 We are going to get started because we've got lots of information to share with you today. Welcome. My name is Monica Hutt. I'm the Chief Prevention Officer for the State of Vermont, and I sit in the Governor's office and also act as the liaison to the Agency of Human Services. Who is who you're going to be hearing from today to talk a little bit about health care. So, yes, representative. Oh, I'm always very reluctant to do this. Is that better? Okay, great. So today we're going to set the table for you and talk a little bit about health care. Talk a little bit about what we mean when we use that phrase, the scope of the health care system here in Vermont, some of the challenges that we're seeing, and some of the ways that we're already working to address those challenges. As most of you have heard, you've been through some of these already. This is a briefing that is designed for legislators. So we will pause often to make sure you can ask questions. If you have questions and it's not a pausing moment, just raise your hand and we will make sure that we stop. We want to make sure you get the information that you need to feel grounded and confident when we're talking about health care and when you're talking about health care in the State House. For those of you that are stakeholders or media, if you have questions, we're happy to follow up with you offline or afterwards. But we're going to focus on our legislative folks for here today. Also, I want to remind folks that we did have one of these briefings on community development that was scheduled or had to be rescheduled, and that will be happening next week. So we hope that you'll come back and continue this kind of ground setting, level setting process that you've been doing with us for the last two weeks, actually. So without further ado, I'm going to get us started. We've got lots to cover. We also do have a group coming in at 5.30, so we'll try to make sure we're wrapping up right around 5 o'clock and leave a few moments for any lingering questions or catching people in the halls. But I am going to go ahead and introduce, and by the way, if you don't have a handout, let me know and we'll make sure we get one to you. There should be some in the back, but I want to make sure you can follow along. And then I'm going to hand this over to Secretary Jenny Samuelson of the Agency of Human Services. She's going to introduce her team and then we're going to get started. Good evening, everyone. I'm excited to see you here. It is so exciting to be back in person with the legislature in session. So thank you for coming. As Monica said, we're going to go through, and we're going to start in a very basic level. And for those of you who are familiar at all with the healthcare system, just bear with us as we move through it. Before I get started, I want to introduce some of my team who are here today. I'm going to be presenting their work, and I want to acknowledge that right up front and the work that they do on a day-to-day basis. In addition to Commissioner Haas, who is the commissioner of the Department for Mental Health, I also have Deputy Secretary De Laus, who's here. I have the director of healthcare reform, Ina Bacchus. Also the director of payment reform from the Department for Vermont Health Access, Pat Jones. And Shayla Livingston, who you see often in the legislature, and if you have any follow-up questions, Shayla is probably a great contact, and she can help make sure that it gets to where it needs to go. I'm just going to check out the technology here. Where do we need to aim this? There you go. So just to ground folks, and I'm getting a little older, so in order to be able to read and to be able to see you, I'm going to swap my glasses back and forth, so patience there. Just to ground everyone, 97% of Vermonters are currently covered by health insurance. And this is really important and an important statistic because health insurance allows Vermonters to financially access healthcare. And it's different than most other states across the country. We are tied or very close to tied with Massachusetts for having the highest coverage rate across the country. But on average, what you will see is that it's much closer to 10% in other states. And so that sets Vermont apart in terms of how Vermonters can access healthcare. It's also important to recognize that that healthcare is distributed across both public insurers, so Medicaid, which covers Vermonters who are low income, often children in Vermont, and some Vermonters who have disabilities, and Medicare, which is a federal program. The Medicaid is administered by the state and about 50% of those funds come from the federal government. And Medicare is covered by the federal government and administered by the federal government for individuals who are older Americans. And so the other 50% of Vermonters are covered by commercial insurance here in Vermont. And for commercial insurance, they typically get it either on their own or they get it through their work or their business. And so that's an important component. The other reason that we focus on healthcare in Vermont is that it makes up a significant proportion of our gross state product, almost 19% and growing for over $6 billion. And I should have grounded us as we're talking about the healthcare system. In this case, we could be very broad and we could talk everything from the very specifics of primary prevention, so things that happen in our communities to keep people healthy all the way up through hospital care. But in this case, we're really talking specifically this evening about the system that provides care to Vermonters across mental health, primary care, home health services or services that are provided, medical services that are provided in your home. Also skilled nursing care and a myriad of other pieces that make up that $6 billion, but it is confined to that care spectrum there. And it does include prevention, but it also goes all the way up through the hospital level of care. So as we think about our healthcare system in Vermont, it is unique in the fact that it is geographically dispersed. And by that, what I mean is that we have healthcare providers that are assigned to geographic areas and provide care in those areas. When you go down to Boston or you go to New York, within a block you may see two or three different hospitals. That's not the way our healthcare system is set up in Vermont. And it means that it's a non-competing healthcare system, which is really important. And for the majority of that system, it is nonprofit organizations. It's also, other than a few exceptions, for example, what Commissioner Haas will present in mental health, it is also delivered by community providers, not