 The Secretary of State's office is our new file, our new rules, and we're going to introduce the order to the legislative and administrative rules. In addition, we also have the Israel Agency Committee on Administrative Rules. This is a group of employees from within the state that look over the rule just to ensure that there are rules from different agencies that are at cross purposes or that are overlapping with each other. And then you have the Legislative Committee on Administrative Rules from the existing employees. We look at whether the agency has already or created a little consistency of the rule with legislative intent. Looking at public input into the rulemaking process and then any economic or environmental impact. And then, of course, we also have members of the public and external organizations and stakeholders that will be providing input throughout the rulemaking process. The steps of the rule adoption process. Just so you know where we are right now with Rule 7 is we are right before step number one. So the first step would be to pre-file with the Interagency Committee on Administrative Rules to get the ball rolling there. Once we finish with ICAR, then we're going to... Excuse me, after we pre-file with ICAR, we also subsequently file with the Secretary of State, which will send a copy of the rule to LCAR. The rule will then be posted on our website. There are also additional notification requirements that have to be met so that the public is aware that a rule is taking place. There will be a public hearing and comment period, which I will get into in a later slide in terms of details of the length of public comment period. And yes, the length of public comment period. And then once we have finished going through public comment, we've engaged with stakeholders. If there are any changes that should be made to the rule, we will work through those. We will bring the rule back to the board and request approval to move forward with filing a final proposal. Excuse me, a final proposed rule with the Secretary of State and LCAR. Then we will meet with LCAR, who will go over the rule, ask us questions, and then we may or may not see the need to adjust the rule based on feedback from LCAR. And again, there will be another opportunity for the rule to come before the board. At step seven, when the board adopts the final rule, which will subsequently be filed with the Secretary of State. I went through that kind of quickly. If anyone has more questions, please feel free to ask when I wrap up here. So rule seven specifically. As I said, the state statute requires that we adopt a rule covering the basis and process for removal of a member. Members of the board may only be removed for cause for the state statute. I think it goes without saying that we hope this rule is never used, but we are required to have it and so we are working through adopting a rule. Rule seven addresses the basis of removal for a board member, the process for removal, and then addresses some specific issues regarding confidentiality throughout the process of removal and also some due process considerations for board members. If anyone in the audience is interested in looking at the draft rule that is posted online with the agenda materials from today. The draft rule is where we are right now and what we're asking for the board's approval to move forward. I would recommend that for people who are looking to provide public comment, it might be helpful to wait till we post the proposed rule, which would be hopefully within the next month. So moving on to public comment and additional stakeholder input. So after the board approves the draft, we're going to send out a copy of the rule to the Office of the Healthcare Advocate and any other interested stakeholders. In addition, members of the public are welcome to submit formal comments as soon as the proposed rule is posted to the board's website or sooner if you wish, but just so you know that you're commenting on the proposed rule. You may want to wait until that is posted, specifically outside of our agenda materials for today. Then per statute, a public hearing will take place no earlier than 30 days after the proposed rule is posted online, and public comment will be accepted for at least seven days following the public hearing. So right now, just so the board has some idea, we're looking at a time frame where we're hoping to have the proposed rule publicly posted in April and then accepting public comment through May with a public hearing towards the end of May. This timeline, of course, might be adjusted depending on if my car has suggestions or modifications to how we might receive public input or if there are any additional changes that are requested by stakeholders that we need to consider further. Our recommendation is that the board approve draft rule seven and direct staff to proceed with the rule adoption process for rule seven. If there are any questions, I would be happy to answer them. Or any, do you have any questions? No, I do not. At this point, we will take any public comment or questions on the discussion on rule seven. Yes. Okay. I will happily move that we approve draft rule seven and ask the staff to proceed with the rule adoption process. Second. It's been moved and seconded to approve draft rule seven, version one. And direct the staff to proceed with the rule adoption process for rule seven. Is there any discussion? Any discussion? So, Mike, again, if you could call the wall. Here. Number used for? Uh, yes. Number called? Yes. Number called? Yes. Number one? Yes. Yes. The record show is unanimous vote. And thank you very much, everyone. Thank you. The shift, and we're going to invite the next presenters to come down front. And that's a point. Good afternoon. My name is Brina Holmes. I'm a general pediatrician and the maternal and child health director for the state of Vermont at the Vermont Department of Health. So thank you so much for inviting me today. I feel like could someone keep track of time? I could talk about this topic all day. My goal today is to peak your interest in some of the depths of this conversation. Certainly won't be able to address the time allotted all of what's going on in Vermont and how we're approaching this topic. But I do hope it leads to more conversation. The first, what I'd like to do today is very, very briefly touch on this study and really shift us a little bit into the adverse family experiences, which is there's a nuance there. Talk briefly about how public health is approaching. The prevention of ACEs, really, by promoting protective factors and strengths in families. And then quickly end with a very hopeful example of how we're moving forward in our state. The kind of quicker way to say this is I'd like you to come away today thinking about strengths instead of ACEs. I'd also like to have everyone leave today knowing that the Pediatric Medical Home is one of the best venues in our system for addressing strengths in families. And I'd also want us to all be excited about the pilots that we're doing with our one care partners in this arena. So, just a reminder that the ACEs study was about adults. It was not about children. It was an incredible study for its size. But we don't remind ourselves very often and how often we talk about this is this was about white adults who had college educations. So this was a middle class cohort. And in that setting, it was super important groundbreaking research to name that when these particular seven experiences had been documented by adults in their memory of their childhood. They had chronic disease associated with these factors. So this was not meant to be at all disparaging of this incredible groundbreaking study but it was described and continues to be our frame in the context of adults with chronic disease. So the nuance here is super important to me that we get it, right? Childhood adversity has lifelong consequences. But I want us to be grounded in the fact that chronic disease is only one of those consequences and the prevention of adversity in childhood is more complicated than those seven factors. So people a lot smarter than I am about eight years ago said, well, let's talk about the adverse family experiences, ACEs, and let's actually ask families about their experiences as families through the National Survey of Children's Health, which is a really, really rich data source if you're a data person. And it actually has its national data also and Vermont, each state has its specific data. So the family experiences actually add in, I tried to highlight here but I can't see, beyond what goes on in an adverse childhood screen which is the ACE study from Dr. Folletti, the family experience asks about poverty, which I'm sure you can imagine is a form of diversity. It actually asks about the death of a parent and it goes on to talk about violence in a more community way, not just whether there was violence in your home, which is an ACE question, but what about your neighborhood? Did you experience racial inequity? And what about moving? Which we could talk about a long time but moving frequently is a major stress on a family and a child. Okay, so that's all I'm going to say about ACEs and ACEs. I think Tom might address it with deeper detail and there's a lot more to say but what I want to say is we can screen people for ACEs and a lot of people are interested in that and that has its merits. What I'm interested in as a pediatrician is asking families about their social complexity and the more common term for that is social determinants. The word determinant has some issues for me but social complexity, what's happening in your family with food and housing and transportation and safety and economic opportunity finances and then I added the last one because we're doing a beautiful job in Vermont putting a full spotlight on the fact people don't have access to high quality affordable childcare for their kids. So isn't lack of access for childcare a stress on a family and a social, it involves social complexity. So I guess the agitation I want to make today and point out is so we already know that adversity and childhood has lifelong consequences. Today's talk is not about brain development I think maybe you've had some of those experts talk to you I'd be happy to talk about that at another time. The brain develops very rapidly in the first three years of life and the exposure to toxic stress has lifelong impact. So since we now know this we can continue to be concerned and want policymakers to help me understand if we know this why aren't we doing more about it and that gap is what I think Green Mountain Care Board has a great opportunity to lead the conversation and I know that you're spending a lot of time talking about primary prevention and I just want to support that that we really, we know that we need to do it and we just have to find the courage to do it. So the other thing about this slide is sometimes people describe that we don't know what kids and families need and I really want to oppose that publicly and say that there's no mystery to what works at least with our littlest kids and yet we have trouble investing in it. So I want to shift our language around I don't want to talk about ACEs I think that many of you knew Paula Duncan Paula was my mentor for my entire career and she taught me and continued to remind me that we need to talk about what is good in families where the strengths are and that when we continually layer adversity on people we're missing the opportunity to shift our trajectory as both a child a family and a society. Super complicated slide except maybe it isn't that we're all born with a certain potential epigenetics it's some really interesting science behind this notion that our brains and our genes have some predetermination and then there's some expression. So if