 First item on the agenda is the Executive Director's Report, Susan Barrett. Thank you Mr. Chair. A couple of brief announcements. Yesterday the Chair and our Finance Director were in the House of Appropriations Committee reviewing our GMCB Remount Care Board budget. And then in a couple of weeks we'll be in Senate Appropriations. We'll look to schedule a time to present that information to the entire Board as well as the public later in February. I wanted to give that update. Also, and I'm sure our presenters will mention this today, I believe we didn't receive any public comments on the two open public comment periods we had. So I wanted to report that as well. And that is all I have to report today. Thank you Susan. Next item on the agenda is the Approval of the Minutes of Wednesday, January 29th. On the approval. Second. It's been moved and seconded to approve the Minutes of Wednesday, January 29th. On the auditions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? If you two are ready take it away. Thank you. Director, this is Sarah Kinsler, GMCB Director of Strategy Operations. And I am the Kessler Health Policy Director. So thank you. Thanks for having us back today at the January 22nd meeting. Act of the 90th preliminary staff recommendations on the proposed amendment to the 2019 and 2020 HIE plan. As well as on the FY 2020 by the budget adjustment. And we're coming back today with final recommendations for the board. So first we'll review the proposed HIE plan amendment on consent. We are, unless the board has questions, we won't walk back through our rationale and authorities and staff analysis. We'll cut to the chase. So we have a slightly revised proposal to recommend to the board. Following the board's questions on January 22nd, GMCB and DEDA staff have worked together to revise section 3A of the consent addendum. More clearly described, permitted and non permitted uses of de-identified data. This new language specifically disallows re-identification in addition to commercial use for sale. So that's the only change that we're recommending from the proposal. And I've also included the slides that we walked through on the 22nd describing the reasoning behind our recommendation. But I won't go through this. So as Susan mentioned, we received zero public comments. Although public comment period is open from the 22nd through this past Sunday, February 2nd. And the staff recommendation is to approve the revised 2019-2020 HIE strategic plan including the HIE consent addendum with a change to the section 3A that was presented earlier. And additional connectivity criteria documentation effective March 1st, 2020. Staff further recommends sunsetting the 2014 HIE consent policy on February 29th. So that they won't be in conflict. Any questions? Did you want to vote on these first HIE plan and then vital or together? I think we can do one at a time plus there's an objection to the board. Does somebody wish to take a motion? I move we approve the revised 2019-2020 HIE plan effective March 1st, 2020 with the replacement language identified for section 3A of the HIE plan addendum. And move that we sunset the 2014 HIE consent policy on February 29th, 2020. I'll second that. And just for clarification, the section that you referenced is to de-identify data. Yes. Okay. Is there any discussion? Seeing none, all those in favor, signify by saying aye. Aye. Any opposed? Is there one for the vital amendment? Yep. Okay. Just to remind the board, vital came at the end of January to request an adjustment to their budget order. This is to reflect the expanded scope of work under their new contract with DIVA. Their contract with DIVA in the calendar year and their budget order is not on the same timeframe. So this is showing the calendar year impact on their current approved budget. Just to remind the board, it's a $1.5 million increase in revenues with a corresponding increase in expenses and it's directly related to the expanded scope of work. Any questions about underlying information? So this is just the background information. I'm short. So briefly the staff assessment was that this budget adjustment continues to meet the criteria that we've set out for vital budget review. It meets the transparency criteria and that vital has implied that all the budget guidance has kept us informed about the possible need for budget adjustment and has continually presented on their budget among other things quarterly. In terms of the line of HIE plan goals, the expanded scope of work that Agatha described supports the HIE plan goals specifically through the HIE consent and communication and collaborative services project through the main timeline and process for development and collaboration with DIVA and vital to ensure that it wouldn't be contracting with DIVA or the DIVA federal approval process. And lastly, we'll ensure that the order that we're talking about is sufficiently clear. So again, as I mentioned, we did not receive any public comment on this. The public comment room is open and the staff recommendation remains that we recommend approving the adjusted vital FY 2020 budget as presented with one condition and this is a condition that we pulled over from the previous, from the original budget order to continue up and do quarterly presentations on governance and operations, finances, technology and the collaborative services project. Any questions from the board? Is there any public comment? If not, is there any other comment? I know we improved the adjusted vital fiscal year 2020 budget as presented with the condition that vital present quarterly to the board for the duration of fiscal year 2020 and that vital quarterly presentations include updated information regarding cooperation, finances and technology and the collaborative services initiative. I would just also clarify that operations would include updates on consent implementation. A second. Okay, is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Thank you. Thank you very much. So now we're going to move to non-standard QHP designs. Good afternoon, my name is Ann Marin-Abergelli with the Green Mountain Care Board. I'm here with Dana Mulligan from the Department of Homeland Health Access. We are returning for you to discuss the non-standard QHP approval process and evaluation criteria to use for approval of non-standard QHPs. We were last here on January 29th to present the proposed process and proposed evaluation criteria. We had a period of public comment, a special public comment period, open through one day. So we did not receive any additional comments beyond those received at the January 29th meeting. Those comments on the 29th were a comment on what is the meaning of value within these processes? What is value and value for whom? And then we also had a suggestion that the Board consider the overall number of plans on the exchange when determining the value of a non-standard plan design. These are the evaluation criteria that were proposed at the last meeting for discussion today. We have the two suggestions about modifying the criteria from the proposed criteria. The first was raised by Board members, which was should we include support of state health care reform efforts, either as a standalone criterion or incorporate within number four, which enhances innovation. We reviewed these two, sorry, and the second one would be, which is the public comment, overall number of plans on the exchange as its own criterion or within likely criteria number five about adding value to a criminal marketplace. As with the process and the evaluation criteria development, Board staff worked with DFR and Diva staff to consider these proposals and come to you with a recommendation. Our recommendation as it is is to approve the process as presented on the 29th and approve the evaluation criteria, which in some way reflects support of current health care reform efforts in the state. The reason why we did not include overall number of plans on the exchange is that Diva as part of its statutory duties back here before making the plan available on the exchange, the Diva commissioner must determine that the plan is in the best interest of individuals and qualified employers in this state. And as part of that determination, Diva does look at the number of plans on the exchange in determining whether, well, how many plans to have. So we do not feel it was necessary to include that as an additional criterion within the pre-mounted care board process. At this point, we're seeking board feedback on where and how to incorporate support of state health care reform efforts if the Board wishes to include that. It's basically just stating how to do it, not what we're doing. It's just making sure that it's in a position to reform efforts. Does anybody have a preference on the board? John? I do. So last, at our last meeting, one of the criteria was enhanced innovation and then there was a section having to do with examples. I thought that the examples were quite broad and I'd like to try to focus them a little bit to align these non-standard QHP plans with the all-air model, which has not been fully achieved. So to me, this is an annual cycle that we go through. These criteria are new but I think that we're looking forward to the 2021 QHP plans in this instance and non-standard plans and that's well into the all-air model and I think that there are opportunities for innovation to help align these plans with the all-air model. And so let me just give you one example. My proposal is to add to the language after the word location under criteria so that that section promotes preventive healthcare, financial incentives or optimal service delivery location consistent with and to the maximum feasible extent in support of the achievement of statewide health outcomes and quality of care targets as established in the Vermont ACO model agreement, especially those regarding chronic condition targets. So that's, I think, a very broad enabling statement or a set of examples but I'd just like to kind of walk through one that could be a possible for the folks that are working on this, on these plans as it unfolds to improve what we have now. And the example I would use and this is just an example is Diabetes Protection Program. We have the Department of Health's statement that obviously pre-diabetes is a problem. Approximately 6% of people have been diagnosed with it and I'm quoting here however an additional 243,000 adults may have pre-diabetes and not know it. It is a major morbidity that is highlighted in the all pair model and then I have, the board has this information and I hope they can deal with anybody who wants it. The profile and the clinical assessment of the CDC's program is dealing with Diabetes Prevention which covers both nutrition and fitness and it's, according here again, their program results in a 58% reduction in the development of type 2 diabetes compared to a control group over 2.8 years, a third group receiving metformin which decreased the incidence of type 2 diabetes by 31% but was less effective. So the CDC program I think from what I've read is the best standard for a Diabetes Prevention Program and that's what we have in Vermont. The blueprint runs a series of workshops that is based upon the CDC plans but looking at their 1918 annual quarter there are only 184 graduates from that program. We're dealing with a morbidity that affects thousands and thousands of Vermonters and we have a program, I think a first class program in place with the blueprint but it's just not getting well used and it's not in the mainstream of insurance policies. So I'm looking kind of more broadly down the road that we have an opportunity to revisit our benchmark plan which was established under the Affordable Care Act in 2014 and has not been changed since but there's much of that has happened in Vermont since then and the possible kind of opening of that benchmark plan which the federal government now allows more flexibly to see whether or not it's best aligned with the all-pair model I think would be a good thing to do and the pre-diabetes program is just one option there that makes sense to me and because fitness is not an option under the fitness efforts or not a strong option or even an option under the current benchmark plan but nutrition is that and understanding that the criteria are dealing with benefits and not the actual benefits because the benefit there is a benefit in the existing benchmark plan with nutrition to me that might be with some innovative minds thinking about it a pathway to make this pre-diabetes prevention program more available through Vermonters through their insurance and so that's