 And that is before the ECL guidance that we have in Melissa Miles on S7, which was omitted from Monday's presentation. So with that, we'll invite the folks who've come down. I guess not really the ones who want to. We'll do our best to follow their questions. Thank you. So for the record, this is Sarah Kinzler, director of strategy and operations at the Green Mountain Fair Board. So we're here today to give a quick summary of Vigil's FY 2020 budget and also to review the board's criteria for making a decision on that budget and make a staff recommendation. So the Vigil budget oversight is part of the board's broader oversight and policymaking activities related to health information technology and health information exchange. And the vital oversight component is that we are annually required to review and approve Vigil's budget. This authority came to the board in 2015 in its first exercise from 2016 and is intended to provide strategic guidance. I'll just note that until 2018, the board's responsibilities included a review of Vigil's core activities as well, but this was removed in Act 187 of 2018. So by the presented, it's FY 2020 budget to the board on May 15th, and I would just get all of us through. Thank you, Sarah. So a recap of Vigil's FY 2020 budget. This slide shows revenue, expenses, and then I will address their anticipated operating loss. So their FY 2020 budget. They're budgeting a little over $6 million in revenue. They emphasize that their state funding has steadily decreased over the last few years in the plan of their expectation. This year, their state funding will usually expect $300,000. So Vigil moving forward plans today diversify their revenue stream by adding value-added products. In FY 2021, they're expecting it to hit $500,000 in value-added products. They call out their collaborative services. We heard a lot about that a couple of weeks ago. As a revenue, it's also an expense because they're paying for these services too. But this is leveraging partnerships to implement some important technology projects. One thing that's worth noting is that Vigil's budget is a combination of awarded revenue and estimated revenue. And so this year, there's an increase in their awarded revenue, which is important because there's a more reliable revenue stream. This is revenue that they know is coming around. They can count it versus an estimate of what my company is. This is a good trend for them. On the expenses side, which you'll see exceed their revenue, labor is their largest expense, about 46%. And their FY 2020 budget keeps their labor costs flat. They do this by streamline their organization. When they were here a few weeks ago, they showed us the work chart. They've eliminated some of their senior management. It's now a direct report to the CEO. So this has allowed them to eliminate some positions and streamline their organizational structure. And their FY 2020 budget does include some long-time executive recruitment costs as we know their interim CEO is on the phasing out. 17% of their expense budget comes from their being high-hosting and their FY 2020 budget keeps their hosting fees flat. They've had a reduction in their office space. Second time out, they've had a reduction in their office space and their cost-containing efforts. And they are reporting that a big part of their expenses is also their FY 2020. They're doing some of the hands-on security in their infrastructure. Those are the major buckets of their expenses in FY 2020. They are expecting an operating loss in FY 2020. This is something they're expecting. They're planning for it. The good news is that their days cash on hand position has increased steadily throughout the years. It went from their FY 2017 audit having a 47 days cash on hand. Their FY 2019 forecast puts them at 150 days cash on hand. And we'll see that going down from 150 to 117, 117 in their FY 2020 budget. And that's to cover their operating loss in FY 2020. Basic recap of their budget. We have many questions now about the budget itself which will be moved on to their criteria in part condition. Yes? So when the board first began reviewing the budget, it established four principles for review with your listed on-board website. In the following slides, we're going to walk through these pretty quickly along with the staff assessment of whether or not the criteria were met. So first, the review process will be transparent and then incorporated with input. We measure transparency based on compliance with the budget guidance study issue and overall transparency of the budget process. And staff found that when it was complied with the budget guidance, the budget was submitted on April 29th, including all requested components. And the board also responded to board members' written instructions about the budget and the timely fashion and provided additional information when requested, all of which was requested in the May 15th budget presentation. In addition to that, a special public commentary that was opened on Wednesday, May 15th through means past Monday. The board received scleral public comments from there. Secondly, the board will review by this budget in order to determine whether it reflects the strategy and priorities consistent with the state's health care, farm goals, and health information technology plan. The board will not direct to the technical details of by those four or the details of by those contract for the relationship with the state. So staff assessed alignment relative to the goals listed in the 2018-2019 HIT user-feature plan, which will be approved in November, which is also available on the board website. Staff found that by those budgeted activities, we'll advance the goals on the 2018-2019 HIT and plan, which are listed here on the slide. By pushing toward more effective foundational services, exchange services, and end user services in these categories will reflect the staff diagram, the full staff diagram of critical health information exchange services that's described in the HIT plan. Third, the board's review process must be structured in time in order to assist EVA and VAIL in negotiating timely and effective agreements each year. And this year, as in past years, the staff will be not fair board will work closely with EVA to ensure that review timeline that we used will not conflict with federal contracting requirements for review experience with VAIL. And then lastly, the process must result in board decisions that are sufficiently clear to enable VAIL to do its work and be able to support that work without requiring review verification or introduction by the board. So, you know, whatever decision the board makes today, staff will ensure that the written decisions that stem from that are sufficiently clear. So, finally, given our findings, staff recommend approving the VAIL budget as presented with two conditions. First, and this is a condition that was also included in last year's budget order, VAIL and EVA will return to the board in late 2019 to present their January to June 2020 budget once the negotiations with EVA would counter your 2020 contract. So, as I mentioned, the budget that was presented presents awarded funds for the first half of the budget year, the second half of the budget year is anticipated for the revenue based on a contracting process that wasn't yet completed. So, when that's completed, we would ask that VAIL and EVA come back in to confirm that that does or does not align with what was presented in May. And then the second criteria or second condition that we propose is that VAIL will present to the board quarterly and provide updates since the FAIL budget approval, which will include updates on governance and operations, finances, and technology. These are all the areas that VAIL already has been providing quarterly updates on. I'll just note that VAIL was previously required to provide quarterly updates to the board under Act 2087-2018 and has been providing quarterly updates back early in 2019 so the condition would really just formalize that existing structure. So, that's all from us. Does the board have any questions about VAIL's budget with the staff participation? Are there any questions? There aren't any questions. I just have one of our staff over the last year and a half that, you know, when I first came on the board, I was on my support and had some very negative reviews. And I think today, much of the change that has occurred, they've downsized their budget. They've constructed their staff. They've increased their participation. And you know, staff has had to work with them through layers of legislative and mandated reports, important reports and updates. The consent issue is somewhat controversial and folks have had to wait through that. And all in all, though, I think we are in a much better place than we were a year and a half ago and we have a lot of staff over here. Thank you very much. If not, I'll open it up to the public to bring comments or questions at this point. Seeing none, if someone would like to make a motion to approve the staff recommendation of approving the budget with the two conditions listed on the last stage of the slide deck. So moved. Seconded. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Thank you, Sarah and everyone. Thank you very much. So now we're going to transition for a discussion about SASH. And do you invite Kim and Molly to come down? Good afternoon. My name is Kim Fitzgerald. I'm the CDO for Cathedral Square and I'm joined by Molly Dugan, who's our director of SASH. Cathedral Square owns, manages, and develops affordable housing. And we are also the creators and state-wide administrators of the SASH program. And so that's really what we're here today to talk about. And we plan to cover the history, a quick history of SASH. The four components, results, new initiatives, and our needs at this point in time. So let's go ahead and start with some of the history. So else the state actively was closing nursing home beds. We had five nursing homes closed between the years of 1998 and 2006. As an independent housing provider, we thought, oh my goodness, what are we going to do to be able to protect our residents moving that may not have a place to go in the future? And so we actually were the first, we opened the first licensed assisted living in the state at our flagship property, Cathedral Square in downtown Burlington. And although assisted living is a phenomenal model, we've gone on to actually open the first affordable memory care assisted living in the state just within the last two years. We realized we just couldn't build enough of assisted living quick enough to meet the growing needs of the aging demographics here in Vermont. And so we thought, what can we do on the ground in the independent housing that we already have to help our residents age and face safely? And so we actually went to our Heineberg residents, and we also went to them and said to them, would you help us design something? We didn't know what it was going to be or what it would be called at that point, but will you help us? And we had 75% of our residents said, sure, we'll help you. And we really needed them to be at that table with dialogue of what were they looking for, what did they need, this is what this program was going to do. At the same time, we reached out to community service agents to say, will you also help us design something so that it's in collaboration with what we do, it's not too complicated, and that it really helps complement and fills in the holes or the gaps that you're seeing in your work already. And so that's exactly what we did. In 2009, we had a year