 And so why don't I just jump in and say that this is a joint meeting which we appreciate having between the House Healthcare Committee and the House Commerce and Economic Development Committee. And specifically because we both are concerned about workforce issues and wanting to and have been addressing workforce issues. And so for those who don't know, I'm Bill Lippert, I'm the chair of the House Healthcare Committee and Mike, you wanna introduce yourself as the chair. Thank you, Bill. I really appreciate the invitation that you extended to us for, to meet with you. This is an important topic for us as well as you. And we really appreciate it. So I am Mike Maricott, I'm from Coventry and chair, House Commerce and Economic Development. Great. So given that we have an hour with Ina, as my understanding of other commitments as well, but I'm not sure everyone on your committee will have met Ina Bacchus before. Perhaps I'm wrong on that, but Ina, do you wanna, so we've invited Ina Bacchus who's the director of healthcare reform for the state of Vermont, to present the healthcare strategic workforce, well, she'll get the name right, but it's basically the healthcare workforce strategic plan which she has overseen and facilitated. And I believe there are links, there should be a link to an overview of that report. Do most folks have aware that they have that and I'm guessing that that will be helpful in following the presentation. The overview link is not working for me. Okay, it wasn't working for me earlier, but then it, I think it was taken down and put back up, can you try again and see if it comes through this time? Do other folks able to access it just by nodding heads? I see some nodding heads. Yep. Yep. And so are those who were not able to access it, are you able to get it now? Yeah, I see nodding heads. Okay, so Mike, if it's okay, I'm just gonna ask Ina to go ahead and begin to welcome you and then introduce yourself and give us the opportunity to hear about the healthcare workforce development strategic plan. So I'm turning it over to you. Thank you. Good afternoon. Happy new year. My name is Ina Bacchus. I am the director of health reform at the Agency of Human Services. And in my role, I am responsible for coordinating healthcare reform initiatives between government agencies and departments and also with the Green Mountain Care Board. If it's helpful to the committee, I can share my screen, the committees. And it is very exciting to have the opportunity to meet with both committees together on this important topic. If it is all right with you, I will share my screen to walk through the presentation. Does that work for your committee? We go back and forth. Sometimes we share the screen and sometimes we don't, but I think it might be helpful. Yeah, I think it sounds good. We generally have screen sharing. Okay, go for it, Ina. I'm just working through. I've been, go. I think now you can see the slide. Yes, yeah, full screen, looks good. Thank you again for having me to discuss the healthcare workforce development strategic plan. And I will provide an overview of the plan today and assume that there may be areas where you would want to dig more deeply in the future. I think it's important to provide you with the background and process for this plan, including the primary legislative charge for it, as well as background and context for our current healthcare workforce challenges, which as you're all familiar, are evolving along with the pandemic that we're now multiple years in and are also not different or unusual, given the workforce challenges broadly speaking. And then I want to talk about the healthcare workforce development strategic plan itself and give an overview of the recommendations that are contained within it. The plan was required by Act 155 of 2020, which provided that the director of healthcare reform in the agency of human services maintain a current healthcare workforce development strategic plan and that it consult with an advisory group in maintaining that plan and in updating the plan as well. The advisory group members are represented here and the membership can included representatives of the Green Mountain Care Board's primary care advisory group, the Vermont State Colleges, the area health education centers workforce initiative, federally qualified health centers, Vermont hospitals, physicians, mental health professionals, dentists, naturopathic physicians, home health agencies, long-term care facilities were all the designated representatives in the advisory group. We also had participants in the advisory group, a number of subject matter experts from state government and sometimes beyond, participated in the advisory group and their participation is much appreciated for the subject matter expertise that they brought. We had regular participation from the blueprint for health, the Department of Labor, Division of Vocational Rehabilitation, Green Mountain Care Board, Office of Professional Regulation, Office of Rural Health and Primary Care. Required by Act 155 of 2020 was for the plan to be reviewed and approved by the Green Mountain Care Board that requirement timeline was amended by the big bill in 2021. And so the plan was required to be submitted to the Green Mountain Care Board October 15th, 2021. The plan was presented to the board on October 20th, 2021. I'm sorry for the typo there. And the plan revisions, there were plan revisions as a result of the public presentation, public comment was received, comments from board members were incorporated and the plan was revised and presented back to the board November 10th of 2021. And the board voted unanimously to approve the plan on November 12th. Current context for our workforce challenges and specifically our healthcare workforce challenges. I am sure that you've all been becoming familiar with the term the great resignation. It is a term that is being