you think about where your trajectory was going to go sometimes the adversity shifts you down so that when you do experiences those circumstances on that list of ACEs your potential as a human is shifted but let's talk more about what lifts you up and all the opportunities that a public health system and a society and a community has to provide these opportunities for young developing brains to change the trajectory so it's really just a math equation the more we layer in parent education high quality pediatric healthcare early care and learning safe neighborhoods the more we're going to mitigate the effects of the toxic stress so some of our national friends are better at describing this as balancing ACEs with hope which is an acronym for health outcomes for positive experience this is where all of my interest in attempts to shift the conversation are because it's not really about putting all of this on a family it's talking about how communities can provide the opportunities for these experiences for young people I also hope you've heard of the strengthening families framework all of the reassurance for you today that these things we talk about are layered and connected when we talk about hope, strengthening families the people that build these frameworks talk to each other and there's tons of science and research that when families have these five protective factors children thrive and even more ultimately there's way less child abuse so I didn't really have time to do all five but I'm going to go really quick and to take the words in the frame and then try to say it in more sort of common language parental resilience means that you have to manage stress life is hard and that you have to figure out a way to function even when times are difficult our nurse home visitor trainer said you have to parent in spite of you know kids don't really have we don't have time with developing brains to say I'm going to get my life in order in the next five years because the development of the child is real time that's resilience social connection way way missing in our current society especially in a rural isolated place like Vermont where we have trouble with transportation so let's care about each other's kids more and let's get and give support and understand that networks of caring people is good for kids understanding child development is really a lot of the work we do in the agency of human services but it's also the work of pediatricians which is the more you know about what's happening with your child in a normal developmental way the easier it is to parent and the more you understand and none of us really know how to parent so that's kind of a nice grounding principle surrounding Vermont families with adults who have some skills around parenting is a super goal concrete supports this is sort of the social determinant work that we care so much about it's very hard to parent in the context of food security housing instability lack of transportation and then social emotional confidence this is a wonky thing but this really means how do we teach parents to support their kids feelings and emotions and many of you know that Vermont has high high rates of kids with emotional disturbance in our public school system and that's just I don't like that term but that's what the term emotional disturbance and we believe deeply that understanding the emotional lives of children when they're little would impact that metric okay really quick or maybe not so quick I put this up for Jessica Holmes it's the Heckman equation I'm okay that things that pediatricians have known forever got called out in the world of economics and the economic folks named this opportunity that the younger we intervene the better the rate on return and this man won the Nobel Prize I also wanted to reassure you today that I think from where you sit you probably hear a lot of disparate presentations and wonder if there's integration these are sort of the top five things I'm working on in my public health leadership role right now and they're all related I promise so help me grow Vermont I'll touch on for one second at the end we can talk a lot about home visiting which we recently rebranded as the term strong families Vermont developmental understanding legal collaboration for everyone the Dulce model I am going to dive into in a couple slides building flourishing communities is alive and well and really a concept about how communities can support families and then I think that the current energy around childcare is extremely hopeful and exciting okay so here's how we think about our work in the agency and this is integrated work between secretary's office department for children families the health department we believe that the opportunities and the access points for Vermont's children in the most primary prevention space are in three domains kids are in their home we are really lucky in Vermont we have very few brand new babies who are homeless so there is an opportunity for families to access and work with families in their home pediatric medical home highest rate of well-child care in the country and we cover all kids in our Medicaid program I mean truly almost all and I'm sorry that's like a weird yellow lime early care and learning programs lots of different data on this 50, 60, 70% of Vermont's children when they're teeny teeny are in some sort of early care environment so these are your domains with our integrated service system in the middle for those families identified in those domains that may need access to more services and then we drew our help me grow system which is really about it's a system of support for child development in all those domains and for families themselves so today I want to just describe the access point of the pediatric medical home with our Dulce model and that if we're for families that we identify in that setting who could use some more sustained longitudinal support we promote home visiting models many of you know that Bright Futures is the preventive service guideline for the care of Vermont's children it is not building Bright Futures which is our state council for early childhood but you know all related but not the same Bright Futures was commissioned out of the Maternal and Child Health Bureau 20 something years ago partnered with the American Academy of Pediatrics to set standards for how we should take care of kids in the office all three of the editors of this national guideline are Vermonters Joe Hagen, Judy Shaw and Paula Duncan so we're very lucky that we have those experts we're also really lucky that some of you in the room or on the board were part of the policy changes in the 1990s that led to such high quality pediatric care we covered kids to 300% federal poverty and all the pediatricians in the state of Vermont take Medicaid that's not true in any other state in the country there are tons of pediatricians nationally that see commercially insured kids and we have to say that in every meeting so we don't lose traction on that because if we didn't have that coverage and that access point and we didn't have such an incredible workforce we wouldn't have the quality of healthcare for kids that we do today the other thing that's really really cool is the right features it evolves and it has additions so the fourth addition came out in March of 17 and it said very aspirationally I think you should screen for social determinants in every visit and the pediatrician said that's great we really will but you've got to figure out how to help us with what we're going to find because if we're going to ask every family and checkups about food and housing and violence and substance use we need a whole network of people to help us so what we love about pediatric healthcare we have the access point because Vermont's awesome there's no stigma when you bring your kid to the doctor it's actually a social good if you're having a very difficult, chaotic day but you still manage to get your kid in that's good and we also know from research and experience that people trust their healthcare profession so we took this on the road did anybody come to the road show? we had a fun road show the AAP paid for eight regional dinners we had 264 human service partners come to these dinners with 48 healthcare providers all around the state and in the dinner we put forth that the fourth addition of this pediatric preventive service guideline was suggesting and recommending that kids be screened for social determinants and I thought as a healthcare provider the human service colleagues were going to say you guys have all the money over there in healthcare you figure it out and that's not what happened at all the human service colleagues in the room said we've got you we will come into your office or you come find us and when you find stuff going on with the families in your practice we will pick them up for you but what? every pediatrician in these and the family practice docs that came said we need to increase the capacity in our office because we want a warm hand out we want everybody to move real time together through the results of these screens we don't want this to go into some referral bin or somebody's queue so luckily we had already we already had an experience in the Lamoille Valley about Dulce which is developmental understanding and legal collaboration for everyone this is a national model with evidence that when you put a family specialist into all well child visits for babies zero to six months you can get families connected to the resources they need as early as possible to improve the health outcomes and the developmental outcomes for their children so I have tons more to say about Dulce but I just wanted to draw this metric so you can see how it all connects in Lamoille Valley the Dulce family specialist sits in the pediatric office and meets all the new babies and we're not speaking in hyperbole when we say we have offered this service to 350 families and maybe two have said no or three you know there's lots of data here if you want us to come back so over the last few years we've recognized that this is an acceptable form of human service integration for families they don't mind it and then the hard wiring of the family specialist to the parent child center is genius because that person goes to the CIS team every week and says I met 30 babies this week 10 of them have these needs who's picking them up in our service array and many of the families would benefit in our offered home visiting because we're a rural isolated state and people are in their homes so the rebrand we've had parent child center family support workers and nurses from our home health agencies doing home visits for many years but it was super confusing to people because it took too many sentences to say I'm a nurse home visitor and I'm going out a long time for a longitudinal way or I'm going out twice and I'm a parent child center person so we pulled it all together in the agency of human services to strong families from out green and then in our layer of who's the professional going out and how long are they staying we changed colors just for the graphic but what we know about home visiting is even more than we know about other things for 30 years we've researched this approach to families strengthening families and what we know is that that relationship that you build in a home with a family of a new baby improves all of these outcomes and more so again since we know this I really need help understanding why we're not investing more in it because home visiting moves mountains for families and then I already mentioned this but we do have a fun wrap-around system called help me grow which involves early childhood professionals including doctors communicating with each other about developmental results for screens through a registry which is part of our immunization