 We have a long drive from ground to ground tomorrow, so we'll just give them a couple of minutes. While we progress the bill, we could take care of a couple of those nine years' time. The executive director directed the bill into approval of the amendment itself. Susan? Thank you, Mr. Chair. I had a few announcements. First, the hospital budget board are posted on our website and have been sent to the hospital. The review of the request, which was yesterday, and just to make sure that we are kept on our toes and our regulatory processes continue without the ACO budget yesterday. So that is also posted on our website. I want to announce that we have an open public comment period for the ACO budget. It started yesterday and it will continue until November 11th. And that information is on our website. If you have any questions, please reach out to us. The last item that I wanted to announce is that the board has posted some salary data for the hospitals. Here's Steve. It is located under our reports section. And the data from Office Report is taken from the 990s. That year that we looked at was fiscal year 2018. And anything over $500,000 including salary and benefits is listed on that report. In addition, we reached out, the board reached out to the University of Vermont Health Network to have some additional data provided on their salaries. And there's a chart in on our website. And I'll explain to you just a few items that the information showed. So we asked from UVMHM to provide their executive compensation. And they had had an executive or an external compensation consultant, which compared their compensation to 30 other similar sized institutions. And they found a few things. First, the executive total direct compensation as a percent of net revenue was .88%. And this is at the 35th percentile in hospital comparison. Second, that executive total direct compensation as a percent of total operating expense is .90%. And this is at the 28th percentile in the hospital comparison group. And last, that the executive total direct compensation as a percent of total payroll expense is 1.46%. And this is at the 14th percentile in the hospital comparison group. So all of this information is located on that same tab in our report section. If you have any questions, please reach out to me and we can follow up. And that is all I have to report. Thank you, Susan. Before we move on, I just wanted to ask about the ACO public comment period. Are you sure the event is a very important state holiday? Yes, it is. In addition to being back this day is my birthday. But the state offices are closed, I think. So would we make the public comment period the next day? That is a very... Is it closed for your birthday or this holiday? Well, it's closed for my birthday, for sure. But we can amend that to November 12th. Again, yes. Make sure we can accept it. Yes. We will do that. Thank you very much. Okay, the next item are the minutes of Wednesday, September 25th. Is there a motion? Second. It's been moved to approve the minutes of Wednesday, September 25th. Would like to add additions, deletions, or corrections. Is there any further discussion? If not, all those in favor, signify by saying aye. Aye. Any opposed? Super. I'll abstain. Just for record. I hope I was not there. Thank you. So now we're going to move right into the afternoon's business. And this is the third discussion we've had in the last couple of years here at the board on the workforce. Of course, the discussions happen wherever we go. And we just got through the hospital budget season. And it was pretty clear that there used to be a real need to address the workforce shortages that we're seeing in healthcare and the lot. And unfortunately, it's not just nurses and it's not just docs, but it's across the whole spectrum, including techs and everybody else. And to this afternoon, we've assembled eight really phenomenal people to discuss this topic. And the main thing is just to keep the discussion going. And really, we could have a couple days worth of discussion and probably still not address everything that's happened. I see Deb is in the audience. I think that was one day dedicated especially to workforce that she held at Cassington College a year ago. And it was very, very helpful. And it helped us to really learn so many of the barriers that people see to trying to overcome the problem that we have in the state of Vermont. And we heard everything from when it comes to nurses, for example, classes not being offered at times where a working parent could actually take the classes. We heard from educators that precepting was a problem. And that's why we're happy that Cabe's here today because what we learned is that even though organizations like visiting nurse organizations around the state were open to taking students, they didn't really qualify because you have to have a master's level nurse that is overseeing the students. And so each of the programs that was at that discussion had been talked about the ability to add additional students that they only had that precepting place out in the real world. And so we see that as a barrier. There's been some excellent work done by the Business Roundtable through the Talent Pipeline. Marianne Sheahan really went out and surveyed organizations to try to determine what the actual shortage is in the short term over the next couple of years for nurses. They came back at 3,900 in the next two years. And that's not surveying all the small nursing homes in the state. So we know it's a greater problem than even 3,900. Trey's on the panel, and we hear repeatedly from Tom Dee at hospital presentations and others. The average age of the physician workforce there. And what's going to happen in five years when everybody's at retirement age. So these are the issues that we've been dealing with. And so we thought it was really important to keep this discussion going and really try to get some key players to learn about some of the things that are already happening in the field and just discuss what might be able to happen to try to help Vermont as we deal with this workforce shortage. And I know that it doesn't matter what industry you talk to in Vermont. They talk about a workforce shortage and whether it's manufacturing, construction, you name it. I would just say that it's not selfish. I'm saying that healthcare should be as one of the main priorities. And that's because we're going to pay for it in one of two ways. Either we're not going to, we as Vermonters, say we, I'm talking about the collective we, we aren't going to have access to the right care. We're going to have to wait for that care. And we're going to pay for the care because as Steve I'm sure will tell us, hospitals can't turn somebody away. They have to serve that individual that walks in the door and to do that they're forced to hire travelers and locums and that's, that cost is two to 300% of what it would cost to have an actual Vermonter in that position. And it's not just a cost factor because we often hear that if you have a traveling nurse they're not as familiar with the equipment in that hospital. And at a time when we're trying to move away from fee-for-service to value-based medicine we want a better coordination of care and travelers and locums may not know all the different players in the community so that the individual doesn't end up being re-admitted to that high-cost hospital setting. So these are the issues that we're dealing with and we're just really happy that we've been able to put together this outstanding panel. Starting on the far side of the room for me we have Steve Gordon, the president and CEO of Memorial Hospital. We have Jeff Spalding, the chancellor of the Vermont State College's system. We have Gabe Gilman who's the general counsel for the Office of Professional Regulation at the Vermont Secretary of State. We have Dina Orfanidis, vice president, chief nursing officer at Northwestern Medical Center. We have Dr. Tray Dodson, chief medical officer at Southwestern Vermont Medical Center. We have Joyce Judy, the president of the Community College of Vermont. We have Anna Noonan, president of the Central Vermont Medical Center. And we have Melissa Davidson, who's a doc in anesthesiology professor at the University of Vermont Health Network Medical Group. So this is an outstanding panel and the way we thought we would open this up is just to throw out a couple of questions to allow each of the presenters to really introduce themselves, talk about something that they may be working on and their respective entities, and basically just start the conversation from there. So the questions that I thought I'd throw out to you initially and hope that we get some feedback on for the healthcare providers, how you address the issues at your hospital and for the educators, what innovations have you proposed to improve educational opportunities? So, Steve, I'm going to pick on you and start at that side of the table. That's okay. Last one here, first one. My pleasure. Can everyone hear me? Okay. We did put together a one-pager, Abigail called me one-page. We did a one-pager of all the things that Pratt & Barrow is engaged in to deal with working force into a proper spectrum of staff members. So folks have that as they came in, because I'm not going to go through each of the programs that we've done. But let me tell you, several years ago, we were having a major problem recruiting and finding medical assistants for the physician practices at Pratt & Barrow. And we ended up, I actually had a meeting with Joyce Judy and I said, can we work together in developing a program? We will guarantee eight slots, eight scholarships, guarantee the positions afterwards. And she's a visionary. And she said, absolutely. And that program is now, I think, in the fourth year, right? And looking to expand those to other job specifications. What I think is critical is a leader like Joyce to understand the challenges we have as a workforce from a healthcare standpoint and develop a program working with the hospital and meeting our needs related to workforce. That was very unique. And I was excited to sit next to the jet because I think we've got to have a better, closer relationship between the hospitals in particular and the universities in Vermont. To produce and help us address those workforce challenges. And we've put together a number of different programs here, both to the RNs, to the LDNs. We have a nurse residency program that we just piloted. And we also have worked with Department of Labor for training environmental services staff. We have a major problem recruiting and retaining environmental services staff. You can't clean your arms. You can't clean your hospital. You can't serve patients. So even at that level, we've got to have a better pipeline. And the only way we can get to that better pipeline is I think working with VTC, CCD, and the colleges in Vermont. Despite all doing all that we've done, we in Brattleboro are different than other parts of Vermont and you're going to get that for probably every hospital. But our competition is not for Vermont hospitals. It's actually Massachusetts. We're right off of 91. And 91 is a straight quarter or commuter quarter down to Greenfield and down to Springfield where Bay State is located with hospitals. So just this past year, sorry, the past month, it's the $30 an hour. Which when I mentioned that at a recent possible award meeting, our market demands that. We can't get to that level of compensation. It doesn't matter how we can sell Vermont to speak if you will, but come to Vermont, we've got to be in the game with our competition with our offices from Massachusetts hospitals. And we took a big leap what we thought that's what it's definitely needed. We're probably going to have to go back to Kevin and the Vermont care board again, some special distanciation on radiations. Yeah, yeah. But, you know, I don't think I know that we would get asked for something. But we have to deserve the bills. Really looking at where we're drawing our nurses from our professionals from, whether it's nurses, LPNs, whether it's physicians, primary care physicians. We're at a high level of market, not just in Massachusetts, but across the river in New Hampshire. So we've got to really, we've looked really hard at our compensation packages and benefit packages. It has to do with our organization. We had to do that compliment all the other things we're doing that you listed on the exhibit that we provided. Okay, Jeff. Well, great. Thanks very much for being here. And I'm probably the least expert person on the panel. But I would say the Vermont State College system as a whole has a mission statement that starts with, for the benefit of Vermont. Not for the benefit of the institution or anything else like that. So we try to work together whether it's Joyce here with Community College of Vermont or Cassington University or Northern Vermont University or Vermont Technical College to actually meet the needs of Vermont and healthcare is actually one of our largest enrolled areas in the various programs. We have over 2,000 students in programs from nursing to allied health and broader range of services like respiratory therapy radiological sciences is a new program in Vermont Tech, it's filled up health and exercise science programs dental hygiene psychology turn out a tremendous number of counselors and social workers and last year we graduated close to 700 students in those programs. And, you know, we have had and continue to develop new direct partnerships with hospitals and longer-term facilities. Steve mentioned a great example that we work with with Joyce. You know, we have and I'm glad that Southwest Medical Center is here when Southern Vermont College was unfortunately required to close, not required had to close its doors. Cassington University stepped in and is glad to work with Southwest Medical Center to pick up those programs and I think what's interesting again is that, you know, it's not just Cassington, it is a partnership and there's a cost, there's a higher cost in tuition and so forth for some of these health-related programs and having institutions help their new and current employees to access these programs really makes a big difference affordability is a major issue and we appreciate that. You know, we have Ann is here at the table with a new partnership with Vermont Technical College where we're delivering I think it's an LPN program and I can't remember which it is right up at Southern Vermont Medical Center we're doing the curriculum they're providing instructors and so forth so, you know, I could go on for a while, I mean we have actually a new good one up in Vienna and St. Alvis with the Northwest Medical Center where CCVs had a good relationship including a new office in downtown and the hospital is helping Vermont Technical College with some new sim lab and skills lab, so I just point out that, you know, we have those partnerships we're looking for more you know, and I'll get back to where we can I think use green mountain care help in a minute. As I just mentioned you know, the program delivery costs, particularly for nursing are high and we already have been forced to set higher tuition rates for both Cassington and Vermont Technical College compared to their regular programs or their other programs and just simply saying to the extent the institutions out there can help their future current employees with those tuition costs will really I think make it more possible for people to enter the workforce there's some here and now stuff and I'm glad Gabe's here pointed out some need for hopefully some flexibility with clinical instructors expert in these but these are actually people that are actually hired by the institutions that are doing the nursing not the hospitals themselves. There are preceptors and instructors and when we hire them under the current requirements many if not all of them the clinical instructors need to have a master's degree and that compounds the ability of us to be able to afford to pay these folks because they make more in their field of actual nursing like you know as opposed to the clinical instructors and most of these folks are part-time so if there is a