of working with both our residents and community service agencies to really develop what is now known as SASH, which stands for Support and Services at Home. And really in that first year, we found that we already had pretty significant savings within some of the core components we were revealing within that first pilot year with them. So we actually went to, at the time, Craig Jones, Blueprint for Health, my predecessor, Nancy Eldridge, and went to Craig to explain to him about the core concepts of SASH and what we had come upon and developed. And he thought it ran way. He totally understood by being embedded in the homes where people live, especially with the low income housing residents that we're working with, that they have a high level of chronic conditions. And so knew that being in their homes, where they're live, that this could actually have a huge impact would help the Blueprint for Health program as extenders for the community health teams. And so by 2011, we were able to receive Medicare money through Blueprint for Health program off. And so that is really a little bit of, like I said, the history. One of the components that changed was when we received the Medicare funding, they did have one caveat for us. They said even though you started out in congregate housing settings, we don't want to discriminate based on where somebody lives, so that we ask that you not only be in congregate housing settings, but you also well out in the broader community for Medicare participants. So today we have about 10 or 15% of our overall participation that is out in the community, not living in congregate housing settings. And so now fast forward to the day. We are, we have over 5,000 SASH participants who are in every part of the state. We're 140 housing locations and we have 68 programs as you can see on this screen. We have formalized partnership agreements with home health, agencies on aging, mental health hospitals and many others to maintain SASH and to enhance the function, quality of life and avoid hospitalizations and emergency room visits. We have six designated regional housing organizations or BROS, those are the ones highlighted on the map, that are able to really specialize SASH for their area. They're able to tailor it to meet the needs of their region while still ensuring that they keep the integrity of the model. This really absolutely helps us with the foundation and network to systematically roll out new initiatives under SASH. Our SASH participation, it ranges in age. Of course we have, we have duals, we have mostly Medicare beneficiary that you can imagine, 80% are on Medicare. We range in age from 22 to over 100 with the average age being 73. And since our inception 10 years ago, we have served close to 9,000 participants through the years. As you can see in this slide, we're able to collect a lot of data. That's partly because of our statewide presence and our statewide infrastructure. And we knew from day one how important data can be so we have always collected a robust amount of data. And so what you can see on this slide is that the median number of chronic conditions our participants have is six. And that is median, that is not average. Three or more is considered high risk and you can see here that we have 75% of our SASH participants that have three or more chronic conditions. We have six big medians that you can imagine how many on the high end have chronic conditions. We also do a lot of screenings as you can see here on the far right of the screen that we have 58% of our participants who are at risk of falls. We have 37% who sell for poor social isolation. And we have 10% who have suicide ideation. And so really SASH is about early detection and prevention. In this next slide, you can see what we did is we compared the SASH participants' chronic condition around the state as compared to the typical one-care participant around the state. Of course, many of our SASH participants are also one-care patients. But you can just see on average here that all of these conditions we have higher rates or higher percentage of in our SASH participants as compared to one-care patients. We're the only mirroring in coronary artery disease which we match that percentage. So that's a little bit of the history and where we are up today. And now I'm going to turn it over to Molly to talk about the four elements. Thank you, Kim. Yeah, so I get the pleasure of telling you like what is SASH? So what we do with the SASH model, as you heard, we're based primarily in affordable housing throughout the state. And what we do primarily is have our, as a voluntary program and our SASH participants become part of a group or community of other participants that are supported by, and you'll see on this visual here, supported by a wellness nurse, supported by a SASH coordinator. You can think of a SASH coordinator as a community health worker. And then they are also supported by a formalized partnership of their community agencies. And what's so key about this model is that the SASH staff that are embedded in the housing have this defined group or population that they're focused on and they're able to spend very flexible time based on the needs of the participants. We have participants that are completely healthy and really only looking for preventative wellness types and programs to stay healthy. And we also have people on the very other end of that continuum that are very frail. Maybe they have Alzheimer's disease. Maybe they have, you know, 12 different chronic conditions. So our model is able to be flexible and calibrate the supports that are provided with the other partners in the community to meet the needs that are presented. So it's really, it ends up being a very kind of circular model in that things are changing continually for our participants and it has the flexibility by having staff embedded where our participants live in formalized partnership with community agencies to meet the needs as they are presented. Importantly, Cam had shown you some of our data statewide for our SASH participants. It's important to note that we're also able to pull data for our SASH staff for each of their populations or panels that they serve. And they serve anywhere between 70 to 100 participants. So the SASH coordinator and the wellness nurse, that's the number of the population they're serving. And we are able to share with them, with our staff, the data that they have access by doing annual assessments with our participants, putting it into our statewide data management system. So we're able to basically run reports for our staff and say, here's the percentage of your participants that have whatever it is, diabetes, COPD, arthritis, very big chronic conditions. Here's the percentage of your participants that are at high risk for falling or high risk for nutrition, deficiency, or cognitive impairment, whatever it is. And armed with that information, our SASH staff are able to really tailor the evidence-based and promising programs that they bring to their populations. And what we wanted to make sure is that, because we're all over the state, as you saw on that earlier map, we wanted to make sure there was access to these programs. So these evidence-based programs exist. Some of them are really easy to download through the Internet. There's also ways to get certified to be trained to run these evidence-based programs. So we've made sure that with partnerships with the Blueprint for Health and other community partners, that we've trained 70-plus SASH staff throughout the state in a lot of these different programs that you see here at Tai Chi, the Crimes These Self-Management Program. So you can be a participant in Island Pond, Vermont, and go to a Tai Chi class just like you can in Burlington or Bennington or St. Alvin. So we really have a widespread network now of these preventative programs in every corner of the state. We wanted to kind of underscore for you all our alignment, the SASH model's alignment with one care Vermont priorities, the population health priorities of improving access to primary care, reducing chronic disease, and reducing suicide and drug overdose. One of, around the access to primary care, one of, we ask a number of questions of our SASH participants in their annual assessment about who their primary care is, what their relationship is, are they seeing that person regularly? And what we have learned is that, we have over 90% of our SASH participants across the state have a primary care provider, which is fantastic. We also, though, ask, how often are you seeing your primary care provider, trying to get at the quality of the relationship with the primary care, and if they're not seeing their primary care regularly, that's where our SASH staff start to focus on is trying to help them improve their frequency of business or improve that relationship. We will provide reminders and health coaching around connecting to primary care or arming them with, you know, hear the questions you quite want to bring up with your primary care, let's write them down, whatever it is. Our SASH staff, primarily our wellness nurses, will share medication reconciliation records with the primary care ahead of an appointment with their SASH participants, and our wellness nurses are in their homes doing medication inventories on a regular basis. Our wellness nurses also regularly take vital signs for participants when they're seeing them, especially the high-risk participants, so that is also shared with primary care. So again, really focusing on improving the quality of that relationship. Around reducing chronic disease, I mentioned the fact that we assess annually for finding out what chronic conditions that our participants have. We are, as I said, leading those chronic disease self-management classes across the state to really ignite the self-management skills of our participants. And then we are, I'll talk more about this in a few minutes, but we're really focusing right now on hypertension and diabetes and pre-diabetes for specific interventions with our participants. Around mental health and substance misuse, we include in our annual screen validated screens on suicide risk as well as alcohol and drug misuse. We are also asking about opioid use as well, and just recently developed in partnership with the Department of Disabilities, Aging, Independent Living, and Department of Health, a whole training module for our staff around opioid overdose prevention for older adults. So that's getting our staff on the state are getting trained up on that, and they're provided a presentation to do with their participants another kind of group program around opioid use in older adults. We're also very much aligned the SASH model with the state of Vermont Health Improvement Plan. We just wanted to make sure that you were aware of that as well, which was just very recently published. And some of the key goals within the state Health Improvement Plan include obviously expanding housing, which we are a bunch of housing, nonprofit housing organizations that operate SASH. So we are continually coming up with 13, 14, 15 different funding sources to develop new affordable housing. So we're on par with that. We are obviously supporting the Healthy Living and Healthy Aging where people are and the other areas as well. One of the things I thought was so interesting in the state Health Improvement Plan is it really focuses and encourages agencies and organizations to focus on what they call the three buckets of prevention. And those three buckets really describe what the SASH model does. So we're feeling very much in line with that part of