 Right. Great. Well, it looks like we have everyone then. So, I'll call to order the Green Mountain Care Boards meeting of August 31st 2023. Today we have one substantive agenda item and it's a presentation from the Vermont Federation of Nurses and Health Professionals. And their president, Deb Snell, will be presenting to the care board on the state of nursing in Vermont from a nurse's perspective. This is an important discussion that I'm glad that we're going to be able to have. The care boards had a number of presentations relating to other issues in Vermont, including primary care and cost shift issues and the like. And I think we're overdue for directly hearing from the nurses and some of the issues that they're seeing and having. I mean, I think we all recognize that the nursing workforce issues are a huge challenge on the nurses. For one, not having sufficient staff to do their jobs and the stress that goes with that, some significant workplace safety concerns. And then on the other side of it, the challenges it puts on the hospitals and the financial system, having to rely on travelers and the amount of money that that has cost Vermont is very, very, very significant. So I'm really happy that we'll have a chance to hear and speak with some nurses today on some of these issues and hopefully we'll have ideas and thoughts on how some of the challenges can be best addressed so that they abate a bit. So thank you, Ms. Stella and others for being here for providing us that information. Before we turn to that, I'm going to turn to Executive Director Barrett for her Executive Director's report. Good afternoon. Can you hear me, Chair Foster? Yes. Okay. So I will be brief. I wanted to remind folks about some public comment periods. We have an ongoing public comment period on a next potential all peer model. So as I've stressed in several meetings over the last year or a year and a half, please send any comments regarding a next potential all peer model with our federal government partners to us. And we also share all those comments with the governor's office and with our partners at AHS. That's number one. And in regard to public comments, the hospital budget public comment period ended yesterday, the official public comment period. But I think everyone knows, and I'll just say it out loud, that the Green Mountain Care Board takes public comments 365 days a year. So please know that anyone can submit any other public comments on any of our regulatory or other work. And we did close the official public comment period in order for the board to consider those comments before they started deliberating. So with that, that is all I have to announce at this point. And hopefully I can get back online shortly. Otherwise, I will be listening from the phone line. Thank you. Great. Thank you. And one other quick agenda item is are the minutes from August 2nd 2023. I don't know because everyone had a chance to review those. And if so, is there a motion to approve the minutes? So moved. Thank you. Any board discussion? All right. All those in favor, please say aye. Aye. Aye. The motion carries and the minutes are approved. With that, Ms. Nell, I'll turn it over to you to introduce yourself and who's ever speaking and take it away. Thank you. Yes, as usual, I'll be doing most of the speaking. So, and please call me Deb. Ms. Nell has just, I don't know, I don't answer that normally. So I am fine with Deb. So my name is Deb Snell. I have been a nurse since 1999. I have always worked just at UVMMC. I have been in medical ICU since 2001, which, you know, we effectively called COVID Central the last couple of years. I am an associate degree nurse that actually got my degree in New York. I thought about getting my bachelor's, but without going back to school at my age was just not something I was interested in. I do want to start with a disclaimer, just that I am not a mathematician or a statistician. I'm a nurse who frankly hated math when I was growing up, but I've done my best to represent the data that I will be giving with you today. My new best friend, Dixell, has helped me with this. So, and this is not, this presentation is not meant to be a deterrent or interfere in any way with the hospital budget deliberations. This is a separate issue that I think, and I thank you for having me here to discuss this. It's something I am very passionate about in my role as president of the FNHP. I am also president of the AFT Vermont Health Care representing about 5,500 nurses and healthcare workers across the state. So I feel pretty genuine when I say, even though I'm sharing this data with you and a lot of it just does come from UVMMC, I think on smaller scales hospital across the state are seeing the same thing. And the nurses that I care from at Porter and our new members at CVMC have the same concerns and issues that we do. So, thank you for having me here for this. Let me hopefully, Kristen, keep your fingers crossed that this will work. So, again, I'm going to be mostly speaking about data from UVMMC. So, I just wanted to share with you some abbreviations that I'll be using in the presentation. I think everyone knows what an R and LPN is. LNA someplace called them CNAs, their licensed nursing assistant, and they are honestly the backbone of the nursing staff. We can't do our jobs without them. MHT's mental health tax, they will often be in our psychiatric units or in the emergency department dealing with our psychiatric population. CPSA is our clinical patient safety attendant. We effectively refer to them as our patient sitters when you have a patient