way that OPR can work with the Board of Nursing to you know make sure that if they're experienced BSNs in there that they can serve the clinical instructor that will remove one of the sort of here and now practical barriers that our nursing people tell me we currently have you know whether our own system and the confines of collective bargaining agreements which we have in the state college that we actually have people with the surprise six collective bargaining agreements and you know we basically have been in a process where basically everybody gets paid the same faculty and in our new contract we hope to have a science seal delivered before the end of October we negotiated a differential pay decree specifically for our nursing faculty and you know it still probably won't be as much as they might earn elsewhere but it's an attempt to try to help us to be able to get more of our faculty members that want to help us provide programs on campus and in the field so you know affordability is a barrier you know that I want to just mention what I consider to be the big one for us you know given the pressures our system already has and I don't need to use this as a stump speech on that it's a challenge for us to cover the upfront cost to bring programs on to life you know like some of you will know just as a sideline on the lens that you're having probably back you know many years ago passed a legislation that set up a dental therapy program Montec is trying to get that off the ground for several years with no money in those programs you have to have a program director you got to go through accreditation you got to recruit students and do all that before you develop the curriculum before anybody ever comes and they don't have the money to do it so I'm just reporting that as an example Cassie is looking at a couple of new programs Jeff can I interrupt there just to ask a question of you and when you're starting a new program like that and of course you know that there will be an ask at some point from us you know I've communicated this to you already I really believe that Vermont needs to have a physician's assistance program when you start a new program like the dental therapist or if you were to consider a physician's assistance program is that outside of the contract and can you start with differentials or does the contract require you to pay the same to somebody that would be teaching a primary care provider as something else it's pretty much within the confines of the contract now there's some positions administrative higher level management positions that are not covered by contract so you know but when we start getting the faculty and things like that you're pretty much in there but it's just that it's just and it's not that much money but it costs money I'm told right now that there's a high need for different program masters and social work which we work in all kinds of facilities after they're in the program but the requirements to get that up and going are fairly significant you know castles them right now in the process of early stages of standing up it's not a physical therapist but there are two of them physical therapy assistant and an OTA occupational therapy assistant they're doing it because it's been an identified need in the Rutland region but you know the program director they're going to take them a long time to do it so my main point if I could is that where we could use help from the Green Mountain Care Board and industry leaders the talent pipeline is helping us identify the future future high demand where work force is likely to be scarce areas like three to five years down the road yesterday and tomorrow because you know it takes us a while if we could just sort of be clear this is what is coming and if there's a way to provide some additional help once we agree you're the right people to do it obviously we're not going to be providing pediatricians and things that the University of Vermont the ones that we can do if we can agree on what they are there's some way to provide through this industry wide area some startup funds for the plan that makes sense to people we can really appreciate that thank you very much thank you and thank you for having me it's just a privilege to be here with people who are thinking about the interplay between these systems I toil away in a fairly obscure agency and we think we've learned a lot and we think we have a lot to learn and forums like this are incredibly important to doing that so OPR is by Vermont's umbrella professional credentialing and licensing agency we responsibility for the licensing and credentialing and practice rules depending to almost every health science provider in the state who is not a medical doctor or physician assistant, a pediatricist or anesthesia assistant nearly every other category of health science provider from acupuncturists to actual technicians is licensed without the professional regulation OPR is not a passive home to our regulatory boards more than three quarters of our programs are not for government they're governed directly by the grant for professional regulation and appointee of the secretary of state we quite like that model because it's very nimble we don't have to wait for a whole year together every month in order to move to Fort Nydans and it is no less transparent it may be more so we are also home though established health science boards board of osteopathic physicians surgeons, psychologists and many others so our functions involve dictating who is credentialed and eligible to work lawfully in regulated fields as well as setting standards in those fields and we do that not based on our own intuition but based on some really excellent legislative guidance that exists in chapter 57 title 26 a chapter I'm confident that no one in this room has read they can provoke you to do that but it's a brilliant piece of legislation between the late 70s and laid out for the state of Vermont to all of our benefit a really clear legislatively endorsed statutory policy on what is occupational professional licensing for and the reason that was done is that gratuitous occupational and professional licensing can be enormously damaging to labor market fluidity to the ability of people to do what they want with the talents that they have and for the ability of people such as our hospitals who want to hire talented people to do that it is a tool that is used when appropriate but it has significant downsides and one of our jobs as an umbrella agency is to remind people of those downsides to police and escalator of regulatory requirements that will come out of just putting a group of professionals in a room and saying you know you're here it's the second Tuesday of the month what new rules can you imagine and we did that for decades throughout the United States and it was really only around 2015 that the dam broke for complex reasons I won't get into and through the leadership of the Secretary of State, Deputy Secretary and Director of Vermont we really tried to harness ourselves to an important national movement that which is also bipartisan in nature a very interesting coalition of folks who are on the left and concerned about social mobility and opportunity on the right who are concerned about economic opportunity and restricting the size of the inspected government and wherever you come from on that spectrum you come to the same conclusion which is that what we have been doing in licensing since the Second World War is not working for the modern economy to that end we have specific programs going on aimed at implementing the policies in Chapter 57 and adjusting them to the circumstance we find ourselves in these are varied I have 10 reports this summer I printed my little list I called them my summer reports and every time I do that now people remind me it's not the summer I'm panicking but those could not relate more directly to what we're here talking about one of the reports is a supplement to a report on the cost and benefits of entering a compact licensure compact this is an interstate agreement entered into by various legislatures that would allow someone holding a compact license to walk into 30 plus member states among them are neighbors Maine and Hampshire and very significant consequences for the ability of hospitals to hire credentialed people also counter availing consequences the chairman is talking about travelers that in a sense at least in the senate so there's no pure thing in this area but in general as a principal permitting a fluid labor market where talented people can go where they want when they want and be hired by who wants to hire them results in better marketplace matching more efficiency and happier people so the nursing compact study has resulted in feedback from the nursing community and the general health science community that is highly favorable to enter that compact and I think we may see some movement on that front very soon we've also been asked to do other things like evaluate where their apprenticeship pathways to licensure I think one of the elephants in this room if not the elephant is student loan debt is a significant factor in the behavior of the people we are trying to recruit in the health science workforce we'll get to later if we have time to roll that plates in our difficulty getting nurse educators interested in obtaining master's degrees but to that end the legislature has asked us to look at apprenticeship pathways to licensure that may be less expensive in two columns that I won't get into for lack of time we have seen the nimbleness of CCD and the community college system and their responsiveness and their willingness to monitor the marketplace and the new demands for mid-level credentialing and to respond to it with existing programs that are accessible to the monkeys where they are that's an incredibly important realization that has a lot of promise in terms of credentialing up and training people appropriately not giving them pointless training they don't need which is a hallmark of our existing system in some places and so CCD has a very important role here and already has been a critical partner to OPR and some of its efforts we have a study of pharmacist scope of practice legislature quite aware that is in everyone's interest to allow people who have a very expensive and technical graduate training to use that training in the marketplace to the best of their ability and I think pharmacists are among the health science professionals who may be most underused their talent misallocated so we are looking at the role of pharmacy technicians in the dispensing process whether liberalizing that role and the supervision of pharmacists whether they lead to efficiencies and we are also looking at whether pharmacists should be able to explore broader clinical avenues up to and including independent prescribing look for that to be controversial but it is a very important conversation to have we are looking at a similar way scope of practice of optometrists to ask whether optometrists should be able to perform certain tasks and thereby to free ophthalmologists and others with more technical equipment to do other tasks and then finally the one that everybody has talked about so far is nurse educator workforce development and the requirements pertaining to who may teach our aspiring nurses I can get into that in greater detail and I will have to get into that because we have a report to write on that subject a very interesting topic in the area of nurse education we historically have found ourselves in a funny place because the nurses the RNs at the inception of the profession and continuing for decades after were trained by hospitals and so state boards of nursing were charged with regulating the manner in which those professionals were trained now there are training colleges and universities and there are college and university creditors as well and the two have kind of moved in parallel neither giving any ground and sometimes repeating the functions of another and so part of that report necessarily will involve asking whether the board of nursing has an appropriate role in the tasks that third party creditors are performing so there is a lot to be done there I should point out that the existing requirement for nurse educators is that they be enrolled matriculated in even one credit of a master's program and actually hold that degree but that again gets to what I was talking about it's the simple behavioral deterrent the idea of taking somebody who is just getting ahead on his student loans and saying how do you feel about a master's degree not good is how he feels so that's a tough hurdle to overcome and so we've got a lot of exciting developments important developments exciting developments and we're really trying to engage our boards in thinking not just about what should the rules be but how do we balance access with quality how do we make sure we're setting a floor and not a ceiling how do we make sure we are getting credentials in the hands of qualified people as soon as we reasonably can without undue red tape and letting the marketplace do the rest so that's what we're up to and I've been probably over time it's okay it's fascinating information so thank you Kate, Dina yes thank you for allowing me to participate in this really important discussion some of the statistics I'd just like to share just to kind of frame where we're going and where I think we need to go in terms of the profession of nursing and being able to support the care of our Vermonters we can appreciate that there is going to be a million nurses needed across the nation by 2024 and I heard a statistic that here in Vermont we're going to be required to have 3,900 qualified nurses to take care of our patients also a known fact is there are 56,000 qualified nursing students that are turned away and not able to be placed in programs because of this faculty requirement so as you can appreciate this presents opportunity for the profession of nursing and the state of Vermont as well as the nation so when I think about this I was fortunate to come to Northwestern Medical Center with a vision that was created by some folks around this table and Jill Barry Bowen as a CEO in identifying a partnership for those nurses in Franklin County to be able to really reinvigorate that academic and provide an economic drive in bringing a school of nursing to Franklin County at St. Dolbyn so very proud to report that we'll be opening and enrolling our first class in September 2020. We'll have joint faculty placement and MC will sponsor and support up to 10 nursing scholarships for tuition reimbursement on the over period of time repayment of those loans in addition we'll be sharing that space with Vermont Technical College in regards to skills lab and simulation lab in regards to a joint place for training both on the academic side as well as the hospital side so it's a wonderful opportunity for students learning environment and how can we then really enculturate them into an environment where there's a mentorship and a support through lifestyle medicine education and training so really thinking a little bit differently although this practice has been placed along other organizations or communities within the country the other things that I would like to capture is that I think it's extremely important in regards to what I call an aspire nurse residency program bringing those nursing students into organizations finding that they have the right academic preparation as well as onboarding to the profession of nursing as we appreciate healthcare for all of our disciplines is quite challenging in relation to workplace violence and I think that's something that we seriously as healthcare community need to think about in regards to making this an attractive career for those young people entering the field I know for myself I'm 30 years I've been a registered nurse in multiple roles and extremely proud and grateful for that opportunity but how do we engage our young youth in that this is a profession healthcare that we benefit from and what it can provide for lifestyle and the commitment to our community and a public service one other additional piece of information that most folks here around the