the state as well. I want to spend a little bit of time talking to you about the hypertension, intervention, and diabetes intervention that we've been doing within our SASH delivery infrastructure across the state. We've been focused on hypertension for the last two to three years with some funding from the Vermont Department of Health through the actually federal funding from the Centers for Disease Control but coming to us through VVH. And what we've done is because we know that hypertension is the number one chronic disease that our participants have and we're at roughly, I mean we're well over half, closer to 70, 80% of some of our panels have hypertension, which is a silent killer. And we have participants that don't even know they have it until they start going to our regular blood pressure clinics. But what we developed was a hypertension management protocol through our program that is basically a formalized communication relationship between the SASH wellness nurse, our care coordinator, the primary care provider and our participant. We identified who our participants are that have hypertension and they're specifically not managing it well and we asked them if they want to participate in this intervention. We then provide them with home blood pressure monitors and then they start meeting regularly with the wellness nurse on lifestyle changes, regular monitoring of their blood pressure which then those logs are being sent to the primary care provider and is a really improved kind of circle of communication between the primary care provider and our SASH kind of team and we've had things happen like medication changes have been able to be made, lots of really wonderful individual stories but then you'll see later that we have some really good aggregate data as well. I wanted to mention because I said something about the blood pressure clinics, so our nurses run blood pressure clinics throughout the state either weekly or monthly that's really how much of a requirement of them all. We have 91 weekly or monthly blood pressure clinics going on throughout the state at those SASH housing sites. So again, whether you're an island pond or Burlington, you have access to a blood pressure clinic through the SASH program. So some of our outcomes around this hypertension intervention we've been doing over the past couple of years, just some data to share with you. Compared to U.S. average, what we know is that in 2017 what we were showing with statewide was our adults that were that had hypertension that were self-reporting, hypertension was only at 46% but we knew the U.S. average was much higher than that. So what that told us is that we had undiagnosed hypertension within our SASH participants, which is very concerning to us as a prevention program. So that's one of the reasons we really wanted to focus on this intervention. And then so once we have started working with identified those people with hypertension and working with them to get them in a control range, when we've looked at our data since then, we're now at about as of 2017 after we started this, 76% of our participants working within this program were in a control range for their high blood pressure compared to the U.S. average. We found, and this was our intervention program was evaluated by the Vermont Department of Health that 70% of the participants in our intervention reduced their blood pressure within a very short period of time. The three to six months is to me really compelling that and speaks to the at home part of our program and the easy access to blood pressure clinics to communication and coaching from all listeners. And then of those that were participating in this intervention, more than half moved into a lower risk category for their hypertension. So we're feeling very good about this focus around hypertension. I just wanted to kind of make this a little more real of just numbers. So I wanted to share with you kind of a just a quick story of one of the people in hypertension intervention. And this was one of our participants as you can see, 79 years old in our Addison County. It's actually in our Virginia. We have a panel right in Virginia. She had been recovering from a recent fall and our wellness nurse had stopped in to check in on her because she had transitioned home from the hospital. And in doing that our wellness nurses always do a med check whenever they check in with people, especially after they realize that our participant here had stopped taking her blood pressure medication after it had run out. And what she found in conversations with the participant that she was basically just really confused about how to take the blood pressure medication how it was even doing anything. She didn't feel any symptoms from hypertension. So our wellness nurse got this particular participant involved in the hypertension protocol with a bunch of coaching with her regular blood pressure monitoring communication with primary care and within five months we'd gotten her into a very at the time that this is a control range for hypertension. The numbers actually, the control range is actually lower now but the numbers are kind of changing. But anyway, this is just an example of what we can do again in a really short period of time with this intensive focus. So we're happy enough with our hypertension results to turn to another common chronic condition for our participants, which is diabetes. And this again is a collaboration we've been in with the Department of Health. We decided to pilot a specific intervention around diabetes in our Revlin-Sash team and do it in partnership with the local community pharmacist who was the kind of pharmacist that most of our SASH participants in that Revlin panel was going to and so he's been very interested in seeing how he could kind of be part of the SASH team. So we decided to do this pilot to include the pharmacist on the formalized SASH team that meets monthly and we decided to look at developing again a very focused target intervention between the wellness nurse, the participant, primary care and the physician and see if we could have an impact on those factors there, A1C, cholesterol, blood pressure, heart rate and BMI. And so we did this pilot for eight months pretty recently, November 1st 2017 to June 30th. We were working with about 23 SASH participants and you can see from this chart look at kind of the average change that's easiest for me to kind of describe what our impact has been in all of the clinical measures that we were looking at with this intervention in place we saw all of them going in the direction that we wanted them to go. So A1C is going down blood pressure, bad cholesterol BMI and weight with these folks. Again, a pretty short period of time to see this kind of change so true kind of clinical change model in the home. Another area that we're focused on in a very big way is around mental health. We have many challenges with participants that are challenged by mental illness and we feel like we have an infrastructure where we have staff in the home and we wanted to see how could we provide more robust support when there's limited resources and capacity in a lot of our communities especially in more rural areas. So what we decided to do is partner with our Howard Center in the Burlington area and decided to try out what would happen if we embedded not just a SASH care coordinator and a wellness nurse in a SASH site but also a mental health clinician that would be part of the team just like other staff members that would be part of the monthly team member and monthly team meetings that would have that just unfettered kind of presence and access for our SASH participants where they live. What would that look like? So we decided we got some funding from One Care Vermont which was fantastic to have this person in place and not be having to do fee for service or just capitated. She could spend 15 minutes with someone or two hours she could do group support groups. She could just do educational things. It was really kind of wide open based on what the needs were. We did the, we piloted this at two of our properties in Burlington Keto Square senior living in their house in the Newark Bend and we were looking to improve access to mental health services to reduce avoidable ER visits obviously increase, improve patient experience with mental health services and then enhance our interagency coordination. And so this is looking at, we're in our second year now of the pilot so after the first year what we saw was very clearly improved access to mental health services which shouldn't surprise you because the person is right where they live but we weren't so sure that that would mean people would go see a clinician. There's a lot of stigma around accessing mental health services for anybody, let alone people in the older age group that we're talking about here. So we were really happy to see that we actually have seen incredible access, successful access to this mental health clinician and I have to tell you that one of the things we were most surprised about was in the first six months of the pilot we had a statistically significant increase and it was actually males the men in this pilot that were accessing services more than women and what research will tell you is that men especially older men are the least help-seeking people when it comes to mental health services. So the fact that in the first six months we were seeing this real, I don't want to overstate it but it was statistically significant difference between men and women accessing the services to us it made us feel like we were on to something here that we've gotten rid of a barrier for especially men to access mental health services and as you can see here, 80% of those participants living at these sites that were referred by either an outside provider or a SAS staff member were seeing either the same day, very same day or the next day right where they live. This is some of the words from our actual participants that are at these two sites and to me it really speaks to the real success of this pilot so far which is reducing the stigma around mental health services and accessing the services and you can see just from all the surveying we've been doing around this pilot that our participants are feeling like they've learned the resources that they're more comfortable about their anxiety or the depression or whatever it is so we're feeling good about that. And then again I just want to share just a quick kind of real person story. This was one of our residents at one of these buildings, 60 year old with some really complex mental health conditions and living at this property for a while, it was a couple of years we're actually at the point where because of behavior and issues around noise and things like that we're at the point where we're having to start talking about lease violations and things like that things we don't ever want to do as a mission based non-profit we want to keep people housed but he was definitely at risk of eviction due to multiple lease violations and this person had not opened to accessing traditional healthcare or mental health services our embedded mental health clinician was over time able to develop a relationship seeing him on a regular basis for short periods of time and longer periods of time and at this point he's been engaged in weekly individual therapy in his home with this clinician for over a year regularly now meeting with his primary care and even has an outside, you know has the therapist and the primary care collaborating regularly which was fantastic and we've been able to obviously not have to go to