kind of the background as to why you know I'm kind of not kind of I am proposing an expansion of the examples in the criteria to try to push this process toward aligning it with the all-pair model Yeah, there are questions of the panel before we go to a motion because I want to go to public comment before we do that so is there any questions or any comments from the board before we open it up to the public? Is there anyone that wishes to comment from the public? Yes, Walter. I just want to know what the difference is in the line here it says change the applicability of a deductible to a service exactly what does that mean because aren't all medical procedures a service? I can't read what's going on. So I can answer that. When they say applicability of a deductible that means that the deductible would be required under that strict plan for that service so deductible applies for example for an invasion service but an issuer could opt to not apply deductible to generic prescriptions for example That's what that language is describing. Who decides whether to apply it or not? Well in the non-standard plans which we're discussing here that would be primarily the issuer's choice and then based on the planned design and structure that they would have to still make sure that they comply within the ranges that are acceptable or their actuarial value. The deductibles are institutions passing policies on the individuals so in areas again is it every service or is it just this one and that one and that one and this one can they change and they not? Most services do apply towards the deductible that's a driver of care to a certain type of service or to just make a plan more attractive the issuer could decide to not apply deductible like I said towards generic drugs or something else as an incentive to drive enrollment to that plan or drive the enrollees within that plan to ensure that the service is in a certain way. So how does this add value to the market? Because deductibles are what keep people from using care. Yeah so if I could just jump in so these are evaluation criteria that we would use in evaluating the non-standard plan proposals so this is a way of saying we would want to understand how the carrier is thinking about the cost sharing so you couldn't if you eliminated all deductibles then your co-pays would be very high because you still need to meet the actuarial value like that's a federal law that's not something that we as a board can change because the ACA so it still has to meet those AV levels bronze, silver, gold and platinum but what this criteria is saying is that part of what we will evaluate is whether or not we think that if the carrier is proposing to not charge a deductible for generic drugs or for well, colonoscopies are under the ACA so that's different I mean that's required by federal law or let's say they wanted to promote chronic disease management so they wanted to say no co-pays or deductibles for the first three preventive care visits related to X disease so that we would be evaluating that based on these criteria but it's not a way to eliminate all deductibles because quite frankly there's no way to do that and necessarily meet the AV requirement which we can't change I mean if you may be able to at a platinum level but you're going to have to still then have co-pays because if you had no cost sharing it would be 100% AV and it has to be 90% Is there any other public comment you're seeing none when somebody wished to make a motion at this time? Do you want me to do it? Go ahead and I'll just add my amendment or I can just add your amendment if you want Okay, so I think we approve the non-standard qualified health plan design approval process as presented and approve the evaluation criteria with the modification that the enhancing innovation criteria include a broader range of examples specifically promotes preventive health care financial incentives or optimal service delivery location consistent with and to the maximum usable extent in support of achievement of statewide health outcomes and quality care targets as established in the ACO model agreement especially in supporting chronic conditions Before somebody seconds it let me just make sure as a presiding officer that I understand what you have just made for a motion where did you choose to add a separate criterion for the state health care reform efforts or did you include it with number four? I included it, I felt like I included it in number four with Tom's language Okay, now I understand Is there a second? Second Is there a discussion? I just have one point I would like to make and others are interested I think I would prefer I like Tom's language and I like the direction it's going to give it more staying power over time I would like to change the language to promotes preventive health care financial incentives or optimal service delivery location consistent with and to the maximum usable extent in support of current health reform goals with particular emphasis on statewide health outcomes and quality of care targets especially those addressing chronic conditions so effectively I'm substituting current health reform goals with the Vermont's ACL model so that this, you know, as we may change the name of our next model agreement with the federal government it just allows more staying power I think of this criterion I would view that as a friendly amendment Okay, it's been taken as a friendly amendment by the seconder, the maker of the motion Yes Parliamentarian, I am not Okay, is there further discussion? Seeing none, all those in favor signify by saying aye Aye Any opposed? Thank you very much Thank you So thank you very much for having us today I'm Marisa Parisi I'm the executive director of Rise Want Statewide based at OneCare Our team there is charged with helping with health care Our team there is charged with helping our network of providers implement Rise Want Statewide and as you know, Rise Want started in Franklin Grand El counties at Northwestern Medical Center in 2015 and had the opportunity to see them in action in October so we were hoping we could come back to share with you more about how the Northwestern Medical Center team has really inspired us to spread the model statewide but more importantly also show you how we are measuring the work that we are doing to really hope that we can see some outcomes in keeping the population healthy So I'm really pleased to be joined by this panel who traveled from all over the state to join us today Dr. Jennifer Garon works with us at the OneCare office on the Rise Want team to really help us measure outcomes and make sure we are implementing the evidence based model so that we can look at indicators of whether or not we are on the right track with our prevention work This is obviously not a picture of Alice Stewart She is here on our panel This is however her preferred head shot This is the wellness sloth at Mount Eskettling Hospital I would like to tell you more about that Alice is one of our early Rise Want program managers that started in 2018 when we started expanding statewide She'll tell you more about some programs happening in Windsor County One of them is here She's an administrator but an early adopter at Southwestern Vermont Medical Center of the Rise Vermont expansion and I'm going to tell you a bit about how Rise Vermont has expanded in Bennington and some of the programs there This is where we're at right now with our Rise Vermont expansion As you know, Northwestern Medical Center really set the tone and pace with Rise Vermont and helped create the evidence based model we now implement statewide and from there thanks to their incredible outreach and advocacy before our team started at OneCare we had five early adopter hospitals come on board to hire Rise Vermont program managers and take on the model in 2018 Last year we had three additional hospitals joining the program from the Memorial Hospital and we do hope by 2020 that we will have a Rise Vermont presence in all fortunate counties that does not mean all towns in Vermont because we're very selective and strategic about the towns that we work in especially because of the readiness factors and health outcomes for the different communities we work in but right now in 2020 we have pre commitments from Rutland Regional Medical Center and Northwestern County's health care to hire Rise Vermont program managers starting in sometime in quarter one and this kind of hospital has worked with Radarville Memorial Hospital to do some coverage in towns around that hospital so we I'm not sure that they will hire a program manager this year but we are providing additional support through Radarville Memorial Hospital for towns around that hospital and Central Vermont we've been in close conversation with about whether or not Rise Vermont will come to Washington County this year we are hopeful that we will be able to provide that level of support and we've been working with the Thrive Committee to talk about what the options may be so we're very hopeful that we will be able to bring the model to all 14 counties in Vermont by the end of 2020 I don't want to take too much time to talk about what Rise Vermont is because I feel like the board has had a very good overview from your presentations we've brought to you and you have your more recent meeting in October in St. Albans where you really got to see some of the work on the ground happen like many of us you ended up dancing in schools and it sounds like there was no bike but I'm sure there were other activities that you got to do but as of right now we have 16 Rise Vermont program managers so those are direct people in communities working on all different kinds of projects which we'll hear about through the course of the presentation at many different levels and many different sectors to round out the MN space model we anticipate at least two more this year if not four more with those other service areas coming on board you may have also seen which is part of our model a new campaign we've launched called Sweeten Up and this is a campaign that is aimed at behavior change marketing to help change behavior of a wider sector of the population beyond where we are just roots on the ground so this campaign which Dr. Laurent will cover more about the pre-research and evaluation we're doing in this campaign to help Vermonters make different choices around sugary beverages because while we are often known as the healthiest state in Vermont our research shows that people are drinking far more sugar calories than they should on a daily basis and that does drive chronic disease including diabetes which we just heard a little bit about from the board we've also since the middle of 2018 given out over $220,000 and amplified grants which are grants directly to the community to do a mind work with Rise Vermont and as we've heard about today we've really developed a rigorous and comprehensive suite of program evaluation measures to look at how are we doing and to help guide our direction with Rise Vermont to ensure we're having impact and as I said our goal by the end of 2020 is to have Rise Vermont in all 14 counties and we have the slide with you but I'm just more flagging some of the innovative programs on the slide that you may hear about your own communities that are going on having the network of Rise Vermont now essentially coordinated by one here is that all of our program managers are able to talk to one another that we facilitate on a monthly basis so no one good idea stays in its location it's able to be spread statewide. So these are some of the models we're going to talk about today many people are familiar with the e-code model which was the European model that inspired the work of Rise Vermont for our purposes today we don't focus as much on people because we see a lot of overlap with the evidence-based CDC approved programs including the socio-ecological model to collect an impact on the 21st strategies to reduce overweight and obesity so we'll be looking at more of those today but really we often refer back to the e-code model as our founding model and the last piece that I wanted to cover before I hand it over to our panelists our questions that we've received about Rise Vermont as we've gone forward with our expansion whether it be from the legislature, the community, our partners so one that we get pretty often is why is Rise Vermont part of the ACO and how is it funded and Rise Vermont is the lead primary prevention initiative for One Care Vermont as we all know it's a four quadrant model it's a long-term strategy to reduce chronic illness among the population which is the biggest