registry at the health department and it's also a part of the two on one call center that just has two full-time child development specialists answering questions for families about parenting could talk about that all day as well and then I wanted to end by reassuring you that this is all part of the ship have you heard about the state health improvement yay so the health department did very strong collaborative two-and-a-half year stakeholder engagement work to come up with a set of priorities not for the health department for the whole state of Vermont around the health of our citizens and achieving optimal development is one of the overarching strategies I brought you the ship today if you want your own hard copy and with the work that I described around pediatric medical home Dulce home visiting strengthening families are strategies with lots more detail within this ship so we describe how important it is to screen all kids we describe how we want Dulce in as the screening brief intervention navigation for the littlest we believe deeply in home visiting and then I added this to just show the early care environment so that the three domains home medical home early care and learning I didn't address much about early care and learning today that's a topic for another day but there is a cross agency approach right now about building the professional development system for understanding emotional lives of children and childcare so that fits in with the fifth of the protective factors of strengthening families okay I'm going to end there I'm going to remind us that we need to talk about strengths and what's right about families and how we're promoting protective factors in our families I'm so grateful that you were invited me today so I could call out my pediatrician colleagues because pediatric healthcare in Vermont is extraordinary and one care really stepped up for us and we're grateful they are allowing us to pilot three, maybe two, three new Dulce sites in the next year with money in the delivery system reform part of their work and so stay tuned I don't think I'm allowed to announce publicly where we're heading but I can whisper to you later if my friend Scott Johnson lets me so I'll stop there I hope I wasn't too much ooh good, didn't do and I'm happy to answer questions or talk later related to Dulce I was interested to hear a little bit more about the legal component of the medical legal partnership I do happen to know the attorney who's working in the Loyal County so I know a little bit from her but I was just interested to hear a little bit more about that involvement sure so thanks for calling that out again not a ton of time today but the Dulce model was developed and utilized at Boston Medical Center and they very quickly realized they wanted a legal partner in the work in their primary care office with the notion that it's not direct legal services for families it's consultation about legal issues to the family specialist who works with families and so when we first heard about this and they came to LaMoyle I think a lot of us thought oh yeah Vermont that's going to be different because Vermont's not a city and we don't have legal issues and it's completely false the legal issues in Vermont are about health access your right to entitlement programs and state sponsored programs immigration employment rights other housing yeah healthy housing so this has grown to be one of our favorite parts of the model and with the piloting and moving to other parts of the state the legal component is going to stay right in the center thanks for asking about that first of all thank you for coming I really appreciate your talk and I have to I'm going to publicly also thank you for something else that you don't know that you do when we live in the same town and obviously in the same last name people think that we're always the same person I get that all the time and I will tell you what I get it the most is when I'm calling for reservations at local restaurants and I say the reservation is homes they say doctor homes and I say absolutely thinking that I might get a better table so thank you for being a team member of our community to get me better tables so two questions actually what do you think if you had to guess the percentage of the nutrition currently screening for social determinants I mean are we at 100% are we at anywhere close to that? That's a great question so I'm always remiss in a talk that I don't mention the Vermont Child Health Improvement Program so the last count there were 100 practices in the state of Vermont that saw children and there's very interesting data that the littlest are really almost all in pediatrics family medicine picks up in the child health arena when kids are about five so in the 100 practices you can see kids there's a network at VCHIP called CHAMP Child Health Advances measured in practice 60 practices in that and last year's project was on food security screening and maternal depression screening so of those 60 practices 45 probably participated longitudinally on the quality improvement so I know for sure 45 practices did food and depression as two of the determinants so some of the work with one care that we're having fun with is how are we going to screen for what how comprehensively there's a lot of interesting validation data from Children's Health Watch in Boston that if you ask the two food questions the hunger vital sign you can get at about 70% of what families are experiencing in all those other domains so it might sort of tighten up the so it's a big topic I don't know that Vermont has the appetite to standardize this you know in my world in systems I like to just say here's the screen everybody do it but there is an individuation to practices and approaches I will tell you the Dulce model uses the CMS-10 so Center for Medicaid and Medicare services came out with the way to screen are you familiar with it? 10 questions so I'm grateful that the Dulce model is using something standardized so we have all that data and the practices that are going to have Dulce but in terms of general pediatrics I think people so bright futures stop short of mandating a screen they're recommending not requiring but they certainly call out all of the standard social questions that we should be asking I just don't so and then the next question of who's screening and how is where are they putting that data because the only way this is going to matter this is going to work for us is if we it's in a central pullable there you just tapped my knowledge of electronic health records so I think we need to make some decisions as a state about how we're going to do this but VCHIP kind of leads the way and doing it in a non punitive mandated way it's through quality improvement which always works with docs they like that is there a role for blueprint? yeah oh and I should say too the blueprint in their women's health initiative which is intimately linked to pediatrics but not kids you know they're also using the CMS 10 so we have an alignment what we're asking in Dulce with women's health and then I think the pediatricians I know for sure they're asking a few things I'm just not sure they're asking all ten things but do they have to that's this I'm sure you hear that a lot and when we deliver health care you can't always just add on so when they added social determinants to bright futures Joe Hagan and some of the editors that went out nationally to get will build will for this the pediatrician said okay so take something out then so it became this terrible like what am I not going to ask about bike helmets I mean there's so many things to talk about in a pediatric health setting which is why we love Dulce because it's taking the heat off the dock and it's saying here here's a family specialist from the parent child center that's going to fill in all the gaps for the things you wish you knew about this family does that make sense? yeah my second question relates to the expansion I know that you can't talk about specific communities but I'm wondering about the timeline of the expansion you know over time throughout the state you know in the next five years how many communities are you hoping will have this model how do you choose communities is it readiness of the community is it the need of the community how are you rolling this out yeah that's exactly where we are right now I mean so it there's this sort of state of readiness that we're seeking between so there's the whole notion of a medical home and now there's a new notion nationally called a high performing medical home so it takes the pediatric it's sort of the you do your bare minimum and then you get really good at this kind of coordination so we're looking for these high performing medical homes at the same time that we have parent child centers that are ready in their structure to really innovate hire a full-time person and send them over there so I would say we're very aware of our need for geographic diversity and to get this out to some of the more rural communities we're going to talk tomorrow again we talk every other month to the pediatric subcommittee of one care with the pediatricians about who's ready who wants and and then honestly we have a lot of funding streams that we're sort of trying to tap into to bring together a collective budget so we can actually really do this statewide so we apply for private foundation money I've got some federal block grant money which is a Toronto Health Seed but you're not supposed to use it long term the one care dollars is provision you know it's get going and then someone else should pay and then we also so we think the health system has a role and then the last time I've actually found a crack in CDC opiate fund you know the Center for Disease Control likes to give us money for opiate treatment and we're wondering if this type of screening and getting to know families early and supporting parents could be an opiate prevention strategy I know it is I'm just trying to get the funding to flow that way I'm probably telling you more than I'm supposed to but to me it's just the the hook or crook thing that we always do in child health which is just sad I mean it's we get it done but it's just not easy thank you for this so Vermont Dagger today they had a recent article about the county rankings coming out and you can click on state and see rankings within the state and you and the the number of the population for primary care precision is one of the rankings by county in Vermont so I was looking at you know the range here in Vermont in Chittenden County is 550 to 1 and the range at the other end of the spectrum in Essex is 3090 to 1 and I have a rough sense can't fully document yet but kind of just looking at hospital budgets that the paired mix by hospitals is in Chittenden County it's the number here is 59% of their pair mix at the U.B. Medical Center is commercial whereas up in the Northeast Kingdom it's 48% and in Springville it's 42% so whether there's a cause and effect I don't know yet but I'm just wondering you said that access to pediatricians they all take the medicated patients and I'm just wondering if that is a kind of a blanket statement or there are nuances to that that would be helpful for us to know about I feel like there are people that know more than I do about this topic but I believe that that is accurate unless Stephanie's nodding it's because things do change you know I'd hate to be if there's one practice to stop doing that what I'm interested in what you're so the disparity in Medicaid populations in our state for pediatric healthcare is huge so the Northeast Kingdom last eye looked their Medicaid population and their pediatric practice was 70% so we're but what I love about Vermont and I don't know if this is true of all my colleagues but it's we sort of do all of this good work