used to describe the current experience for the American workforce prompted by or disrupted by the global health pandemic in COVID-19. Americans are quitting their jobs and record numbers. The US Chamber of Commerce reports that employers in South Dakota, Nebraska and Vermont are experiencing the greatest challenge as the total jobs available in these states outnumber the total workers to fill them. So we are in a group of states experiencing some of the greatest challenge. We observed headlines just in the last couple of days about the rate of Americans quitting their jobs in November being the highest since that rate has been captured at the federal level. So we continue to see Americans and Vermonters leaving jobs. Unlike past recessions where healthcare sector jobs have stayed strong, if you will, or continue to grow, we now can observe that healthcare sector jobs are falling sharply alongside jobs for other sectors. And the Kaiser Family Foundation reports on this in a recent data briefing. And here they depict the Kaiser Family Foundation using statistics from the Bureau of Labor depict that health and human services employment in all sectors is below what it should be. Here you can see the sectors as depicted. This is the percent difference in November, 2021 for health employment by setting actual versus projected were it not for the pandemic. So we are seeing healthcare employment below what the projections for healthcare employment determine would be the appropriate level of employment. Also over the last decade, Vermont's home care workforce has declined. The home care workforce is defined as combined employment counts for two occupation types, personal care aids and home health aids, personal care aids assist older adults or people of all ages who have disabilities with activities of daily living. While home health aids provide routine individualized healthcare, such as changing bandages and dressing wounds. And you can see that in Vermont, our number of workers in this sub sector of the healthcare workforce has declined. And we are among a group of states, a small group of states where this number has declined. In order to maintain access to healthcare services, Vermont providers are relying on traveling staff. Traveling staff have increased in their use, not only by hospitals, but by other healthcare employers as well. The Vermont Hospital Association reports that for hospital fiscal year 2020 to projected 2021, the use of travelers for hospitals who have reported information has increased 26% from 270 to 341 positions, while hospital costs associated with these services has increased 50% from 50 million to 75 million over the course of the year. Further, here home, excuse me, skilled nursing facilities are also relying on traveling staff in order to offer services and are relying more so on traveling staff in light of the challenges that the healthcare workforce is facing. So here you can see that in 2021 is estimated that the skilled nursing facilities will have spent $37 million for traveling staff to ensure access to their services. With that context, I want to share with you today a number of strategies that the advisory group determined, it would want to recommend to improve our healthcare workforce in Vermont. These strategies include financial incentives, education and training, recruitment and retention, how we can ensure that regulations promote healthcare employment in the state, how we can ensure that the practice of healthcare promotes more employment in the state and recommendations for policy changes or advocacy at the federal level that could promote and foster and strengthen healthcare employment in the state of Vermont, permanent healthcare employment in the state of Vermont. These recommendations are all framed within the report as being organized through interagency and department collaboration. And that collaboration is necessary in order to carry through with these recommendations just as you're meeting in a collaborative way across committees today, that is really the spirit of the framework that we recommend in the report for following through with the various strategies for improving healthcare workforce in Vermont. We also recommend that they are be designated a health data hub where data that describes healthcare employment in Vermont is brought together in a common place, particularly so that that data can be better harnessed for supply and demand modeling, which we don't currently do in the state of Vermont with workforce data, but we would like to see in the state of Vermont for workforce data in the future that supply and demand modeling better preparing us for future need and informing policy decisions regarding the healthcare workforce. So the first grouping of recommendations are financial incentives for healthcare workers to live and work as permanent employees in Vermont. These recommendations include broadening and expanding existing loan repayment programs to more professional types. Based on an evaluation of existing data and potential new sources of data, the advisory group and the strategic plan recommend that the area health education centers should develop a proposal for expanding its service-based loan repayment program so that it can include more health professionals such as mental health and substance use disorder treatment professionals and naturopathic practitioners, for example, and increase its current program offerings on the whole. These recommendations should include the funding necessary to increase existing loan repayment programs as well as the funding necessary for including additional professional types. The next recommendation is to increase scholarship funding created by Act 155 of 2020 and to identify a permanent funding source. And the plan recommends that there be that the interagency task team should recommend whether and how these scholarship and service