that is maybe like older and confused or coming down off of something and pulling at lines and trying to get out of bed. They're the ones that are sitting at the bedside so the nurse doesn't have to to keep an eye on them. FTE is a full-time employee, again, defined as at least 72 hours in a pay period, 72 to 80 hours at our hospital, and I believe the CPSA network is considered a full-time employee with your full benefits. So, as of the end of July, we're not quite through the year yet. This is the amount of openings that we have for full-time employees at the hospital I shared with us. Nursing, 28.4% vacancy rate, that has been fluctuating during the pandemic and onward, obviously. I believe that years ago, maybe we had a 10% or even 8% vacancy rate. L-Pans fairly high. Our LNA is 39.1%. They are the hardest to keep at the bedside. A lot of times they are going on and they start as an LNA and they're in nursing school or going forward in another position. Medical assistants mostly work at clinical offices and again the CPSAs and MHTs I explained and nursing leadership was just like a number that we happened to have, so I wanted to share. So, at the end of March, we, this was our vacancy rate at that point, so I just wanted to show you this number in particular because the difference between March and the end of July is that hopefully you have a number of nurses applying because they finished school. So, I would hope to see that number a little bit higher. I think in Vermont, part of the issue that I see is, for example, Castleton. Most of the nurses at Castleton go and work at Rutland Regional because that's where they train. That's great. VTC students, they end up all over the state because their campuses are all over the states. UVM in particular, a lot of their nurses do come work with us, but because so many other students are from out of state, a lot of them go back home. So we don't see as much of an influx of nurses from UVM that we would probably like to see. The alarming thing on this slide for me was, again, the LNA that we've actually lost traction in getting more LNA at our facility. For those that don't know who have ever been hospitalized, they're the one probably answering your call bell, bringing you the water, helping the nurses turn the patients, answering the doors, answering the phones. We, like I said, we could not do our work without them. Recruitment time. So this is the time to fill a position and what this means is from the day the position was posted until the day someone actually accepts the position. So 170 days, that is fluctuated. Obviously, that seems like a high number. During the pandemic, the research I did shows that actual time to fill in most states is like around 105 days. So we're above average, obviously not in a good way. But again, I think it's part of the uniqueness of Vermont and the economic, I don't want to call it instability, but that we have here in the housing shortage in our state as well. And again, some of these numbers are high, the CPSA is 354 days, I have no explanation on why those positions are so hard to fill. I don't know if it's pay, I don't know if it's the job itself, but I know they are actively working for them because we desperately need them in all departments. So, I put this in here. So terminations doesn't mean that someone was fired. So this is just to like show you, yes, we've had a number of people that have started, but we've had almost as many leave terminations are people who voluntarily leave whether they're moving out of state because a family they've accepted another position. Very few of them have actually been fired. We get a list as part of our union of any nurses that are terminated, and there are not that many. So most of these people are leaving of their own free will. So, over time, kind of like the being of nursing existence. So, when your unit is short staffed, whether it was short staffed from the beginning because a, you just don't have enough nurses, or B, whether someone's home sick or had to leave sick, sick child, whatever, you get a phone call asking you to come to work. Now, one phone call. Okay, fine. But when you get five, six, seven phone calls a day asking you to come to work, you're drained. You know that your colleagues are having a really horrible day and you want to help, but you need the away time. Absolutely. So, all of these phone calls are just like pressure cookers. We had people posting on our Facebook page, sometimes pictures of their phones with just the UMC UMC UMC UMC just all the phone calls that people are getting constantly to come in. Especially our resource department and I pointed them because they work in so many different areas of the hospital that they can get called not only from the resource department, but from like five or six other units that maybe they could potentially work in. In the number that I mean, let us say I was when putting this stuff together. I was a little surprised by the numbers. Mostly not in a good way, unfortunately, but in March, just in March alone, nurses worked almost 12,000 hours of overtime in our hospital. The travel nurses that work in our hospital worked about 9,720 hours. The LPNs 148 hours. Again, the LPNs mostly work in clinics. There's just a few LPNs that actually work in the inpatient setting. The LNAs 4,357 hours and overtime is not just time and a half actually. I think maybe except for the LNAs and the LPNs not 100% sure, but most of them actually come in their work is they're getting paid double time. We had multiple variations that we've gone through over the last few years of whether it's incentive, which is two times your pay or being on call two times your pay or our special pay. It's sad. It's a fact that that's what it takes to get people to come in to work on their days off or to work extra. Yeah, got hot topic travelers. So, as of like the middle of this month from the data we received from the hospital we've gotten approximately 343 travelers that would potentially be in union positions. 