eviction and even have seen reductions in the complex between residents and reductions in these violations. Okay, I want to go to some of our larger kind of aggregate outcomes we've been at we've been doing this program for we've been counting the pilot for about 10 years now and we've been rigorously evaluated all along the way so I want to share with you some of our outcomes first I want to share some of the measures we collect a lot of data on our participants this is our own data that we collect through our annual assessments we just pull some of the measures that we look at to help us figure out if we're going in the right direction I've shared with you the hypertension data we also are very focused around vaccination making sure our participants are vaccinated as you can see we're doing really well not only year over year in our own history but also compared to U.S. averages falling is a tough measure to make change with I'll be honest with you especially when you're working in an age cohort that if you're successful in what we're doing we're keeping them longer which means our participants continue to get frailer and frailer but our goal has been to stay steady or of course work below the World Health Organization fall rate for 65 plus which is about 32% and we're really holding steady saw a slight dip in 2017 we also have a big focus on end of life planning knowing that a lot of times people haven't put in place an advanced directive there's a lot of high cost medical care at end of life that some of you may not have actually wanted so we have a big focus with our SAS staff of asking about end of life planning working with our participants in conjunction with our community partners to get advance directives in place so we've been happy with those numbers as well we have been as I said robustly evaluated by a third party evaluator since we began going statewide in 2011 RTI is the evaluator and this evaluation was funded by the Human Services Agency and Housing and Urban Development they came together and funded this evaluation because they wanted to see if a health and housing model could you improve health outcomes and get some cost savings on the Medicare side so this is year over year what we have seen is our evaluators are they've seen by looking at Medicare claims data and comparing SAS participants to a control group is that we're seeing statistically significant reductions in the growth of Medicare for our SAS participants to the $1,100 to $1,400 per person per year as compared to a control group that does not have the SAS program one of the things that our evaluators told us is the fact that we've seen this kind of cost savings now for five years in a row is very significant clearly they are able to dice the data more specifically to see which parts of the state have the strongest results if you're looking at costs which types of populations and panels are having the best results so you'll see there's some difference between rural and urban panels that we've just gotten that information recently which is really good for us to get because it helps us tweak our model to make sure we're being as consistent as we possibly can with our outcomes recently one of the reports that our evaluators got a report published in CityScape which is a HUD publication where they were digging deeper into our many years of data that they have on us now and we're able to make it clear that where the categories of cost savings are occurring at the SAS model and they're able to the key findings here is that we are making a dent on emergency room Medicare expenditures that those are trending lower for all SAS panels also expenditures on specialist visits are trending lower and then we're seeing statistically significant findings in both urban which is Chittenden County is considered urban by our evaluators everybody else's rural and then early panels meaning we also get started in the first nine months after we went statewide in 2011 also our RTI found that there was a statistically significant reduction in Medicare expenditures for our duly eligible participants so our Medicare and Medicaid in both those early and again Chittenden County the most recent report that's come out by RTI again digging more and more into our data they have always been only looking at Medicare claims they were able to work with on point through vcures get Medicaid data for our SAS participants so for the first time and this hasn't even actually public yet but we've been told we could share it with policy makers that for the first time they're looking at Medicaid and they have found that SAS participants living in affordable housing communities where the SAS is most of the participants are living in the congregate setting and in our rural panels that we're seeing a statistically significant reduction in the growth in Medicare Medicaid spending sorry for nursing home care and this is for not rehab stays but custodial like long-term care so we're seeing that the number is like $400 per person per year reduction in Medicaid spending again as compared to a control group so very robust study and then importantly all the other panels even the Chittenden County ones are also showing lower spending as well just not to a statistically significant rate the other thing I want to mention is that when we looked at the data on this most recent report it also showed that there were some slight increases in spending on Medicaid for home and community based services so we were seeing reductions in nursing home care and slight increases in home and community based services which is exactly where we want to be because our whole point is to help people for as long as possible stay in their homes and reduce premature long-term nursing home stays so that's the kind of balance that we want is between those cost categories and then moving us on to some of our new initiatives the first one that I want to talk about today was our telehealth initiative so we are working in partnership with the union medical center one care and north western medical center to expand on the massage platform to bring a doctor visit to the home through video conferencing and so this is really just a phenomenal offer for our participants or our residents so that they don't have to leave their home to have a doctor visit that they don't have to go out in Vermont in the elements in Vermont we've had physicians tell us that they sometimes schedule appointments after the winter months because they're worried about their patients going out and slip and falling on the ice and so they'll arrange their appointments accordingly and so they don't have to worry about that any longer they also don't have to worry about transportation so they don't have to worry about calling, scheduling missing appointments waiting for their ride to return to come up in the first place they also don't have to go and be exposed to other illnesses while waiting in the waiting room so from our participants perspective this is just a wonderful wonderful thing to be participating and we've had everybody we've asked absolutely I would love to do this and then on top of it for our memory care residents even greater to have it at their location so they don't have to go out into a new environment and have change and at least the environment is somewhat used to they can remain in to be able to have a visit in addition we can now have a daughter let's say who lives in California who wants to videoconference in and be part of her mom's visit she can now feel part of her mom's health care and ask questions and just be a part of the appointment from the convenience of her office or her home she can be able to videoconference in we've also found because of our wellness nurse who is an RN and as Molly already mentioned takes vitals on a regular basis does medicine reconciliation they're already very familiar with these participants so be on the call from the physician's perspective it makes these calls and having a medical person on the other end with the patient makes this a lot less scary because there's a lot of information out there now where you can just pick up your iPhone and call a doctor but there's who you're getting where they are and what kind of information they're going to be advising you of so really having that RN there who can talk about things that they've seen as they've been doing this patient we know of course the last month or the last couple weeks whenever their last appointment was as well as being available to our participant to remind them of things they wanted to bring up on the appointment I'm sure we've all been to a doctor visit where we leave and think oh gosh I forgot to bring up that I wanted to ask about that or we leave a doctor appointment and say now what did they say about that again like you know I just don't quite remember what I was told to do or the answer to the question so now you have somebody there who is seeing them on a regular basis who can remind them remember what the physician said or if they have questions the nurses there to follow up before and after the appointment so that's also been a really a win-win situation and we have no calls no shows you know our staff go and get the patient to come and have these visits so it really is just wonderful all the way around we currently are focusing on a pilot really with UVM Medical Center patients who are also one care attributed who are also sash participants so it's kind of a little bit of a narrow feeling right now but it really does extend the primary care practice into people's homes and the equipment that we use is just phenomenal I mean having the nurse again there can do can have heart sounds, can have lung sounds and the doctor can hear them right in the means of their office whether it's their own office or whether they have a room that they go to either way they can hear it as if the patient was right there in the room with them. In fact we had one physician tell us that he liked our stethoscope better than the one that he uses in his office because it had some controls on it if you had slight hearing in your right ear you could turn up the volume of that ear but he said it was better than the quality of the stethoscope if the patient was right there with him so we don't have any funding for Cathedral Square and for SASHDA at this point for this work we are looking to get funding for that we do not have any currently but under the one care waiver they do have billable if they can bill in urban areas for people on Medicare so that billing is pretty situated it's just on our side we don't have any mechanisms to bill at this point in time but we are very excited and want to do a lot more in this area another initiative we're working on is SASH in family housing most of our housing providers across the state have general occupancy housing as well as senior housing and so really almost from day one we started SASH and they started seeing the incredible results and the incredible impact they started asking us when can we do this in all of our housing when can we do this in family housing or general occupancy housing and so we are just this year partnering with Down Street in Montpelier as well as Housing Vermont to come up really with what a design of what would this look like so just like we did with SASH back in 2009 we're reaching out to family service community providers who provide services to find out from their perspective what do they need help with and then also to families what are they looking for how can we be helpful to them because it really is obviously all about them so we're just starting this work we do have some money