driver of cost so at One Care the goal is really to have a plan for every person and that includes people who are healthy or may believe they're healthy now but really have underlying health issues that they don't know about until you get a diagnosis so what we're really trying to do is create the healthiest environments possible so that people have the greatest opportunity to be healthy we are funded with delivery service reform funds which right now can only flow to the ACO and Vermont and from there we feel a responsibility to make sure that all of those funds are coordinated and evidence based to make sure we have statewide impact so Rise Vermont is really the conduit to working with our partners statewide and this is how we're going to really hopefully measure the impact of the work we're doing and the impact of the dollars we're spending and this is a the last point is really we find really critical and we've seen it out in the field as well is that sometimes there's a tendency with the medical community that they know that prevention is important they know that 80% of health care is happening outside of the medical office but if it's not there someone in their office drawing them out into the community they may think that prevention is being taken care of somewhere else so by placing the Rise Vermont program managers really at hospitals and in the clinical setting we've really been able to draw health professionals and clinicians and practitioners out into the community to really meet people in a different environment and engage more in prevention work so it's been a real benefit to have us based at hospitals across the state the next one is is Rise Vermont duplicating efforts and I think that's a great question I haven't worked in the nonprofit field for a long time before I came to OneCare Vermont would ask this question often is that we need to do a very good job in Vermont so that there's not duplication and the Rise Vermont mission is to work together in Vermont's communities to improve the quality of life and build healthy environments where people live work, learn and play and our number one value is partnership explicitly work with our program managers through our work plans to make sure that we amplify existing work before we launch anything new so that may be we provide additional staffing or support or money to help local efforts that are already great whether it's a municipality, an organization even, you know, key individuals we help further their work and then when we see gaps we fill gaps and providing that additional capacity for efforts has been really important because we just are only trying to be in places where that capacity didn't exist before so how are you measuring, how are you measuring impact and outcomes? This I'm going to hand over more to our panel of experts but I do want to say that measurement is built into everything we do at Rise Vermont we look at all of the high level population measures collected through the youth rose behavior survey the breadth of survey and the census and then we take a closer look programmatically because some of those larger population measures take a long time to see if anything can get different so we're trying to make sure there's a lot of rigor in our programmatic evaluation and then if anyone was interested in learning more getting really deep into the details of our evidence based models or how we're doing this evaluation work but there is more on our website and I would encourage others who have questions to take a look so with that I'm going to hand over to Dr. Laurent to talk more about the evaluation measures Good afternoon, can you hear me okay? We can, I guess. Okay great so I'm Dr. Jennifer Ryan I'm an associate professor at the University of Vermont College of Nursing and Health Sciences and part of what I do there is obesity research at the University of Vermont and so what I'm going to do today is kind of give you a very I guess brief overview of what we've been up to in terms of how do we best evaluate or evaluate our metrics to make sure that what we're doing is going to at least pay off over time and I think as Marissa had mentioned these preventative measures do take a fair amount of time to actually kind of show their benefit so currently we're doing many things but this is just a snapshot of this slide telling you exactly we look at population health trends which Marissa had also talked about and I'm going to walk you through each of these we also have a study looking at the program managers which are our key informants and what they're doing how they're doing it and kind of getting some quantifiable measures with that we're also in Franklin Grand Isle we're using that almost as a pilot community and really taking the time to do BMI surveillance in an objective way in our early you know early childhood so anywhere from like age 6 to 11 which really isn't currently done in the United States we're also tracking these amplified events that Marissa had mentioned to see where our dollars are being spent and how we can quantify the dollars that are being used for our interventions to see how that might impact specific developments we move on and then lastly looking at the behavior change for the evaluation of the sweet enough campaign so when we look at monitoring the population health trends we're just giving you a snapshot so as Marissa mentioned we take the graphics in the YRDS data and we actually along with the census data we actually extract that so that communities have a really good snapshot of what's happening in their community I think it means a lot to communities when they can actually see oh we're doing really well here we need to work a little bit harder here and this just gives you an idea of what we have on the website for population health data our key informant interviews this was a group effort I can't actually take much claim out of this one but just to kind of give you an overview we have about 75 projects in the state of Vermont that are active of those 42 involved the community as a whole which is pretty impressive and of those 44 involve environmental changes and sustainability it's the environmental changes that really are going to impact us most over the long term this again was a group effort and we came together to figure out how can we really look at the efficacy of what we're doing and this is kind of the holy grail of community based work is trying to figure out how to make sure our efforts mean something and we can account for the dollars from my graduate student as I move on because she's not here today because she's taking care of patients but she should be but she really led us on the path of developing something what we call the DOS methodology and so this is something that actually started out in the Midwest and they standardized by using some fairly advanced statistics to figure out how to quantify these measures so that we could say if we were doing an intervention in the school we could actually assign a number and then so all these interventions would be assigned a number and we could aggregate that data and actually give them a score and that's called the CPPI index CPPI index it's the community policy and program index so it actually is a number to that has been shown to as the number increases as the CPPI index increases over about five to six years that has been associated with a decrease in BMI in children so it's been studied Colleen Akers is probably the one who's studied this best and it's in Kansas so we really have kind of adopted her methodology or her teen's methodology going forward this just kind of gives you a little idea and one of our panelists is actually going to walk you through the actual dose calculation but I'm just going to kind of give you an overview here this is a slide, it's a little blurry but this is the CPPI index and then this is the change in body mass index which is basically the population health measure that we do to kind of evaluate who is obese who is overweight, who is with a normal weight and so what we have found is that as the CPPI index increases there's actually a decrease in body mass index and so the higher the strength or the higher this index has been actually shown to decrease BMI and a certain unit by one or two units which is a little bit difficult to translate with children because we look at other things besides just BMI to kind of determine whether they're overweight or obese so this was in 130 communities with over 14,000 children they key informant interviews and whatnot so it really has some good evidence behind it that we're adopting as we move forward and so what we've done that's the next slide or not this is just for your reference if you're really interested is really this is the grid that we use to calculate the CPPI index so we look at how long has that intervention been going on how far is it reaching, is it community wide is it the whole health service area or is it just a grade you know a grade within a school and what is the behavior change strategy I mean we're looking specifically at the CPC strategies when we're collecting our data and so what we're doing is we're hoping specifically in Franklin Grand Isle because we have very good penitents that arise from not in Franklin Grand Isle we're using that community as a pilot and what we've done is we've instituted this BMI surveillance program that has gone through the institutional review board so it's been you know vetted for making sure that we're you know upstanding and we're holding true to the human ethics and we're going into the elementary schools we've got all of the elementary schools in Franklin Grand Isle and we actually had a wonderful team go in and measure the BMI of all of the children in grades 1, 3, and 5 in 2017 what we found out was 40% of the students overweight or obese which is way above what we're finding in terms of Vermont and general so we've gone back in 2019 and I'll show you that slide what we're hoping to do is taking the dose calculation and really watching very closely the trends in BMI in the Franklin Grand Isle to see if really this adoption of using this CPPI index can actually really help inform and predict what type of BMI change we might see over time and that time is 5, 6, 7 years it doesn't happen quickly I want to point that out can I do anything else? oh there we go so this is just a snapshot and I need to stress especially as an obesity researcher I am impressed with what this statewide team could actually the team that was able to collect this data we collected data in 2017 from 1,600 800 some of the students in grade 1, 3, and 5 and we very very little push back there were very few parents who opted out of participating in their children and then there were even less children who refused to participate so it kind of speaks to the fact that we can do this we can do it very well and this will actually really inform our efforts we actually again this is just a pilot in one region and we did not get pushed back we feel like we need to give back to our superintendents in our school so we have actually met with the superintendents and were about to meet with them about the 2019 data to really talk about what's going on and we have not as far as I know the superintendents haven't gotten any pushback but we have not gotten any pushback from superintendents and teachers feel fairly engaged because we have mechanisms in place to protect these kids so it's not like you just line up and get on a scale like maybe you did 30 years ago we have private booths we have some very entertaining team members who can divert attention so it's been incredibly successful the model that we're using and it does align with other models that are being used throughout the country we're happy I think reluctantly happy to say that we didn't see an increase in BMI in two years and considering the population statistics that that's a very positive thing that we didn't see an increase we didn't see a decrease but I think it also was too soon because we really started to increase our penetrance of Rice Vermont in Franklin Grand Isle but also in the state in general I thought that was going to be a question so the other thing that we're hoping to do or I'm hoping to do is use these Amplify grants and the Amplify grants are essential because anytime you're doing community-based work you really can't tell a community what to do because we don't none of us like to be told what to do specifically children don't like to be told what to do so it's hard to get executives you don't want to tell them what to do so really in all honesty they have to self-identify so this is the cool