opportunities be expanded to more healthcare professional types, including nursing faculty, and recommend, along with that, evaluation and ongoing funding source. We also recommend evaluating the effectiveness of existing scholarship programs available to Vermonters who attend dental school, making financial assistance options for healthcare workforce clear and transparent and easy to find, and using VSAC and its resources as a clear wayfinder for this information. So that potential or current health employees can find programs to provide for potential financial assistance. In the category of financial assistance recommendations or financial incentives for healthcare workers to live and work in Vermont, we also propose a number of recommendations that would promote permanent healthcare employment and residency in Vermont. These include revisiting tax incentive proposals looking at how other states have utilized tax incentive proposals to recruit young professionals and healthcare workers to live and work as permanent residents in the state. And in this reconsidering or revisiting of the tax incentive, the plan also proposes that there should be consideration for the exemption of preceptor income in Vermont to participate so that there is a stronger incentive for healthcare professionals to participate in educating new professionals to the field. And also that there should be considerations for those tax incentives that could be offered to employers who are offering housing or other benefits to full-time employees. And generally tax incentives that can strengthen the ability of employers to recruit and retain professionals as permanent employees in the state. We also recommend identifying barriers to recruitment and retention for the non-licensed workforce, identifying the most significant barriers for recruiting non-licensed allied health and direct support professionals to participate in Vermont's workforce. And there should be consideration given here to benefits, cliffs, housing costs, transportation and competition from other industries. The training needs for this sector and career advancement opportunities for this sector of the healthcare workforce. We also recommend that one-time funds be used for healthcare employers to attract permanent employees. And here, this recommendation has been taken and is reflected in the proposal, both for the budget adjustment as well as budget adjustment too. Through that proposal, there's, we are recommending an investment in total of $33 million for healthcare providers to recruit, train and retain staff to be permanent employees. And through this investment, we are offering flexibility for employers to be able to use dollars flexibly to attract and retain staff. Can I interrupt and just say, I'm thinking that many of us will want to know more specifics about that proposal, but perhaps not now as we'll work our way through the broad recommendations, but I know that I have questions and I'm guessing others we've heard about this initiative, but not the detail of it, so. And I would be happy if you wanted to circle back to this in questions and I can, or I can take questions now or we can keep going. Michael, I'm being inclined for us to keep going and circle back because I think we could swallow, get swallowed up by this, but let's keep going. Okay, the final recommendation in this category is to consider a longer-term grant incentive program and hear the advisory group and the report recommends that there be consideration for a longer-term program to entice health professionals to seek permanent employment and residency in Vermont and that such a program could be modeled after or expand upon the remote worker program. And here's another theme that runs throughout the recommendations in this report or runs throughout the report, really utilizing our existing platforms for recruiting workers to Vermont where necessary highlighting specific ways that Vermont is particularly well-suited for health professionals, but certainly capitalizing on our existing tools and resources for attracting workers broadly to Vermont but to include healthcare workers as well. The next set of recommendations regards education and training to strengthen the healthcare workforce. The first recommendation is to increase enrollment in nursing programs and the advisory group recommended that the office of professional regulation should facilitate a working group between the schools of nursing and clinical sites, healthcare organizations and others to establish a preceptor model of clinical training to maximize opportunities for student nurses who need to obtain the required clinical time and that would minimize the need for nursing programs to recruit additional faculty. Further, the report recommends that this work group should consider how preceptorships should consider a model of preceptorships that span the care continuum, including home and community-based settings and the work group also recommended evaluating any gaps in compensation between academic faculty and practitioners, identifying possible solutions and making any further recommendations necessary including funding. This work group as described in the plan should also consider how nurses transitioning to retirement could be incentivized to work as nurse educators and the working group should identify any additional barriers and recommendations for increasing enrollment in nursing programs. The plan also recommends supporting a transition to practice program for professional roles and within the $33 million that has been recommended to strengthen the workforce in terms of immediate need for recruitment, retention and training. This aspect here is represented in that investment, meaning we see a role for transition to practice programs within those dollars that can help strengthen training for new graduate health professionals. We also recommend strengthening incentives