table and I suspect you'll hear more of is really allowing for tuition reimbursement I agree with that the student loan debt commitment that it's continuous learning when we think about outcomes related to clinical nurses there is evidence that obtaining a bachelor's prepared and a master's prepared your quality outcomes are correlated to that there's literature to support that so I think it's important as a healthcare leaders that we encourage and we facilitate making that happen in a reasonable way I'm fortunate to work with an organization at Northwestern that is very competitive in regards to that tuition reimbursement but more as a community of Vermonters how we can think about that maybe some of the same or a little bit differently I think is one of the key things in regards to steps in that area also I just am grateful to hear that I think it's really important to consider that compact that compact license really gives flexibility for nurses to enter the state of Vermont and not have barriers relating to licensure New Hampshire, Maine having that yes I believe you know folks would consider that it could be directional but honestly the profession is fluid the work force is very fluid and I appreciate capturing that it really is a satisfaction so I'd just like to close with that thank you thank you Dina thanks Kevin decided to be here and decided to learn a few things Jeff had mentioned that Southwestern Vermont Medical Center has a program now that went live officially September 1st it's pretty simple basically it's for RN jobs there's actually location in Bennington now for these students and SVHC will provide up to 100% reimbursement assuming that they meet certain criteria of coming back to the hospital and working and you know we did this as you would imagine you do it from a financial business planning aspect and it was very straightforward the ROI to those numbers right now but it was not many years into the future that the return will be great for the community and we've done extremely well in this first class it's kind of funny because most of the students were already in our system somehow they were already familiar with SVHC and familiar with the community so that's going to be great we're looking forward to that just trying to think outside the box I think we've presented the Green Mountain Care Board but for the past couple years we've been taking homes downtown this is nothing new there's a lot of places to do this it's been really successful for some of our staff where we take the homes we improve them we use local employers most of whom are married or have relationships with somebody in the hospital to begin with so we keep it really local and I think we've had four homes now we're on our fifth one it doesn't sound like a lot it's actually very important for four individual families to have them stay in the community so I'm very excited about that one the next two are moving forward into the future the first is the Putnam Block which you may have seen because this is a pretty big investment it's about $60 million investment in downtown SVHC along with eight community partners formed this coalition there's a lot of mechanics there talk about a not simple type of range but I couldn't be able to re-explain it but we're starting on phase one now that'll be complete within a year phase two will start this is a total revitalization of the downtown and one main aspect besides trying to get people to come visit it's actually to get people to come live there so in the first phase I believe there's like 30 apartments and then after that there's another 60 and they're nice places that families can live in and live downtown so that should be very productive for developing our workforce then a much bigger one it's early but I hope in five years we'll be really moving forward and that is we are developing a founding medicine residency program in Barrington at SVMC we're partnering with Dartmouth Hitchcock it's a little complicated because Dartmouth can't do a founding medicine residency but they can certainly partner with us we haven't gotten through all the hurdles but we have done all the background items that make us believe we can do it both financially as well as regulatory and then 2022-2023 will be the first class and there will be four residents per year that's 12 new people over a three year period new founding medicine physicians that hopefully will stay in Vermont and it's shown that about 65% in primary care physicians will stay in a state that they trained in so whether that translates exactly just even a few I'll be very happy I know Kat back there overall we'll be very happy if we can keep some of these physicians here and then we're also doing a lot of telemedicine as are many hospitals I look at it a little differently than what you may be thinking you may be thinking about that's access for members not having to travel to see specialists absolutely that's the whole point but there's other main points we can't keep a solid ICU nurse in our ICU especially one that hasn't had that much experience they're getting offers to go elsewhere and gain a lot more experience here we can keep patients now we have our ICU going with critical care physicians and critical care nurses and that's actually attractive new hires for us both as hospitalists and as well as critical care nurses because they see oh I can stay in a role and you can get all the benefits of being in Vermont and yet practice at a high level and continue my education that's pretty exciting as far as things that I'd like to somehow talk about the way that we can all work together this is a little anecdotal but having now recruited for many years where I see the most success is when I'm able to recruit people that want to be here not for all of the financial reasons they have huge debt so that's something to focus on but if I can find and target if I can, if I can have help if we can all work for targeting people that want to be here that's really successful and I would say probably of our last 10 to 15 physicians at least two thirds of them when they looked for us because they looked towards Vermont and the type of lifestyle they were envisioning would be here and it's hard to piece that out when you go out and just recruit in your normal fashion and you certainly don't do well when you pretend to be a place that that you're not well thank you for the opportunity to talk a little bit about TZV and thank you for previous references from Amy and Steve you'll have to remember that visionary quote there you go just a quick sort of thumbnail sketch of the community college of Vermont we think of Vermont as our campus we have 12 locations strategically placed around the state of Vermont and we serve about 5000 students who walk through our door and enroll in our programs in addition to our on-ground we have a very significant online program actually of the 800 courses we're offering right now almost 40% of them are online and that's being driven totally by our students the student needs and you know people come to TZV for really good reasons one is that if they're young or if they're adults and they want to start a TZV and they have aspirations to transfer transfer within the Vermont State College transfer to the University of Vermont transfer wherever they can start with us and do that the second is and probably the most important they come for jobs it's something related to jobs either they have a job and they want something better they're stuck where they are they're veterans who are transitioning back from military service they've been in the construction business and they're in curve and they have to transition into another career so we just see a lot of a variety of folks who come to TZV and I often times describe as we're the open end of the month we are a place where people can start and most students who come to us aspire to something beyond TZV so we are the group that sort of we work with younger students and we help them and we build pipelines to other programs I'll give you an example more than 70% every year the students graduate in nursing from Vermont have to start at the TZV that's a significant pipeline in terms of that CCDs has the largest number of students, co-largest transfer cohort transferring to the University of Vermont and I will also add that this is a pretty good part of this so many students start with us and aspire to go to other places there's been a lot of talk about student loan debt and it is a huge issue and quite frankly it's one of the reasons why Vermont has one of the highest school graduation rates and it's because people here on the street that they're going to come out of college with so much debt but there are ways to put together your education that are much less expensive I'll give you an example students can start at CCD and transfer after two years if they went to school four times I should start even earlier though because you work so hard on early college but if a student started at CCD earned their first few years we had guaranteed admissions programs with many programs at UDM like Russian Year $10,000 a year and so that's worth $20,000 on the front end of a college education is real money and you can do that with the Vermont State College you can do that with the privates so there are ways to put this together and as Kevin was saying one of the things that Vermont has been very forward thinking with the legislature is dual enrollment where students make their eligible to take two college courses they also if a student wants to do their whole senior year they can at a college they can do it at CCD or other participating colleges there are any other Vermont State colleges they can use it so I and she had just recently had a single mom say to me you know I have two children I wanted my kids to go to school I never thought we would afford it but because I had a daughter she had a senior year she did early college as a senior she entered Cassington University as a second semester sophomore and started at ground zero in terms of the cost so there are ways to really think about this and you know we have students who go on the nursing program and we have a student who has just completed an event program which is a full-fledged dense so people community colleges nationally struggle with the stigma of our ways to really build your future by starting out but one of the things I really wanted to talk a little bit about is yes we serve as students who walk through our door but one of the most important pieces of our work is our work to businesses and Steve has alluded to that we're doing some really interesting work with something like hospital it's really about how do we work with businesses and help you grow your own 95% of the students who come to CCD are romantic they're staying here they're here and how do we help them become the workforce of the future and so but as we think about adults the two most important barriers are time and money and so if they if there's ways to think about helping people move forward in their education and address the two components of time and money it is a win for adults and so I use are you going to talk about this? okay then I will leave that to Anne but I think what's really important and Steve has alluded to this with his program is how do you most adults and again when I talk about adults I'm talking about 70- and 80-year-olds or 60-year-olds they cannot give up their livelihood and continue their education so how do you help them learn and earn at the same time and so I think there's some really innovative things that are going on we have really dipped our pretty heavily into the apprenticeship area and it's a great way for adults to earn and learn one quick example we were approached by CVS a year ago they are desperate for pharmacy technicians and so we have worked with them to develop a pharmacy tech apprenticeship program and so we just enrolled our first class we have 14 students that was all we could handle this fall and we have several pharmacies CVS, Shaw's a number of them throughout the state who are sponsoring pharmacy tech so they are working and they are taking courses at the same time so in the end the elbows are much more paid and they will be able to there will be such an asset for the local pharmacies so I think what I see is I think there's tremendous potential but we do struggle with kind and money in Vermont and I'll just finish with we do have a problem in Vermont we have the highest high school graduation rate we have the highest in the country and we have one of the lowest college graduates and it's not about college it's about the willingness to continue your education whether it's a significant whether it's going into military whatever and so somehow we have to flip the narrative that it is really important to continue your education because every year we're graduating between six and seven thousand high school seniors who only about half of them are continuing any form of education in two years so that's a significant number of people that are just out on the street from the entry level and I'm going to start with and it would be a benefit to us and to Vermont and Vermont businesses if we could really sort of work with that group and build that high school so Joyce before we go on to Hanna so glad before we go on to Hanna of the you said roughly half of the six thousand were out of college how many finished how many of the students who continue their you're down to three thousand how many actually finished college so here this is a really good question Kevin because I would say that a lot of this is old metrics now community colleges don't have our graduation rate is 15 to 20 percent but let me tell you how graduation rates are figured you know every industry has its own challenges so the way graduation rates are figured in this country are on a first time full time cohort so if you're a first time college one student and you're enrolled full time in a college that's the cohort that is figured that your graduation rate is figuring out so a thousand new students started school and of that about 85 of them were first time so our graduation rate for three years is figured on that 85 students out of a thousand who really did start with us but here's two catches to it so if they transfer to castleton or transfer to the non-tech they're not they're they're dropped out of the cohort so they're considered not a graduate they don't graduate and if they drop a little full time they're not they're out of the they're out of the graduate cohort so the data is just not that good so the data is just really troubling and I will also say that I think one of the things that we have to sort of think about is how are young folks accessing education today it's yes there's always going to be the top 20 percent who are going to enroll in the middle-nurse and Dartmouth and Congress and that's really important but then there's the rest of the adults or the rest of the students who are going to take some courses, get a credential go to work get stuck where they want come back, take some more courses continue you know this great long trajectory that that I will say that my generation was used to is just not the way that a lot of our students are accessing education so graduation rates for me are a challenge because what do we mean by that you know if a student takes seven years to get their associate degree at CCB because they stopped and started that's a success but they're not even in the realm of time so yeah thank you it's wonderful to be part of this panel we have a lot of things that are even touched on that we do at CBMC as well but I'm going to focus on a couple of areas that are new programs for us that have really made a difference for us and you've already heard about the importance of those partnerships and the partnerships that we have enough with CCB and a lot of colleges so that's been phenomenal for us so I'm just going to step us back we probably all know these stats but June 19 the latest statistics from the U.S. Bureau of Statistics in Los Alamos unemployment rate is at 2.1% I think that's the lowest on record and we certainly feel that every day when we're recruiting staff before our organization