delivered by the state. And that's an important distinction. When we think about it, and tonight, and I'll explain why, we're going to focus in on a couple of key areas. But to give you an example of what we mean by that geographic distribution, we have 14 hospitals in the state of Vermont, geographically dispersed. We have mental health and substance use providers, so 10 community mental health centers, and nine preferred substance use providers across state. They are geographically distributed. We also have home health providers. They are also designated geographically minus one, which is statewide, to serve an area of the state. And then we have about 165 primary care practices that are equally distributed around the state. So that just gives you kind of a landscape. And that landscape is important because it creates some distinctions in our healthcare system that you don't see in others. So tonight, I want to talk a little bit about the impacts of the pandemic and why we're going to focus in on four key areas. Essentially, the pandemic reinforced for us that there are parts of our healthcare system that interact with each other, and that when those parts of our healthcare, one of those parts of the healthcare system doesn't work or is strained or stressed, we see people get care at the highest level of care in our hospitals, in our mental health hospitals, so not getting care in their communities, in their homes, in places where they would prefer to get their care, but really in places where they may not be getting the care that they want or need at that moment. And so when we look at that as we go forward, the pandemic has also made certain components of our system very brittle. They are strained right now, and we'll talk a little bit about why, but the inflationary costs and staffing pressures are very acute in our healthcare system. Specifically, you'll hear a lot about traveling nurses and then pushing the budgets over where a nurse might be normally $50, $75 an hour, traveling nurses can be as much as $200 or $300 an hour. So the workforce stress and strain of it, not having people, but also the cost is there and apparent. And so you'll see that in these four systems. Our primary care system, when it's not working well, folks back up in the hospitals, our mental health and substance use system are skilled care. And I want to say more specifically what I mean by that. When I talk about skilled care, that really breaks down in many different directions. But for tonight, we're really going to be talking about skilled nursing and home health services. And then also, as we mentioned, our hospitals. So the reason that, and I want to make sure folks understand is that we are focusing in on these areas is that during the pandemic, we were acutely looking at what are the impacts to our overall health of our population and also what are the impacts to our healthcare system. You might remember the mantra being trying to make sure that we don't overwhelm our healthcare system. And so there's a few key data points. And in this case, if there are questions on them, I'm going to turn them over to Todd, who has been monitoring and managing a lot of our response to the pandemic. But we can go to the next slide up on the screen. Essentially from our health outcomes, there are two alarming features that we're seeing. The first is an increase in the number of people who are dying from drug overdoses, which has increased during the pandemic. And the second is really the number of people and the trend that we're seeing in deaths from suicide. So really demonstrating an acute need that we have for mental health and substance use treatment. In addition to that, when we look at our healthcare system, and before the next slide goes up, I want to say I don't expect you to be able to read this one. But really I want to assure folks that we are looking in the area of our hospitals at what our hospital capacity is. And on a daily sometimes or several times a week basis, we have a report that comes out from the hospitals that tells us what their capacity is. And the color coding is probably the most important here, whether it's green, yellow, red, similar to a stoplight, black. It tells us whether our hospitals have the capacity to bring patients in and deliver the care that they need. And in this chart what you see is that we monitor the number of individuals who have acute needs that can't get in. We monitor those who no longer need a hospital level of care and could be transitioned to home health or to a mental health treatment or to community-based treatment. And so this gives us a sense of what might be putting pressure on our hospitals. And in this report we see regularly. So on the next slide, we monitor the number of available and open beds. And during the pandemic this has gone up and down. And there are times when we've had four ICU beds open. And that has, if you recall during the pandemic, has drawn significant concern. That's one car crash away from a hospital being able to triage and treat people. The second are the availability of our medical surgical beds or our normal hospital beds. And the capacity for our hospitals to treat and see that. And you can see that throughout the arc of the pandemic there are times when we've had more than 62 acute hospital beds available. And then in the last couple of weeks that's dipped down to 15 or even down to four ICU beds. And so we are not out of the woods yet is what this demonstrates and shows. And the question is why? And really what we see in talking with our hospitals and our system is that individuals who have been hospitalized and are ready to be discharged either to their home or to rehab in a skilled nursing facility or for long term care in a skilled nursing facility that they are staying in beds longer and in the hospital which means the hospital cannot bring more folks into their regular hospital beds. I want to say that a couple of weeks ago we were excited because we finally got down to less than 112 people waiting for a hospital placement outside of the hospital but over the last couple of weeks we've seen that surge again. And so that shows an alarming trend of that going up and down based on what's happening related to both admissions to the hospital and what's happening in our long term care and home health facilities and the strain on those systems. And then lastly one of the other areas that we look at is how many individuals and how long are they waiting for mental health placements. And again on this slide what you see is that that goes up and down and green are individuals this is the total number of people who are hospitalized that we monitor and watch and green are individuals who are there. The