for preceptors for all professions. Exploring opportunities to expand family practice residency programs, modifying the curriculum to introduce primary care earlier in medical school. And here we recommend that the University of Vermont College of Medicine modify the curriculum for medical students to put more emphasis on primary care. And as an example, that students would start that primary care rotation early on in their programs and continue into the subsequent years of their education. We also recommend advancing a coordinated approach to promote healthcare careers in K to 12 educational settings. And this approach would leverage existing resources in the state such as the area health education centers, the Vermont State Student Assistance Corporation, BESAC, Vermont After School programs, Vermont Career and Technical Education Centers and Vocational Rehab programs. And through leveraging these resources and working across these programs, clearly document and develop a plan to actively promote healthcare careers in K to 12 educational settings. We also recommend establishing a physician education program that recommendation requires, however, the Vermont State Colleges to study and provide a report to the legislature on the potential to offer a physician assistant program, including an analysis of the employer demand for the program. The study would also include a timeline to implement the program, the financial resources necessary to develop it and to equip staff to operate such a program. And the report would need to include a timeline to obtain accreditation and to launch the first cohort of the program. The workforce development strategic plan also recommends modifying curriculum to prepare students for work and interdisciplinary teams across the continuum of care. In addition, the program would also include the continuum of care. In addition to preparing students to practice in acute care settings, the Vermont State Colleges here and other institutions offering nursing curricula in Vermont should modify curriculum where necessary to prepare students for practice across the continuum of care, including home and community-based settings, long-term care facilities, mental health agencies and public health entities. The strategic plan also recommends developing and identifying strategies to streamline advancement through the nursing career ladder and to up-skill existing staff and specifically to identify best practices and programs to help professionals transition within the career ladder, for example, transitioning from LNA to LPN and identifying more ways to streamline advancement through the career ladder while working in clinical settings. The plan also recommends that there be healthcare education offered to all students before leaving middle school. And the plan recommends that there be advertisement and recruitment for existing apprenticeship opportunities that are already supported by the Department of Labor. The next category of recommendations is about recruiting and retaining health professionals. And the first recommendation is to inventory and highlight state programs that support recruitment and retention of health professionals. In this recommendation, the plan puts forward that working across agencies in the state of Vermont, there should be inventory to promote existing state programs that assist healthcare employers in recruiting and retaining staff. For example, the Department of Labor could clearly advertise its role and ability to assist Vermont organizations that are seeking international staff members. We also, in this category of recommendations, recommend modifying or expanding programs that support working and living in Vermont already. The state working across agencies, the state team here should recommend and identify strategies to support workforce development and employment in Vermont. And key strategies would include increasing available housing and childcare for all professionals and healthcare workers. For example, team members could identify and highlight existing opportunities for healthcare employers such as the Vermont Rental Housing Investment Program and recommend how these programs and others could be modified, expanded, or newly implemented for greater impact. Examples could include fully funding the existing pipeline of housing projects, investing in the successful Vermont Housing Investment Program, investing in a new private home builder program that's focused on creating missing middle housing for moderate income home buyers. We also recommend in this strategic plan capitalizing on existing incentives to live and work in Vermont and promoting new incentives and to do this through work between agencies in the state of Vermont to market Vermont naturally as a place to live and work. And then again, to highlight those aspects of Vermont that are particularly appealing to healthcare workers and potentially to highlight new programming that would be even more appealing to healthcare workers. Some things that are important that we already know can be highlighted include the fast track for healthcare professional licensure where through the office of professional regulation healthcare workers can become licensed to work in Vermont in a streamlined fashion. And Vermont is very competitive in this area in what the fast track program offers from the time that someone applies for licensure and becomes licensed. And I'm sure that's an area you may want to explore further with the office of professional regulation. We also recommend in this section promoting healthcare careers to new Vermonters. And in this recommendation, particularly promoting again the office of professional regulations interim administrative rule for assessing foreign credentials. This administrative rule is also designed to streamline the path to licensure for persons who have foreign credentials looking to work in the state