for all the kids it's not it's sort of pair agnostic you don't walk in you don't really know who's on Medicaid in a practice that might be different now I haven't been in practice in a few years but it's the notion that so many kids are covered that it's more than half in our minds so we provide services for all does that make sense so yeah I think the score of my question I wonder a little bit though is there enough pediatricians in places like Essence County to handle the caseload so the workforce piece of this conversation is fascinating I would say we probably need more in the rural communities but what I I guess I'll flip it in my strength way and say we did an evaluation of Dulce and LaMoyle Valley of the pediatricians and she said I feel better about my job I know my family's better and I go home at night with more satisfaction because she's physically I mean this is now I'm diving into the model but she's next to not a call someone down the hall they do the visit together and that I wondered if that would resonate with people that pediatricians feel better I hope it does but that's a little self-serving but the workforce preservation part of Dulce matters a lot because it's the growing pressure on the pediatric healthcare setting is to address the social complexity because babies in Vermont are beautiful and healthy we have the highest rate of prematurity the lowest rate of low birth weight we have really good care and the babies come out of the earth healthy but then the social milieu in which they're growing is really challenging and that needs it to be addressed early in the office and the other question I had was just thinking about insurance plans and you made the observation that we spend a lot on treatment and not as much as we should on prevention and I think that's true across the playing field but as you go through the development of your programs benefits that you come across that are prevented in nature that we might adopt in a more formal way within the state benchmark plan for two HP plans so that access to those preventive services are more readily achievable I have a little bit of an awkwardness because I work for state government but did I say that at the beginning? so sometimes what works best in my world is for me to bring expertise and frame and then let others come in with dollar amounts and price tags and stuff only in that I do share such deep passion for this but I think and what I'm really meant to say is that please don't I know people need treatment desperately and I don't like that sort of Sophie's choice thing it isn't really that I just go like this with my hand a lot because it wouldn't take a lot of reframing but it doesn't mean that we don't have desperate treatment needs obviously you guys have been grappling this for a long time I don't have easy solutions I look for opportunities but it's simple it is it's actually no mystery Marie do you have any questions? No I'm very interested thank you very much if you are thank you good afternoon my name is Tom Reese I'm resident of South Burlington lifelong resident of the state of Vermont and it's a pleasure to be with you and I appreciate you sharing time with me it's also important to see what I brought with me which is in fact the canister that's marketing Prina's program we're all together in this I'd like to share with you today a journey that I've been on and and the resulting education that I've achieved during that journey I'm by training in many years of experience in the hospital executive healthcare consultant and have dedicated my entire career to that but my career has taken a very different turn over the last several years and this is the reason for that turn and I'd like to share with you just briefly the motivation for the change in some of the direction in my life this is Ben Ben is the big guy in the middle of the picture and with Ben is his very lovely young lady friend and those happen to be my three granddaughters with Ben and Ben is my oldest grandchild who lived with my wife and I eight years ago suffering from toxic stress very complicated situation but originally planned as a hiatus in his family life of eight months to finish his eighth grade school year at South Brunden High School resulted in in the discovery that Ben was affected by at least five and maybe six aces manifested itself in some pretty dysregulated behavior in his family which extended to us as grandparents as soon as we picked him up in the airport in Boston having come from home in Harrisburg outside of Charlotte, North Carolina and it's been an amazing journey of learning for both he and his grandmother and I but the journey started with understanding that we didn't know what was happening with Ben and no idea we were disturbed about his interactions with us on the way from the car from Boston and then became deeply troubled actually the first evening that Ben was with us we had set up a bedroom for him in our home and he proceeded to come into our room, my wife and I room lay down beside his grandmother who was Nana and proceeded to hold her hand the entire night so he could sleep that actually went on for 30 days until he could sleep in his own room safely and comfortably on his own fortunately for us and fortunately for Ben and Ben fortunately for two reasons one Ben came to the state of Vermont where the state of Vermont does very special things for its children and I think you heard from Brena how good we are at caring for our children and Ben would not be in where he is right now if it were not for the fact that he came to Vermont there is a little question of that the second very fortunate thing was that my backyard across the yard neighbor is Chuck Myers who is the president of NFI Vermont and a very very skilled therapist in pediatric behavioral trauma and he guided us the first step saying you're going to need help you're going to need lots of help but we can't tell how much help you're going to need why don't you start with first call which is a program of family support from the Howard Center in Burlington within 30 days we had progressed through that system to the belief that Ben and Nana and I needed into family therapy to support this child's needs into the future and we happened to have as a therapist David Melnick from NFI who is certainly God sent to all of us Ben proceeded when it came time for Ben to go back to Charlotte David said there's no way this child is going back to that environment it's not going to be successful for him it's not going to be successful for his family and so Ben stayed with us we got him through high school barely as bright as he is and as full of personality as he is we got him through high school with enormous support and support extending even when he was in high school extending to on the phone support with NFI staff when we were on vacation in Maryland he needed a year between high school and his next step and fortunate enough to go to a school in Maine called Bridgeston Academy that enabled his growth to continue and at the end of that in between year he was accepted as a student at the University of Maine in Orlando where he originally wanted to become he thought he wanted to become an athletic trainer and and within a month made the decision that he as a employee of the South Brooklyn Rec Department and Rec Camp during summers had had four young men that were in his camp that he took a great affection for and really appreciated that they appreciated him and he said that in view of the fact that he could really help them and wanted to continue to help children in that circumstance decided to change his major and become a social work major and Ben is now a mid junior year major in social work is and I say this with a lot of pride in him he is a really big force on the University of Maine campus and in fact is going to be the director of the on-campus director of student intramural athletics next year for the entire campus it's a great success story and what has driven me is letting every child in the state of Vermont to the suffering from toxic stress have that ability and the resources available to them to make that same transition we can heal these brains and he is 95% healed so along with the way in this journey I volunteered to become a board member at NFI and had no understanding of what was going on with this young man and then suddenly started to learn what was going on with him and Brina has mentioned the brain science that we have all come to discover that leads us to do the understanding that as long as we diagnose toxic stress and start working with individuals suffering from toxic stress we can heal these brains until their age 24, 25 or 26 we know that's capable and so I'm not going to spend a lot of time on this slide just to bring it to your attention but the results of toxic stress are pretty profound and this is part of my educational journey and the part that I want to share with you so if a child has three or four in Ben's cases five or six aces we could look at behavior that's going to be risky for him which is lack of physical activity smoking, alcoholism, drug use and staying at home not going to school not going to work but the long term effects are all the effects that you're dealing with from a healthcare systems perspective and that is going to continue to be extremely costly for us how many children are affected and I hope that you've seen this but I'll go through it briefly right now there are in the last count there are 15,800 children in this state who are affected with three or more aces and they're probably more than that because as Brena said aces don't take into account homelessness they don't take into account poverty some of the social departments that are additional to these that we know but you can see the array of the major ones here being divorced and separated patient, parents, family income, hardship and substance abuse issues there's a subset of that of children under six and so we have 3,000 children under six who are living with toxic stress that are going to be demanding resources from us the magnitude of the problem is I began to to sort it out in my own mind as a healthcare professional became obvious when I started talking with some of those that I'm close to in other areas of interest education and spent time with Melissa Bailey as a commissioner of mental health services Con Hogan who was a dear friend and advisor Charlie Smith who was also a secretary of the AHS as an advisor we started to try to scramble what this impact on all of us was really like so this is a graph of the expenditures for departmental health directly related to children with ACEs. This is Melissa Bailey's graph which shows the slope of that graph beginning to change in 2011 and accelerate on a something like 10% per year basis similarly this is from my dear friend and colleague David Young at the South Row in the school system I will share with you that my first conversations with David were back here in 2015 when he said this is problematic for me at $9 million a year I am struggling with that amount of budget money dedicated to my budget and it's a challenge to me this is 2017 2019 that number is now budgeted well $11 million for David and David is saying this is no longer a problem this is out of control and I can't continue to manage it. So this is the richest school system in the state of Vermont that is saying whose CEO is very very skilled in attuned to these who is saying I can't manage this anymore in my school system and that goes across the system for all of us so here's the high point of my learning from the challenge that we face toxic stress represents the most vexing, ubiquitous public health crisis we have ever faced I will add to that that we right now believe we face a huge public health crisis which we do in opioid use but those who study addictive behavior