yellow are those folks who have been there for a little bit longer for placement and the red are those who've waited or really have acute and complex needs and are waiting. And so we've made giant strides in this area from where we were earlier this year but we still see some strain in the system there. And so Commissioner Haas will talk a little bit about that. So what this demonstrates is that if we're not treating individuals in our mental health and substance use and many people I'm sorry I should have said this from the beginning often think of substance use as addiction that can be somewhat offensive to individuals receiving treatment. So that's if folks were confused about what that is that's what it is. It's treatment has formerly been called addiction treatment. So if our community mental health systems not working our primary care systems not able to catch people earlier our home health systems downstream are not able to move people out of the hospital or keep people from going to the hospital. What we see is significant strain on our hospital systems and that is financial strain because that is the most expensive place for us to actually deliver care. So we're going to ground our that's kind of an overview of the health care system and some of the main strains that they're experiencing right now. And I want to pause there to see if there are any questions about both what our system is and why we're going to focus tonight's discussion on a couple of key areas. Any questions any comments. This will be a lot more fun for everybody. OK then we'll keep going. Again the four key areas that we've talked about are on the next slide. It's important for us to understand some of the pressures that our systems are experiencing. So the question is why do we have people backing up in the system. The pressures are very similar to many of our other sectors and I want to acknowledge that the pressures that we have outside of health care impact health care and vice versa. So when we look at our health care environment workforce so it's the number of employees because of the demographic trend and shift. Many of our nurses and other folks have retired. It's career pathways so getting folks in and Ina would probably could spend three hours talking about even more. It's also housing and many recruiting people to the state of Vermont and then them not being able to come because there's not enough housing for them when they land here. It's also some of the other pressures that they're experiencing are the demographics of Vermont. People are older and getting older and they and as they age they aren't individually getting sicker but our population is seeing more chronic chronic diseases like diabetes and hypertension or also high blood pressure. So we're seeing more of that in our system and they're living longer. So when we talk about the skilled nursing facilities it's not just folks who've broken their hip but now it's individuals who have mental health concerns who might not normally have made it to that point in their lives who need support and treatment. It's individuals with dementia who might have behaviors that make it difficult to care for in a normal, in a usual, it's not normal but in a usual staffing model for long-term care. And then the last is alignment among our health insurers and that will be a key in addition to those stabilizing those key systems of care it will be incumbent on us to make sure that there's alignment. One of the things I didn't say is that right now in healthcare we're trying to go down two lanes. One is coming out of the pandemic. The stability of the organizations is fraught. Financially for the first time we've got home health agencies as an example who are reporting losses. The majority of our hospitals reported financial losses last year. Our skilled nursing facilities are closing because of these pressures. They don't have enough staff and when they do have enough staff it's too expensive. So we're working on stabilizing the healthcare system and that will be a key theme as we go forward and we're looking at trying to create a sustainable future recognizing that the demographics of Vermont have changed and that the way that we deliver care has also changed over the last couple of decades. So again, stabilization and sustainability as we go forward. Thank you. Finally a question. That's a great question. I will say that we're working with our healthcare providers to pull together that data. In some of our public safety work they can see some instances of that in the public safety data but it's really masked as if someone created a violent crime and we can't tease it out of hospitals. So we're needing to get that data from the healthcare system itself. So we're working on it. But it is an issue that is prominent particularly in our emergency departments. When we think about it one of the things to contemplate is that our emergency departments are a front line. And we have worked so hard in Vermont to work to make sure that individuals get a fair and true assessment to determine whether it's a medical issue, a mental health issue, a substance use issue before we incarcerate them. And so oftentimes they're brought to the emergency departments to get those types of assessments done and in that process sometimes and it's not just because of the medical mental health or substance use issues individuals continue to perpetuate violent activities. And so we're working with our emergency departments to look at how we can relieve that over time including is there another place where we can do those types of assessments. We do them right now for individuals who are intoxicated as an example in our public inebriate programs. Can we do that for mental health outside of that and that then gives a path that if it is someone who's violent and not violent for a mental health substance use or other issue they can go and move on through their criminal justice system. So it's a great question and it is one of the reasons that we do have some of our health care providers say that they have decided to leave the work. So when we get to the mental health component of what we're talking about think about our emergency rooms as an extension of our crisis system of care and and that's I think it'll be an important component. Let me check in with our data folks and get get back to you and looks like Shayla stepped out for a second but one of us will there you are. Shayla will get got it and we'll get back to you. So it is a good question and I'm glad to have you press on it because it's an important issue. So at this point what I'm going to do is I'm going to turn it it's a great segue to turn it over to Commissioner Haas who's the commissioner with the