high high level of competition for all positions you've heard about the R&D position challenges you're going to hear about the position of provider challenges but the entry level position challenges are also pretty intense so it's very difficult for us to recruit into our entry level direct care providers those being LMA's licensed nurse aides, CCA's clinical care assistants and then an area that nursing has moved away from but we're moving back in is the notion of reality on the licensed practical nursing we have a definite role particularly in the still nursing facility arena we have a 153 head licensed still nursing facility it's very very challenging for the staff in that some of our most vulnerable populations was meeting our elders so we've got all the traditional stuff that you probably know most healthcare organizations do the job fairs, the sign on bonuses relocation fees we cover those things tuition reimbursement all of those things are just part of the portfolio now we have to do those things we have to stay competitive and our market is really the New England market is actually a lower base if you go across the nation so we are recruiting as my other colleagues have mentioned more regionally and those salaries are high so we have to stay competitive if we want to bring those individuals into our organization in Central Vermont we did increase our base salary ranges for a variety of areas and roles in our organization we have this process we go through one of the hot jobs the jobs that are difficult to recruit into that we have turnover issues and we try to use the dollars we have to position ourselves to those types of roles and that's something that's been ongoing we did increase our R&A base salary even people that fill these roles will move in and out of organizations for a quarter and that's real, that's very real that's significant over a full time role that's a significant dollar amount to those individuals so we did increase our base salary for most of our R&A level roles we're not quite at the $15 but we're just a little south of that and another thing we've done is just retention how do we keep our employees within our organization so we're a strong believer an employee like council we started an employee council in our nursing home setting we have a strong shared reference model the QQ care setting was spreading that across organizations and we believe that when people have opportunity to engage in decision making around their practice and their profession they'll stay and so that's proving true for us which is wonderful and we've also established career ladders for both L&A's and our CCAs those are traditionally not roles that have career ladders but it is part of it they're part of our fabric and investing in them both at the entry level and guiding them and then here how we're trying to do that at CVMC into higher level positions and how care is also so trajectory for them that they may not have advantage prior to some of these programs so this year we launched a licensed nurse assistant educational program we were grateful for a belong training grant that we applied for and were able to receive all of our educators we heard us talk about the need for educators even in these roles those educators are critical so our center of the law center staff serve as the educators and clinical preceptors we've also given the opportunity for seasoned, very confident L&A's that are more senior they serve as preceptors and that's also a retention piece for that we get a lot of gratification from teaching what they know and have learned and we'll get into the curriculum but no it's pretty comprehensive for that level we've run three school courts through that program since we launched that in April and 16 have completed the program to date and that's pretty significant for us we have another school court starting in November we've warned individuals that this is their first entree and to health care is in this L&A program we support them by ironing them into the roles and then training them so they get a salary while they're learning that new skills the CCA level this was a new role for us in our organization in our practices which we have 27 practices across the Central Malani area there was a high population of R&Ms and very few of these clinical care associate roles which is pretty common role to have in a practice setting those individuals are the ones that reach you for being in the room, they take your vital signs they may do a lab law, weights, those sorts of things and they do a very high level of intake and it's really a facilitator for the provider those roles did not exist in our clinics and so we're looking at our cost structure that was something that we began to bring in and the other piece of that is we really needed to shift our R&Ms to focus on care coordination our nurse wellness visits, health promotion and education so we want our R&Ms focusing and really providing care at the top of their license and so we're moving them in that direction and just changing the skill mix so the things that we don't need in our R&M life is to do what we're going to have the CCAs do the challenge with that is no CCAs existed in our market so it's the field of growth but if you build it, they will come so we decided we needed to build that curriculum as well and again, same thing as the R&M our nurses provide the education to them, we developed a curriculum that's pretty intensive that you can learn to do baby culture, sewed, brought in blood all of those things and that's about a 100 hour program and the LNA program is about 110 hours again we've got two cohorts going through that a total of 12 people have completed that program and as they complete the program, we place them in those practices that use their training in those practices and the clinical experience is there as I mentioned before have a career ladder so once they're a year in that CCA role, they move to a CCA level 2 higher level of compensation there will be more skill sets that will come forward with them and again we're trying to coach them to keep advancing into the health care arena and then the last program that I want to talk about that was really the significant partnership with from our technical college in CCB is our health care program so we also I can say this nurses nationally at the preparatory level we're phasing out LNA they really felt as a profession at entry level where nursing should be at that level and I'm a strong believer of that, I'm also a realist and so there's a role for LNA and there's particularly a role for LNA in the skill nursing facility arena and we simply cannot find them so we're the partnership with BTC and CCB we've created that curriculum and that program that launched, we picked that program off August 1st we had 18 individuals going through that program they we developed prerequisites of course we worked with CCB in a way that you've heard Joyce mention so they've done their prerequisites, there were a few that didn't need those prerequisites and I don't know what the label of it is but it's just to see what the competency level is because there's some people they haven't been doing any education for 100 years this is wholly new for them so it's just the way of establishing where their competency is and they test down on that CCB provides that, that's phenomenal and then from there they're doing their prerequisites but the kicker is they're doing their prerequisites at CVMC they're doing them on-site so around we did a series of focus groups and we asked folks in our organization if we provided this would you participate and they said yeah but the challenge for me to participate is we've heard it already, cost I can't afford it, I have to I have to work, I have to pay for my rent and my mortgage if they have one all the things that one needs to cover with the salary they can't afford to stop working to do any of these programs so that support as an employer to pay for them while they're doing that is the other thing we heard is even transportation was a challenge so it's hard to travel to where those classes may be offered the races address that and others have addressed that through the online curriculum, that's phenomenal but the other barrier we found is they wanted to go to a place that's familiar and this is a big jump for them to go from doing the work to going to think about going back to school and going back to school at a collegiate level is a huge challenge so we're offering all the class work with the exception of the anatomy lab at the Central Online Center all the faculty are fortunate we have a number of masters prepared and faculty prepared nurses they are serving as faculty for the program which is we're just thrown about and for those nurses that are serving these work for them as well so they may not have had that on their CV in the past now they can have their faculty as well as have that experience formally so that program launched most are completing their pre-rex and then in the year from now they'll formally start that LPN program again all of that curriculum is offered on site and they'll be mentored and IR masters and doctor prepared nurses the one comment that I actually enjoy to mention is the Museum had the answer to this data that 60% of the individuals going through that LPN program they will be the first ones in their family to have a college education and it speaks to what it was just talking about and if we can provide them the staff holding and they're being mentored through this program so not only are they doing the academic piece and the clinical piece but they're also being supported as part of our team and I also want to just give a shout out to Green Mountain United working bridges and to our organization and they provide staff holding and I know others do this in the state as well around financial literacy they help our staff their income taxes those kind of things and we've actually offered working bridges to this cohort both at the LNA, the CCA and this LPN program to just give them the other supports that they need it's hard to go from doing what you do every day to thinking about I'm going to go and take classes and start going and you may not have ever done that or you may be the first one in your family that is doing that at the age at low and that's a stretch so giving them that support and that guidance is also helpful and as far as what you all can do to support us I'm going to tell you those seed grants for us were hugely helpful you've heard about loan forgiveness I think that's critical the burden on people with those programs is very, very high and I think as employers we have to really explore those innovative partnerships with some of the folks at this table and we're looking for those we're going to continue to advance those we have to think differently about how we have people enter in the healthcare and for us it starts with do you want to enter have an LNA level or a CCA level and then from there maybe go to an LPN that stepwise approach for some is much more achievable than thinking I'm going to go four years to do the some of the other programs in the state so I'll just pause there thank you Melissa thank you, thank you for having me as you said my name is Melissa Davidson I'm here now as an anesthesiologist today but I'm actually here representing graduate medical education my title up at UVM Medical Center is the designated institutional official the DIO of all the residency programs for University of Vermont Medical Center which is called the sponsoring institution for all the residency programs and that designation is according to our the accreditation council for graduate medical education the ACG&E which is our accrediting body all told we have 42 residency and fellowship training programs and of those 17 are core residency programs and 25 are fellowship programs oh maybe I'll just make a little disclaimer here I do represent University of Vermont Medical Center but I do have just enough knowledge to be dangerous our undergraduate programs are a college of medicine so because some of the initiatives that are going on actually is in partnership with the University of Vermont Medical Center so I just want to say that in terms of our 42 programs 17 are core programs which means that these are the programs that the medical students immediately leaving medical school will go into that program which will give them primary certification then there are 25 programs or subspecialty programs once they finish the core program they can do further training so an internal medicine resident might choose to be a cardiologist and go into one of those programs while that seems like an imbalance between our core programs and subspecialty you have to keep in mind that the 17 core residency programs account for 80% of the residency so we have 275 residents in our 17 training programs and 63 fellows in our 25 subspecialty training programs of those 275 residents I've counted about 104 of the 275 are in primary care programs and I call primary care programs family medicine internal medicine pediatrics OBGYN those programs really provide primary care to our population in Vermont and it also includes four dental residents because we consider that a really important piece of primary care that sometimes people forget about oral health if you then include surgery as taking some component of primary care psychiatry because mental health is so important in our state of psychology that accounts for 163 of our 275 residents so there's a large cohort of residency programs they're taking care of our people in primary care in some fashion in terms of how our residents do when they leave here about 25% of our residents our residents and fellows stay in the state of Vermont which doesn't sound like a large number but it is a large number in terms of total numbers that really stay here we don't have a great understanding of why they're staying here we're really trying to get that information but they are staying in Vermont and a lot of them are staying in primary care 49% of all of our graduates are in primary care and 65% of our graduates if you account for those other specialty surgery neurology and psychiatry we would like to get better numbers about why they're staying and why they're not staying but to jump ahead a little bit if we ask why are we not attracting more people into our residency programs in terms of why are they not coming here the information that we have is actually kind of interesting the number one reason why residents or medical students are choosing not to come to a Vermont program the number one reason is that there's no job for their spouses and partners who are professionals so that's the number one reason other reasons that they're not coming here is because of lack of affordable childcare in the state which nobody's mentioned yet but I think that's a big driver for why people want to be here and hence stay here number one is the lack of diversity and so we're really trying to address the lack of diversity as well but it's sort of a self-affording prophecy in order to get people here to make our state more diverse they have to feel comfortable being here and so getting our medical students to want to come to Vermont when there's this is one I heard recently there's not a good Asian market and I mean a grocery store and so those are very important drivers to why those students will or will not come to Vermont so we're really trying to pay attention to that in terms of our workforce for a lot about what the workforce needs are well across the country they estimate that by 2032 we're going to be in short supply of somewhere between 47 and 122 thousand positions and that's a wide number because we don't know what's going to happen in terms of nurse practitioners and PAs in that workforce so it's a huge range but we know that we are going to be in short supply by 2032 and that accounts for about anywhere from 21 to 55,000 primary care physicians but it doesn't stop there 25 to 65,000 specialists and up to 23,000 surgeons so we are going to be in short supply and that's why we're trying to address this today across the country our medical schools are expanding the bottleneck is still at the graduate