and numbers coming out of the University of Tennessee Health Science Center and their directive of addictive behavior says that 84% of those people with opioid or other types of substance abuse and addiction have in fact 3 plus aces so that while opioid addiction is certainly a public health crisis we in fact need to take on the root cause of that crisis which is toxic stress and adverse childhood events so we skip the second line we know that already those numbers of children mean that over 5 children in our school system are suffering from toxic stress which means that each classroom of 20 students has potentially 5 children who at any one point of time are going to exhibit disregulated behavior and cause disruption in that classroom out of the $411 million dollars we spent on care for children who were suffering from toxic stress in 2017 12,000 or 46% of that was spent on education and in the educational system the long term impacts on Vermont of toxic stress healthcare impact is $363 million dollars we believe that there were almost 80,000 visits in emergency rooms last year resulting in $120 million $26 million of expense there and here we sit and Brino was saying how 7 old this piece of academic study was and we're 20 years later and there has not been anywhere in the country a systemic approach to addressing this problem and it's covering all of the states within the country and it's not a problem that is unique to the United States here is the best I have been able to put together is a cost of ACEs in the state of Vermont some of these are computed costs based on actual numbers within our budget and then there are national estimates that are based on the ACEs studies so I know pretty closely that we spent the $411 million in 2017 the numbers would indicate there's another $136 million dollars in criminal justice long-term healthcare and then there's a whole other bucket called lost productivity caused by ACEs affection people's lives so that the best guess from the ACE study is that the impact of ACEs on the state of Vermont is something in excess of $2 billion a year what do we do about that and so beginning from this slide which is now 18 years old 13 years old 13 years old this is Khan's slide this was Khan's plea as to how we can get ourselves reorganized to take on toxic stress so he said we got to get out of our silos we got to broaden our thinking we've got to do things differently than we have been doing things we've got to have data we've got to have indicators of outcomes and we've got to understand what we're doing and what effect we're having and we've got to go to a prevention oriented approach this is just a graphic presentation of my learning this is not comprehensive learning at all this is a graphic presentation of 21 programmatic initiatives that have either been implemented in the state of Vermont or have been studied and you'll see Dolce is up here there are other nurse home visiting models there but the message is that we have lots of activity going on in this space there are a lot of people trying to make things better I won't go over this it's Heckman's graph and the graph is pretty simple we need to invest way up street in our dollars it's not going to be effective to investing dollars out here if we're going to counter these problems so as my journey unfolded so what do I know that I can apply and help with this one of the things that I learned fairly early on in his journey in working with Don Burwick from IHI was that his triple aim which is improving the health of a population enhancing the experience of care and reducing per capita costs are the keys to solving our healthcare prices without that we don't have an affordable system and we are going to continue to struggle so packaging that foundational programmatic approach would indicate that we're going to have to try to integrate our systems in a different way our health system, our behavioral health system our educational system our human services and our criminal justice system those really were driven by conversations I had with state leaders in all of those areas whether it be education and David Young whether it be criminal justice and conversations with T.J. Donovan it appeared that we needed to have a proactive systematic way to integrate those services that led to my belief that we could in fact construct a discovery project unique to the state of Vermont based on state of Vermont learning values and experiences ranging from all that the legislature has done to move needle on healthcare provision to all that the health department have done in home visiting and all that we have aspirations for doing behavioral health and primary health that it would be possible to actually conduct a control trial study of what a new system of care and services for the state of Vermont might look like part of that belief is built on this particular slide which actually was crafted by the agents of human services back in 2017 where they wanted to work from across this continuum from a network to an integration perspective and in many services they are now out here with some really really tight collaboration and specifically that collaboration in integrated family services in both Addison and Franklin counties have been very very successful the aspiration is to get those integrated but certainly they are very very collaborative and the second very very pointed piece is the collaboration between inter agencies that is reflected in this program which is in fact collaboration between the health department and the agency of human services but the entire focus has been to create a respectful model of care for those that we are trying to serve so along my journey and see how we are doing for time along my journey I was reconnected with Ken Epstein Ken was the CEO of NFI Vermont in childhood trauma back in the mid-80s prior to the discovery and quantification of ACEs Ken was working with a group of his peers from San Francisco on trying to understand more about what was happening with children Ken and I have worked together to try to figure out what a research project might look like and this is Ken's experience PhD wisdom from the University of California San Francisco where he has been a faculty member for a number of years and his belief is what would be most beneficial is a public-private partnership that we are proposing to try to do which would codify a blending funding structure for children and families that are consistent with their core values and these are SAMHSA core values relative to behavioral health services that would rest in a single continuum of care organization a unified organization and here is a really important key that organization would be in a position of taking joint funding accountability so that in essence this is saying that research study would study an integrated continuum of care that is a sub-provider under an ACO arrangement this would be a continuum of care that could take a capitated amount from an ACO and move that down to the community level and the entire reason for doing this would be to redirect special education mental health and child welfare criminal justice services and in our belief those need to be moved upstream into both home visiting early childhood education and care and home care the continuum would have these attributes would be defined collectively by the participants it would be proactive countywide inclusive of everybody up to age 25 because we were able to heal brains up to that age it's got to be trauma driven data driven because we need to understand what we're doing both clinically and financially so that we know what the benefits are that are working in those that are not certainly trauma informed highly functional and in my belief it should be in four cohort clusters the pre birth 00 to 3 4 to 17 and 18 to 25 all of which have different characteristics so we saw this slide this is what we look like at the present time this is what I think we could look like and we could look like a system of care and services that are integrated that have clean handoffs between very fine sectors of providers and that are in one way or another on their way to definition by themselves this one here you heard today it's pretty it's pretty robust and certainly growing more robust and it is a key component because it is the early stopper of childhood toxic stress and so the more we can get into this system of care the more we can take that 16,000 young people and narrow that down in numbers we're all working hard here 0 to 3 0 to 4 we're all working hard on the 5 star child care system my belief is it needs to be on steroids it needs to have very very robust dulce like integrated like support services in that 5 star model so that children can move from home to home care to day care that's going to give them the same support structure that they have had in their home care visiting and then we're going to need to look at this educational system and figure out how we're going to balance the social service structural support needs versus the educational needs in a very thoughtful and different way than we're doing it right now we cannot just move dysregulated children into our school system and expect the school system to fix it it's not going to happen and then out here we have a whole group that as I've served on the NFI board and have come to understand more fully we have a whole group of those who are 18 to 25 who are suffering from toxic stress whose brains are not healed who we don't provide any services to and out here at that age group we have those who are forming new families those who are marrying those who are bringing children into the world and it's a prime time space for intergenerational toxic stress and ACEs so that's a proposal that's floating around and it's floating around in Addison County it's floating around within the legislature it's actually floating around in AHS and we'll see where that goes I bring it to you specifically as we're looking to accomplish this it is a systemic approach we we need to we need to look at how we're going to integrate all these services out here in one system of care that we can finance outside of the outside of our own resources and we can do that because of Ken Epstein's presence as a major force in trauma throughout the country who has direct contacts with several of these entities most importantly Robert Wood Johnson, the Harris Foundations and SAMHSA and so the project that we're proposing would be directed by the RTP which is organization that has been a nonprofit organization we formed back two years ago to in fact hold some of this effort it was formed by David Young Charlie Smith Chuck Myers and John Sales and myself we would propose the study to be conducted by Ken Epstein and myself as co-principal investigators supported by data from the FTI Center for Economic Policy Center for Healthcare Economics and Policy and that we would use presently existing data streams out of the data system that is shared between the Department of Mental Health and the Department of DCF objectives will be pretty clear measured improvement in the health of Addison County residents measured improvement in the satisfaction of families and their interface with the services and we need to bring back to everybody most importantly to you and to the legislature and to AHS a measured and quantified impact statement of what can be accomplished with the various component pieces of change that are currently in play when they're packaged together we know there's a rate of return to be gained from Dulce home visiting we know that's somewhere in the neighborhood of five to eight or nine percent we know that there's a rate of return to be generated from five-star child care and that's probably from five to 13 percent we don't know what the the rate of return is to be generated from applying