just this year to really just start that design phase as I would like to call it but we will have to then be looking for implementation money for an implement something we don't have any funding for that as of yet but we do believe that we can have a major impact with family housing just as we have had with senior housing in areas of immunization rates health screenings, ER visits as well as evictions, hunger stability all of those areas we do believe we can be helpful in so that's something we hope to do much more of as well and then moving forward we've already talked quite a bit about some of our history here we clearly started in 2009 we've experienced them for 10 years now we expanded statewide within two years now we are statewide and just two years ago in 2017 because of all the national work all the national recognition we've received we actually expanded SASH into Rhode Island so we have worked with say Elizabeth community in Rhode Island they have a location called The Place which has now been operating SASH for the last two years and we're working this year with them to expand to two other housing organizations within Rhode Island just this year in 2019 we're also working with Nancy Eldridge to replicate SASH in Minnesota they were able to secure funding through the Carfield Foundation and have funding for two years of SASH pilot so we are working with Presbyterian Homes and Services to replicate SASH in four of their housing locations in Minnesota in addition, we mentioned before HUD has been instrumental in our evaluations and they had asked us what if we had a magic wand and could change anything about the SASH program what would it be and one of the things we told them is that we would double the nursing time and so they have actually created a I wish demonstration which is based on the foundations of SASH and with our recommendation they are replicating the I wish model in eight states at 40 housing locations and so they're in the middle of that three year demonstration right now and there is hope that by 2022 we'll have the results of how that pilot is going but we're very optimistic about their results here's a little glimpse into just some of the national news and media that we have received as a result of the results that we have had as Molly mentioned, our evaluators have said that it's almost near impossible to see you actually break even in these cases but to actually see the cost per bend of reduced expenditures is just phenomenal so that's why we've been able to get so much national attention and also to be able to replicate the national and we'd love to be in every state in the nation someday and with the results it is absolutely about our participants and the people that we serve the Vermont Department of Health did an evaluation of our participants two summers ago now where they interviewed 60 of our participants and these are some of the quotes that our participants gave to them I'd like to tell the story that we had a resident who moved into their house location in Maryland and when she moved in she had time left to live and she walked through the cane she didn't walk much but she was walking through the cane and really thought her time was pretty limited and by joining SASH she is now walking 35-40 walking loops a day which is in a courtyard where there's a walking loop and she leaves her cane in the corner of her apartment to remind her of what her life was like before she joined SASH and I think one of these quotes is one of just if if I didn't have SASH I was just fighting before SASH the top one there I was just fighting to stay alive and then our growing needs so we've been limited to 54 panels or pretty much this entire time so we're capped so we really can't expand there are definitely areas we would like to expand into there are also new properties that we would like to have SASH services in that we don't currently are able to because we can't increase our funding and so that is an area that we absolutely wanted to bring to your attention and the next slide really shows these are areas that are underserved or unserved so we actually don't have a SASH panel in that particular town as we mentioned earlier we are on absolutely every single county but there's clearly areas on the map where we really don't have a presence so we would love to be able to have obviously more funding to be able to do the work we have you know for us it starts with Vermont it started here we wanted to expand more here than really you know across the nation that would really be a useful and then just kind of wrapping up I would just want to remind you all that you know we receive currently our funding through OneCare the original 3.8 million that came through Medicare to the blueprint to us is now funded directly from OneCare to us so you will see SASH in the OneCare budget in addition the state of Vermont funds us to almost a million dollars and that is for not only our statewide administration but it's also for the droves that I mentioned earlier around the state it's also for our partner agencies that come to team meetings it also funds the HOS program that we have kind of assumed under SASH so that's all part of what the state funds and you may remember earlier this year I was in the audience and spoke to the point of that was not the governor's budget this year and we were worried about what was going to happen so I did just want to let you know that it did pass that it is in the state's budget that SASH the state portion of the SASH funding is secure for the next three years they used one time general fund money with a three-year match to make us whole for the next three years with the intention being that by year four that 541,000 between the state general fund money and the match that it draws down would be taken over by OneCare so it has at least afforded us the opportunity to work with OneCare over the next three years to have them assume a portion of our statewide funding that we currently have this year so with that I'll stop and ask if there's any questions Great, thank you very much for your presentation One of the things that you learned is that similar programs around the country have not been as successful as the last and have not been able to demonstrate through evaluation the quality improvements and savings that we have getting calls from around the country so what do you say to them that's a great question I would say yes we are and especially when we do presentations like this which we have done across the nation and then we do get a lot of calls and so then it really is working with what can they do in their state to fund it that's really been the biggest hurdle as you can imagine so then they do look to the all-hair model in Vermont as well is that a solution for them in the future so if we look at the all-hair model now we hope that that is a potential solution for other states we don't know what will end up happening with the HUD demonstration I mean that's another avenue potentially and then we're just working with states by states where they can find funding themselves so in the case of Minnesota they were able to get funding through the Cargill Foundation but it is of course limited funding too so I'm not sure what will happen after the two years but we are definitely being raised as a model that people should emulate, that people should replicate because we've been so successful I would just add that when we talk to people from other states we make the point that they really need to be partnering with their state government agencies and hospitals because that is I feel like the reason the SASH program has been one of the reasons we've been so successful is from the beginning we embedded ourselves with health care and realizing that we had to as housing organizations prove that we had value to that that we could make a really big difference and really extend primary care where people live so the housing organizations in other states are telling you can't do this just try to do this all by yourself you have to start having conversations with the agencies, with your hospitals with your primary care that's what I think is a big part of our success and what we want to keep having is those kind of relationships So you would say that there would be a difference and probably the reason for the success here as opposed to similar programs elsewhere is the collaborative of the law working with hospitals and other organizations to make sure that there's a primary care and I wouldn't even broaden that collaboration to say the collaboration amongst the non-profit housing organizations these are 22 independent housing organizations that came together to say yes let's do this together because that's how we're going to go statewide and do it in an efficient manner and then the partnerships with the community agencies the area agencies on aging, home health community mental health they were all part of this from the beginning and also saying we're all serving the same population we have the same goals we have the same vision and if we come together how can housing add value to the great work that you're already doing and that was kind of our start Other questions from the board? Tom? I had a quick question about the concept of moving into family housing and whether you connected with let's grow kids because it seems like this could be in there in housing we have in fact we have like this really what was striking to me was we knew there was going to be a lot of partners just like there was when we started the sash the traditional sash but there's like double or triple the amount of partners that work with families which is great there's a lot out there so let's grow kids was definitely on that list and Eileen Peltier head of the down street I know at some point reached out they seem like I think we were hoping like maybe they could be a funder I'm not sure that's really it but anyway thank you for We had just a question on the composition which was 70% women and 30% men and whether or not you've been able to kind of dissect is that related to economic reasons is it related to women living longer is it related to your outreach so I would say that very much mirrors what we see in the formal housing period so that is very much about age for sure the demographics just of aging and women living longer as well as the low income perspective of that too so that's a very similar percentage to what we would see in the formal housing period for age specific meaning 55 thank you thank you thank you thank you two quick actually just data questions on the sash versus one care participants statewide live I just wanted to make sure I'm sure that comparison group is so the sash participants compared to all one care participants or is it one care participants who match between the one 70% women and 80% non-medicare it's a matched sample of similar one participants who are not in sash not at all it's very crude yeah it's very crude it was really basically we got information from the community population profiles for one care that was kind of here's kind of the trend statewide in these chronic conditions so we kind of grab that well let's look and see what it looks like as compared to sash so there was no matching or anything like that so great question okay thank you my other question was on the access to mental health services I was wondering before the pilot what was the base in referral interaction I didn't quite get that I may have missed in your presentation but I understand what is actually the delta that we have we don't actually know specifically what the days were we had anecdotal information that