medical education level the residency programs are expanding but the problem is federal funding for residency programs is stagnant at the 1996 level so that's the cap that was set in 1996 so we are expanding without any more federal funding so we have expanded the University of Vermont Medical Center since 2010 our numbers are about 50 to 60 and just in the last couple of years we've expanded by opening an emergency medicine program because the need is so great in our network and I think that we have seen a higher quality physician in our emergency departments and the interest just in having this emergency medicine program has really helped us with our workforce in our local emergency departments at CBPH, CBNC UVM Medical Center those are just the nearby network programs that we've really seen a big difference so far maybe if you could speak more today if you want to at some point so in terms of our strategic plan and where we're going we are hoping to expand we're hoping to expand in those critical areas we've expanded just in the past five years and I'm in primary here in internal medicine we are hoping to expand we've heard a big need for gerontologists having to care physicians and I'm personally this is my dream I'm hoping to start conversations about preventing medicine residency because that's where we start talking about population health and public policy so that's a dream that's a dream I'm hoping to win Powerball so that we can start paying for some of these programs but you need like a win I'm starting to make so in terms of some of the other things that we are doing in terms of expansion we talked about that we in the medical school they've started the longitudinal integrated curriculum where we have placed four students down in New York and some of our rural tracts I believe we're starting we have six that's starting in Central Vermont Medical Center and this is a very big deal because what this means is that our medical students in their 30 years are not moving hospital to hospital rotation to rotation they're staying in almost exclusively in one hospital and primary care setting where they're getting all of their training in all the specialties in one place and we're hoping that that means that they're going to want to stay in that area that's especially important for training our rural physicians so that's really important in terms of expansion we have expanded not University of Vermont Medical Center but the health network has expanded into New York and we have a new family medicine program in New York and they just graduated their first cohort of physicians it started with a class of four they're graduating three one had to decelerate so they graduated three physicians in family medicine and all three have stayed in the area that's huge I mean that's absolutely enormous so that's what we're hoping to accomplish with some of these other programs some of the other strategic initiatives this is a University of Vermont Medical Center program it's our nursing residency program I don't own it but the word on the street and by the street I mean and the locker room because I still change every day when I go to the operating room the word on the street is that it's very very successful and it's becoming extremely competitive and so that's really important and helping our young nurses get the appropriate training that they need so that they stay here they're not getting some training and they're not being unhappy with the training that they've gotten and leaving and going we want them to stay here that's really important and finally one of our initiatives and this is in partnership with the University of Vermont Health Network and with the College of Medicine is trying to think about the academic structure like an academic office to better coordinate our learners we are stepping on top of each other every day because the University of Vermont Medical Center and some of our local hospitals in the network we are about the only game in town in terms of having the appropriate preceptors and the faculty and every day you know you wonder who these people are we definitely need that coordination of clinical care so that when we open up a PA program Kevin we know where we can place them through the appropriate training so that we're not fighting for the clinical cases so that's going to be really important and that's really just at the ground level still trying to figure out what that's going to look like the biggest challenge for us again is the funding piece of it we are looking for as on a national level to support the more funding to support residency training so there's two bills on the floor right now one in the house and one in the senate so what can you do to help us when those bills come around and we are looking for support get your campus people in your centers to support those bills because that will help us expand our residency programs and again you've heard over and over loan repayment is huge and our medical students the average debt for medical students on average across the country is $196,000 that does not include their undergraduate $196,000 that's a driver unfortunately of the special fees that they're choosing so they may not be choosing primary care pediatrics because the debt that they're holding especially in two physician programs or two physician families the debt is double it's not unusual to have our families be indebted for over $400,000 just for their medical school debt but if you think that's bad our dental students across the country their average debt is $267,000 that's huge so loan repayment programs that's where we really need to start thinking outside the box and being creative about how we can help our graduates stay in the state of the month thank you Melissa so I'm going to open it up to the board for questions and I'm going to start with the board member Robin Wynch and you legislate this pass on your task a group called the rural health task force which Robin is the leader of I'll deliver you a report to them and I know that one of the things that they've been working on is suggestions on workforce so I'm going to turn it over to Robin thank you as Kevin said the rural health services task force is taking a deep dive into workforce issues in this area and we actually have several of our members in the audience as well as Steve he's on the panel so one of the areas that I'd be interested in is if you had to choose one workforce initiative that you thought that we should promote as a rural health services task force what would it be so that's question one and then my other question to Gabe would be I'd love to connect with work we can do this offline but I'd love to connect more about the studies that you're currently undertaking so that we can understand better where you are and we have a report as well due on in January so the question is if that's your number one priority for workforce initiatives that you'd like us to think about who would like to start I think you've heard low repandence the big one I think that's a central theme and we've talked a lot about that in the rural health care task force in the presentation now or the most you may a couple weeks ago I had the money I put towards that and we do it on a local level at the hospital level and the interesting thing for the three graduates from CVPH who stayed in the area to practice family medicine departments they have a loan payment program where they get some loan forgiveness and that has made a huge difference anyone else if anything comes to mind later let me know yeah this isn't a one-time shot well it might not sleep you come up with a great idea email somebody I'll go ahead and say I think the seed money some of those small grants that just allows us to explore some of the innovative programs sometimes those are harder to launch if you have to find dollars in early but I think that that kind of grant process also allows for some really rich competition around just thinking differently and I know that was very helpful for us for the programs we still have on the loan payment two things that I've seen just the past ten years is first off that it has gotten to the level now where people are making their decisions so I can't say in ten years how many people are making their full decision it was a nice thing to have but now it's like sort of inundating when they go and you don't want to bring someone who doesn't want to be there and then second is and I don't have to answer this but how can we be innovative because you just say oh okay we'll give you $10,000 per year it's taxed quite a bit what are some innovative ways to get around that I was just interviewing a surgeon and she really wanted to be in our area and have some connection and I asked her how much debt she had and she said 250,000 and that's like gosh that's so much money and what's the interest rate at and she said about 7% and that also moved me away because my little 15 years ago I worked near that level first off but 7% interest rate wasn't even trying to do that so I don't know what those innovative things are but maybe there's something other than just trying to pay them back is there some way to do something different I also think that if there's other a way to craft the child care or not because child care costs are enormous people who work at child care don't agree much and people who are paying for child care it's way more than their work so I mean wouldn't it be great if Vermont, what's magical about 5 years old the first grade if Vermont could figure out a way to fund child care from birth just to grade 12 it would then it would reverse people would want to move to Vermont it would solve our workforce development issues it would just address so much we had capacity now we don't have the infrastructure so we have empty schools in every community why aren't we taking and we only have 39,000 kids in 0 to 8, 5 can't we figure out a way to fund that in a way that invites people that oh I want to move to Vermont because I don't have a child care cost and I have child care available I mean if you can find if you can afford it I was talking to someone the other day I lived in Waterbury she's 21st on a week she's 37 before it was the number one spot so somehow with all the workforce issues there's a few key issues and I just think from a small amount we ought to be able to solve that problem and we could and we would be in front of everybody else we're not just at around the child care we also need to think about most of our staff we're called hour shifts and a lot of the child care facilities do not stay open until 7 p.m. in order they take in children at 7 p.m. a night for the night shift we started at 24 7 and I guess a lot of broken weekends and holidays and so those are the kind of very real challenges that I think that's a big change that would be a marketing tool for us as a state and just to reinforce the notion of how many empty school classrooms we have I know in my community that's a huge issue those buildings are there but they're mostly on thinking a great opportunity thank you see you Tom well first I want to thank you all for being here today I just have this feeling of somehow being able to pay for you all to go away for a weekend into a few days you can come back to the road map to help us get far down the road my first question is I think for Steve look coming over here because one of the things that bugs me in this whole thing is kind of a waste of money in a way and Kevin started out by saying we're paying a two and two hundred percent premium for the staff that we have when we have to go to a traveler so I went to the 990s, the IRS 990s just to get a feel for what this means and there's a contract that UVM has with a company called Cross Country Traveling Nurses and that's a 15.6 million dollar contract at CBMC there's a contract this is in the 2018 fiscal year just to staffing medical solutions a little over a million bucks and there's a contract and this doesn't include the contract with Dartmouth for its positions but for the company called PPR Travel 1.6 million so it's significant amount of money and I'm just curious from the hospital side mostly, Hannah Deanna and Steve is how you approach this as an asset to be leverage to try to get to the other side where you're paying kind of straight up one for one for the staffing that you're looking for You want me to start? Sure. It's probably our biggest budget variance paying for the Traveling Nurses and that's probably about 11 to 13 FT's which on a bigger scale isn't big compared to all the staff that we do employ but it's probably our biggest vulnerability so that's why this year as we look at our competition especially in the Massachusetts market we need to attract more nurses based upon salary despite doing all the things we're doing locally with CCD VTC we needed to put those dollars instead of with a traveling nurse to our own staff and that's why we did make that investment and our goal in that investment is to drop the number of travelers by early spring out of 50% of what we're running right now we've got to get to six travelers and it's not just nursing, we have a traveler in the laboratory and some of the other areas but the biggest bogey out there is what y'all read and we had to make that happen because none of what we're doing the residencies, the scholarships all of that are all free but this was the other piece that we had to recognize when we had to deal with this year and hopefully we drop that in the next IRS filing down to half a million dollars we'll probably never get to zero because we're always going to have some turnover but we've got to we've got to address it like every probably every other hospital in Vermont and it is as I said the biggest challenge we have out there right now is on the workforce piece I would also agree and it's not only nursing but we see use of local travelers across all disciplines although nursing seems to be the highest volume in particular related to specialty practice, your EVs, your critical care potentially your authorating room so you really have to you know, having had my career and practiced in several places and your workforce and the purpose and when you need to use a traveler to care for patients having said that some of the creative things you need to consider is having incentivize your own employees and clinical teams on maybe additional shifts but always balancing that safety issue as also your per knee staff but you really do need to think creatively it's not one and done but you know this is real and we see this you know I've always said take a hospital across the country this is real and also my experience is that the generation may truly nurses will come get that experience and a wonderful nurse residency preceptorship enjoy the opportunity with the intention they're going to travel and any organization outside after you've done that hard work will pick up pick up a nurse and even hey you know if you have agreement related to contracting hey you know we will put you through this residency but with a two year commitment another HR department will pick up that cost to get that nurse so it's tricky so just adding to it the argument said for us that's what prompted us to start the programs of both the RNA and the LPN space we were a pain traveler at that level of freedom at that level of individual it was extraordinary and to be frank the quality was not necessarily what we were accustomed to the balance act it was a cost and quality equation as well so definitely the business case for us was easy to make it was a no brainer and I just wanted to be clear I didn't develop these programs my team did and they did a phenomenal job together but I asked for that business case it was very clear that if we can educate people locally and remember that at the end of the day nurses travel now the new grads that come out of nursing school want to travel that's what they want to do it's just a different mental model than certainly when I graduated a number of years ago and so what we really are targeting is people that want to start a family and live in the line and so what we've been successful and I guess my colleagues have as well is we've actually enticed some travelers to