? Is the heat turned off? Do they have electricity? All these kinds of things and making that linkage back to the primary care practice and so if they're seeing things that really they think some interaction is needed and it might not be an interaction by the primary care practice but between that connection we then can we can connect with some of the organizations and some of the people who may be able to help them with getting food and if you'll indulge me I would like to tell you some more about some of the food security programs that we're doing but there's a lot of resources that we then can pair up with and at the end of the day we're trying to keep people from calling the ambulance for a ride to the emergency department of that when that could be avoided and trying to help people avoid costly healthcare interventions where it is avoidable. We've now, so again that was initially funded through a nonprofit in Chelsea with that ambulance service. We at Gifford have put our own skin in the game and we're providing grant funding to the ambulance services, the South Royalton and also White River Valley ambulance which White River Valley would serve your area, Charles. So we're doing it with them as well and again it still is somewhat of a pilot project in large part because the ambulance services are struggling with staffing as well but indications are that it's going well. I think the numbers we have at this point the statistics are probably too small to draw too many conclusions on but we know anecdotally it's helping people and we've gotten information from ambulance services that if they're not able to make one of these visits to someone who they interact with frequently, typically that the chance is far greater that they're going to call and want to ride to the emergency department. So that's what we're trying to avoid. So I just know that we do have a number of food security programs as well and I don't want to prolong with all that but I've got a whole page but if that is a question. That's fantastic. It's really neighbors looking after neighbors and at least with the home visits program it sounds like it's very low cost and maybe even reduces an overall cost of healthcare system. So that's fantastic. I hope it is able to be long lasting. Thank you. Yeah. Is there someone that's able to speak to rides to wellness? Rebecca, are you on? Yes, I'm here. Can you hear me? Yes. Okay, great. Hi, thanks for the question. The rides to wellness program has been a grant funded initiative through the state that we have participated with Tri-Valley Transit which we call stage coach in our area. It's Tri-Valley Transit. I will always call it stage coach. That's just what's going to happen. And so we have an agreement with them that if we have a patient who needs a ride sometimes we can work it out with Tri-Valley Transit that they pick it up. Other times we have to coordinate with maybe the patient's friend or a neighbor or someone who can get them here. And then we basically through invoicing pay that person a certain fee to get the patient here to an X-ray appointment or even to pick up prescriptions at the pharmacy, things like that. We also tried to set up with business Uber with Uber for Health, which actually does exist. And yeah, we've got it all set up. We just need some Uber drivers in our towns. So we've tried to do it a couple of times online to make fake rides for us back and forth to different places to just see if we can get an Uber. And if you schedule it ahead of time, sort of like if I have an appointment next Tuesday you can actually get it to work. If not, you know, if it's the same day thing and urgent care visit or something we just don't have people in Uber in our area yet. So it's worked really well. I don't know, the funding was sort of a pilot program. I think that's what you were referring to earlier. It didn't really take off so much in the Springfield area. And so they expanded it and that's how we became part of it. So that's the program. And I like Dan would be happy to talk about food security. It's my passion. Absolutely. Well, very nice. Thank you. Thank you. And share homes, I didn't have any more questions. So I think that's it for the HCI. Okay, great. Thank you so much. At this point, I would be happy to open it up for any public comment. So if anybody wants to make a comment about this budget the Gifford budget, please just use the raise your hand function on teams and I will see you. Okay, at this point I'm not seeing any hands raised. If there's anybody on the phone that wants to speak you can also do so by just unmuting yourself and speaking at this moment. Okay. Well, I'm not hearing any public comment at this moment in time. So just want to thank you to the Gifford team. We appreciate your insights into your budget this year and thank you for sharing some of the really innovative initiatives that you're taking with your community. It's really impressive and inspiring. I think there may have been a couple of follow-ups. If there were, now I can't remember all the budget hearings are going in my head but if they're already Sarah and team will follow up with you. But actually I think Jen you've had answers to everything because you have numbers off the top of your head and lists and do all your homework. So I don't think you did. At this point, this is the end of our day five. We will have closing ceremonies on Friday. So when we will be hearing from Copley and Northeastern starting at 8.30 in the morning I'll end our hospital budget cycle for this year prior to our deliberations. So at this point is there a motion to adjourn? So moved. All right I'm going to take that from Tom Pelham as a motion and Tom Walsh as a second. All those in favor? They say aye. Aye. Aye. Any opposed? No. Sounds like it's a unanimous decision to go have a margarita. So I'm getting a little break from it. Thank you all. Yeah. Thank you very much. Good for it. Appreciate it. Thank you. Have a good evening. Thank you. Thank you.