Department of Mental Health that will and she will focus on some of the work that we're doing in mental health. I do want to say up front that when we're talking about mental health the agency of human services this year is really has really worked with the Department of Mental Health and our other departments to assess what Vermonter's mental health needs are to identify in our system of care where there are gaps and to begin to look at making targeted strategies for those gaps and Commissioner Haas will talk about those and that's our real that's an approach to that we're not just pouring in money or funding into one type of organization but that we really truly understand how we can make a shift or a turn for Vermonter's and so you'll see things like mobile crisis and I'm going to I don't want to still Commissioner Haas is thunder but mobile crisis and you'll see alternatives to emergency departments and so again our goal in our mental health investments is to look at the service needs and to make those types of investments and that should be apparent I thank you like Jenny said Emily Haas the commissioner for the Department of Mental Health I've had an opportunity to talk to the next couple of slides through many folks in here so it's nice to see you all here so maybe you'll have different questions from the first time that you saw this so this is essentially our system of mental health care in Vermont and so as you'll see our bottom our strongest section of this system is our community resources and if you can see that bottom line I cannot so that tells me I need to go to the eye doctor because this is a pretty big screen those are the individuals providing services throughout our community mental health system so those are folks who are delivering case management services to youth and adults this is folks being served in schools additionally these are individuals who may be getting services in residential homes or group homes depending on the particular part of the state it's also a host of private outpatient providers they also play an important role to our mental health care system so that is our bottom building block there the next step up if you think about this as levels of care that's also your least restrictive level of care so you move up one more level and those are our crisis supports and response so each part of our state has crisis beds those came out of act 79 remember that so each community mental health agency serves adults in crisis beds we also have youth crisis beds down in our Bennington area and also in northern parts of our states in Chittenden County if you move up another level those are what we refer to as intensive residential programs so we offer intensive residential programs throughout for adults primarily and those are located like I said for example in Westford or in Williamstown or down south in the Springfield area and so we offer numerous beds across that particular level of care if you think about the next highest we offer services within a secure residential system right now the state of Vermont and department of mental health the middle sex therapeutic community residence and that is a secure residence in middle sex it's currently a seven bed residence and then we will be expanding that to a sixteen bed residence and moving that to Essex the name change for that will be the river valley therapeutic residence and so that is for folks who are perhaps stepping out of the hospital who still need a structured environment to receive care before they step down through the other levels of care down to the least restrictive then you'll see at the top like secretary samuelson summarized this is also our most expensive and these are our inpatient beds and so for youth all of our inpatient beds are currently located at the Brattleboro retreat they serve youth as young as up to eighteen they also have a transitional age unit where folks who may be eighteen to twenty five they're able to be coordinated as a group on one unit there and then they also offer beds for our highest acuity folks and so when I say acuity in this context I'm referring to individuals who meet hospital level of care but also may require additional services for them to have their treatment needs met so Brattleboro retreat like I said is primarily serving well is serving all of our youth and then some adults we also have adult beds at Rutland regional medical center they also have beds that are high acuity beds or historical language refers to those as level one beds and then we also have Vermont psychiatric care hospital there's a twenty five bed facility located here in Berlin that's a state run facility for adults who are under the care and custody of the commissioner meaning that they are involuntary bright next door central rock medical center offers I believe sixteen beds for adults the uvm medical center in Burlington has two units one for those folks who two to seven days and then another unit for targeted towards folks who might require just a little bit longer but maybe not needing the additional resources like say of Vermont psychiatric care hospital or one of the other level one units so this is our system system snapshot I'll also mention that our system is a co-occurring system where you are receiving care throughout these different levels are also being provided opportunities to get treatment for any substance use disorder they may be having if they need specialty substance use care they're being referred for those individual services and we really try to treat the whole person the DMH perspective and desire is for folks to be able to get services when and where they want those services and so while we developed this pyramid we also identified some gaps in our system thank you it's like you read my mind and we identify or define our system as four pieces to the pie so we have someone to prevent someone to call someone to respond somewhere to go and if you think about someone interacting with really any health care entity but specifically for mental health care when we think about someone to prevent those are initiatives such as hub and spoke and expansion blueprint addressing co-occurring disorders within our primary care setting and then someone to call I think folks should be aware of 988 which is the national crisis line you now have to use those ten numbers to call somebody in Vermont and that's because of the 988 line so folks of any age who are in a self-defined crisis or also aware of somebody else who might be in a crisis can call that 988 suicide and crisis prevention lifeline those are answered by Vermonters about 90% of the time and they can get you to the help that you need and also work with you in that moment or work with an