thing about our Amplify grants and as Norissa had mentioned $223,021 has been spent directly in the community for things that the community has identified that's important to them whether it's a salad bar or whether it's working on a safe crosswalk to get to school and so the community then becomes invested in making it a healthier community where they live, work and play and so this also allows us eventually, this is a particular interest of mine, is somehow fiscally looking at the association between the dose of what we're doing and how much that's costing and what we're seeing in our long-term outcomes so that we can really say as we increase our dose that those dollars can be accounted for in different ways and again our grants are aligned with the CEC so there's evidence behind that as well I think I forgot to mention that in our key informant interviews the statewide team is going out every six months to talk to these program managers to recap about what their current interventions are and to actually recalculate the dose so it's really helped hold the program managers very accountable to they know every six months that they have to be able to speak to what they're currently doing in their community, how that translates to dose so that we can really kind of look at maybe we should perhaps be looking at some high-dose strategies again one of our panelists will walk through this and some low-dose so maybe we get a nice mixture of community-wide there's some school maybe there's a free yoga class so we have a mixture and then looking at the physical impact of the money that we're spending on that so a question about who is making the decision at a community level community level sure so for my grant we have right now 36 identified groups that we are so we have rise one in and we accept grants from community members in that town there's a short grant application and through that application they need to identify what CDC strategies they believe that activity is going to hit so that we're collecting all of that information the majority of the grant applications do come from the towns but as all of us know there tend to be hub communities and to give you an example Morrisville it's a perfect hub community where there's some other small communities around if people shop or work in Morrisville so we have accepted grants from surrounding communities where we might not be doing specific rise grant programming but we know we're hitting all the same people I guess my question was so if it's the town are you doing the town manager the select board does that help do you mean in terms of the grants yes it varies we are open to we have grants from our state partners we've had grants from individuals in the community like the yoga teacher schools municipalities we've done grants for so if we are open if there is a project that is aligned with these strategies and aligned with the work we are open to funding it but lastly I'm going to talk a little bit about our most recent campaign called sweet enough which is really addressing this really crazy problem with sugar intake in youth but also in adults as well so this actually doesn't really focus on youth but the triple down of adults drinking a lot of sugar speed beverages certainly impacts youth consumption and so what we did is we wanted to get again some preliminary data you know Vermont is the healthiest state in the nation so what are the healthyest states what are the Vermonters doing in terms of sugar speed beverage consumption and so we hired a firm to actually look at knowledge and beliefs and patterns and so what we did find is that on average and these are adults and the consumption in adolescents is much much higher than this on average Vermonters are consuming about six and a half sugar sweet beverages a week and in all honesty that translates to about 2,000 extra calories if you think about our daily caloric needs most of us don't even need 2,000 calories per day so you're talking about a great contribution towards waking but also not metabolic dysfunction, diabetes and other health issues so we identified that as something that really we need to change behaviors give them alternatives swaps that type of thing so that we can motivate them with this social marketing campaign behavior change to really kind of look at their behaviors and think oh what can I do that would be easy tasty and whatever so that I reduce my caloric intake and also my chances of developing diabetes specifically so we are I think in the fall of 2020 we'll be collecting that post-campaign data and so we'll be able to report back to you what we found there I have a question about that campaign what was your involvement of the Vermont Department of Health? in the sweeten up campaign? yes we are doing that campaign independently we partner very closely with the Vermont Department of Health in all our activities and especially locally our rise in care paired up with the district directors they're doing great work together we've provided local materials for the sweeten up campaign we've also been working with the beverage industry to identify some convenience stores or places where people shop for their beverages we're actually willing to re-organize things to include the sweeten up signage and then everything behind the signage the goal is that nothing has any sweetener in it at all can you hand this over to Alice Stewart? so I'm Alice Stewart I'm the rise Vermont program manager based at the Mount Estetny I cover four towns Windsor, West Windsor Weathersfield and Heartland so I'm here today to talk about two projects that I'm working on the first one I want to talk about is health on the shelf and this is a project where we're trying to generate a sustainable supply of healthy foods in the area of food shelves so the food shelf patrons who are trying to prevent or manage a chronic illness and we're doing that in partnership with the food shelves it's a very consultative collaborative partnership we've tried to be really careful as we're doing this work that we're respecting each food shelves unique culture, capacity and clientele and then we're also recruiting local businesses, municipalities and other organizations to sponsor food drives so this is just a quick profile on the food shelves as I mentioned I'm working in four towns there are five food shelves the biggest takeaway of this slide is that it's very small and that they rely heavily for their donations on area residents and in some cases area businesses who might give them a monetary donation so the main goal obviously is to get the sustainable supply of healthy food but we also have some secondary goals one of those is community education around nutrition and that goal is actually very important to our Vermont Department of Health Partners and then we're also using this initiative to help build that accountable community for health mindset with our area businesses and other organizations the Post Street you can see on the screen there was designed by our statewide partners who are super great and so we made copies of this for each of the food shelves so that when they get deliveries from us they can put that up so their patrons know that those foods are available so our key partners I want to give a great shout out to Kate Rohn who's the chronic disease designee out of the Springfield Office of Local Health Kate's been with me every step of the way on this project she's brought great resources and great thinking to it and I really appreciate it a little bit of detail now so for the first phase of this project what we really worked on was getting input from the food shelves and then also some input from the clientele of the food shelves so when we have this idea when you have an idea sometimes it's not a great idea so we started out with the Winter Food Shelf where we had a pre-existing relationship and we talked to them about the idea and they liked it but the thing they brought up is well we need to be really careful about our volunteers it's very hard to recruit and maintain food shelf volunteers to burn out and if the food shelves don't have volunteers then they can't stay open so we took that to heart and so one of the big pain points for food shelves is the work that's required when they get food donations to go through and find all the expired food that gets donated and then throw it away sometimes up to 30% of the donations they get have to be thrown away so we said okay we'll take that on so I have some volunteers like we have an AmeriCorps VISTA at Mount of Scotland in the community health department and we work with our sponsors to these food drives and we get the food from them we go through and cull out all the expired food before it goes to the food shelf one of the other pieces that we do is we organize the food we sort it all by what category it goes into so you can see up there the different categories we were looking for low sugar, low salt, whole grain, gluten free we've also added protein to that so we categorize everything for them so when we give them their allotment they get boxes and bags they're all labeled for the different categories and then we also give them an inventory where they have a list of the things we've given them and how many of each item so that's one thing that we did to be really responsive when we, before we got started so we have the food shelves on board they all like the idea but we also needed to find out what do the patrons think and when Kate Rahman I first designed the survey we designed it around what chronic illness do you have and the manager at the Windsor Food Shelf looked at it and said okay this is a good survey and then he stops and he goes well what about Frank Frank has diabetes Frank doesn't care Frank is not going to eat low sugar foods and so because of this great piece of feedback we changed the question and we changed it from what illnesses do you have to what healthy foods would you like if you could get access to them what should we try to get for you and I liked that because it also put that prevention angle into the survey so now we're not just talking about people who are sick but people who for instance maybe have a family history of diabetes or hypertension so they were able to give us input about the types of foods they wanted so that they could keep themselves and their families healthy so moving on from that phase where we were talking to the food shelves and all the food shelves disseminated the survey for us and then we compiled all the data in phase two we've really been looking at sort of a quality improvement small test of change kind of approach because you can do a food drive and it can be not a very successful food drive so we've been looking at different elements we can bring into these food tribes to make them more successful and part of the idea behind that is then we can go to new potential partners with a menu of things that we've tested out and have them tell us which of those things they think would work best for their environment for their clientele, for their employees so we've really been focusing on ways to generate donations because we need a sufficient flow of donations to make this sustainable and also making sure that we're getting the things that we actually need instead of just generic food donations so I'm going to show you two examples that we've worked on. The first test we did was a shopping list so we had the different categories of food that we were looking for and then some suggested foods under each of those categories and then on the flip side we put a food label with call outs I think if we probably hold everybody in the room and said ok for something to qualify as low sugar how many grams of sugar can it have to qualify as low sodium how much sodium can it have so this by putting this food label on here this goes back to that idea around the community education it really gives people an opportunity to think about what's in the food that they're buying not just for the food shelf donation but also for themselves and then one of the things I wanted to highlight on the shopping list you may notice there's some herbs and spices on there we put that on there deliberately because cinnamon can help food taste sweeter so somebody who's not having a lot of sugar in their food can put cinnamon on there and have it be tasty same thing if they're not going to have salt having some spices in there can help replace that flavor and it makes it easier for people to stick to doing those foods and then this just started this week this is our heart health month we're working with the banks in our towns and we are doing gift trees with heart shapes