75 in technical professional job so that's anywhere from a tech in the OR to a respiratory therapist to CSR, which is the central sterile reprocessing. 268 of them are RNs and LPNs. I believe only two of that number are LPNs. I believe that there are other positions in the hospital that do employ travelers off the top of my head and no phlebotomy does have travel staff as well. That is the group that is currently in bargaining so we don't have that kind of information just yet. So we do recognize that travel pay has gone down significantly. The last, especially the last year during the height of the pandemic, it was probably around $200 an hour. A lot of times they were called crisis nurses that came in on short notice would only work like, you know, two to six weeks. But where we are now is, well, these are their pay rates. So for our technical professionals, there are a few that can end up to $125 an hour. Looking at them, I think for this mostly respiratory therapist and maybe an MRI or nuclear technology technician as well. The few LPNs are 75 an hour RNs range from 90 to 170 an hour. I'm not sure why there is such a very in pay to be honest with you. It's not based on degree or where they work that I could ascertain. It's kind of all over the place and we have anything from a diploma nurse to some have a master's or mostly a bachelor's degree. Out of those staff, 103 and five of the tech travelers are working 96 hours in a two week pay period. So while, yes, our numbers for travel staff has gone down significantly. If you add those numbers in, I think you would probably add like another like 20 people if they were just working a normal 72 to 80 hour work week. So in a two week pay period. The hospital unfortunately has to pay out about three million just over $3 million for travel pay. In July on our reports that we get for our union dues and staff. A two week pay period was almost 8 million in an average to be paid period that the hospital's paying out that includes regular pay and overtime mind you. So this is a slide I found most disturbing honestly. So our members. I think the slide actually speaks for itself. Our average member pay in a pay period and this is before any deductions anything. And then compared to the 343 travelers. It's almost $5,000 more in a two week pay period that is paid out to our travelers. So when you average it out. So what I did is I took the number of travelers times their bill rates and came up with an average of 113 72 an hour for our travelers. And I was trying to be generous because an R and three actually. There are more R and choose a lower pay scale than R and threes but I was trying to be nice and bumped it up a little bit on step 12, which for our union contract is the middle of our pay scale we have 24 steps. So you pick step 12. So their hay, including their benefits is 5517 an hour. So, when you average it all out, there's a difference of 5855 an hour between what is paid. Now, I am 100% fully aware that the travelers do not take that kind of money home. Back in February 22 represent well senator then representative wealth there was an article in Time magazine where he was disparaging, not the travel nurses but the travelers companies that were price gouging and I was quoted in that article. And I fully understand that and I hate to use the term necessary evil because some of these people are my friends now, but it is it's a sad fact of life that it was a they were demanding pay that was crazy but hospitals have no choice but to pay this kind of money out. Thank God it's improved now but it's still a regular full time staff member costs less than having a travel nurse in that position period. So this is the, I keep saying these are alarming and they keep getting for me I apologize for that. I will try to end on a more positive note if possible. But what bothers me the most about disinformation is that when you're a new nurse fresh out of school and maybe you want to get away from home and maybe you want to travel, and you're looking for a place to go. And you're researching this is what they're seeing online and that's what's alarming to me. So, in nurse journal.org in February of this year our overall ranking just in general not even pay was 49 that a 51 states in Becker's hospital review in May of this year we ranked 46 for salary adjusted for cost of living. And in wallet hub.org also published in May of this year Vermont ranked 42nd overall, but fifth in the most job nurse job openings per capita, and we ranked 48th for nursing salary adjusted for cost of living. So if you're a young nurse, starting out with the heavy student loan debt unless you're a rich parents. That's what you're looking at when you're looking for a place for a job. And the one thing I will know back into in the wallet hub. In the wallet hub.org back in 2018 and 2019. And the one fifth ranking for job openings and salary was the same. So unfortunately it just has we've not been able to really make any hard way. So, we know we just can't look at salaries if we look at just salaries were probably when the latest ones I saw was we rank like 20 anywhere from like right in the