individual in that moment to help either de-escalate a potential situation and then connect with services so that crisis line is what we're really trying to get out to that number so that folks do call that because the next step is that you can get a referral or a handoff to a treatment provider what did you want to do that many folks call that and that's enough and they do not wish to be handed off to another treatment provider so someone to respond a priority for us over the past couple of years has been to expand mobile crisis response and that is meeting individuals in the community where they are a two person team 24-7 in order to help meet folks before they need to go to an emergency room additionally somewhere to go we've talked a lot about psychiatric urgent care and testimony the department of mental health just closed on an RFP for alternatives to emergency departments and there were certainly opportunities in there for parts of the state to develop a psychiatric urgent care what that means is that instead if folks would like to get services outside of an ED they can access crisis services through an alternative to an emergency department like a psychiatric urgent care so we know that there will always likely be some instance where somebody may need to go to an emergency room for an assessment typically because they're presenting with some other medical issue and so that would certainly still be available but for those folks who don't need that level to be able to serve them in a more appropriate way I think that oh I have one more slide, thank you thank you for that so when I was talking about our system I mentioned the Vermont psychiatric care hospital like I said that's a state run facility and it is for individuals adults who are involuntary so under the care and custody of the commissioner we've done great work to get beds back online there they also experienced a workforce crisis and a staffing shortage just like most of the healthcare system but they are currently back up to 21 of 25 beds we've also focused on stabilizing the rattle borough retreat the rattle borough retreat is getting ready to be back up to pre-pandemic levels of being able to accept their facility kudos to the rattle borough retreat team in their collaboration with the state and working together to form that strong collaboration and getting those beds back online and then the last like I mentioned was expanding our secure residential moving the middle sex therapeutic community residents to Essex and expanding that to 16 beds and that also is adults I feel like I dumped a lot of information on you and so I apologize any questions or comments at this point I don't know the details of what the juvenile facility is currently proposed at inpatient okay that makes more sense to me sure so last fall or last spring the department of mental health put out an RFP for youth inpatient and those youth inpatient beds were to meet a few needs of our system one we were experiencing an increase in youth with complex medical conditions who needed access to inpatient psychiatric care and folks oftentimes don't necessarily understand the limits of a standalone psychiatric facility and that they don't have a code team so to speak that can respond to medical emergencies like a medical facility would and so we saw youth wait longer and sometimes be served on adult unit and that's not something that we want to see happen again and so knowing that we have youth hitting our system who are also maybe pregnant who may have untreated diabetes or severe eating disorder those folks can be challenged in finding the appropriate placement due to the medical needs that they require so the RFP is to help serve those folks so that they're not waiting longer and then getting served in an inappropriate setting like an adult unit we had one bid to that RFP we reposted it after that initial bid pulled back from that project and Southwestern Vermont Medical Center was the next facility to bid on the RFP I'll highlight that's still in a feasibility study stage so there's still more information to be learned including how many beds which I know is a key focus should it only be 6 or should it be 12 and there's a lot of different complexities to how many beds that's driven by need it's also driven by staff numbers also driven by a caseload for a psychiatrist so there's a lot of things that go into what a bed number is that feasibility study should be complete by the end of this coming March and that will help us pave the way to either continue with Southwestern Vermont Medical Center or repot it out to bid our goal is to increase access as soon as possible to youth who need hospital level of care Daisy did you gosh okay two wins with that sure sure and we monitor that almost on a minute by minute basis because folks can come in and come out of a bed multiple times in our system throughout the day so we do provide and have data there's a a bed board that our emergency departments can check to see where open beds are that bed board shows availability for youth it shows availability for adults also crisis bed availability and intensive residential availability we're looking to expand that so that there's more resources for folks to access from that one particular website but we do have a keep track of that I will say in general and I would imagine this is likely the same for med surgery ICU is a bed is not a bed is not a bed so it could depend on if that's a shared room and the person in the other bed is may not it may not be a good match for whoever's looking for admission so there are some admission decisions that go into that we do have numerous beds close throughout the system and that shifts every day based on staffing availability acuity, a number of things but I'd say in general more beds are open than closed and there are typically people waiting and there are open beds available but like I said that shifts on a daily basis but that's the department of mental health has a team of care managers who help triage folks in and out of emergency rooms in collaboration with all of our inpatient units and community mental health providers so that folks are not waiting longer than necessary mentioned in your question was EMS so emergency medical services being able to access those beds and so commissioner has I wonder if you can explain the pathway that it's not as simple as you know mental health hospitals don't have an emergency department specifically for mental health and so EMS can't bring someone who's in mental health crisis straight to a hospital do you want to talk a little bit about what that pathway looks like? Sure I can do that if that's helpful for your question so let's I'll use a couple of examples I'll start