those across the continuum of care and until we have that number then the legislature and administration can't safely say we ought to invest substantial amounts of dollars in changing our numbers and our social support structures until we can define what the rate of return is going to be on those dollars and this is your charge relative to ACO development in ACES it is a big it's a big responsibility for you to understand the dynamics of this extremely expensive and pressing problem expensive from the perspective of finances but from the perspective of its impact on our children and families that's my journey thank you for allowing me to share with you thank you Tom questions for Tom from the board Maureen do you have a question? he doesn't know so at this point we'll open it up to public or comments questions thank you very much Tom yeah of course so Michelle Degree Health Policy Advisor with the board I'm just going to provide a brief introduction to those of you here and the next set of presenters for today's meeting as you'll recall section 10 of act 113 of the Act 2016 established the primary care advisory group with the intent to provide input and recommendations to the board the language at the time specified three topics related to administrative burden and required the Green Mountain Care Board to provide an update on the work of the PCAG in our annual report despite our best efforts there was no action taken to amend the statutory language so the PCAG officially sunset on June 30th of 2018 given the general interest of the board to have primary care provider opinions and perspectives we used existing authority to create or to renew the PCAG outside of those statutory requirements each member of the group that started in 2016 through 2018 was urged to reapply and we did work with external partners to expand the reach of those applicants including the medical society and by state the review of applicants we did make sure to pay special attention to ensure the group had representation from various categories and types of practitioners to spend use in geographic locations and I'm pleased to say we did a pretty good job there are 13 providers who meet bi-monthly and our fourth meeting of this newly formed group occurs this evening so they're here to kind of talk about and highlight opportunities for improving access to primary care from their perspective another piece of their charter is to work with the board on areas of interest and so with that said we often do have a board member in attendance at the primary care advisory group meetings to sort of work through those topics with the providers any questions? any questions? I didn't think so yes Robin will be there tonight we always have a board member in attendance and we always have the executive director in attendance so I just wanted to clarify and there's always a staff member so with that I'm going to bring up the three providers we have here today and I'll let them introduce themselves and I will step away thank you very much I guess we should introduce ourselves first and go into my name is Tim Tanner I'm an internal medicine pediatrics practitioner working at the Danville Health Center and I've worked with Northern Counties Health Care I've been here since 1993 I also do part-time work as a hospitalist at MBRH I'm Leo Presti and despite what the agenda says I no longer work at Gifford Health Care I left there in January and we'll be starting with in FQHC actually located in North Adams Massachusetts but still serving in other parts of Vermont and I'm going to continue to live in Vermont and be insured in Vermont so I still care I'm Faye Holman I'm a family practitioner in Wells River, Vermont been there since 1993 also a broad scope of family medicine and some inpatient care at Cottage Hospital which is in Woodsville, New Hampshire as well I'm sure you've been the opportunity to come and present our concerns and appreciate the time that you're allowing us and also to hopefully answer any questions you might have about any primary care related and the sort of desperate topics that we're going to be bringing up and I've been elected to go first You just speak a little bit louder Sorry So my topic is on documentation parcels if you will the primary care providers face and how that impacts access and burnout and I'm hoping to sort of give a little bit of a brief history if you bear with me with that and maybe throw out a few bizarre ideas solutions and maybe something that actually we might not care about that I have one slide that I'll ask if someone could project it not yet I don't know where those are on the agenda is that possible Which document was it? It was E&M Audit form but not yet It'll take a few minutes so I'll just get ready So there's been a lot of talk about high value care high value documentation and the value part depends on your perspective who's looking at the documents So once upon a time in medical history not as long ago as the brother's grim but not that long ago medical records were a mess just with something you scribbled on on the bedside and it was hard to follow and then Dr. Barry Weed in the 1960s sort of developed a system that's kind of standard now and that's been sort of carried forward and originally documentation was principally for clinicians to be able to remember what they were talking about the next person coming along to try to figure out what's the story where do we go from here then came in some requirements for the medical legal aspect if there was a document you didn't do it so that maybe improved things a little bit and then the demands on documentation and that really has where we've been for the last 25 plus years of documenting to the bill and if you could now project that that bomb Hopefully you're on the 1200 step Yeah 12,000 12,000 So this is an example of the headed filling audit form that our organization uses and I just projected for the emotional impact because it's kind of a Chinese menu of things that you're supposed to document in order to justify billing an office visit at a certain level for reimbursement and the result of this sort of is notes that have lots of verbiage that really don't have a lot of meaning to the clinician the electronic introduction and electronic health record has made templated notes and clicking boxes the ability to do billing better but made these Frankenstein notes that grammatically don't flow that have information pulled in in order to satisfy a billing requirement and then added on to the billing thing where recently has been the expectation that primary care providers provide documentation for population management for quality and for research with defining ICD-10 codes and things like that so if you add all these things up the clinical need, the need for medical legal coverage the billing which is the major driver probably and then the population stuff this all takes time and that's time away from patients it's time more in front of the screen it's less access if you're an employed physician as I am it may be less time for patients if you're a self-employed physician it leads to burnout because you're doing charting well into the night how many days so that's sort of the frustration part and then so where do we go from here and this is sort of the ideas of two other problems out there in a galaxy far far away you could jump forward I would like to see the day where the patient comes in and puts their smart phone down on the desk and that's recording into the combination of artificial intelligence that the provider does and analyzing the metadata the stuff that's going on that shows where we've been perhaps the note could be all the documentation would be done through that the medical information is the patients ultimately it should be residing there the ones that contain it more realistically I was hoping that with the all peer model perhaps there could be a waiver so that we don't need to document all this stuff in order to get reimbursed CMS is actually now starting to move that way they're proposing in 2021 to change the billing requirements and drop the history and physical parts of documentation and just build based on problem complexity number of time and I've seen some of the templates and they don't look any better than this one really in terms of what's required but from the standpoint of the Green Mountain Care Board at least when you're reviewing budgets for the ACO or hospitals to raise your concern about what are you doing to try to decrease some of the click counts the documentation may not be directly clinically relevant when you're reviewing budgets to sort of decrease provider burnout that's all I have and that's a great segue to me who was assigned to talk about burnout in detail because that's a big concern one of your priorities for this year listed in your 2018 report is healthcare workforce and this greatly impacts the healthcare workforce I had to work with that segue first but again I want to thank you for inviting us and listening to us and by having a board member and the executive director attend all our meetings taking us seriously so one of the big concerns in the medical literature has been burnout among providers and I had two slides or two things I don't know how whether they got entered or whether you just handed them it's a table and a figure and the table shows over five years of it okay the table shows over five year periods in the medical literature the growth of articles on burnout and of special interest of course to me in primary care is that the number of articles in five year periods increased by 20 times in the last 25 years so that's table one there's the article so I just picked a well respected journal the New England Journal of Medicine and the bottom thing the figure is the graph of how many articles they had on burnout each year in the New England Journal and you can see that from 2016 to 2018 it has just exploded most of these articles when I reviewed them used something called a Maslack inventory so there are well validated measures to measure burnout if you will and healthcare providers I'm going to qualify that in a second the Maslack inventory covers three areas emotional exhaustion depersonalization and personal accomplishment high scores in the former two the emotional exhaustion and depersonalization contribute to a potential conclusion of burnout and low scores in personal accomplishment do the same so you have to have high scores in two of them and low scores in the third unfortunately however despite the number of articles there is no great upon definition about what burnout is so that's up to the author authors of the article but if you give them that freedom they say that the number of providers that are experiencing burnout symptoms is between 20 and 40% and when they look at this with regard to other aspects the burned out physicians and other providers are associated with higher turnover and occasionally in some articles with worse patient outcomes neither one of those is a good thing for the state of Vermont incidence of burnout in these studies is higher in female physicians I haven't seen an article about there's higher in female providers in general just in female physicians so I have to say it that way but that's an increasing segment of our physician population I can tell you I'm an old guy okay my class at UBM medical school that was 14% female I believe they've been over 50% for several years and nationally we are over 50% female in medical school classes so as these people if you will grow up and go out into the world if burnout is higher in them we're going to have an increasing problem to deal with so I have some theories about this one of them is low and behold electronic health records and the stuff that came with them including the high tech act and meaningful use the documenting for quality