tags and each one of the tags has a couple of food items on it each tag would run somebody about 5 or 6 dollars if they went to the store and the idea is people pick up the tags they go shopping and then they can drop off their donations at any of the participating banks and we base this off of a successful drive we did last summer for school supplies once again working with the banks we talked to the school found out what school supplies kids needed and then for all the kids in our summer meals program we were able to supply them with all the school supplies they needed for the beginning of the year using this model with the gift tags and the bank lobbies so I have a planning and evaluation work group as part of my steering committee and one of the things they've been working with me on is results based accountability so we've developed measures for the health on the shelf project and you can see those first two members of the organization sponsoring the food drives and as I mentioned back at the beginning we're really trying to make this sustainable so the idea is we want an organization whether it's a municipality, a group of banks a major employer to agree to sponsor a food drive on an annual basis so that that way every year they're doing the food drive in February or May or whatever month so we want to measure that because if we go to somebody and they say yes the first year and no the second year that means we're not doing a very good job especially because we're talking about very small towns here so there are a limited number of organizations that are big enough to sponsor a food drive and then the last measure there is really focusing on whether we're collecting foods that people want because it doesn't really benefit the donor, the food shelf or the people that go to the food shelf if we're collecting food that nobody wants so I mentioned earlier that we give the food shelves an inventory so the Windsor food shelf which is the largest of these food shelves does actually track everything against the inventory Nan who works there and the committee on this planning and evaluation work group came up with her own system to work for their food shelf where she does these color coded stickers so when we give them an allotment she stickers everything and then they can tell at a glance what they've got that we've given them if somebody comes in and on their seat they're marked as somebody for low sugar any one of the volunteers can tell by the color coded stickers what they've got this low sugar that might work for that patron the other food shelves are a little too small to be able to manage to do that kind of inventory control that given us plenty of anecdotal information for example we know that all the low sugar items went really quickly they're in really high demand and it's hard for us to generate sufficient supplies of those and then also that another piece of anecdotal several people told me that the clients with celiac or who were otherwise sensitive to wheat when we started being able to offer the gluten free items we're very very grateful because that's not something they've been seeing in the food shelves before so we talked about dose earlier and I'm not going to pretend to be an expert in dose this was introduced to us at our retreat this summer and then we had some nice in depth training out of our program managers meeting in December and my planning evaluation work group is a really interesting dose I've described it to them but this is my first take on dose and we're actually meeting next week and we're going to go over the dose calculations and see they really want to see where we are on our whole portfolio for the region so just so you can see the total score on this one is the 2.55 the duration is high because these are ongoing food drives the reach I classified it as medium because it's based on the assumption that it's not just reaching the people in the food shelf getting the food but it's reaching all of those people that are donating all the people that are hearing our advertising, hearing our promotion for different healthy food items hopefully reading the backs of the shopping list and then the behavior change strategy we ranked that as high because we're really looking at this as a systems change piece we're really trying to change the donation system adding to the current system and adding this piece on to it and then I just wanted to share some really quick short term outcomes one is just the anecdotal piece that I have heard from donors that they are actually reading the backs of food labels and are kind of horrified at how hard it is to find low sugar items and then also that the Windsor food shelf has actually changed its buying practices as a result of participating in this project they are now with the money that they get when they buy canned vegetables they are only buying no salt added vegetables which I thought was a really great win so the other project I wanted to talk about really briefly is the Windsor walks project and this is a project to develop a series of walking loops in and around downtown Windsor varying in length from a quarter mile to four miles and at least some of them to be negotiable by people of limited mobility or people with strollers we're not talking about ADA compliant because quite frankly the infrastructure can't support it but what we're trying to do is have some of the loops be like if you had a power chair and there is no ice out there and we're doing that by partnering with the town of Windsor and our friends at the Vermont Department of Health and once again Cape Roan has been a really great partner on this and then also I've been working with several community consultants and these range from avid walkers who are out there four or five miles a day every day no matter what the weather to people with impaired mobility because we're really trying to design a system that is going to work for a variety of winter residents and the simple sign over there that's the almost final design if you notice it's kind of long and skinny that's because when we went to the town manager with the original design and he liked it and then he said but the sidewalk snowplows are going to hit it so we went back to the drawing board and designed this sort of long skinny thing and it enables us to each one of them will be custom but we can some of them will have the map some won't, some of them will have the points of interest some won't it'll just be like whatever pieces of information need to be on there and one of the fun facts about this is we're going to be manufacturing them we're partnering with the folks that make the nursing pods and apparently in that nursing pod manufacturing process they end up with a lot of scrap so these signs are actually going to be made from mama vala scrap so it is a fun recycling angle to it so the primary goal of this project is obviously to get more people walking if they're already walking we're trying to get them to walk more if they're not walking we're trying to get them to think about walking using wayfinding and decision prompts but there's a secondary goal here of trying to promote Windsor as a healthy place to live or visit or work and that's typically the image that a lot of people have of the town of Windsor and the town manager and the select board and a lot of people in town have been working really hard to help change the town's image and we see this project as another way to help them do that and I know you probably can't see it because it's kind of not it's not easy to see but that map there was put together by our friends at Southern Windsor County Regional Planning Commission they've been doing the ArcGIS work for us and that's just a preliminary map there are actually several other neighborhoods that my community consultants would like us to expand to this is not a one-and-done project we are going to keep iterating on this in some cases there's some trail work that once it happens we can add some other pieces onto the loops and one of my key partners is Bob Haidt, the zoning administrator and you can see him there in the picture we went out in November we were shooting photos of where the signs were going to go can we see him? he's just like eggs in his hand so um anyway he's been when we first came to the town about this project he was super excited to pull out all these pieces of tissue paper because he had been working on not this exact idea but something similar for some time so using a Vermont Department of Health 3-4-50 grant which is what's paying for the signs and my time is the Rise Vermont Program Manager and Bob's vision we've been able to really make this a really robust project that's involving a lot of different sectors in Windsor and it's going to cover a lot of the territory in Windsor and then this project does not have any results based accountability not because we didn't try we've looked at it I think five times now in the Planning and Evaluation Work Group we did the brainstorming we really had trouble finding measures we thought were really going to work and so I've been talking with Denise Smith who's sitting over here from our Rise statewide team she's the one who does the key informant interviews and so she's pointed me in a couple of promising directions on ways we might be able to get something measurable we really want to be able to see what the impact is yes we can do some convenience sampling surveys and things like that but she's made some suggestions about getting a laser pedestrian counter I did check with our Regional Planning Commission after she said that they're too small they don't have one but they think they can borrow one from a bigger Regional Planning Commission so anyway everybody's kind of pitching in to try to figure out how to do this but I did want to highlight the dose score on this one the duration of these loops many of them will be available even in the winter the reach it's you know because even in winter we anticipate quite a few people using these especially because I have one of my community consultants has already offered to start walking groups once the loops are up and marked and then for the behavior change strategy I mean we're making an environmental change here and we actually really see as the culture will change as well we're really trying to change the culture around walking in winter so I think that's everything I had can we switch seats last but not least my ability from Southwestern Vermont and I have worked at Southwestern Vermont for the last 10 years and I have to tell you that certainly I've had a long career as a registered nurse but the work that we've been doing for the last 8 years that surround the accountable community of health is absolutely the most rewarding work of my career and I feel more and more every day that we're going in the right direction and transforming care delivery in the state of Vermont so I wanted to rise Vermont from the moment that I heard about it and so I just want to tell you that story Jonathan Billings who's sitting in the audience happened to present at a conference that we had in 2016 we were really excited about the population health work that we were doing and we wanted to share it across the state and we invited all of the people that had gotten grant funding to come together we had about 120 people there and had a day long conference and small group discussions and Jonathan did a presentation on Rise Vermont and that day our team from Bennington said we need Rise Vermont so at that point I started counting him and trying to figure out how we could get Rise Vermont so the fact that this group chose that as something for the whole state was just perfect so we started before we could have Rise Vermont we decided okay maybe we can't use that name but that concept is what our community needs so the department of public health leader and I brainstormed after the conference and said let's get a group of people together in our community and talk about this and see if we can get some enthusiasm so this is not necessarily the group there are a lot of different ages but we got about 20 people that started to meet on a monthly basis to talk about health in our community and what we could do collectively to get the ball rolling with that Bennington county challenges you know it because you've heard about it for years you know we ranked 12 out of 14 counties with our health outcomes we have lots of poor people with housing issues with food insecurity we have many children living in single households and many living in poverty and all of those things make us really want to focus on children and come up with a plan and Rise