when our participants were reaching out or when our sash staff were referring for mental health supports it was often delayed and not necessarily because of the community provider sometimes it was delayed because the participant couldn't get to where the appointment was but we weren't we hadn't been specifically tracking that beforehand now we are thank you just a couple questions on the aspect of of sash where people are staying in place for longer because of the supports that they are getting and not will be nursing homes is that possibly a short term dynamic in the sense that the ageing population in Vermont is growing and by keeping people in place they're living longer in their homes for some point in time that has backed up is going to be at the door of the nursing home and is that a concern? so I would speak to right away even today for those that are low income that's a concern today I would say we don't have to wait for a backup we have over 800 people on our waiting list just to get into our independent housing today and in our two assisted living that makes that number over a thousand because they each have hundreds of people waiting on their list to get in but what I would say is now what happens is we're having folks who will stay with us until their end and they don't actually ever move to a nursing home so we have that definitely happen I mean that happened before as well but I would say it's a higher percentage now higher percentage moving to assisted living versus having to move to a nursing home there are absolutely still people who do and should move to a nursing home but it is definitely a lower percentage in fact when we track just cathedral squares move outs and the reasons for them it used to be that death and nursing home was really the top two reasons they still are but what is actually trumped those two has actually been moved within our properties which means they're moving not necessarily always to assisted living but they might be moving to a different floor that's better for them or to a different community that might be better for them for health reasons or family reasons and so that's now becoming one of our highest followed by people passing away in terms of your relationship with one here do you have an explicit process with them where savings in their budget are documented such that you're funding from one care from the world based on an explicit measurement for major fund savings over time no so this current year is actually the first year that we're truly under one care last year was that kind of wake up year and so they still had money coming through Medicare for us so 2019 is the first year we were able to get their three and a half percent increase which is our first increase in our entire existence for the rate of growth increase for 2019 we've just brought up with them yesterday whether that will hold true for 2020 and we don't know yet to answer your question directly I would just say no that there is not currently a mechanism for that we'll open up to public comment or questions Dale thank you for all you do and nice presentation are you okay if we push back a little bit I know for example the building right within is a sash for our neighbor and I do utilize sash as far as because you're in my building I interact with them I'm 64 I'm actually quite young compared to some which is a nice feeling because I go other places and I'm pretty old I came home one day and there was this notice on my door and the leather head is I would assume standardized leather head and so sash was on there but the message in the letter was follow the rules or leave and it went to everybody that lives in the building so I went to the sash coordinator and I said either way do you know that your leather head they got sent out with this message and there were no they did not and they were obviously concerned those to show just as a quick example of when they say housing is an issue or the vulnerability that can occur or the person staying in the housing that's much more real than it looked up there it's much more challenging than it looked up there a lot of this was more challenging to accomplish but I actually would rough it up a little bit be more real about it the blood pressure I lost my primary fear of position he's moving to Florida to be with his children and to practice I just want congratulations I think he's the majority right now I hear this often it's like good, be constant someplace to go we can be with your children that can't be informant what more could you ask for anybody would want that so I'm thinking well gee what will I do I now will get a primary care position that's named only I thought a sash it's like okay I can go downstairs talk to the sash coordinator and see what I can do for support services while this all gets worked out which is not going to be a quick fix we know from previous presentations how long it takes to replace a primary care position nonetheless if a blood pressure tough breaks you can't always go down and get your blood pressure taken because they don't have enough equipment and I think actually in the rule settings I've had some problems with workforce as well you lose nurse practitioners that you need to replace that takes time so your antics get delayed please let them comment on top of what I'm saying because I'm not trying to mislead in any way I'm just trying to say wow, yeah they do really good work if anything I would say they need better support and I would say they're actually an anchor more than this also shows what they can do they may need to do considering what is happening within our healthcare industry as we lose primary care positions as we retire and so forth especially in an aging community that's huge you've got to have somebody to go to and I think these are some of the people that people are going to look to or hopefully can't so I think they need our support I think they need more in their getting I think they have a lot of potential but they face really huge challenges just gloss it over way too much Bravo thank you for all you do I would just say that absolutely you better believe there's operational challenges when you go from one side of 59 people to having served close to 9,000 in a 10 year period of time so yes and we've definitely had our operational challenges we still do just like any organization would and I think they'll totally hear what you're saying so we're there's always that tension with property management and SASH because even though we're all non-profit housing organizations there's still leases everybody signs and there's rules the ways that people have to live so it's really amazing how our staff on the ground try to balance those issues and it's not always easy and it's not always pretty but I can tell you that I feel like all doing really overall really good job we definitely have issues with when we lose a nurse that can take quite a while to fill or just like everybody else with nursing shortage most of our wellness nurses are contracted through the home health agencies and I know you guys have heard about the shortages of nurses for home health agencies you're right when assessments start getting backed up the model isn't working as smoothly because you're not knowing your participants as well and you're not able to react as quickly so I appreciate you mentioning that and I do think that operational challenges exist and it's good advice to be open about it other members of the public would like to comment or ask a question none thank you very much thank you all very much so I did announce earlier that there's a slight change to the agenda and Melissa you can give us the update on S7 first that would be great okay so on Monday Susan and other remount care board staff presented to you on the remount care board's 2019 legislative overview there was a bill that was passed May 22nd so at the very end of the session which we've been tracking all along it's called S7 but it was not included in the slide deck so I just wanted to give an overview of it for you right now and we'll update the slide deck for the record and for the website so this bill is the title is an act relating to social service integration with Vermont's healthcare system and there are three main components to it and they are laid out here so one of them is that AHS and the Green Mountain Care Board requested to submit the plan to coordinate the financing and delivery of Medicaid and behavioral health services and Medicaid home and community based services with the all pair model financial target services this is a requirement of the all pair model which we will be submitting in December of 2020 AHS is in the lead and we are in collaboration on that AHS will be asked to go in and provide an interim presentation in 2020, January 15th 2020 on this plan secondly what applies directly to us is that by December 1st the Green Mountain Care Board has been asked to submit a report evaluating the manner and degree to which social services including the parent child network designated in specialized services agencies, home health and hospice agencies to what have since they're integrated into the ACO so we will be receiving a report from the ACO at the end of October and we will then use that report to finalize this report to the legislature and then finally there was a new budget criteria that was added for us to review when we're reviewing their budget and it basically talks about what the resources are that are provided to primary care practices to ensure that care coordination and services such as mental health and substance use disorder counseling that are provided by community health teams are available without imposing unreasonable burdens on primary care providers or ACO member organizations so I wanted to provide that and now we're ready for the other slide thank you, are there any questions I should ask from the board I will be, yes thank you very much for the update on S7 we were surprised that it wasn't to be done Monday one question that this brings to mind and I've received different answers I'm asking this of the board and not of the staff is there in a memorandum of understanding or some similar agreement that exists between the Green Mountain Care Board and the agency of Human Services with respect to the reports like the one with student S7 that have to be produced as a result of the all-care model my understanding as I've heard you Mr. Chair reference it from time to time was that Green Mountain Care Board and AHS had been working on developing a kind of memorandum of agreement as to which agency or entity was going to do which part of the work required under the all-care model agreement but I've looked and looked and I don't see any I don't see that in any of the public records on anyone's website so I'm wondering if it exists how I can get a copy a great deal of work was put into preparing an MOU and at the end of the day the decision was made that the agreement would speak for itself and the agreement spells out usually what under the all-care model and so there was no formal MOU excuse me and in this specific instance relating to this report it is specific that AHS in collaboration with DMCBF so it's the agreement no no I mean the all-care model agreement itself I think if my memory serves me right in this specific report it's clear that AHS is in collaboration so our legal team did spend a lot of time on that many of us would have liked to have had it your problem had alone okay anything else if not we move to the ACO Guides okay so we are before you today to present the 2020 ACO regulatory process I have Marissa Malamed Khalitha