of Vermont. I also want to highlight here that within the $33 million and specifically within the $15 million proposal that we have identified that some dollars be made available for the purpose of assisting employers with costs that result from and that would support employment of international health workers. We also recommend developing a cross system strategy and this language is very particular to a particular section of ARPA, of the American Rescue Plan. I think you're probably more familiar with thinking about this section of ARPA as the home and community based services 10% FMAT bump. You may be familiar with the federal program that provides for strengthening the home and community based services sector by providing for enhanced federal matching dollars. And again, we emphasized in the report that these dollars be used to strengthen the home and community based services system through recruitment and retention programming and these dollars are contributing to that $33 million total investment that is being proposed. We also, the plan recommends supporting organizational wellness and peer support programs and specifically promoting wellness and peer support for healthcare employers and leveraging existing resources for doing so through our Department of Mental Health. And finally, the final recommendation in this category is to reduce administrative burden for healthcare providers so that there's an easing of the burden of practice and here the recommendation is for the legislature to review the results of the reports being submitted pursuing to Act 140 of 2020 and to take further action to implement any recommendations included in these reports that could lead to reducing administrative burden specifically regarding the administrative burden associated with prior authorizations. In the category of regulatory strategies to address the healthcare workforce, you've heard me name this strategy already which is to advertise and promote the fast track for healthcare professional licensure for all OPR regulated professions. And in this regard, again, a theme in this report and in this presentation is to utilize existing platforms for the state of Vermont, such as the Think Vermont program as a way to advertise, promote and elevate Vermont's fast track to licensure for healthcare providers. We also recommend in the report differentiating Canadian healthcare workers from international healthcare workers to create an even more expedited path to licensure for our neighbors and sharing of a border. We also recommend reducing licensing barriers for telehealth practice and taking into account the recommendations that have come forward from the work group that was created by Act 21 of 2021. The plan also recommends further evaluating opportunities to remove barriers to licensure for mental health and substance use disorder treatment professionals specifically. And because of the types of credentials in this field, there are potentially more barriers for licensure for persons in this field who are coming to work in Vermont and the recommendation here would be that within the next five years, the OPR would undertake a systematic review of the licensing process for mental health and substance use disorder treatment professionals and make recommendations to address these barriers to licensure specific in this field. And finally, the final recommendation in the regulatory strategy category is a consideration for temporarily waiving licensure fees for first-time licensed nursing assistants in the interest of reducing as many barriers as possible for people to come into the healthcare workforce. This category of recommendations speaks to modifications to practice that could provide for and or stretch the current workforce to accommodate more need. These recommendations include maximizing Medicare's flexibility and reimbursements. There are a number of ways where through Vermont's particular agreement with the federal government, it may be possible for Medicare reimbursement to be provided for certain services where it is not provided now. And that would mean that there would be more Medicare coverage for those services and those types of healthcare professionals, thereby multiplying the workforce at least from the perspective of what Medicare is reimbursing for. This section also recommends developing commercial reimbursement models for audio-only services, expanding telehealth coverage, making telehealth billing requirements clear and exploring how we could establish a statewide telepsychiatry program in emergency departments similar to one in North Carolina. So that there could be a system to help treat and divert psychiatric patients that are seeking care in emergency departments. And finally, I want, there are within the report a number of other recommendations for federal action, but I wanted to highlight these recommendations for federal action specifically with regard to traveling staffing agencies. Because these agencies, while we have some local traveling staff agencies, we also have the presence of many traveling staffing agencies that work across state lines. So really becomes a federal issue. We recommend supporting strategies that would minimize the increasing trend towards travel staffing. This trend does result in unsustainably high cost increases for healthcare employers. We recommend that these strategies could include anti-poaching provisions that would be directed at travel staffing agencies, price gouging prohibitions directed at these agencies and potentially reforming federal tax incentives that very strongly advantage these traveling staff agencies over employers because the agencies can offer non-taxed housing stipends non-taxed per diem, such as meals and incidentals and non-taxed travel reimbursements. And that's the conclusion of the overview of the report and recommendations. Oh, thank you. And if anyone else isn't kind