middle we're right in the median 2526. It's obviously I mean this is no secret the high cost of living in our state the impossible housing market. I can't tell you how many travelers that I've worked with that actually most of the travelers that come here they love it here they love our state. They love the people that they work with we become friends with these people they want to stay. They can't afford it. They can't afford it. And that's sad. We've had travelers that have had to cancel their contracts because they couldn't find housing and I think there was even physicians hired in. There was a traveler who told me that he had to leave the facility because his Airbnb fell through and he was sleeping in his car. So it's just unfortunately that's how things are in our state right now. And so I did want to share this and I don't want to get Union heavy here at all but when I know when you BMC at least in this time period when they were looking at like the cost of living adjustments that we were asking for. So first of all we weren't trying to compare ourselves to Boston we were trying to compare ourselves to Plattsburgh across the lake because at that point in time they were making more than we were with a lower cost of living. And I'm pointing like you can see me. So it's so I did some research and in my role with AFT I've been lucky to make contacts with other local presidents around the country and I found Portland Oregon which I found very interesting. So there is an 576 bed academic medical center there working are expanding the same as UVM and see and what our hospital focused on at that time for cost of living was a cost of a two bedroom apartment in Burlington or in Chinden County period. And here in Oregon we see anywhere from a high median of 1950 down to like 1700. In our state and I use the same I searched around to the couple of comparators is anywhere from 2150 to 1872. So that's several hundred dollars difference in an average two bedroom apartment cost. However, the nurses at that hospital. They start a brand new nurse day one is making forty two seventy five an hour compared to our thirty six oh four an hour. So it's twelve thousand a year. Hey deference for similar if not better cost of living rates. So there's a lot on this slide and I'm not entirely comfortable giving you a lot of information other than what's on here. This is a work in progress that's happening right now. Pardon me. I think someone just had a hot mic. Yeah. Okay. Um, so, um, the network recently hired this company BDO, which I had to look them up. It's been I did get it somewhere. Binder or like an opt, I believe it's the fifth largest. All right, moment. It is the fifth largest accounting network in the world. They do have a health care section and they have come into our facility recently. I think Dr. even might have been the one to bring them into our network to look at the way that our volumes and are some of our staff. Well, this is supposed to be about high value care. Some of our staff loving refer to high volume care. What it's doing or what it's looking to do and it hasn't 100% rolled out yet is to shorten patient visit times to 15 minutes. This is right now from what I understand mostly in just our primary care areas. What is driving me crazy about this is how is this putting our patients first. Instead of working on. Recruiting more a PR and encouraging more people to go back to school for a PR and paying for a PR and education recruiting more primary care physicians to our state, which we all know we desperately need. The answer is not to shorten patient visit times. To the point where the providers are feeling uncomfortable and not feeling like their patients are getting any real information out of their meetings. And this is not just the appearance it is from what I understand medical the positions as well. Again, this is still a work in progress, but we are very concerned and are going to be keeping a close eye on this roll out. And for this next slide. Is Tracy for nausea on this call. This is an example. So in our outpatient clinics. The nurses have what they call an in basket and it's work that needs to be done that day on top of like anything else that may be occurring that day. And I admit it, I am not an outpatient nurse. I'm starting to learn a lot more about how they work. And I will it also that this is an extreme example, but it is a scary example. So the are the Rx requests are people that are calling in to get their prescriptions refilled or asking for a new prescription. New calls. Those are supposed to be answered within 24 to 48 hours. The patient advice requests. Those again, those are mostly through that new system called my chart where people are sending in questions and want a response from the provider. The referral messages are patients that have been referred to like a specialty clinic, but something's missing, like they needed an x-ray or something that hasn't been done yet. So they're calling the office back to get that done before they can even set up an appointment. And the prior ops are usually medication related. I believe mostly come from our pharmacy and it's usually dealing with an insurance issue. Now, you have 45 nurses trying to get come in starting the day and this is what they see that they have to try to tackle on a day. And it's just not possible. It is not possible for them to get through all of that work and get back to the patients in a timely manner. Dokingly this particular clinic actually had their nurses come in on a Saturday for four hours to just try to work on getting down the basket