Rose, Sarah Lindberg and myself Melissa Miles who would be presenting on our ACO budget guidance and certification eligibility verification this is our agenda that's pretty simple and direct we're going to discuss what our process is between the certification and the budget guidance we'll be walking through some of the certification elements and also the ACO budget guidance elements highlighting in particular what is new in the ACO budget reporting requirements and then we'll go through what our timeline is for public comment and vote so in the Act 113 or 18 BSA 9382 and our rule the process between the ACO certification and the ACO budget process is separate and we have operated with two different ordinances for each process so as you'll recall we provided one here with an initial certification after an extensive review last March of 2018 and that established their certification and standing for taking Medicaid and commercial payments in Vermont so then this fall we released another verification form which included an update on all of those materials and as well added three new certification criteria that the legislature had put forth last May we reviewed this information and verified their continued eligibility in January of 2019 so I do want to note that the legislature did not prescribe any new certification criteria for 2019 so we're in the process of developing that form at this time secondly we have our regulatory process where we perform an extensive yearly review of the ACO's projected budget and we're going to now walk through how we look at their network payer contracts budget and population health programming and then we also as you know monitor them quarterly throughout the year and we're going to now dive into both of these processes I'm going to run you through the timeline for the budget guidance approval budget submission and review obviously say it's June 5th where we're presenting on our guidance and development it is posted to our website and we welcome and encourage any public comment on the guidance we ask to have that public comment by June 17th so that we have some time to review it and incorporate it into the final guidance we have scheduled a potential vote for June 26th for the board to vote on the final guidance that's with the aim of posting the guidance to the website and giving it to OneCare by July 1st that will include both the guidance and the certification form I want to note here that this guidance is developed specifically for OneCare as the only operating ACO in the state in the event that we're notified of another ACO to file a budget or apply for certification we have a generic guidance but it would have to be adapted accordingly and there would be a process for that so as Melissa talked about the certification process in previous years we were working toward aligning the certification and budget review concurrently so they're completed by the end of the calendar year in preparation for the next year those have gotten a little closer over the years this year we are releasing the guidance sooner on July 1 we are requesting that the ACO submit their certification eligibility form by September 1 that gives us a month in advance of the budget to review it the budget will be submitted October 1st we have scheduled a hearing for the ACO to come before the board on November 6 the staff will present their analysis on the budget December 4th we ask for a public comment to be submitted by December 13 again I want to know what the board accepts a public comment at any time but we realize that the period for the public to review would be from the time of posting through the various presentations but we would need to receive comment by the 13th for a quick turnaround to bring the final review to the board by December 18 when we've scheduled a potential vote and then we expect an issue with the boarders 45 days after so as Melissa mentioned when certified the ACO must annually submit a form to the board currently developing that form which will allow us to verify their continued eligibility for certification the form is substantially similar to the form that we used last year we'll have an updated policy checklist and updated questions again I don't think I think Melissa did a pretty good job of reviewing what the certification does but they are required to describe in detail any material changes to the ACO's policies, procedures, programs organizational structures provider network health information infrastructure other matters addressed in the section of table 5 like the budget submission the certification form must be verified under both the in addition to annual eligibility certification review and ongoing monitoring the ACO is required in statute to notify the GMCB providers such as changes to operating agreement bylaws within 15 days of their occurrence and they have to comply with quarterly or other regular reporting requirements as required through the budget boarders so I say all this because much of the certification eligibility review is rolled into quarterly reporting that we do the certification form is from an annual check on if anything is up to date it's our opportunity to ask the ACO to attest to these changes and verify that we received the latest documentation and then on the slide these are just examples of documents policies procedures that we receive and review and ask one character to be sure that they are they provide us the most up to date documents this is the table of contents the way the guidance is structured again the guidance is designed to collect information necessary to review the ACO's budget and risk models the ACO's models of care and the relationship with providers, payers and the community against the statutory criteria we are going to give you an overview of each section of the guidance and highlight changes from 2019 so part one section one is ACO information and background changes this year that we've added the verification under oath into the instructions the verifications to be signed by the CEO the board chair and the CFO and this is aligned with the verifications that are submitted through the hospital budget process this year we divided this section into two questions asking for an executive summary of the full budget submission as well as a question giving the ACO an opportunity to highlight major highlights in their budget including network changes program highlights operational changes and assumptions made in the budget proposal section two covers information on the ACO provider network including network provider participants, network development and provider contracting we have added discussion of implementation of the 2020 network development strategy specifically asking about priority areas of primary care and mental health as well as discussion of the ACO's strategies for maximizing the scale and achieving scale targets as outlined in the model agreement and the anticipated impacts of these strategies this section asks for a description of provider risk arrangements and risk mitigation measures again identifying changes from 2019 to 2020 the ACO will also submit provider contracts and agreements section three asks for information on the ACO's payer programs including program arrangements and information on scale target ACO initiatives in this section we collect information on each of the payer contracts to review alignment among the payers as required in the all payer model agreement changes to this section this year include the new scale target initiatives and program alignment form which replaces an excel spreadsheet which collected this information last year the new form was already used once to collect information for quarter one 2019 reporting the annual ACO scale target alignment report that's due to federal government later this month we added this year the section and appendix and questions asking for an explanation and assumptions for projected growth rates by payer program section four so section four covers the ACO budget and financial plan for 2020 through appendices one point four through one or I'm sorry one four point three we're going to continue requesting the balance sheet income statement cash flow statement this year an update is that that will be into our adaptive insights reporting software that we use for the hospital budget process as well but the look will still be the same when the board staff and the public see this data we've updated our appendix four point five revenues by payer to include member months as well as breakdown of PMPM non-claims dollars versus the PMPM claims dollars this year we've also added reporting on total shared savings or losses to the ACO by program and year from 2017 to what is budgeted for 2020 and that can be found as appendix four point four through appendix four point six we are continuing to request the completion of the all payer model accounts down by hospital which of course still includes the fixed perspective payments value based incentive payments hospital participation fees maximum all care model risk and estimated attributed lives in addition to the requested financial data we continue to request a narrative surrounding the ACO's budget we have included a request for definitions surrounding accounts under operating expenses in the income statement for clarity surrounding in particular the administrative expense ratio that the board continues to track in the case of reviewing one cares budget the administrative expense ratio does include all the operating expenses we continue to request the same benchmarks when developing the administrative budget methodology behind provider incentive payments and goals for the state of investments an HIT strategy both ACO level and provider level any service utilization assumptions as well as any changes in network configuration and impact to the service utilization we've requested a narrative description of the funds flow only if there have been changes from the 2019 submission this year we have also included a request for quantitative and qualitative summary of both the shared savings distribution plan and quality with full distribution plan for 2018 in the area of risk just as last year we are asking the ACO for a detailed risk mitigation plan which will include a plan for any risk within the ACO risk pushed to the hospitals and any other providers risk covered by reinsurance and so forth we will once again request an actuarial opinion surrounding the financial solvency of the ACO when it comes to risk arrangements and finally we will again request any additional documentation such as policies the ACO may have surrounding the financial management of risk this is a nice long list for the the population health section so here we've included quality their model of care their population health investments and how they're working with the community to integrate services and you know as their model of care has evolved we have a question asking them to translate from 2017 to 2019 how the communities are maturing at the local level and working at the state level together to improve the quality of care for Vermonters and we asked them to dig into how the ACO's clinical consultants are working with the blueprint for health how their the ACO's technical assistance has encouraged that transformation in care and any results that they're seeing from that we also asked them for projection of goals and objectives for 2020 to 2022 regarding quality and data we we were asking for the quality measure section in the payer contract section but determined it would be more appropriate to ask for it here to see a side by side with the all care model