with a voluntary example somebody can call say the Brattleboro retreat and do an intake assessment and can be admitted from their home they don't necessarily need to go through an emergency room if a primary care provider has labs or something like that they can send that over and they'll take a look at the medical stability along with the psychiatric needs for that individual that person can go and however transport they want to get to that facility we also have folks who are in an emergency room waiting for placement they've been screened likely by community mental health emergency services screener to determine if they A, meet hospital level of care or B, will go voluntary or not voluntary an ambulance provider EMS can transport somebody from an ED who's voluntary or not voluntary depending on an assessment of safe transport and so then that transport would occur let's say down to the retreat or down to CBMC or Rutland depending on where the admitting facility is we also have youth who end up in the emergency room they're screened and then they are determined that it's safe for that individual to wait from home with a safety plan responsible adult that individual will then wait from home for access to that inpatient bed so that they don't have to spend prolonged periods of time in an emergency setting that can be quite chaotic and often quite triggering for individuals did that answer your question? Yeah, I thought so I remember Yep Yes We could spend a lot of time on mental health and so Commissioner Haas is going to stay but I want to make sure that we that we also get a chance to touch on some of the other areas these were going to breeze through relatively quickly but I want my goal is to ensure that folks have an idea of some of the things that you may see come in legislation or come up during the session related to related to what's happening and going on okay so when we think about primary care it's important for us to know that Vermont has a strong foundation of primary care that includes our federally qualified health centers independent primary care which our practices are owned by physicians and in hospital owned primary care we need to continue as you heard some of our challenges in mental health and substance use have increased throughout the pandemic we'd seen that they were coming down the pandemic has made them go up it really has identified an opportunity and a challenge for us to meet and to evolve into as we go forward because primary care can be foundational the significant number of individuals who commit suicide and our success who take acts of violence against themselves and are successful actually saw their primary care provider in a very short time period before they did that quick question how do we bridge that gap so I can see Ina kind of at the edge of her seat a little bit on this question and there are some policies that are already in place that allow access to primary care with lower co-pays and other pieces and I don't know Ina if you want to speak to that before I check up in addition to that statistic that you shared about those who are who are categorized as uninsured I think it's also important to talk about the results from our household health insurance survey from the most recent year in that survey has some information in it that demonstrates at least at the point of that survey that Vermonters were accessing care and were accessing care in ways that were more frequent than in historical surveys and also that Vermonters debt due to health care costs and service utilization was not that that debt load for Vermonters had in fact improved over a period of time so I think that's a place to really look at a number of data points together to better understand what people are experiencing relative to their particular coverage it is the case that people are categorized in that under insured category but we also know that many Vermonters have health savings or health resources resource accounts that their employer have offered and that they are utilizing those resources to help with these copays and deductibles when they can those are paired with what looks like in a survey like a lesser coverage or a under insured model so oftentimes what we'll hear from our constituents is that these are true issues for us to tackle is that people are having problems accessing a primary care provider for two reasons one for some practices who aren't accepting new patients and so if you're new to Vermont and you don't have a primary care provider it's hard to find one and the second for some practices because of workforce shortages and others when they call their primary care provider they're having a hard time getting in within the time frame that they want to get into and so some of that information and the data on that is in both an access study that was done between the agency of human services for financial regulation it's also in the household health survey the second place is coordinating care with other providers we see that when people do need care outside of primary care we see it as a critical function for that to be coordinated preventing and managing chronic conditions so making sure that you get your if you have diabetes that you get your blood work done and then also addressing mental health and substance use and in this area it's by identifying our lives and you'll hear that as often screening for mental health and substance use but also the term social determinants of health so what about housing insecurity food insecurity, violence that's happening in the home, we know that all of those things are impacted in individuals mental health and well-being and so in the near term what you'll see us working towards is really making investments in primary care to integrate that mental health and substance use and that screening for those health related risk factors and so that will we're working and that comes out of the mental health integration council with primary care as a key focus how can we get more staffing into those practices that are skilled at doing that I'm going to move on quickly into skilled care again that's home health and skilled nursing facility care and I want to recognize the demographic trend here and the need to evaluate what's necessary at a local regional and a statewide level what we see as individuals are getting older over the last few over the last few decades there's been regulatory pressures to make sure to keep and check the number for example of skilled nursing facilities because people were being warehouses what I've heard people talk about in the past or put into a level of care that they didn't want and that they didn't really need and so there's been a lot of effort to right size that but as