to an acceptable level. Apparently in most clinics, they might see about a third of this. This is a specialty clinic that more and more patients are needing the service of and these nurses are drowning. So, I kind of talked about this a little bit in the beginning that I feel we're behind the ball. And I sent chair foster I sent you a survey that was recently put out by the amen talking about staffing and nursing and their survey. And I'll quote has consistently warned that the combination of growing nurse shortages due to increasing retirements of baby boomer nurses, a dearth and education and training for the replacements and the rising utilization of healthcare services by a rapidly aging population would eventually lead to workforce related healthcare crisis. We call it a perfect storm of approaching causes and circumstances. And then COVID happened. So we knew before COVID nurses knew before COVID that we were looking at a shortage. So I, it bothers me that they're now talking about it like they knew about it all along. But why wasn't anything done when we went out on strike in 2018? The one issue we kept repeating at the table is we need this money, not even for ourselves, but to get people here and keep people here. I've been a nurse there for 24 years. I make decent money. I know that if I live somewhere else, if I live in upstate New York, I'd be living like a queen on what I make, but not here in Vermont. And we recognize that and we know that, you know, we, the hospital and other hospitals will often say, well, it's not all about money, but unfortunately sometimes it is. And getting people here so they can afford to stay and live here. Unfortunately, it truly is. As an example, and I know Dr. Lefler is on this call so he'll probably not be particularly thrilled with this slide, but our members recognized fairly early in the pandemic that we were in trouble. We saw how many travel nurses were coming in. More importantly, we saw how many colleagues were leaving. And not necessarily, I mean some were leaving because honestly they were afraid of COVID. I get that. I was in the thick of it. I understand how horrible and scary it was, especially at the beginning, but they were also leaving for opportunities when travel nursing were offering, you know, at that point in time, $1,000 a week in New York City. You know, if I didn't have a family or obligations or my role here, I might have thought about doing it. But they were leaving. And we knew that we needed to try to, you know, put a plug in it. So we approached the administration and said, would you consider it? And Dr. Lefler said yes, we would consider it, but don't even talk about double digits. I understood that. When I brought it to my members, and I see Chris Gagno on the call, he can attest to the fact that we worked really hard to get people even down to 10% because they were so angry. So we approached him, but the 10%, it was flat. No, won't even talk about it. Fine. A few months later, the hospital actually asked to meet with us to discuss a waitry opener. We put together a bargaining team. And the hospital came back to us and they were basically offering the same 10% that we had asked for five months, six months before that. And unfortunately, the terms they put on their proposal of 10% were unacceptable to us, meaning that they wanted us to not have to negotiate until 2025. There were just things that we found unacceptable. So we turned down their offer. A few months later, they came back to us and just said 10% across the board for everyone with 5% in October 2022 and this coming October 2023. So we accepted it and the condition was when we went back to the bargaining table, which we did last year, wages were not discussed, but we were able to open up other articles that we felt were vitally important. So the question is, they obviously knew it was the right thing to do. So what took so long to do the right thing? So, in light of this presentation, I asked our secretary and she magically was able to put together a quick survey and get it out to our members for me. And I just, I just wanted to know how people were feeling and what they were thinking and I believe I haven't updated this or have been more responses since then. Nurses are notoriously late and looking at their emails, but 39 out of the 258 that responded were planning on leaving UVMC before the end of the year. 37 plan to change jobs within the organizations. The biggest factors playing into this were salary and benefits. Workplace violence, which we know is a huge issue at our hospital. 77 responded family, like moving better opportunity and 29 responded better opportunities and 120 responded work life balance, which we know many of our members are lacking right now. Some of the comments that were made. So administration making money led decisions without a clinical lens. I depend on my support staff. And they are not currently paid enough to reflect the value to our team. Our end should be paid more as well. I support my family. We've never been able to for daycare and live paycheck to paycheck. Lack of support for management being asked to do more with less non of CTO, which is our vacation time. The dreaded parking and travelers that are not invested in our community. CTO has always been something that we have tried to bargain over parking. I think Dr. Lefler and I will agree on this is just not a problem we can solve for a thing now. Unfortunately. But the living paycheck to paycheck and most nurses that I talked to are the break winners in their family. And it's sad that so many people I talked