ACO measures so we are asking one to respond to their quality measures from their payer contracts and tie them into their quality improvement plan and this is actually an example of how we're working to align our certification and budget process because we receive the quality improvement plan through the certification but we'd like to see the results here with their payer contract results as well we will have the results for the all care model quality measures in September of 2019 and that report will be produced and submitted to the feds in that month and so we're going to be asking them to respond to those if not in their budget guidance then in their presentation and their hearing when they come in so we're also asking them to stratify their population by health service area and into the four risk quadrants that they talk about and we're hoping we asked for that last year as well and we're hoping to track that over time and see if there is a change in their population see if the risk population shifts in one direction or another and we're asking about variations in care in those health service areas as well so finally we've included a similar question which Sarah Lindbergh's going to speak to in her section about the total cost of care by PMPM in each health service area and we've tailored the questions that the hospital was asked we've tailored them to the ACO so those are in the end of the guidance as well and then finally we're asking them once again for their projections on their population health investments and the programs that they're planning and how they're addressing all of the elements that are found in the budget criteria Act 113 anytime the benchmark comes up we'll get here for me so I think we're still starting out some operational questions related to the calculation of the benchmark for 2020 but in the meantime we are very clear on what our obligations are under the all-care model and that is that there's the 3.5% for the entire Vermont population and there is the national projections which we need to stay under for our ACO financial targets and we also have some duties under the all-care model agreement where the benchmark must be set such that the annual growth rate is 100% and it's below the projected annual national growth from 19 to 20 and again those projections come from the call letter which is designed to set Medicare Advantage rates and includes some national projections for the traditional equal service Medicare population the other one would be that so the compounding annual growth rate for the ACO benchmarks will also potentially be set at 0.1% no more than 0.1% points above those national trends so that's a lot of gobbling gook but basically we can either pick the annual trend to tie to or the compounding growth rate to date to tie to so those are the two kind of tests that we'll have to set so what that boils down to is this chart so 17 to 18 the floor so there were no projections at play but for the opportunity to use the floor floor was dictated by the projection rates so that is locked in at 3.7 through the life of the agreement for 2018 to 2019 those came from the call letter that was released in April of 2018 and that's what we were thinking about last year and the 19 to 20 come from the call letter that was released in April of 2019 so you can see for accountability purposes what we're on the hook for is that compounding projection to date so for Asian disabled or non-ESRD population that compounds to 3.97% with the target being 0.2 below that which is 3.77% for our ESRD population a little bit slower growth 3.34% with the target being 0.14% and when you blend that using a stable ratio of 0.3% ESRD it's 3.95% which makes our target 3.75 obviously that is higher than our all-payer target of 3.5 but again those are a little bit different looks we're currently still thinking about the Medicare financial targets being tied to the low population at this point so it's a different look than a subset of the all-payer targets and then again as Melissa said to try to add some cohesion to our regulatory processes we used these estimates for the total cost of care over time by HSA these numbers are unadjusted they come right from V-Cures and the population does change over time so for instance you'll see some dramatic changes in the commercial business between 15 and 17 due to the effects of the Joe Bae decision however our thinking is that this is for accountability purposes what the world looks like so it'll be very interesting to us to see how that compares with both the hospitals and the ACOs versions of the worlds to be clear we have the advantage of non-utilizers that help bring it down from the worst and we also are looking at things based on where a person resides so they may or may not attribute to a primary care provider at all and certainly may not attribute to one within the HSA where they live so this is probably a much different way for ACOs to be thinking about it but I do think that their data will give them a little bit closer lens to this and then say a hospital which may have some more constraints about the data directly available to them in their day-to-day lives but this is all payers so this would be Medicaid, Medicare and commercial it is restricted to the primary payer and clean's pay this primary so we're doing our best again to kind of use the definition for the total cost of care and to help with investigation we have developed an interactive data and analytics portion of our website you can see the total cost of care over time and also membership by HSA over time and if you would like more detail there are data available for download that show the results on a quarterly basis with some additional information you will note that these estimates aren't exactly the same as those in the table that was based on a prior run of the estimates but we wanted to keep it apples to apples at least between the budget process but this is always going to reflect the most up-to-date data of course and certainly similar for magnitude and direction but they might not be precisely the same so part of that also has to do with the way that we looked at the non-plans portion of the spending so just if you have any questions about that you know hard to find that pretty much concludes our presentation of the 2020 guidance I'm just going to bring you back to the timeline we will open it up for board questions and then public comment I'm a reminder for the public to comment to us and then we will come back for a vote thank you I wanted to thank our staff who have really done great work updating the guidance and really trying to take a step back from last year and say what worked, what didn't work what could be improved, how could be improved I very much appreciate your cross-team collaboration and also trying to keep an eye on the integration between the regulatory processes particularly between hospital budgets and the ACR budget since those are so closely linked so that was my thank you I just also wanted to say I really appreciate the addition of the executive summary I think it will improve readability with this submission for folks who aren't necessarily living and breathing it every other day like you guys are so I think that will be really helpful for the public and also for us as we delve back into the youth level and I also want to say I really like the new scale for any other questions or comments before seeing now I'll open it up to the public for questions or comments I just didn't hear but are they feeling comfortable with how this is going to trend for the curious thought I've had at different times and looking at information on this is what affects the changes in the national trend is what affects us as well so do these parallel or are we do we have more risk here in the sense of things that may affect us like the workforce you've used and so forth I believe it's national but do you see what I'm getting at or did I end up not asking your question are you speaking specifically to part 2 with the benchmark table that Sarah spoke about how they parallel, yeah I'm curious if they're going to use the national trends is what occurs in the state or they don't occur at all yeah so I'm saying because we have smaller numbers we're always a little more susceptible to volatility so national trends seem to be pretty capable of stable for national projections and national actuals it's a little bit of a mixed bag and the state level results no, I don't think both of us have no in the guidance and in the agreement we actually are allowed up to a 4.3 trend we're aiming for 3.5 we could ask for a corrective action plan if need be if there were trends that were unanticipated at the time of the agreement and I would say to your second question about workforce capacity that's one of the reasons why the total cost of care table in the ACO guidance and in the national guidance is to start to look at the big picture of Vermont and the opportunities that are being faced around Vermont and what may be impacting some of those PMPM rates at the local levels at least that's the way that the ACO questions were targeted last year the guidance on the ACO certification process there was a form that ACO was supposed to fill out that just asked them the question like do you swear under oath that you have or have not engaged in the laundry list of activities that would constitute basically unfair trade practices and that's how the remount and care board has chosen to exercise its obligation to protect Vermont from the undue impact in case that the savings or the health improvements somehow outweighs Trump's that undue impact. I couldn't find that form in the appendix of the materials this year so I'm wondering A if I missed it you could just tell me which appendix it's in or B I'm wondering maybe you're changing your process for how you're going to exercise your stay out. If I recall correctly last year it was an antitrust guidance and an attestation on behalf of the ACO and that was included in our certification and we will be including that again this year. So it's not I don't think that would have been a I'm going to remember that there's a budget and there's a certification and so that goes to the certification not the budget. So all the appendix is a remount certificate. Right, that is all budget. As Marissa mentioned the certification verification form is going to look very similar to the one that was posted last year and we're finalizing it at this time and it is posted on our website I think Marissa is starting to move to make our website a little bit clearer we're starting to move some information around so if you frequent the ACO certification section often you may get lost in there initially but we're hoping that it will improve the way that you can go and look for information. Will there be a separate comment form? Because it was very similar to the one last year we were planning on providing it in a memo to the board and could be also posted it will be posted once it's complete. I would say if you have a specific suggestion I would just submit it in time unless there's a public comment. I'm a recovery lawyer so if there is a public comment process on that form there'd be a public comment process on the board but if there is one on the unit and there is one on the board except public comment so if you have any other comments or questions is there any old business to come to court before it is there any new business to come to court before it? We don't deserve ocean to adjourn it's been moved to adjourn all those in favor signify by signing aye thank you everyone have a great rest of the day