stay so if we can bring them to our organization they're coming at a premium but if we can show them the love I wonder what it is to work at Center for Law Medical Center and be part of our amazing team and live in this beautiful state and be exposed to all of that we have two people from Los Angeles that stay and are working on this sort of right now, husband life that to me was that big my day we started the year we had 30, we're down to so for us that we had 1700 employees we're down to 15 and that's good we still have a ways to go and I just want to echo it's not just direct care providers that are in this traveler's space and I smile when we talked about the farm tech program thank you because one of our travelers is farm tech so we are seeing travelers in more disciplines as well the other thing for us from just an operational issue I guess some of our smaller organizations have the same challenge we can, our census can double in a day so we can go from having 45 patients to 80 plus patients in a day and having practiced previously at EVNMC I think if I walk into any of those rooms and said we're going to double your census in a day they'd let me out of town but in a community hospital like that is not uncommon so we have to understand how we can stabilize some of those peaks and valleys in a way that makes sense for us and so that's another operational challenge we're looking at as well so we've been kind of very difficult to flex from 45 to 80 patients and that's actually what got us into the traveler business this year is that really peak census and we talked about during our budget hearings that we were all seeing aged patients with multiple probabilities these individuals are very sick and they come back repeatedly we had a re-admission initiative we reduced our re-admissions by 12% thank goodness we did because if we hadn't our margin would have looked even worse so those are the very real operational issues we're all challenged with and I think this frame comes in the partnerships with some of what we've seen exemplified here today very important for us one more quick when I was visiting the New York Country Hospital I was talking to CFO who said to me that we were talking about ideas and trying to downsize the flowers and upsize the kind of more stable staff and he had what I thought was a good idea in terms of trying to help people with their mortgages to kind of get them to stay rather than student loans which keeps them more mobile to get them invested in a piece of property and what he said when he presented to his board there was not from the board but there was almost immediate pushback from people in the community who felt you know all these great jobs in the hospital and now they're giving them additional enhancement and then even from inside the hospital staff we were saying well if we're going to give it to them we should give it to us and I'm just wondering is that dynamic kind of been watered down enough because people see that in the more global sense that hiring travelers is not the best use of money I would say that usually folks are relieved that a traveler is there because there's a need really how do you enculturate them into the environment and create a space for them to feel part of your your organization and also you know it's telling the story because you know I think travelers you look at their compensation they're not receiving that their agency is and also when you look at the cost of a clinical nurse a fringe on that your benefits, your earned time these folks don't have that so you know I know that's helped you know tell that story what it truly means to be a traveler I think by label it seems because it is an expensive source it's $90 an hour for a specialty you get into critical pay crisis pay it's definitely a big bulk so I believe it's really how do you enculturate them my experience is they're there at a critical time when your workforce is low you know we're always in the business to hire permanent and I appreciate Anna you know it's that re-recruit and put the hook in and have somebody convert to permanent first I want to thank this is a great presentation you know we really stand where many of the problems are starting with you know the students not being able to afford the education to the education not being able to necessarily afford setting up new programs to you know the hospital is not able to pay for people because they're not there and so I just you know wonder one of the things too is it's kind of like we're on this gerbil wheel where we're really what's going to happen in the next three to five years and we're trying to fill all these spots and everything and we tend to even be a little more disadvantaged you know this is a national problem as you said there's 100,000 doctors missing and you know we're looking for a small piece of them and so just trying to look at what other things can we do in the future rather than just try to do the same thing as we go forward and I think you know Dr. Davidson brought up some of that with the you know really looking for preventive medicine and population health and you know how do we get into the telemedicine how do we change things in the future because we can sit here and try to set up all these programs and you guys are doing wonderful things and you're doing some scholarship programs but a lot of the numbers you were talking about are still relatively small you know say we have 15 students here at 15 there I mean we're talking really large numbers that we're going to need and so you know I think part of it is going to in some ways probably force us to really get some of the ways out of the system be more efficient find new ways to do things and you know just how do we get that into this whole workforce thing too because I think everything you're saying with childcare, with travel and spouses with you know diversity is more and more challenging to get people here and so we can try all these things which we're going to try to do right and try to fill the gaps but we could be here in 5 years or 10 years and the problem is even bigger so you know I don't know that necessarily that there's an answer I mean I think this was all fascinating and you know hearing each piece but you know one underlying theme I've heard almost across everything is everybody needs money which I understand that but where do we get it you know it's either coming from either the hospitals paying for things and maybe they can do that with part-wise for the programs it's got to come from taxes if the state's going to pay for it I mean it's probably not that's probably not going to happen so you know and student debt and everything else I mean until there's some big fundamental changes it's a tough thing to solve so just don't know if anyone can talk to things about how we're working on just in a system in a way and changing things and you know what is the medical system going to look like in 10 or 15 years you know I mean we love to say you love to hope it's all going to fit together right but you know I've only been on the board for 3 years but this is one of the biggest problems we've had with just workforce, workforce, workforce but it's not just across this area right I was in the corporate world before really tough to get people to come here and when they came many of them would leave because it just didn't fit their needs so don't know if anyone has an answer or any suggestions because it's a tough thing and I'm just not trying to you know rain on the parade it's just it is a huge issue which it's like we need some really big amazing ideas to try to change it I guess one thought is that you know there probably isn't one big silver bullet that's going to do it being here I have a full kind of guy I mean just listening to what's going on here tells me that we're heading in the right direction and it is those partnerships where they're both talking about the Brownborough Northwest and Southwest and Central Vermont and Airborne once we've learned what's working you know we've got to keep building on them I tried to get more optimistic with this fact that we've had a lot we're heading in a good direction to expand what we're doing I just say also that I mean not sort of echo what you said like in medicine when I'm treating patients I think about standardization leads to reliability but it's innovation that leads to improved outcomes so I think it's not being afraid to fail like the mortgage example to me I can see the problems with it why don't we push try to push forward a little bit maybe some rendition not exactly what the original thought about leads to that improved outcome yeah I could a couple of things I'm thinking about is it's really a multi-pronged approach but one of the things and I think Trey actually addressed it is thinking about telehealth in this rural setting when I think about that from a nursing perspective there's expert eyes right so can I think about a different care delivery model that can afford potentially and I hesitate to say this but if our ends are at this shortage what would that look like but I need a nurse or a physician who respond in these rural settings to be able to have those expert eyes and to deliver care but if we don't have that resource is there an opportunity I think we we need to think about that and how does that become affordable and or re-inversible for organizations I mean I think the whole focus on health and we're investing our dollars in the healthcare system is very critical to this all of these things have to be running in parallel at the same time I mean the reality is while we started the CCA program is to shift the cost space in our practices right so we didn't need our ends doing the things they were doing we need our ends to be at different spaces and we needed those our ends to work at the top of their license and this is a perfect role that entry role in the CCA was a great way to address the need for that a much lower cost space we're starting to look at in the nursing home space that is appropriate in the state of Vermont in the New York state in the state of Vermont you can train educate someone to be passing those medications in the skilled nursing facility that's a huge difference in cost depending on how you do that and the number of the population we're treating in that space is very different than the acute care setting any of the acute care setting have those expert nurses so it really is looking across in a very holistic way on how we can really shift some of our care mechanisms so that they really advantage and brag about the wealth and the cost down at the same time making sure we're improving the outcomes we are going to have to leverage our medicine no question that's key going forward and we are testing some of those pilots now we're doing that with some Vermont hospice and home health we have a monitor in those individual's homes so that nurses have to go in there and they work with us on the acute care setting to monitor those patients so those kind of innovations are ongoing now and more of that needs to happen there's so much of that going on what we have to do is study the ones that get the most leverage and then replicate those for system one we have to think about not just use higher education as an example even though we think we're really progressive we're pretty stuck and I think that people it goes back to the question the way people are accessing education is not what we are familiar what we know about and so I think the same way we're going to attract a workforce of younger people we want things very different they are going to change jobs six or eight times what's important to them they want a lot more free time they don't have the loyalty to one institution so how do we design jobs that really speak to that and so I think if you really want to get we can tweak around the edges and we can make some changes and we can do different programs but I think really radically different what kind of environment is attracted to the 20 to 35 year old and what fits with their lifestyle and so telecommuting is a very big thing I keep all of them safe I work for CCB I don't work at home well I write down we need to and then I have to realize a lot of our students access their advisors it's very different they don't want to come in face-to-face with an advisor they accept that my nephew you should go talk to your advisor you look at me like I'm head I'm not going to walk across campus but I'll text them and I'm like face-to-face with them but that wasn't what but I think we have to think about that when we're designing jobs that really speak to that I don't have any silver boilers in terms of really how do we design something that feels very different we can kind of see what the millennials are doing not to stereotype because there are a lot of great things that they do and I have two of them but they do change jobs every two years companies aren't necessarily giving them silver packages anymore but what is it going to mean in another 10 years it's going to be different than what this group is and you will have a lot more work at home and flexibility and how do you do that in the hospital setting or in the medical setting I think it's how do you be responsive yes you can't throw the baby out in the back bar there are certain core things but I heard some things that would challenge us to really think differently like students now want like for so many years a 15-week semester is pretty standard well now students are much happier you're taking the course 7 weeks and then it's like is there not back then I think it would have happened back then but I'm thinking really needing their needs in a way that doesn't radically change what we're doing but there are some adjustments we can all make I really agree with Jeff that I think the glasses have won because what we've heard people say is that people who are applying whether it's to nursing school or to medical school there's a large turn down rate just because the capacity isn't there so we do have somewhat the ability to grow our own and the only way we're ever going to be successful because this is a national problem is to grow our own and so I think that there's a lot that can be done and even the work that Gabe is doing if we can make it easier to precept and we have to push our medical community to it's a lot of work to precept but it needs to be done and if we all come together I think that we can at least alleviate the problem if not solve it just okay thank you I agree and I actually want to thank Kevin for looking at this panel your own effort and interest and trying to think about workforce issues and thank you all for coming Gabe I want to say to you first I'm so glad you mentioned the nurse licensure contact because it was something that I looked up at the end of the summer to understand it better because I had a conversation with a family friend whose daughter is in nursing school down in Virginia and I said fantastic we need nurses I hope she's coming back and he said oh no she's not coming back she's at her 100th degree in Virginia and Vermont is not a part of this licensing licensing compact and there's 34 other states that she can get jobs and she's not coming back at least not in the near term so I quickly looked at why are we not in this trying to understand why would we be losing Vermonters that want to come back and stay in the state so I know you're working on it I just want to say please work on it I also want to say there's a perception of reality gradient there too we have a nursing license out of that office down the street within 24 hours of completing our application based on having passed the enterprise we have to change that for a second but the perception becomes reality if you have one of these compact licenses you look at that colored map and that's the menu and you don't inquire into little Vermont because it's very burdensome to figure out the requirements of states like us but it is you know I don't want to oversell the gradient between now and then we have our office in the same day you finish it that's the millennial it is well there's a risk of it I reject the idea that millennials are different I think their environment is different and they're