and that Jen mentioned so the use of EHR is nearly quadrupled from 20.8% to 78.4% between 2004 and 2013 now the growth in the articles itself was pretty steady through most of those periods of time but that's just one of the factors another one that concerns me is an increase in the number of administrators now I worked very hard to find the raw data for this chart but I couldn't find it so I didn't put it in the stuff you were given because I didn't think I could say that it was absolutely reliable but I have seen the chart in four or five different sources it's almost always the same chart that shows that physicians grew about 150% which was the rate of population growth pretty much matches the rate of population growth over the period of time from 1975 to 2010 during that time the number of health administrators and how that was characterized in this study which is why I was looking for the base data and couldn't find it supposedly grew 3200% in other words that it's 32 times more administrators in 2010 than there were in 1975 the problem with that from a primary care perspective is that each administrator requires us to work to support them because we're the people who bring the money into the organization we and obviously the other providers do that so we have to do more work to support them at the same time we're trading that for decreased control over our life and again we don't think that's a good thing the third theory that I have is the rise in hospitalist care this may only be applicable to primary care but in the 10 year period from 2004 to 2013 that same time period that I was talking about the EHR the number of hospitals in the United States tripled from 14,000 to 42,000 I gave up doing hospital care unlike my colleagues here in 2010 because I was going to a practice that didn't do it and I thought that was a great thing because sometimes working in the hospitals happens at inconvenient times and all kinds of things but I have found that no longer doing hospital care has led to less contact with patients at high stress times which impacts my feeling of whether I'm providing them really true continuity of care and I think that it also decreases the amount of trust that they have in me to deal with their worst problems than I can deal with their more minor problems in the office as well in their minds it also leads to more constricted areas of practice and I think less challenge in my practice obviously the people in the hospital are sicker than the people in my office and that challenge and intellectual challenge of dealing with those things is lost when you stop doing hospital care it also leads to less interaction with specialists and with other primary care colleagues who we used to see and passing in the hospital say hello, how you're doing all of that kind of stuff we never see them anymore and that leads to more isolation so I think that those things all contribute to the feelings of burnout I don't have solutions for them unfortunately but I want to I did not know I didn't look at Tim's this way but if we could put that back up there I'd like to close with words written by Alexis de Tocqueville in Democracy in America which has nothing to do with medicine but he wrote that we will be smothered with a network of small complicated rules minute and uniform through which the most original minds and the most energetic characters penetrate to rise above the crowd the will of man is not shattered but softened bent and guided men are seldom forced by it to act but they are constantly constrained from acting such a power does not destroy but it prevents existence it does not tyrannize but it compresses, innervates extinguishes and stupefies the people that's burnout in my mind well I'm not going to top that I don't think I actually scribbled a couple little things in my margins while Tim and Lee were talking and just a few numbers and thoughts to support what they said there's a paper that says that for an average patient to get through a primary care visit it takes 233 clicks in the computer so decreasing that clicking would go a long ways to decreasing burnout and in terms of this insane documentation that we do the electronic health records response to it is to produce all these templated notes notes that have all the yes and no answers already put in them, notes that have these 29 point review of systems already answered and the idea is that the provider is supposed to go in and take out the ones that they didn't ask the patient and what really ends up happening or take out the parts of the physical exam on the patient and what really ends up happening is that there's a lot of documentation of stuff that didn't happen just by human nature because you don't go in and revise line by line your notes so that the complexity is actually in a perverse way sort of making there be in accurate documentation to Lee's point about burnout I was at a talk within the last year where they said that to recruit a new physician the cost is often about $300,000 so burnout is a money issue or is a cost to the system issue as well and documentation is a huge cost to the system and I'll just mention that at the federally qualified health center where I work if you count our employees who are there because of the electronic health records so our IT team who keep the nuts and bolts working informatics team that makes the templates collects the reports crunches the data and then our medical scribe so we actually have people who do our documentation for us if you count all of those IT related people we have six IT positions for seven provider positions that's insane there is no way that that expense is reflected in improving quality so now I'll do what I'm now I'll talk about what I intended to talk about which is strengthening primary care in Vermont I think you may have an outline but don't look at it because I'm going to jettison it completely when I was it's really just for reference because there's some thoughts on there that you may want to look at but when I was putting together my thoughts on this talk I realized that my outline for this talk was exactly the same as an outline for a talk I did in December of 2017 and also one that I presented to you in 2018 and so I thought you probably didn't need to hear me rant further about quality measures and the electronic health record but really I just want to talk about peak hag which is in this new iteration there were a number of people that didn't sign back up and several of them told me that the reason they weren't interested in continuing was sort of this feeling that although we have a lot of ideas a lot of thoughts and some great conversations that happen that in terms of really visible outcomes there hasn't been a lot we don't feel like we've really changed things very much and so if there's one thing that I could say about the 2.0 version of peak hag it's that we want to look for ways that all these disparate organizations institutions can really work together for implementation of some of these changes there's really no argument I don't think anymore about the centrality of strong primary care to increasing access to care, increasing quality of care and decreasing cost that's been really well proven but it feels like there isn't much of a sense of urgency about making those changes and those changes require institutional change and cultural change which are not fast but in terms of that sense of urgency there's one paper from the annals of family medicine that I like to that has just stuck in my head it says if cost trends continue at current rates that by 2033 which isn't very far away certainly in policy terms not far away at all by 2033 the cost of a family health care premium will equal the median family income so knowing as we do that building a system that has primary care central to it will increase access and quality and decrease cost seems to be really maybe the most important goal we could have there's really nobody else who's offering improved quality access and decrease cost there's no other proposals that get there one of the things that has been shown to move the needle a little on establishing a strong primary care base is this increase in primary care spend rate that was undertaken in Rhode Island and I know that all of you know about this and I'll just quickly recap for anyone in the audience who might not be aware but out of out of one health care dollar currently about five to nine cents is spent in primary care in Rhode Island when they decreased that number of cents from five to eight they decreased 18% the total cost of health care in the state so it was a really effective way of getting towards our goal there are a couple of bills in the legislature I guess one now at this point S53 that begins to sort of get at that primary care spend rate and how to increase it there are probably a lot of ways to go about it in Rhode Island they did it by legislating that the insurance companies had to figure out how to do it but I'm sure there's many other ways and this is what I'm talking about when I say that Peacag would like to figure out how to work together with other institutions because I think we could brainstorm some real ideas there and you know people think I'm kidding when I say that there's only two important quality measures and I really am not kidding I mean it absolutely there really are only two quality measures that matter and they are not in the electronic health record there are population questions do you have a primary care provider and have you seen them in the last year that's how we move the needle on this and so anything we can do to build that system really should be a priority there's one little ticket item that we talked about in Peacag and that I think we should find a way to make a reality and that's a Vermont common drug formulary that would be a document wouldn't have to be cast in stone wouldn't have to be 100% accurate but a document that if you chose a med from that document when you were with a patient the high likelihood would be that it would be a tier one drug for your patient that you were sitting with that day a document like that has sort of existed in the past someone from Blue Cross brought us or told us about a project that a pharmacy intern had done with them that kind of got at establishing that kind of a document on Peacag in terms of implementation and action we would really love to know how can we make that a reality would the insurers take it on would our new pharmacy school and Burlington take it on how can we make that a reality in terms of decreasing the amount of clicks and the amount of time and administrative time that we spend in our office and that pharmacists spend on their end their low ticket goal I'm going to tell two little stories about one of my items on the list being developing an electronic health record that really works for documentation and communication not just for billing so in the current world I've ranted before and I won't be labored about the discharge summaries that I get from, we'll say hospital A where most of my patients go they're really long their length one is 42 pages but very frequently the discharge summaries are 20 to 30 pages long it's enormously time consuming to wade through and see what was important and what I need to pay attention to I had one of our IT people reach out to hospital A to see what we could do to get more useful documentation and the reply she got was we can't control what our doctors put in their discharge summaries that's the world we're living in right now if we had a system where primary care was really seen as the central organization or the central thing on which healthcare was organized I would hope for a different answer and to illustrate that I'll say that a couple weeks ago my father-in-law was hospitalized at hospital B in Vermont and I was