to are living paycheck to paycheck and can't afford daycare or most of their check is going toward daycare in our state. The comments what they love about me the other thing. Their colleagues, their patients being well staffed. They love that we have safe staffing patient ratios, their patients, their coworkers. And I love that making a positive difference in my patients day. So the nurses there we love where we work. We love what we do. We love taking care of our patients. We just need the tools to do it better and safer. So that is the last of my presentation. Thank you for that. Thank you. Yeah, I'm going to try to board member questions and comments. I had a couple real quick, if you don't mind. No, would you put the slides back up for a second? I think it's slide 20 or 21 20, I think you have the survey results, the number leaving or thinking of leaving or. Um, yes, it was, I had it from 39 out of 258 we're planning to leave our institution before the end of the year. And then 37 out of 257 we're planning to change jobs within the organization. And then underneath it, it says factors playing into the decision, but then these numbers like 113. But there's only 39 thinking, thinking of leaving. Yeah. So, um, they, um, I may be the way the question was worded. Um, and I think just because I left at the end of the year, there were some in the comments that said, not before the end of the year, but in the next two years. So I think that's probably what. Okay. Um, that makes sense. Do hospitals typically run these kinds of you might not be the right person to ask, but do hospitals run these kinds of surveys. So they sort of have a finger on the pulse of what's going on with the workforce. They do. They usually run them annually. And if someone on the call can remember the name of the survey. Um, it is like a nursing satisfaction survey where it does really delve deep into your relationship with your coworkers with your manager with positions, even with case managers and dietary. So they do do that survey. We're waiting actually for some of the most recent results to, to come out. And have those been run. One of your slides said that it was reactive some of the negotiation and changes that were happening because of the pandemic. Have those types of surveys been run, you know, historically consistently or is that a new thing. Um, no, they have been run. Um, I know. Um, immediately, like after we went out on strike. The hospital, I think, was really like caught off guard and ended up doing a survey. They brought someone in. And it was like, not the entire staff, but randomly through out the hospital from like multiple different departments talking about their feelings about working UVMC and the issues and stuff. And at that point in time, I think they were caught off guard about how unhappy their staff was. Um, and they toured all the facilities. They did openly share all the results from with everybody. And I applaud them for that because that did not be an easy thing to do. Um, the unfortunate thing is I don't feel like a lot of it has really changed. Um, we may see our managers more. I know Dr. Lefler and Pegami, our chief nursing officer, do make a point to try to go out and round and just say hello to people. So at least they're seeing, but on the ground level, we're just not seeing the changes that we need to see to to keep people here. And then you said that on salary alone, Vermont was at median. And I presume you mean for all of Vermont, not just the hospital, not just the UVM Medical Center, but all of Vermont. Um, that's actually nationally. Vermont ranks 26. Right. The state, the state of Vermont ranks 26. Yes, yes, yes, absolutely. It's across the state, which tells you that it's not just UVM MC. It is a state problem. Right. Okay. And then my last question is, do you have that national ranking of nurse salaries over time? And what I'm trying to understand is, is that something that we've moved up on during the pandemic? Are you historically lagging or have we kind of always been sort of in the middle? Um, for salaries, since I've really been paying attention to them, we've always been right around, like just on salaries around the median. Okay. And I would welcome any of my colleagues to speak up to answer as well if they think I'm not quite correct. And then the strike, I was living here and I remember reading about it a good amount, but my memory is fuzzy. How long did the strike last? It was only a two day strike. It was the first strike that we had had at UVM MC. And as an officer in our union at the time, we really didn't know what to expect. We had never done it before. So when our members voted to go on strike, we initially agreed they would be a two day strike. And there was a possibility that we were going to go out again for longer, but we decided that we're going to try to do our best to avoid that and stay at the bargaining table. Those are the only questions I had, but thank you for presenting to us. And I'll open it up to the other board members for any comments or questions they may have. A couple of questions. One is to, and you may not again be the right person, Deb. So my apologies and just if this isn't the right question, I'm asking you a question that isn't appropriate for you. I'm wondering how it works. A little bit on the traveler for the traveling nurse. So you had said, you know, obviously the contracted amounts with the company are not all paid directly to the nurse. Do they have things like health insurance benefits from that company or they expected to buy that separately? How does that