Vermont has really given us an avenue to come together as a community to make this a reality we started again before we were able to start so we used a summer intern that we got from one of the colleges to help us build momentum before we got the funding for Rise Vermont through one pier and we started doing show up activities we then hired Andrea Malinowski who is our program manager who has been a rock star and has done so much in the year and a half since she started that I would be a really long time to share with you all that she's done right out of the gate Marisa and Emmy came down and met with us and it was like a little pep rally and we walked around the town and they looked at all the people that were smoking and we were brainstorming all of the things that we needed to make better with Rise Vermont our stakeholder group that we started with we capped and expanded and through it and I have to tell you our stakeholder group meets monthly and we sometimes have 30 people there with all sorts of ideas they are volunteering they are covering all of the things in the community that we need help with and it just has been so well received by the community of Bennington this is just a slide that kind of tells our story certainly this is part of our accountable community of help that we're trying to put together this is just a sampling of all of the people that are sitting at the table and that are really partnering with us and this is just some of them there's so many more we work really really closely with the Rise Vermont team and they are always available for what we need we have full support from Tom Dee and our executive management team to do this work and that is Andrea with the green Rise Vermont t-shirt and she just has gotten into every corner of the community no one says no to her she's very convincing and she can talk people into all sorts of things that really are making a huge difference in our community one of the things I really want to talk about is the steering group and I really wish that I could have had a camera in our last meeting these are the people that are on our steering committee and it's certainly Andrea and it's myself as the director of population health we have the assistant superintendent of schools who is committed who's at the table and really helping us get into the schools and do the work that needs to be done we have the director of community development in the town of Bennington that is just really a huge difference with helping to align all of us going in that same direction sharing resources we have the director of volunteer services and community engagement and that's helping us get volunteers which feeds the programs and really gets it going and critical partner in the department of health she started beside me shoulder to shoulder there was turn over the next person was totally on board and that has been critically important and then United Counseling Services which is our mental health arm that's a whole other piece that we're working with them and we're branching out into programs for people with depression and suicidation and people that are isolated and alone and trying to get them to our special events and then our business is the president of our local credit union and he is helping us to gain support from all of our businesses in the community so we kind of have this ideal team and in our last meeting we had just introduced the dosing measuring and at that meeting what we decided to do was take all of our events from last year and dose them now figuring it out and also look at besides dosing them can we find other measures that we want to now put in place with our programs going forward and they were on board they're using their spare time to do this it's not just that they come to a monthly meeting but they're in and this is a picture of all of the program managers with the rise for month team and just imagine all the steering committees across the state that are doing this kind of work it's just amazing and so so powerful we've given thirty thousand dollars in grants we've touched every single corner some of the ones that I want to highlight is we decided that we really wanted to start with young children and head start and early intervention so we've had programs for those kids we've also started a mindfulness program in kindergarten so the kids and their teachers learn mindfulness and our hope is to measure behavior problems and kids that have to leave the classroom and see if over time grant that foundation I was wondering if you would turn for those teaching skills to Washington if I had the opportunity for sure so that again is something that's catching on now the businesses want mindfulness and the hospital just started three times a month we're doing programs for staff for families of staff for employees for patients whoever wants to come so that is something really important you know I think that healthy eating and cooking is critical we have an issue in our community with lots of people without affordable housing who sometimes are living in motel rooms with four children and don't have kitchen facilities so we're coming up with creative ideas with Rise Vermont we bought a whole bunch of crock-pots we're doing crock-pot recipes with tasting cooking times for those families so that we can really help them to better feed their children in the circumstances that they're in right now bicycle education we have like a lending library for bicycles for snowshoes for cross-country skis for kids that don't have access to that equipment but really could benefit from it now free fitness classes are everywhere and they're spreading like wildfire and we're trying to make it fun so people that would always say no thank you are now doing it and this was in the middle of the winter it was about 10 below zero and a group in the hospital said let's see how many of us will show up for our noontime walk and there was quite a big group of us that did it and that's the SBMC Wellness Walkers and our new year-long program just started so we're going to be out there a lot community show up events this is a critical piece our dreams that every Friday during the school year kids will get a list of free activities all these snacks and access to some sort of exercise and activity and they would be free so that we can get people out of their homes and to these activities and our numbers are going up and up and up with the people that are getting involved we also have a special program starting for the summertime where they're going to have a passport and we're going to have kids in all the schools get the passport for I believe it's going to be 4th grade through 8th grade and there's going to be prizes at the end of the summer when they return in September and show us all the great stuff that they did this is really action in the right direction we're now infiltrating businesses infiltrating schools Andrea is on the wellness committee for the school system and right now we're this close to getting approved that no longer will taking away recess be a practice in the school system because kids need that activity and to take that away probably doesn't really help their behaviors and it's taken us a while to get teachers on board and administrators on board but it appears that we are no longer can food be used as a reward and we're changing what birthday party celebrations will be including activity physical activity and healthy food and so all of those kinds of things are really changing the way that we work in the schools the way we work in the community integration in the community right out of the gate one of the first things that we did as a stakeholder group is we sent a contention of our members to a select board to say please make decisions from now on based on health and they looked at us kind of like what are you talking about and we had a whole long list of the kinds of things we need sidewalks we need playgrounds we need safe pathways for bicycles and places for people to walk we need walking trails and we need you to understand and partner with us on this journey so much progress has been made since that first meeting we're at the select boards a lot we have respectful relationship with them and with the community and we really are leveraging long lasting change in our community we also are starting to place various people on various boards so that we can have a presence with decision making in the places that we are going to make a difference to improve health in our community future plans Andrea, who you just saw just finished her pre-diabetes training in Newport she didn't know Vermont went so close to Canada when she drove to that program last week but she's ready to help with our pre-diabetes program we have three one year cohorts of that program over the past year we're certainly working with doctors to give more and more referrals so I totally agree with the sentiment that that program is critical and we need more patients getting involved in it but one thing we did new and different this year is we added exercise so we did that program sometimes doing physical activity at the same time and the people had improved results with weight loss with the A1C which is the measurement for diabetes so Andrea is positioned in a perfect place right now she helped do that program with the exercise and now we're going to connect the dots and hopefully next year you'll have much more people in that program and you can share that data with you these are the other things Food Pharmacy is a new program that we're doing from our Food Service Department at the hospital no food is being wasted in our services right now we make soups, stews, casseroles and bring them periodically to the food shelters to the low cost housing areas and now this program is going to provide a family of food for five days of the week providing unhealthy food with the goal of decreasing their A1C and helping to change the health habits of that family so we're writing grants right now and we're ready to go with that program and Rise Vermont is right there beside us with them we're also trying to connect healthcare workers in the schools to do much more health curriculum there's very little in the schools right now and they desperately need it and if we offer up our services to do that for them they seem able to fit it in to the curriculum so that is another exciting plan for the future so in closing I really have found from the moment I heard about it that Rise Vermont was going to be a catalyst for change in our community and it truly has been you know I think I've only been in Bennington for ten years working I live across the border in Massachusetts but from what I understand generations of families have been unhealthy and poor in our community and we're trying to break that cycle and so we're really starting with the children and I'm hoping you know a generation from now we're really going to see that we're we're really laying the foundation for a healthier future thank you any questions questions from the board I just have two first of all I want to thank you when you come and present your passion and creativity for all the work it's very much appreciated and a lot of these innovations I'm hoping will spread once you learn if these are actually working and I appreciate the attempt at evaluation and measurements to think about that maybe this is maybe best for Marissa, I'm not sure but I know you all think about balancing local control and the desire for autonomy in the community in designing programs with a more standardized centralized approach based on best practices what you've learned in other places throughout the state or elsewhere to think about what kind of programming you want to fund and want to manage and I'm thinking about when the slide went up with the 75 projects going all over how do you see what is going to grow at what point do you think that you might or will you ever narrow it down and say hey 75 is a lot these are the top acts I don't know what the number is that seem to be working let's focus in on those how do you balance that and think about that as you're expanding it's a great question I'm not sure I've asked myself that yet to be honest because we have been starting to vote for two years right but what's most I think what is most important to us is find striking the right balance with ensuring we are implementing an evidence based model right we want to be able to measure outcomes and really know that the dollars we're investing in prevention are going to get us where we want to be which is healthier communities people not having as much chronic illness however in Vermont people really want