of tired when thinking about everything that needs to happen and is some of which is underway, we're not alone. So I'm gonna turn to my companion co-chair, Rep. Mark Hot, and I see a lot of hands are going up. Is that the practice in your committee as well to use your electronic hands? So I'm gonna make sure that we all work together on this. Yes. Okay. You know, I'm gonna suggest perhaps that we take down the screen sharing so that we can all see each other. And while we really have some limited time ahead of us, that's Mike, are you okay with just starting to take questions? Yeah, I think that's fine, Bill. Or do you wanna weigh in at this point with any thoughts or comments? No, I think it's probably good to go right to questions. And I think if anyone from commerce has questions, if we don't get to them, I think we will ask Ina to come into our committee for further discussions as we go along with our workforce. Yeah. And I can just say this is the next step. It's not the final step in this process of working together with Health, Healthcare and Commerce and also looking at the budget adjustment proposals, which we're trying to become more familiar with. So let's get right to it. I'm gonna start with, I'm gonna alternate between committees just as kind of a principle of how to proceed. So let's start with Representative Cortis and then Representative Kimball. And then we'll go back to Representative Peterson. Thank you. And thank you Ina for providing us with the recommendations. And I wanna preface what I'm about to say is that this is not my, I am frustrated and I may be blunt at points and it's not directed at you, Director. The great resignation is happening for a reason. It's happening because healthcare providers, healthcare workers, people in the system are burnt out. We've been working overtime and yes, we get paid for working overtime, but that's not sustainable. Where the crisis is well beyond a lot of these initiatives which frankly, we have put into programs and into bills in the past before the pandemic. So yes, tuition reimbursement, making licensing more efficient. All of those things are good things. I don't wanna say they aren't, but they're not gonna fix this problem. And it's a very little about retention of existing workers in this program. And I recognize that the state doesn't have jurisdiction over private employers. So I get that, but I just want it to be clear that before the pandemic, there was a vast gap, inequity between just compensation for workers and the administrative portion of, and I'm thinking of institutions right now. That has further caused injury at this point when the kind of work that we're doing and the intensity of the work that we're doing we're not gonna be able to recruit more people and retain people by offering tax incentives and education, tuition reimbursement. We're just, we're not, as I said, we're well beyond that. And there's a lot more I could say, but I won't. I'll just end by saying the, I know we don't have jurisdiction over the federal, what the federal government does, but to take away, I think we need to be very careful or the federal government needs to be very careful about taking away the, one of the only options that workers have for just compensation, which is by taking away the opportunity to do travel work and get paid what they actually should get paid instead of focusing on keeping people in state and not expecting retirees. I don't know when I'm gonna be able to retire. I'd like to, maybe, I'm just gonna end there. This is, we need to do more than this. And I do appreciate all the work that went into this and I hope that frontline workers if they weren't involved in this planning process that they get invited to be part of the process now. Thank you. I'm just gonna take on the role of moderating the questions at this point and alternate between committees as I indicated. So, Representative Kimball, Representative Peterson. Thank you, Robert. Thank you very much for your presentation. I think you've probably listed every conceivable incentive program that has been discussed over the past. You're too, I guess my question, because we can't certainly do all of them if the advisory committee was looking at prioritizing them and saying what was more effective than others. I think the second question in terms of looking at the fundamentals is, is there anything that Vermont is doing now in the delivery of healthcare that stands out above its peers or could there be that would attract professionals or retain professionals to Vermont that stands out because of the way that we either educate or the way that we deliver healthcare services. Did the committee look at that as a different tactic? So I'll take both of your questions and I'll try to take them in order. So first, the question about the prioritization of strategies, I think that that is a very fair question because this is a very comprehensive contendium, if you will, of strategies. I think the advisory group felt strongly that that these strategies do and are interconnected and rely on one another. We could have a great way, we could have all the slots in the world for persons to be educated, but if we're not kind of fostering that excitement about the healthcare careers in the K through 12 realm, for instance, then we may not have people who want to move into that field as an example. However, in terms of prioritization, the challenges for the workforce seemed very apparent and daunting at the time of this committee's convening. And I think have persisted and even become more acute since the time that this report was written. And so that is why you see, again, a proposal for investing a total of $33 million for healthcare employers to provide in the very near future for recruitment and retention, retention of their existing employees and hopefully recruitment as well. So in that sense, that's certainly a priority