given his discharge summary and it's important to note that these two hospitals used the same electronic health record I was given a copy of my father-in-law's discharge summary and it was three pages long it had everything anyone needed in it the five diagnoses he had been treated for what was tested for, what the results were and what the primary care doctor should follow up on as an outpatient it was the most concise useful document I have seen since the days when we dictated letters to each other and I had a system that believed that primary care was central my IT person would call IT person at hospital A and that person would say that's fascinating, let me go see what they're doing at hospital B and see what we can do to improve the quality of our communication so that gets me down to workforce which if we're going to strengthen primary care obviously we need a whole lot more of us and on PEC we've talked about a lot of ideas about that is really this concept of narrowing the salary gap between specialists in primary care I'm not talking about upending our system and paying family docs and cardiothoracic surgeons the same I'm really just talking about a little nudge in the system so that our students who come out of medical school have an option of choosing primary care my illustrative story is of a woman I know who left a dermatology fellowship recently well about three years ago I guess she was offered a job with $150,000 signing bonus and a $1.2 million salary not in Vermont but not in that different of a state honestly her signing bonus is more than any primary care provider in my organization even the medical director makes per year so again not asking for more money from the system as a whole just a little nudge to bring those things together together there are a lot of ideas in P.K. about improving our workforce and improving the number of people who are trained in Vermont last week was match day at UVM and match day is this really heady day in your fourth year of med school and everyone gets in the same room and you all open your envelopes and you find out where you're going to be for residency and for the next three or eight years depending on what you're specializing in last week and you make some corrections for the percent so the three specialties that are most likely to go into primary care would be family medicine, pediatrics and internal medicine you have to apply a little correction to that because in P. it's only about 44% stay in primary care in internal medicine it's way lower only 14% stay in primary care most specialize in family medicine that's about 91% so if you apply that correction to the match day results from last week at UVM, 16% of their graduates from this year are going into primary care that's a really tiny number there are programs across the country innovative programs some wave tuition for people who commit to 10 years of primary care some look at identify students as young as high school that have an interest in medicine in primary care they shepherd them through summer programs they establish job shadow opportunities for them as young as high school in their own communities have them go back to that job shadow when they're medical students and when they're residents those programs are working Alabama has figured out how to get their own residents to provide care in their rural communities how do we move towards innovative programs like that just in the medical school training but the same thing could be applied to nurse practitioner training in Vermont and we could look at our residency training as well we make six we graduate six family medicine residents per year in the state that's the same number as we graduate in ear, nose and throat surgery and anesthesia there are ways to move the needle on that PECAC has a lot of people who are enthusiastic, energetic even idealistic a few of them we would love to talk about ways that all of these organizations because it will take small hospitals, big hospitals insurers state agencies it'll take all kinds of institutions to change a little bit with approach and culture to get there and so I'll wrap up and hope that we have a little time to talk about that now, thank you thank you, questions from the board thank you for being here as the board member who used to come regularly under the previous version of PECAC most of you are very familiar to me and I appreciate all of your volunteerism that you have provided for the board a couple of things I just wanted to mention in the conversation one is about for the folks who didn't continue after the Act 113 version of the group I'm sympathetic to the frustrations around the charge of that group in Act 113 and really what the board is able to act on because I think that those three items that PECAC was charged with were really for the most part not within the board's authority so there's kind of a mismatch in some ways I think we were chosen really to facilitate the group and provide the legislative report and that was maybe not clear so I'm hoping that with the reconstituted PECAC now that it's directly related to providing advice to the board on really our purview that that will be a more satisfying process for you all and for us because it certainly is frustrating for us to get really good information and really good recommendations that then we don't have the authority to really do anything with so I just wanted to hope for the best for our new reconstituted charge and on the primary care spend I know that our staff has been following those bills related to the primary care spend we did a ACO budget to start to test that it's not really I don't think it accomplished what we were hoping for but that's certainly something that I think I'm very interested in us looking at one caution I think on the ROI in Rhode Island is that they had not really implemented patient centered medical homes and they were hoping to do that at the same time so there could be some conflation there in the savings between the patient centered medical home and the increase in spending but regardless for me personally I think that it's a very interesting concept that hopefully we'll consider looking at that more in the future Any other questions from the board? Comments? I don't have any questions for this one thank you very much for coming and I've attended a couple of recent PTA meetings and a lot of your insights have been quite helpful I'm looking forward to more conversations I just want to share my frustration because some of the administrative burdens we've been talking about these for more than a few years more than a decade we don't seem to be making the progress that we should be making I've said repeatedly that workforce is the biggest crisis facing medicine in the state of Vermont and it's not just a lack of congratulates but it's also keeping people in the workplace people to be honest with you I'm about to pale on your two quality measures because my primary care doctor is retiring and despite my wife telling me repeatedly that I had to get out to find another primary care doctor before the retirement date I'm a week away and I don't even know why I'm going to get the records I'm going to find somebody quickly so that is very scary and I know that one of the things I said is we're getting older I should be finding a younger doctor we're good luck with that so it's a real problem until people are willing to make the decisions that are willing to make changes I'm not going to go away I'm going to try to take all of us in small things that have happened we've seen Pyrost or OneCare things like that but again it certainly doesn't seem to be enough I can tell you that my primary care doctor is retiring next week is his last week I remember the time when he told me that if he had to do electronic medical records he would retire but he somehow managed to live through that whole change in medicine but he's ready to call it quits I don't think there's anything that anybody can do or say that's going to change his mind and everybody should be allowed to retire at some point so that I just want to thank you and open it up to the public for comments and questions Chair Malik can I just say one other thing just to tie both of these parts of the conversation together I have taken down some notes on some of the things that I think would be helpful for us to go back to the PCAD with on what they can do to inform you and this is great to hear anecdotal information but I think I'm definitely hearing workforce as a real issue on both sides so I want to make sure that we follow up with the PCAD so we can potentially find some real solutions to these issues can I actually manage to add something because you're talking on memory a little bit so we have had the conversations we had a panel about administrative burden to retire off in the last month we have continued conversations with carriers so we haven't forgotten about it and those conversations continue and what we're hearing there's conversations happening at the carriers about how they might move forward with some potential school charting so I just want to update you all that we have not forgotten that that's great Ms. Malik I just want to back up Senator chairman Mullin said in the family practice that I go to in the last ten years I've been through four primary care providers they've all gone to the hospital retired or what not and who knows how long the moment I have now is he is actually younger than me surprisingly you're doing pretty good married him pretty good we're both here another comment wants to address one speaker said yes and I have two comments on that one is concerning the bills we've been trying to do a universal primary care bill for the last four years and it's got absolutely nowhere this year SH 129 did not even get off the wall of the house health committee I'm not sure about this but three I don't know if that's just for study or something like that I haven't really dealt with the bill yet but the will to do something like this is simply not there up in the dome up in the building they don't want to have anything to do with it they want to push it somewhere else the money you can go for this or that but in the meantime I wrote a commentary in the Vermont Digger that was actually published yesterday on the struggles that the Digger Moncters have to do sometimes to get insurance to get access in the primary care and that details what I had to do and that's just one person you know I had troubles with insurance and with Medicaid and when I went into the doctor after getting all of that they discovered that I have a condition that could be fatal down the road genetic basically and it's the problem but if I hadn't I actually had to go through Vermont Digger Lake and no one should need a third party advocate for them simply to get into a primary care but the problem as one of the presenters said is access and until we have the moral and political courage and I don't mean the board I mean the legislature and our society we're never going to be able to tackle this we're not going to do it for one care we're not going to do it we're trying to push the buck kick the can down the road so they don't have to pay for it which is what's really going on but more and more Vermont Diggers are having so many problems accessing because of the way the insurance system $500 for an insurance premium for one and then you've got a deductible and and I talked to one woman last night who deliberately keeps her salary just above minimum wage so she can just get access to her this is the problem thank you for the comments and questions from the public seeing none thank you very much thank you thank you thanks is there any old business coming before the board seeing none is there any new business coming before the board seeing none is there a motion to adjourn we'll be in second