to do what's right for their community in their own way and so what we've really worked on doing is honoring that and I think specifically using those CDC strategies to identify like the grants is a really core way that we help support the community do what they want to do in their way but we do ask them to tie it back to those CDC strategies because they're evidence based we know that they will have an impact they may be creative and I think there will be things that are unsuccessful and we will have to just know not to repeat those and since we're in the start of phase I think it is going to take us a little bit more time but that's why we're doing so much evaluation is to not repeat trying to not repeat things that we find in front hearts that aren't successful okay and my second question is around the slide you had here around making sure is Verizon want to equate efforts and you mentioned in here doing extensive assessment in communities and working with state partners and so I'm wondering this to some degree relates to HRAC the Health Resource Allocation Plan that the board is responsible for updating I'm actually wondering about your assessment that you're doing in each community to assess need and whether it's standardized in every single community you're asking the same basic questions you're looking at the same population health metrics you're assessing what the needs are and then using that assessment to figure out what is going to be the best programmatic investment to address those needs but I'm wondering about that assessment process what we might learn from it as we're building HRAC absolutely yeah so it's two fold one guess it's standardized initial sheets you saw that are the county snapshots show it's really hard to get that real granular town level data that's one issue but we do our best to get some town level data we do use a standardized to have our program managers do an assessment of all the towns as much data as we can collect about their health outcomes food security transportation that type of thing and then they look at all of that qualitative data about the demographics and what's going on in the communities in their health service area but then there's always a second part of it that is harder to quantify and that is a readiness factor because Ryze Vermont beautifully designed a well-branded thanks to the start-up work of Northwestern Medical Center and it was homegrown in St. Albans, Vermont and they're very proud of it, it was homegrown there but other communities want to feel like Ryze Vermont is homegrown in their community just like Billy has shared about Bennington that they were excited about it but they did the work to create their own what Ryze Vermont was going to look like for them within the model so what we often have to do is a lot of just asking people do you think this is something your community would want or is ready for so we have to look at the data and say we often know exactly where to go from the data but whether or not the town would want us there we have to respect that as well so we do a lot of disrelational work of just asking questions doing interviews in the community this is something you would like to start in your community because you're ready for it so it's two parts one is more scientific than the other one last thing related to the first question our steering team really liked looking at the list of CBC guidelines and that really helped us to go through as kind of a cross community group and look at the things that are being taken care of by something else already in our community and it helped us to hone into what is missing that Ryze needs to get involved with so I think that that could be different community to community and lends itself to sometimes choosing different priorities going forward right that makes sense with the dosing of the CQBI I'm just wondering as you were describing how you were categorizing some of these interventions wondering how do you ensure that how you categorize them are more objective more evidence based putting something in a high category versus a medium category I know there's some guidelines here but I don't know if I can flip back to that slide to me so for example behavior change strategy implementing universal free school meals in the same category as trail signage I don't know how do you decide they're both there's actually it's a really good question and again that's one of those things it's really really hard to quantify so what the what Collie Akers and her group did is they really were looking at ranges and again this isn't that exact statistical estimate but it gives you this range of things that you quantify in terms of reach dose keep going reach dose and behavior change so it really kind of gives you an idea we've looked at several that are similar to the CPPI but this fits a little bit better with those homegrown community based initiatives where they're all very different but it allows us to really look at so the estimated population that we've reached and then it gives you examples of different types like so if you were going to quantify something as a behavior change change strategy that was high it would be like almost from a systems level you know those policies you know access infrastructure all that kind of stuff that increases behavior change whereas low which is cut off down here it's just that informational type of of things that you're delivering so you actually get this aggregate score out of it and again it's we have an adopt we think it's going to be a good fit for Vermont we don't know if it's going to be a good fit for Vermont but it's really kind of the best that's out there in terms of how to actually assign a number to what we're doing and then track that number over time and relationship to what's happening with our specifically our BMI in the state so it's not a great answer but it's the best for that unfortunately that's just the nature of population health research is that it's messy which doesn't work great yes yes do you ever tie the allocation of resources to a specific community program to outcomes well that's our I think that's our long-range goal that is definitely our long-range goal do you say long-range? well long-range because first of all tracking outcome measures are hard to track you have to have some objective outcome we're choosing BMI it's there but it's probably not the best so it's going to take us a long time several years to figure out the fiscal impact versus the intensity of the intervention is that what you're getting at? what I'm getting at is let's say a community is going in the wrong direction with BMI for example right have you explicitly told them if you're not eating the outcomes that you will not have future funding? no because and I say that so frankly because what RISE Vermont tries to be about is really tapping into that community energy for wellness and I would say we're very likely to see the outcomes in St. Albans but that there are many towns in Vermont that the BMI is going in the wrong direction and there's quite a few years of behavior change and systems change around those individuals and those children to get them on a better track so I think probably over time we will see BMI continue to get worse until they get better but we don't ever want a community to feel like if you don't get better you will be penalized by the losing funding from us we are really here to cheer and support and move forward communities and they may not do well for a little while but after that we will continue to coach them and provide resources to turn things around we hear repeatedly from legislators and others that want immediate results and they're continuing to press us as a regulator to try to find ways to assess the effectiveness of different programs that OneCare is putting out there and I would just encourage you to try to you know, maybe shorten the time frame of what you think your goals are to start reaching them because I don't think time is on our side I think that there's a huge argument being made out there that traditionally every community in the state had a recreation program it was paid for with local tax dollars, they encouraged swimming basketball and you name it and is this just a little more reach out for someone else to pay for that and if you can't prove your results it's going to be hard to justify the funding it's just my advice to you Thank you for that and I assure you that is our goal we would love to see results sooner and that's why we're staying as plugged in as we possibly can with this rigorous evaluation model we've shared we will have results of the sweet enough campaign and we feel really good that we will see some results there and anything we have real time when we have it we are publishing and sharing it the way though that I have framed the prevention efforts for one care which is the smallest investment at once less than 1% of one care's budget all of this incredible work that's going on statewide is this is the long-term strategy and I think about it my father-in-law is a CPA and in my 20s he said make sure you start contributing to your retirement because the dollars you put in now are going to work the hardest for you later and that's what we're doing here the small amount of dollars that we're putting in natural to rise Vermont and prevention initiatives and incredible work of our team that is what it's going to pay off for the long-term and we really have to be looking at both our short-term results but then also how are we just going to completely change the background but the only pay off if you get the real changes that last a lifetime that's one of the things that's been going on for 20 years school board trying to put in place lifetime sports that people could fall in love with and do throughout the course of their lifetime and so just to give you an example we here are always tracking total cost of care in the hospital service areas and when hospitals come into us at budget time you can almost give the speech for them the reason why they need more is because the demographics are bad in their area they have high smoking they have high obesity you know it's a canned speech and yet the problem is that you can't use it as an excuse you have to you start to try to turn around in a community which is what RISE is trying to do to assist in that and you know I just I worry that if we're not more conscious of trying to demonstrate what results are that everything will fall apart so so my question is in the same genre as Jess's and Kevin's if you can flip to the chart that is that shows the trend lines from the Healthy Community study it's either one up or one down from the one that you were just on so I'm just curious as to there was this Healthy Community study it was over a six year period there were 130 communities thousand of participants so that's a fairly large base in order to build a statistical relationship and I'm just wondering what is the statistic that drew you to this in terms of those trend lines and if it was a regression model what was the R value that that drew you to it and given the largeness of this study relative to anything you're going to face in Vermont you get to smaller and smaller communities how does this model apply as the population that you have is diminished and therefore there's a wider margin of error so we chose this as an evidence based model so we don't actually know if it will work in Vermont then it's evidence based that it works for them which don't decrease VMI significantly over six years is probably the best model out there that we can find to try and quantify how much intensity is enough intensity to get whatever behavior change our outcomes we want without overshooting spending too much money or fiscal dollars or whatever so we don't know that this is what's going to happen that's what we're hoping and the evidence shows based on the work done in Kansas and the Midwest is that statistically when they had a higher level of intensity there was a drop in VMI so what we're hoping to do and we only have two time points for our Franklin Grand Isle is really using this model in association with some of my statistician colleagues is really look at some forecasting efforts if we can take all of the data that we have to say okay you know what we can give you all the stats and everything we can give you what we're doing based on this particular model and dose we can forecast out three, five, ten years to see what it might look for Vermont that's a huge work in progress right now which is kind of really the intensity that's as opposed to a stop set because I'm just wondering yeah that's a