in the very near term. When it comes to how the delivery of healthcare stands out in Vermont, different than other places to make it more competitive. I really appreciate Representative Cordes' suggestion for frontline workers to be contributing to this work because I think it's the frontline workers that would be able to identify where Vermont stands out best in terms of how practice looks different. But we also have discussed among those in-across departments as we think about strategies and how Vermont can be competitive in a fiercely competitive environment. One of the things that stands out is Vermont's vaccination rate so that healthcare workers coming to provide care in the state understand that they are coming to provide care in a highly vaccinated environment. I'm going to continue with, so Representative Peterson and Representative Mulvaney-Stanik. Yes. Black and Dickinson. Yes, thank you. And thank you, Director, for a comprehensive presentation. It seems to me, well, let me just ask a question, I guess, before I go into any other things. I think we need to, we need to. I know. You're right. And we'll take our testimony to you later. My question is this, does the state maintain a list of retirees from the healthcare industry that they can then go to and maybe coax some folks out of retirement to maybe work half a day, a couple days a week or a full day, one day a week or assist in any way possible to take the burden off of the healthcare? I didn't see anything in your presentation about that because part of my philosophy on this, on the lack of workforce and people not coming back is a lot of older people working and when the pandemic hit, they were the most vulnerable. They left and found retired life pretty good and they never came back. But all of us that are retired can use three or 400 bucks extra a week. And it seems to me that might be a way too. I wondered if that was considered. I'll leave it at that. Certainly there was consideration for whether or not the retired nurses would want to serve as nurse educators. Whether or not we have a comprehensive listing of those retired individuals, I think that's something I need to follow up on. But there are a number of, and someone can please help me. The name is escaping me, but we did see and have seen many retired health professionals participate in the delivery of vaccines to Vermonters and in testing and in other ways working with their local healthcare providers as ambassadors or in other roles. Representative Mulvaney-Stanik. Thank you Representative Lippert. Hi Anna, it's nice to meet you. I serve on conversations that we've met yet. And I just was wondering to build off a little bit about the existing workforce because I think it's a lot of folks what we heard in the state of state yesterday and even in this plan, the focus is a lot about bringing new people in. And we have a lot of Vermonters here working in healthcare, working in mental health and substance abuse field. And I was, I share Representative Cortes' point a little bit here about, I'm curious if we can learn more about how to retain people in these fields. Because when I see folks working in the healthcare world here in the state, I'm wondering about livability of these jobs in terms of what they're paying and the hours required of folks. I'm wondering about safe and inclusive work environments for folks who especially are new Vermonters where there's language access or other issues that might come up with workplaces not being inclusive and safe issues of racism and other things. I've heard stories from UVM Medical Center near my district. So I'm just curious if the advisory group went into the weeds a little bit to consider these pieces of the existing Vermont workforce and why we're losing people because if we keep recruiting people into a system that's going to lose them in a year or two, that's not solving any sort of problem. The advisory group did have discussion and consideration, perhaps not comprehensively to address all of the factors that you just named, but certainly in acknowledging and recommending that there be strategies specifically to address burnout in the healthcare and the health provider workforce. And so that is where our dialogue was addressing your question and in those recommendations specifically. So again, I'm aware of the time, I'm aware of trying to balance, we've got more questions and I'm sure there are even more. This is a next step. And so I'm gonna be also respectful of our witnesses' commitments which I understand and she is actually going to be testifying in the Appropriations Committee, House Appropriations Committee later this afternoon, our committee is going to go and follow that testimony as well. And so represent Mark, I'm torn, but I'm thinking we probably need to not continue much, continue any longer for that matter, despite the fact that we have many questions in front of us because our witness needs to meet another commitment. So... I agree, Bill. I think it's a beginning, not the end. So as you said, so I would ask my committee members to hold on to their questions and as we meet again, we'll bring those questions to the forefront. Thank you. And while our committee has done a fair amount of work, frankly, on healthcare workforce issues over the past number of years, I think it would be helpful at some point, perhaps for us to benefit from what your committee and House Commerce and Economic Development has learned generally around what you understand to be the most appropriate incentives, et cetera. So let's consider this the beginning and take some further steps together at some point in time as we can figure that out. So I apologize for members who haven't had a chance to pose their questions. I'm sure, you know, it would welcome you to reach out to her directly as well. And unfortunately, I think we need to bring this to a close for the current moment.