on the heels that people are badly burned by promises that educational debt was never bad but as we try to grow our own as the chairman has suggested I think the thing that we need to do is to protect those intermediate stops you know if you talk to engineers and say how about I make a staircase that goes 10 flights up with no landings the engineer will say please put landings in people are going to get tired on the way up and some of them are going to fall and we want them to stop on the way but for something that's somehow different in our professional training system and we need those intermediate levels so there isn't such a daunting thing to say I want to be a physical therapist but if I don't make it the consequence shouldn't be that I'm a quarter of a million dollars in debt with no potential and the same for bachelor's level nursing and so I think it's very important that we protect the landings that we protect the intermediate stops so that somebody who has gotten three quarters of the way up has a place to land on injured and that's why I think protecting those intermediate levels in nursing is very important and I really wince when I hear that everybody with a BSN I think our and workforce doesn't have one and things seem to be okay and don't mess with it so I do think we have to be really careful and all of you will learn as you're operating in the institutions that you are that there is this relentless credential escalator we know we're sitting on two health science professions that our legislature thinks are baccalaureate professions that have just started to require clinical doctorates through their creditors and if that isn't stopped we're going to have a bigger problem but I don't know if we all have a handle on where these pressures are coming from I can turn it down as it's coming out of our office and everybody's on board with that but we're not an exclusive input okay, well thank you sorry just wanted to say keep working on that minimizing transactions costs of getting credentials on the state of Maine is very important obviously as we're facing these shortages I think about it financial incentives like Steve was saying you just have to up the wages but it sounds like a lot of folks are starting to think about the non-financial enticements are being created some creative solutions and I'm wondering so if child care for example turns out to be an impediment to residencies or an impediment to workforce hospitals for example are investing in housing, why not on-site child care? particularly if you're for example if you have UVM undergraduate college right there with an early childhood education program why not you know or CCB with early childhood ed so I just will throw out there has that been a consideration if that's an obstacle the hospitals are already investing in other ways in their community why not on-site child care? so we've had it at SCMC for 27th of the years and it's been a huge way to recruit nurses, physicians it's the program is not near as big 2009 financial hit really that was the first place that had to go down and we haven't been able to expand it back but it has been very successful in that way so other hospitals have this and it's a sort of partnership with Down Street and Capstone in the Berlin area for both the affordable housing and child care and so we're again it's early in that discussion but we're looking at those type of partnerships because we're not necessarily in that space but we can partners with others and they have that expertise they've had started program as an example in Capstone and so we want to leverage their expertise and just partner with them to provide that child care for our employees so those are conversations that are just initiated now and the other thought I had was typically when we had faced workforce shortages maybe not in our current climate but visas and attracting foreign workers to fill workforce shortages and I'm just wondering has there been conversations around exploiting any kind of visa, relaxed visa restrictions for foreign nurses or anything like that particularly as it relates to diversity issues and things like that so I was wondering if that's the conversation or exploration not currently at NMC but I do have experience understanding the recruitment and visa using agencies that really it's difficult in terms of jumping through all the loopholes however places companies do it well what you have to really consider is your culture in particular I would say in the Vermont region because folks will come from the Philippines or maybe India and look at and assimilating them into your culture and environment as well as our patient population that we're caring for it could be perceived differently but there are organizations and I believe UVM the medical center maybe utilizing international travelers within their organization but it's certainly something that you know I believe most places if you're you're unable that that might be an opportunity I was thinking you were more permanent so most of the agreements that you have will have them come and they'll have a two year contract or an agreement with a conversion rate and some of them are like at about 60% people will convert but what you need to do is build community so for example I don't know who mentioned well I don't have an Asian market but if you bring that community church is really important you have to wrap around that nurse or those folks that are coming from a foreign country in particular in our state related to not having that same diversity and similar to our border state New Hampshire that is also a common issue in that area for physicians you know J1 visas 30 in the state of Vermont Vermont's like the only state that doesn't fill is 30 I'm not really religious enough to know that we have several positions that come from J1 you have to pay for them but it's worth it I'm familiar with some hospital services that come out of J1 and it's really great I will say though that for the first time in many years we had some residents and fellows that were supposed to matriculate in and could not because so that's the flip side this is the world that we're living in right now I recognize we're in a different world and I'll just share this with you I wish I had kind of found the article but I had seen this maybe about six months ago that it was about a rural hospital somewhere in the Midwest or out west I was trying to recruit a rural workforce there and one of the ways in which they did that was recognizing that those people who are served areas typically are also the same types of individuals who want to go do sort of doctors of that border or some of these foreign volunteers and so one of the perks that they offered to try and attract those individuals was paid time to go to Haiti after an earthquake or an event so in some ways attracting those type of individuals who would probably like to work in those sort of areas I'm not sure, there's not a question I'll throw it out there, I wish I had the article but it seemed interesting that it seemed like it was successful in that particular hospital and the last thing I'll just throw out there is it seems to me if we have the highest high school graduation rate and yet we have among the lowest higher enrollment rate initiatives about trying to get people into the health care profession have to start in the high school middle school okay, middle school, high school so I'm just wondering we didn't hear very much about that and I'm wondering is the agency of education on board are there any initiatives happening to attract people to the health care profession in high school, kind of about the financial awards the tuition reimbursements, the job security all the wonderful things that a career in health care does what are we doing in high school, middle school well I can just speak in general not necessarily to the health care field one of the things that we have started we just keep, you know for so many years we were just focused on adults and then we started to see more and more younger students coming and then we're realizing that we're probably going to make a change for the number of students who are continuing any form of education that we have to keep dipping lower so one of the things we do now is we do middle school activities and it's all with philanthropic support but bringing all grades we can't keep up with the development for bringing grades and to spend a half day or day at CCD sampling, you know mini courses because it really is we talked about it, you know in terms of it's a huge leap for people for so many kids to imagine they can go to college and I will say that I think another piece that's happening is families are simply taking themselves out of the college game in elementary school because of the student loan debt narrative is out there so I think anything that we can do to talk about the, you know to change the narrative that either school isn't going to because what's happening is people from higher income brackets are going, their kids are going to college at the same rate they always have it's people from lower and middle that are hearing that narrative and like saying you know right in middle school we cannot afford to reduce our college so there's a lot of work not only getting people interested in the health care field but just interested in continuing their care for possibility for the day to continue education and we're just seeing growth it's not even in the yeah I was just going to say I can imagine if you had middle school and high school going to the hospitals and learning about what you'd like to attack and what you'd like to be a nurse and then learning about the tuition reimbursement and how it is affordable but having them go to the hospitals we have we started a program a couple of years ago and it's an open house for the most high school students in the Brown borough of surrounding areas and you know they can afford the OR they can go to the wound care center they can go up onto the floor to get them exposed to what it's like being in a hospital AHEC also has a program called MedQuest and we host 28 high school students through this program and we actually did one I think just a couple of weeks ago I tried to get a couple of them interested in the health care administration by the way nothing about the health administration but those are the kind of things absolutely most of us are engaged in and those are formalized programs again, AHEC and Brown boroughs with our local high schools and the staff loves it because the staff is so proud of what they do in sharing that experience and the parents provide a cafeteria for the parents who can be there as the kids go through different experiences of different departments we all as adults have to change the conversation too because there's that false narrative that you have to leave Vermont to be successful I know that that's not true there's lots of opportunity here and we need to spread the message to let kids know because a lot of kids really do want to stay in Vermont but they had it engrained in them that it would be successful is to seek opportunities elsewhere so I just think that we are part of the problem ourselves I think one of the things I've served about a number of these panels and there's a panel next week that people always having on nurse retention or improvement of workforce I think it's in a good place but one of the things and it's been up to sitting next to Jeff I think one of the things we're missing here is the relationship between the hospitals and healthcare organizations with higher education in the state of Vermont and we've talked about it you're doing some phenomenal programs with Western you're doing great things at Central Vermont we're doing things at Brattle Road but there's not that I don't think there's this collaboration or an opportunity that we hardwired between the relationships we have with higher ed animal hospitals whether that's a commission of blue ribbon panel blue ribbon panel because I don't know how you make your decisions at the schools in which programs that participate or is it all at the local level I think we're kind of siloed in that in each one of our communities but I think we need to bring it up whether it's Jeff Teemans in the audience or the hospital association working with you Jeff to kind of put all this together so that we're what should I replicate the program that you're doing and vary for CCAs for LPS I'm doing it for LPS as well in Brattle Road it seems like we've got to get our act together and create a different form that's really hardwired so that everyone in Vermont knows about these programs and we can standardize the programs across whether it's CCB, VDC university system as well that's my pitch because I think a lot of stuff is being done we've got elevated the other thing is we talk so much about money but we really need to start to look at what's motivating one of those two which is a real deep desire to serve and when you can pitch a profession at the end of the day you've helped someone you've got a lot to sell so with that I'm going to open it up to the public for questions or comments yes, Jeff I have a question for Mr. Gellman on the nursing-lessonship compact so I know it's very fluid and model have they compared it to states with similar costs of living over a long time the nurse retention rate? sure, we did a lot of modeling on that and we're actually filing a supplement to the initial report that we filed with the legislature but a number of these states in the compact do have comfortable costs of living and we did quite a bit of modeling trying to anticipate who would move in who would move out, etc and as far as the cost of the nursing-license now? we actually did calculate the cost of the increased cost of the nursing-license and that was one of the big hangups that prevented movement I think in the first half of the biennium was uncertainty about whether the licensed population found that a worthwhile tradeoff because in our licensing system each unit is self-containing the nursing board's expenses are borne by licensees and it's just expenses divided by licensees and that's your fit so the question became do they want to bear does the community of licensees want to bear that cost with the cooperation of the National Council of State Boards of Nursing we were able to do what I think was a quite objective and credible survey of our nurse population that had an extraordinary response rate for a survey that type came back highly favorable I think we, by parsing and looking at who liked it and who didn't we were able to learn some interesting things but in terms of net approval and acceptance of the idea it would be a worthwhile expense to the licensed all thumbs up because the children for you will make us expensive in a country like that I don't know where we'll be nationally and some of it depends how you parse it you know there's no question that we are comparatively expensive in terms of biennial fee but we're also settling in whether you have a teacher's license or a nurse's license it's pretty typical in Vermont that the administrative cost settles in around 100 a year if you have an enforcement apparatus attached to it which is expensive but I think that one nice thing about Vermont's model is that we do not impose expensive regulatory burdens like continuing education on nurses in many professions people fixate on the licensing fee which isn't to say it's not important but forget you know you can have a compliance fee that's both utterly pointless and very expensive and tuples the actual fee you pay over two years and nobody planks twice and it's sort of weird but you're right I think nationally at post-compact we will be on the high end certainly in a high quartile and I appreciate your comment about the BSNs as a working nurse I've been I was an ADN graduate I've been working in critical care at the medical center for the last 18 years as we keep pushing for the BSN role in nursing I almost feel like our profession is shooting itself in the foot a little bit by not appreciating what the LPNs can do and the fact that an ADN nurse passes the exact same test as a BSN nurse to become a licensed nurse and what's happening