we see the demographic trend that's putting pressure up on that and then financial workforce pressures and demographic issues we've talked about so in the short term right now we are working to evaluate the financial viability of home health and skilled nursing facilities and look at how we can address that we're evaluating the choices for care program which I'm just going to describe what it is but it's a way to get services in your home home make services that have someone help you with things that you can't normally do that would make it so that you would need a nursing home level of care but that you might not be eligible for under normal Medicaid it allows us to provide those services so that you're able to stay in your home and not go to a skilled nursing facility so evaluating how that program exists and it's funding investing funds in opening nursing home beds right now due to staffing so trying to cover the difference in the staffing cost so that as you saw those pressures go up working with some of the facilities to open closed beds by covering some of those costs and that's a very short term it's not something we can do forever but it's something that's critical for us to do right now as we try to figure out the financial sustainability long term that's just the stability and then opening specialized beds as I mentioned before individuals are aging who have mental health substance use issues who have violent behaviors because of dementia or others and our skilled nursing facilities aren't rightly positioned now to provide care and that's what a lot of the folks who are in our hospitals right now waiting for a bed are waiting because it's not that there aren't open beds but there isn't the right bed as Commissioner Haas talked about and then lastly Commissioner Haas mentioned that we've been working with the Brattle Burr True we dug in deep with them and I'm going to use them as an example up front we dug in deep with them to really identify what it was the care needs of Ramaners were where they were losing money and in those places where they were losing money that we didn't necessarily need them to provide that care they discontinued it they did not the state and then in those places where they were underfunded we provided supplemental funding and as we look at our hospital system and the sustainability going forward there is a need to do that on a broader scale to identify what we need at the local regional and statewide level for our hospital levels of care and to engage in that in a collaborative process with our hospitals around the state because they've experienced regulatory pressures over the last few years to really control costs coupled with the pandemic they're in a very different financial position than we've seen before they're brittle, they are losing money and it's been important for us to really work to stabilize them as well as the other parts of our system we're not going to efficiency our way out of our health care cost problem anymore and so recognizing the role that our hospitals play in our local economies they really are foundational in the health of our communities which draws new people in and they are an economic driver in our local communities it's important for us to look at how we stabilize them so we're working with the Greenmount Care Board to evaluate as I said the local, regional and statewide needs we're doing that in collaboration with health care providers and we'll work on that, that'll be at the state level but we'll work hand in hand with them to evolve what the future model looks like for community hospital care and that's work that's ongoing and so I want to pause there any questions I breeze through that as Monica said this was going to be really fast we're going to try to take a multi-layered set of issues and we're going to try to introduce them in a rapid fire fashion just to kind of wet your appetite for the future so any questions on those three areas Representative Rebecca efficiency our way out of this that's a great question glad you picked up on that so for the last few years I've spent and I'm one of the folks who really said that we need to look for efficiencies in our hospital based system and we do and that we will gain enough cost savings out of that to really turn the cost curve and make critical community investments we still need to work with our hospitals to find efficiency but there is not enough room in that Vermont is the lowest cost Medicare state in the country we are not in terms of the amount of dollars to come in we are not going to be able to squeeze enough efficiency simply out of our hospital systems to continue to make the investments and if we do we are going to jeopardize the viability of hospitals it won't just be the Brattleboro retreat who is on the edge of not being able to move forward and Springfield hospital it will be many of our smaller community hospitals so there may be investments not just impacting but investments that we need to make in the future but we have to do that with hospitals and we have to be willing to evolve. I'm glad that you brought that up and I think it allows me to point to a cornerstone of what you see today which is we spent the last five years focusing on changing the way we pay and that's really for healthcare and that's really important moving from paying for every time a service is delivered to getting in different ways that would help to give providers flexibility and send outcomes. The agency in working with our providers has really refocused a lot of our attention now what is the system of care look like that we need and you see that as we talk about looking at investments in primary care with a specific intention in mind mental health you see that as we talk about the investments that the mental health system is like so really what are the services that we need. You also in proposals underneath that like the blueprint as foundational to primary care see a work to evaluate how we can do care differently in those practices to improve and so in the past it's been a lot about if we pay differently care will be delivered differently we're really refocusing now on how do we care differently and then use the payments to support that care and so that is a change in in our focus and also from just provider driven reform to a public private partnership because the pandemic pointed out that when the state partners closely with providers we hear better what it is that providers need we can resource that better and we can work collaboratively to provide the training and quality improvement supports the blueprint for health which is a program that works with primary care providers as a perfect example of where that works really well so thank you