good question so what we're hoping to do it gets a little again muddy because what we're hoping to do so we have really excellent Franklin Grand Isle data with the ACO kind of incorporating more and more counties in Vermont we're hoping to actually be able to mine that data and be able to get VMI in kids and be able to look at, use that as kind of a marker of other communities within Vermont right now I think the analyst thought that that might be something but again it's a little messy of how it's reported in through vital I don't know if you want to speak to that but that's just kind of a secondary way that we're because we understand that we can't do this type of intensive monitoring all over Vermont we don't have the bandwidth we don't have the money, we don't have the resources so we're trying to figure out a marker so we can actually use it so that we could then use this to model for Vermont we probably could in another two years model it for Franklin Grand Isle but that's just a snapshot of Vermont and so really using what we currently have to and some advanced statistical modeling to look forward so we can achieve this type of dose you know which is around 0.8 I think is the high intensity you know what might that look for other communities sure so this is just from a program managers perspective obviously I don't have a bank of statisticians but by using the dose methodology it helps a local program manager assess the portfolio of projects that they're working on because if everything you're working on is down in that low dose then you need to rethink what you're allocating your time to so that's how I see it as a valuable tool and that's why my planning and evaluation work group is really interesting and it's okay if not if everything's way up here and high because you want to have a mix of strategies but if you think about it from that perspective when we got the presentation this summer Breanna the nursing doctor of nursing student who did the research showed us several different models and she went through the other ones everybody in the room was kind of like and when they got to this one all of a sudden everybody was like oh and you could sort of feel it in the room that everybody got it and it made sense and I think that's why we feel as program managers we don't know yet until we start really using and figuring it out but for right now it seems like a really helpful tool for us Any questions from the board? If not we'll open it up to public comment Yes Susan Susan Arnauth and the Romance Development and Disability Council Could you turn to slide 7 please That's great So the third bullet says I'm not responding to delivery service reform funds which can only flow to the ACO So I just feel compelled to clarify this for the record I'm not sure where you guys got your information but for the sake of true truth I do believe truth matters I'm holding in my hand the menu of Approvable Delivery System Reform Investments This comes directly from Vermont's global commitment Medicaid waiver These delivery system reform dollars that doesn't mention in that slide are Medicaid, pure Medicaid and right in our waiver it says that these dollars were intended for two types of organizations in ACO and the organizations that are on what we in Vermont used to call the Medicaid pathway Those Medicaid pathway organizations are defined as the following providers Medicaid community-based providers including designated mental health, disability support substance use disorder providers and long-term services and support providers So that statement that it's funded with delivery service funds which can only flow to the ACO is just patently wrong I know OneCare has made similar statements in legislative committees I hope it chooses to provide true and accurate information to the public going forward and I think the Green Mountain Care Board which is on record as reaching out to the legislature and the governor to direct more of these delivery system reform dollars to OneCare can appreciate the fact that these dollars were intended to support the community-based agencies that support people living in communities with disabilities and Medicaid dollars and none of them have gone from the Agency of Human Services DIVA directly to the organizations that were intended to benefit when representatives from the Green Mountain Care Board in the past were sort of selling this to the Joint Health Care Committee in 2016 presented charts showing this is a permission slip and these funds will be available for the Medicaid pathway gone directly to the Medicaid pathway organizations hopefully the legislature might clean that up but I would just request respectfully of OneCare and Rise Vermont in the future to please put out accurate information those funds it says right there can only flow to the ACO that is just not true Okay, other members of the public any comment? Yes Jeff Patista State Auditor's Office in a previous lifetime I was a doctoral candidate studying socioeconomic factors and how that motivates people to walk and how that affects their obesity so kindred spirits right here a couple of methodological questions if you can go back to that graph showing the different ethnicities and the impact of community interventions I'm concerned by the difference in performance among different ethnicities I understand that Vermont is I'm guessing 95% of the white by census data however you define that but if this is how community interventions based on the model you're using impact populations then we would expect less robust results among some of the least advantaged people or at least represented people in the population how would you compensate for that? You're absolutely correct and I don't have a really good answer as to how I would compensate for that I think it's a flaw in the majority of the research that we do and I think it does point like you had mentioned to the social determinants of health I mean until we actually really address the underpinning of why we even need an intervention like this it's only just a small piece and so to really look at how we're going to actually change BMI and those who are at higher risk it probably hires for co-morbidities like diabetes and the African American and Hispanic populations but BMI and obesity I always think of it as a driving force behind chronic conditions but the social determinants of health are the driving force behind obesity to a large extent and there are there's genetic familial all sorts of influences so it's not a perfect method that we're adopting and hopefully as we change our diversity within Vermont and we're all hopeful that that will happen that we're going to have to really think about new and different ways of you know, aiming our interventions or targets to those populations that perhaps may not be affected as much and I guess I'm also hopeful because our communities are identifying these strategies for us so other communities become more diverse the hope is that the efforts of that diverse community will therefore help, you know, reduce well in this instance the BMI but increase the health of that community does that make sense? I think we have to have those that's why it's so important that we are putting the dollars and the choice of that particular community whatever ethnicity it might be okay, following up on that some of the questions are already grown up by the board and I'll read this as I prepare it this morning after looking at it on the website obviously it depends on countless factors right and while evidence based models are great to guide program design they don't prove a causal link between RISE, Vermont's initiatives and the outcomes you see in public health I mean you've acknowledged that to an extent already so in evaluating success at the population's scale how will RISE, Vermont demonstrate the share of public health trends that come from its efforts and not from other trends overall? I don't think you can that's the money nature of population health and research is that we can't there absolutely cannot be a separation between what RISE, Vermont is doing and what other healthy behaviors one huge corporation is doing I think the dose will help quantify what we're doing and then the penetrance throughout Vermont can kind of help guide us and I think that it only can be a guide as to whether we're making an effective change so there isn't really a good answer I mean if you have one please share I mean it's the ultimate you know population health research is just so hard to quantify and so we're trying to really do our best to quantify so that we can demonstrate efficacy but on the other hand we can't say that that's all RISE, Vermont but it can spread and as it does I mean we all know that certain like obesity is almost communicable in terms of the spread of obesity within communities and states and whatever the health culture of all that kind of stuff my memory with that is say let's look at the St. Albin's children weight and height measurements over time if that declined over a two year period can RISE, Vermont claim that their efforts were a part of that no and we're not saying that that's not the intention of this study the intention of this study is to kind of help us you know so if the obesity rates decline great I think everybody gets to take credit for that but I guess it's the best way that we can actually objectively look at this in a scientific way and have some sort of evidence base behind what we do but I don't think that any effort whether it's RISE, Vermont the Department of Health the United States government I don't think any of them can really claim that and that's again what makes population health research so challenging and one final quote that's okay I feel like what RISE, Vermont has done has been a catalyst to get us all together so that the businesses and the schools and the town are now at the same table having conversations all doing their piece so it won't necessarily be RISE, Vermont and its programs but I feel like in our community it's aligning people going in the same direction with a better chance of success Excellent so the final question I know you probably overshot timing so RISE, Vermont is with many partners in a project you brought up the Windsor Walks example bringing these community consultants planning divisions health advocates all of that how will RISE, Vermont demonstrate the share of project outcomes that come from its efforts or how would it quantify that show it's worth giving RISE, Vermont more dollars as opposed to all the efforts of the other partners particularly for projects in which RISE, Vermont is not the lead partner or the lead project leader I think we've outlined today how we're trying to really track everything that we have some impact with whether it's granting because we've done the amplified grants measuring we look a lot at who our stakeholders are who's coming to the table and then we do very specifically measure through our dose calculation and also putting together our work plans what work we've done very specifically like what has Alice done out in the community but then after that we're just trying to do the best measurement we can of things we've touched and then after that I think there will be things we won't fully capture Okay, other public comment? Jonathan? I'm Jonathan Billings from Northwestern Medical Center and one of the original founders of RISE, Vermont and would like to thank the Green Mountain Care Board for their role as this spark has gone statewide that there have been times over the years where we've received encouragement that moving towards a healthier future for all of Vermont is something that Vermont believes in and folks have encouraged us to keep going and to keep trying and to keep looking and I think today you've got to see that Vermont as a whole has embraced that and we're headed forward and we're to change VMI's and to change population health and to change generational poverty and generational obesity takes time and we have to have patience Somebody said it takes 20 years to change obesity I've been in my role at the hospital 30 years ago, 30 years if we'd started 30 years ago we'd have the real success that this group is looking for maybe 10 years ago international research shows it's possible these folks are on the right path we've just got to continue, thank you Is there any other public comment? If not is there a new business coming before the board? Is there any new business coming before the board? Thank you Is there a motion to adjourn? Second Move and second it to adjourn All those in favor signify by saying aye Aye Thank you everyone have a great day