part work? So I think every company might operate a little bit differently, but most of them do have health insurance. Some of them do have retirement part of that money. They do get to pay for their housing and that's like a huge deal because they can get anywhere from like $600 to $1,000 a week for housing. That is not taxable. So that's a big deal as well. So they get some in their wages, but the rest of the company obviously gets a pretty good chunk of that as well. Got it. Okay, thank you. That's helpful. And then the other question I had is so every five years we get a new workforce strategic plan from the agency of human services who is in charge of kind of pulling together this kind of strategic plan. I'm wondering if that's something that you've or your union has ever been involved in if that's something that might make sense to try and engage in so that your perspective can be brought into that strategic thinking from the administration at the state's perspective in terms of planning, at least from what the state is able to help or provide with. Yeah, I'm aware of a lot of those things that happened a few years back. I was at a really large meeting that Senator Sanders had actually put together and the governor was there. I think a couple of members think Kevin Mullen was there and not that it was a problem, but most of that group was made up of the college educators, which I understand they play a huge role in that. They are the ones providing the nurses hopefully to our state, but there wasn't. And I would always laugh because whenever I'm invited those meetings I always find I'm the only like labor person in the room. And then a lot of times you only actually full time working nurse at the bedside. And I really think that we do have a voice that needs to be heard and these types of meetings but we're kind of shut out from them honestly. Thank you. Those were, those were my curiosities. Thanks for your presentation. Yes, absolutely. Thank you, Robin. Hi Deb, Dave Merman. Thanks for your presentation today. One question and then a comment. You mentioned some nursing vacancy rates. Do you have benchmarks for nursing vacancy rates among peer group hospitals? I do not. Just on an as I mean, it's, it's difficult. There are some states who are apparently doing it right that are not seeing the shortages that the rest of the country is. It's part of my job right now. Actually, our nurse bargaining next year is to really be looking at those numbers. In fact, doing this presentation, I felt like I was getting ready to prepare for that. But nationally, I don't know if they're as high as like a Vermont academic medical center. I don't know that. Just listening to colleagues, they often have really high vacancy rates, especially in Connecticut and Washington. My friends there tell me that, but I don't have an actual number I could share with you at this point. If I get it, I will certainly send pass it on. That's that'd be great. Thanks. And my comment is, I don't know if you know, but I'm an emergency physician. And I think, you know, as a, when I was a medical student, one of the things that was just most enticing about the emergency department is you get to work in this great multi, you know, multi professional team with nurses, EMTs, techs, rads, techs, respiratory therapists and, and much of what you say today resonates with many of the stories that I've heard over the last 20, 20 years. One of them that is almost most striking to me is being out for a mountain bike ride with nurse friends who work at multiple different hospitals and just getting hammer called to come in. And it's, it's, it has a big drain of guilt, I think, on people who say, no, I'm going to go for a mountain bike ride today instead of instead of go in, but thank you so much for your thanks so much for your presentation and coming today. Thank you. I don't actually have any questions or comments other than thank you for coming and sharing your thoughts with us today. And I thank you so much for having me and listening to this. Like I said, this is not supposed to be even though the only data I can really share was from my hospital. I truly believe that this is like I said on a smaller stale across the state and what is happening. Nationally, but I think Vermont were a little unique, especially with our housing market playing such a huge role in this. But I'm again, thank you for having me and if you would like me back for any clarifications, please just let me know. And I'm happy to give you any updates, especially positive ones if they happen along the way. Great. I'm not sure if the healthcare advocate has any questions or comments. I'll just turn on to turn on my camera and my sound to say thank you and thank you Deb personally. You've been at this for a long time. And thanks board for taking the time to listen to this. Right. And I'll open up to any public comment we may have via the raise your hand function. I'll call people in the order of their hands are raised. I don't see any. So, I think we can move on with that. Sometimes there's a lot and sometimes there's not. Well, thank you miss now for putting this together and educating us a little bit further. We appreciate all that you do and all the nurses do for our health system and thank you for for taking the time we really appreciate it. Thank you. Okay. And I'll turn to whether or not we have any old business or new business to come before the board. And is there a motion to adjourn? So moved. And all those in favor, please say aye. Aye. Aye. And we are adjourned. Have a good day everyone. Thank you.