for that question go ahead and if you could just say I don't with so many new and old names and two years it's hard to remember and so if you yeah thank you that's an that's an interesting one I can see Monica kind of on the edge of her seat and to dig in on that one so department for aging for disabilities aging and independent living does have a general sense of what the beds are in the state what you saw earlier was us really tracking availability on a day-to-day basis I would have to dig in with them and I'll get back to you to know the degree to which they are monitoring that my understanding across all of these industries what's preventing people from getting in is often times as much reimbursement as it is the workforce shortage so it really is the fact that many of the beds that we have here that providers don't have open it's not because they don't get paid enough it's because it's because there's simply not enough staff to staff them so I can dig in with Dale with our department a little bit more to get back with you with a more fulsome answer but that is generally what we're seeing in terms of people coming into the market in long-term care and leaving the market in our assisted and skilled nursing facilities is because they simply cannot get the staff and if they can it is so expensive at this point that it's not financially feasible so thank you so let me for everyone else in the room let me describe what one care is and then I think what you're talking about is Blue Cross Blue Shield is that what you're talking about? okay it's a good guess yeah no that's okay I'm gonna move around a little bit so one care in Vermont is an organization of providers who have come together and agree that they will manage the health of an entire population and that they will get paid in a different way for hospitals it's through a fixed payment versus getting paid every time they do a service for their care and in general it's been described as a way that providers come together and they get paid differently and that they agree that they're gonna provide care differently in order to help moderate costs and quality to Representative Rebecca's point and our goal was that that would help with some of the quality improvement so over the last five years Vermont has been testing this model where one care is an ACO that provider type of an organization and they have hospitals as members and primary care all the providers that we've listed and Blue Cross Blue Shield came forward and said we have concerns about whether they are providing the value that is worth the cost in the system and it is as a payer the agency of human services actually administers Medicaid and so as a payer ourselves we are working to evaluate that question as we go forward how do we want to provide care differently and pay differently to continue to get our systems to be where they need to be and that said for us as Medicaid while we try to decide that over the next couple of years whether an ACO is or is not involved in our healthcare system in the future it was important that we continue given the brittleness of our system that we have right now to not do anything that would be catastrophic and harm our providers so if Medicaid were to pull out our providers the way that they get paid but not only would we not get investments from Medicare that we currently get into our state of Vermont but the way that they get paid it would create operational inefficiencies overnight so we need time to decide what it is that's next and we need to make sure that we are responsibly evolving to that whether an ACO is a part of that or not so that we don't further destabilize this system and so the agency of human services has been working with Medicare to define what it will look like going forward we've been working with Medicaid our insurers have been involved in those conversations but we have real recognition that we need to pull together our insurers so that we can align on what was the last slide really align on what the quality measures are that we should be measuring how we're going to evaluate the effectiveness of programs like the ACO and how we want to pay differently going forward because that lack of alignment is causing instability in the system right now but we can't shut something down overnight or it will cause more brittleness does that answer your question mostly yeah so that we're still working to quantify and if Ina or Pat would like to answer it Blue Cross Blue Shield has said that they will continue payments to the primary care providers who receive augmented payments through Blue Cross Blue Shield's participation but if we talk with the ACO and the primary care providers they would say that for the amount that Blue Cross puts in that money gets additional money gets added and the primary care providers may lose payment so they may actually it may result in primary care providers which are key to the foundation of our prevention in the system don't have as much money going into the next couple of years and that's what I mean about making a very quick decision you know us understanding what the operational consequences of that takes more than a couple of weeks to determine and so we're still working that through and we would want to make sure that we keep our primary care providers whole I don't know Ina or Pat anything you want to add did I answer your question? there are consequences I just want to make that clear there are consequences and the majority of that's to primary care it could and I'd be happy to stay out I know we've got to be out of the room for another meeting but I would be happy to stay after and answer more detailed questions about that but the fact of the matter is the consequences we'll have to find out as we move forward of that and our direction for the ACO and where we're going in the future is a part of the broader healthcare discussion any last questions? I'm sure Monica is going to help everyone kind of end the evening but before we go I want to say thank you for coming this is something that is a deep topic but it affects every single person so I appreciate you being willing to give us an hour this evening and our team is always here to answer questions because this is multi-layered and we've just touched on four parts of a multi-part healthcare system so thank you for coming tonight nothing more to add thank you all so much for coming I expect we'll see many or all of you at the governor's budget address tomorrow and just as a reminder we rescheduled one of these briefings next week so we hope that you'll come back and hope that these continue to be valuable to you as you are getting grounded in the work that you're going to be doing this session so thanks so much