though is in a lot of our hospitals we are having to do the continuing education credits because not only do they appreciate BSNs they want nurses to be certified in special areas so there is increasing costs that are going on at hospital levels my other question was about retention and a lot of our hospitals are offering $8,000 to come to Vermont $6,000 in relocation costs and you're only asking them to stay for two years and what we're seeing is those nurses are staying for two years and they're leaving I had several friends who have gone to travel so they've come back to our own hospital and they're paying $60 an hour but they're also getting $600 a week for living expenses so they're rents being paid for they're not hurting in any way shape or form I guess my question is about what are we doing about retaining nurses because it costs $50,000 to $65,000 to train and nurse in your facility and then two years later they're gone to travel so what are we going to do about retaining the nurses that are here one thought that I had was we need to get the state who are involved, the state is not investing nearly enough in our educational programs especially health care educational programs we need to really boost that and what if we looked at something like a five year plan you bring a nurse to our state or a new graduate in our state and say you stay with our facility or any facility in Vermont will ever make you happy because we want you to be happy and stay here you stay for five years and we will continue to invest I mostly cold water for me I think there's really no superior substitute to cash compensation and every time there's a workplace especially at the top of the business cycle when we hear this from in the mental health counseling field the minister is always desperate people are always asking what if we give them a state Prius and they can drive it around while we're here we can get more money I think at some point we run into a lot of unintended consequences with that and if you have a long term employment contract or a commitment before you get the aid off you can wind up inadvertently placing unhappy people in unhappy situations they can't leave and that's why I said if you're not happy say they came to work at my medical center and it just wasn't a fit for them but there was someplace else in Vermont that did fit for them as long as they're staying in our state and we can't compete Dartmouth right now is offering $25,000 fine on bonuses to physical comparison that they're getting in their first paycheck we can't compete with that in the state it depends I don't think you can compete head to head with it but I think that anybody who is moving across the country for $2,500 is making a very short if that's the only input is making a very short if that's the only input but I'm moving across the country for $25,000 I was off by a decimal 25,000 is pretty enticing that's very hard I mean it's a very hard nut to crack we can do what we can to make more pleasant and less expensive to get here but ultimately the compensation gradient is something that no one of us is going to no and I agree we can't fix the cost of living that's why like every one of the panelists has been saying it's about bone forgiveness and how do we make it attractive to stay here and ask from one of your commitments so people have a chance to put down roots in our state yeah it's a real challenge I think I agree with everything that you said except that I'd be very reluctant to extract commitments for people who are actually there otherwise because it has some unintended consequences any other members of the public Jeff I just wanted to thank the Green Mountain Chair Board for hosting this forum this issue is so important for everyone on the panel for all the providers in the state and for the patients we serve and for your kind of constant attention to this and hospital budget hearings and other forums where this topic is also relevant so I just want to thank you for convening the group and to Steve's point I know a lot of great ideas have surfaced today some of which I was aware of and some that I wasn't and so one thing we've been talking about at VOS is how to create kind of a clearing house of some kind to share this information across our really pretty small membership and be able to get that information out to people who can use it effectively so we're working on that and welcoming it but thank you thank you Jeff other members of the public I'm Susan Aramoff and the Vermont Developmental Disabilities Council and I want to I know Jeff and thank the Green Mountain Chair Board for holding this panel and I'd like to encourage you to hold a similar panel with similar expertise and maybe some of the exact same people especially Joyce Judy to focus on a different healthcare workforce a home and community based workforce which loses workers all the time to the hospital workforce so someone at a designated agency gets a license and certification and then they can earn a heck of a lot more in a hospital we know that story but I don't know if the Green Mountain Chair Board knows that story I work for people who depend on services provided by the designated special services agency by home health nurses by choices for care programs and Medicaid funded and that workforce has similar problems and constraints but I would say they're even worse and so we have people who get approved to receive hours of support in the community high tech nursing support the parents of the most medically fragile kids will get approved for hours of care for their kids but they can't fill 50% of their hours so it's a different set of pressures but I really love to see a panel on the home and community based workforce and the pressure to that when Alba Bay was chair from the Green Mountain Chair Board the legislature had a review the budget of one of the designated agencies powered by health he made the comment that these guys don't even grow at the rate of inflation you can on the hamburger stand grow at the rate of inflation budget at least having growing the designated and specialized services agencies at home health agencies not leaving the rate of inflation so different sets of pressures that would be wonderful to have a workforce panel so I think hopefully we can unite to kind of solve the problem and then I did have one very specific question for the government from the office of professional regulation one issue that would really benefit maybe the hospital workforce back home community based is if or not was able to employ more what are called community health workers and I know that when the Affordable Care Act was passed there was an opportunity for states to be able to have Medicaid funding to reimburse a new set of people that was faculty kind of coming up to the office of professional regulation so I just wonder has there been any if not a higher state plan if you create a category of people that could be paid this workforce is like the peer workforce that's so effective with people in recovery from mental health people in recovery from addiction people with disabilities to be able to pay peers who don't have necessarily the traditional background of addiction so have we made progress none in terms of that being a credential that's been proposed you've hit upon this really interesting problem that we find in this field which is that it's simultaneous to people like me singing about liberalizing marketplace and letting things work and not regulating things that don't need regulating we do see third party payers wanting the creation of credentials that would need to be created in order to open a revenue stream and you can have a very perverse effect from that too we have any mental health where providers are holding three licenses and any one of them would have let them legally do and they're paying for it so I think it's a kind of a careful what you wish for thing but I'm too ignorant of that particular federal designation to tell you where it is I do know I haven't seen a proposal that it be created as a credential okay I remember the public yes sir hi I'm Robert Patterson I work at CVMC I'm the Vice President of Human Resources and Public Operations and I'd like to thank you as well for having this panel I learned a lot in hearing what others are doing I've had the benefit of working with others to kind of do some of this innovative creation of some of these development programs this year you know one question I have that and I think Steve you hit on this that was really interesting was that you know where we kind of talk a little bit around the 3,900 positions that we're going to need over the next couple years for nursing knowing that you know and I looked at a report called Reliance Future of Nursing that came out and they're stating in that report that there was about 265 RN positions or RN graduates in 2017 I don't know if that numbers changed since then just that seems those numbers you know if you look at it from the top of the house do not seem to add up well for that we're going to be able to really kind of meet the ongoing need and we know over the next 15, 20 years we're going to have a doubling of the folks that are 265 and above so certainly there's going to be a lot of demand so I would imagine the pressure for us to have even more nurses is going to increase I'm you know I really think it's a big piece of the lie for us to be innovative and come up with programming but I'm also wondering what are we doing from the state in order to just kind of decrease that bottleneck of graduates I think we already heard that there's plenty of interest in just getting into an RN program however there's not the capacity to get folks to actually enroll just because there's going to be a number of instructors, professors and so on so it seems to me like we need to really look at this from a high level and Howard is going to get that demand to come up with some pretty strategic plans kind of address that I'm just wondering if that's been an area of focus I would say that's been an important topic and to be honest I don't really know the answer I mean I know what we've already talked about everything from getting the clinical placements for the instructors, the receptors but those all seem surmountable sorry I'm glad to have the attention on about the best I can say I think one of the things to look at is you have a lot of nurses BSN nurses that have master's degrees in health administration other master's of preparedness and they should be able to qualify for being an instructor whether it's an LPN or an RN and I think that's one of the things the university system needs to really look at because someone that has 20 years of a nurse that is semi-retiring out of clinical care that has a BSN that has a master's degree should be able it doesn't have to necessarily be a master's in nursing that person has some phenomenal skills and like that person that part of that that knowledge base to new students to new nursing students I think the board needs to look at that I think the board does give you the option of an alternate master's degree not just nursing but the challenge within the university system of moving to a different degree not just that master's in nursing so we need to be talking about more other members of the board John? John Austin from the State Office of Rural Health and Primary Care one of the things that we do in addition to supporting hospitals in a number of ways is collect the data and analyze it publish reports on the 40 plus health care professions that many of which are licensed through the OVR we publish those reports on our web page and we also have a number of maps that show the distribution in the relative variation of distribution among different parts of the state so those are available Google help workforce for monitoring of the core pages Steve thank you for bringing up the work that AHEC has been doing for years with promoting health care professions to middle school and high school students they've been doing a tremendous amount of work so I don't need to repeat that what I will say is that we also manage those grants to AHEC to support their work and those budget lines have not increased in 10 years to support that work of both AHEC program office as well as the two regional AHEC so that is something that would be an ask not for me because I'm not the commissioner of health I just work for him but that's a fact that we haven't increased those monies in a while on the topic of J1 visa we also manage that program for foreign medical graduates for physicians as someone mentioned each state does get 30 slots to fill each year some larger states fill those by they probably fill them by now because they got them available October 1st and I'm sure they fill their and have waiting lists we won't find out if there's any waiting lists of folks who want to come to our state until February when they run through their processes so we typically fill about 5, 6 and maybe 7 of those slots each year that's actually increased so I appreciate the work that employing hospitals and federally qualified health centers and others have done to recruit interview and offer to to form medical graduates we can be doing more of that we're working with a number of folks including UBMA and by state's primary care Vermont and New Hampshire recruitment center to promote the benefits and the process of the J1 program so we can bring more folks in and fill more slots that still has to be a good fit for your organization and the applicant there's still the same issues of any trailing spouse not to mention distance from their home country those home countries tend to be we've got a good mix and I'll have the numbers on the top of my head but I did look at them the other day we tend to get applicants from Canada from several European nations several of our recent applicants that we've been approved have been from India, some from China some from the Caribbean so we're seeing folks move a wide range of regions across the world and we don't do the hiring we don't do the offering we don't do the recruiting so we're trying to rely on all of you folks to broaden your search prospects and interview candidates who may very well prove to be a good fit for your community and if they are a good fit they'll stay longer than three years under contract thank you gentlemen good afternoon Mike Fisher healthcare advocate I've heard a lot of discussion about the regional or national market place for this competition but I can't just sort of dawns on me about this conversation I wonder whether there's also a state competition whether this is a bit of an unfair question to ask a bunch of people from different healthcare providers but to what degree are you all competing with each other for the same works and how does that play out yes in all those states as I said one of the things we are trying to address is attention we may commit to hire more LNAs versus nursing assistants to assist on our research course to make it a better experience for the RS and a number of those LNAs came out of nursing homes in the market place but then behind baseball but you know it's part of it is competition in the house plus the work is our competition is also on the state but yeah it does happen Mike I can say my experience with it is glass half full here it's very collegial competition and in fact my colleagues call me and ask me about candidates and I tell them all about them we go back and forth because you really want people to be where they want to be because they're going to be the most productive in that regard but they want to go to New York that's a different story unless you're in our network unless you work with us okay well at that point I think we're beyond our schedule time but I really want to thank you all for your time coming up this afternoon and you know this has been a really good conversation and I can see that things are starting to come together as far as what actually steps to be taken and it's just great to have this conversation with higher education and healthcare community to try to discuss some real obstacles moving forward and how we can all get there together so thank you all it's been a really wonderful afternoon thank you