 Okay, good morning. Good morning, everyone. Welcome to a joint meeting between house health care and house human services today. We're going to be taking up the topic of what the hospitals refer to as boarding and looking at sort of the the exit to lower levels of care and what are some of the barriers and I hope that we get to what some of the solutions are as well. So I want to apologize at the outset. I have to go to a conference committee meeting on the budget adjustment. So I'll be leaving right around 930. But you'll be in the capable hands of chair Houghton and vice chair Bromstead from my committee. So thank you. Thank you and welcome all and I hate having our backs. But we would love to see Dr. Lefler join us. All the way down there. Right. Good morning. And I did mention to witnesses if they if they have something they're going to share that they need to join the zoom room. Yes, before they get to the head of the table. Sure. My name is Dr. Steve Lefler. I'm an emergency physician by training. I've been a doctor for more than 30 years at University of Vermont Medical Center. The last five years I've been the president and chief operating officer of the Medical Center. I'm here to talk today about the boarding crisis in the hospitals across the state. I'm going to talk about one component of that, which is patients that are staying longer than they should in the hospital because they can't get to the next level of care. So the first thing I want to do is I do want to acknowledge and thank HHS. We've been a good partner on this. We've worked very hard with them for solutions. You should know that since the pandemic we've lost about 500 nursing home beds in the state of Vermont. And prior to that, I would argue that it wasn't perfect prior to the pandemic, but it's made it infinitely more difficult to discharge patients. I always like to start with the state of where we're at right now. So at the University Medical Center this morning. At eight patients boarding in our E D waiting to go upstairs. We had 68 patients that were ready for discharge did not need to be at the academic medical center. We didn't have a place to go of those 68 28 were people who needed what I consider to be regular nursing home care could go if there was a bed ready for them and 40 or what we call long stay or custodial. They're going to give us for a long time. They are difficult to transfer out because they either have complex health care needs. They might have a behavioral health need. They might have dementia. They don't have a good payer. They might be on a very expensive medication. So those 40 patients can stay months to over a year. We discharge one over the summer that been with us for more than a year. This problem. Impacts every hospital in the state of Vermont Vermont is so small. Our hospitals are small and don't have much excess capacity that a border in a patient bed at the medical center and literally impact St. John's very this morning. So right now this morning we have five patients across the state waiting for transfer to the medical center. It's never gets the first thing I as a doctor look at every day who's waiting to get down to us. It can't come right now because those are people that we've identified in the other hospital that identified need to come. And we're trying to make room for that. So a long term border on one of our medical floors may not seem like a big deal. We have 430 beds but every bed is full. We already have EB borders. Where is that patient going to go. And so we try to do our best to help manage have St. John's very managed that that can have an impact on them. They might have to have an extra nurse be with that patient or change what they're doing today. So this problem impacts every part of the system. I also want to say that. It's hard to fix only one piece because we're monitors. You have a continuum needs. So any one person may need to start and St. John's very transferred to us for an academic tertiary care problem. We need to do our part of that job and then we need to get them back. Either maybe to a nursing home, maybe to assisted living, maybe back to their home where the local DNA can care for them and get them better. So all parts of the system have to function. There's really not a lot of excess capacity in Vermont right now to manage us. If we were in Boston and one of the hospitals went on diversion. They'd manage it all the time and go someplace else, but we really have no mechanism because we are the place for people in the most high acute needs and we're proud of that. By the way, you want to be that place and we want to accept everybody. And if they need to come need to have the capacity to do that. I will. Our apps is actually not anything for the academic medical center today. I'm not here advocating for UVM medical center where they work. My ask is to basically make investments into the continuum of care, make investments so we have more nursing capacity. More beds for patients with high acute needs and more that more opportunity for people to get care in their home when they need it. If those 28 patients today can go out of today sooner, that makes a giant difference to can be transferred to us. If there's 40, 40 patients who can get the care needs they met need met not in the hospital. That will open up a lot of capacity to get people to the right place. Stop. Thank you. Once a couple. All right, we're going to alternate so. And then Dan and then Jubilee and art. So I'm thinking obviously of cost of care. Is UVM being paid for these 28 or are they sort of. When I know Medicare will sort of pay for a course of care and if a person needs to be discharged, they're based sort of stop paying. Or what's the payment. So that's happening with that. Patients come to the medical center for medic for all the payers. We get paid a set amount of money for how long it looks like they need to be there. So for patients long stay patients came in with pneumonia. And you get paid for five days. But now they've been there for 95 days or 105 days. We get no more money from Medicare for that. Thank you for your testimony and thanks for talking about this issue because something we need to really address. I was just wondering you said you've been practicing medicine for 30 years. You seen anything like this before. No, not exactly. So across the country right now, hospitals, many hospitals I want to be honest and many states are facing this problem. Over the country, we lost a lot of nursing capacity through the pandemic and hospitals are interdependent on especially academic medical center, which I know really well. We need our small hospitals to get patients stabilize them, identify them. They need to come to us. We need to be there and ready for them. And when they call, we can say yes. Then we need to do our part and have a place for patients to leave. Prior to the pandemic, I think we didn't have quite enough nursing home beds then, but we often had what I would say we had 20 long state patients, which was too many. And if you'd asked me to come testify five years if I would have been came and said 20 is too many. Last week we had 83 patients waiting for discharge that has a huge impact on the state of Vermont, not just the medical center. It affects every Vermonter goes into ER across the state who might need advanced level care. So I think the problem was smaller in the past. I think the problems gotten bigger. And I think that what people need is to get older is more complex. And so more people need us now at the academic level center in the past and our options to get people out at strong, which makes it harder. We've done a lot of things to try and manage more we've opened up a floor to try and hold some of them longer. But that's not an ideal solution by far. So I don't have an exact answer. I've not seen exact mean during COVID. We prepared to have a lot of people be very, very sick. For month and amazing job in COVID. I want to say that. And so we had some small issues. But a lot of other people we were delaying care for, which left the capacity in Vermont to manage that. Thank you. Really. Yeah. Yeah. Yeah. You mentioned that because of COVID, the nursing homes closed closed down. What's the status of them now? Do we have any feel for them reopening? If I know you said 20 was too much and now you have 80, if we can get some of them reopened with that help alleviate it and what's the mechanism to do that. So without any question, getting more nursing home beds online will really help. I think it's going to take money. I think they're closed because they can't afford either pay travelers, pay current wages. We just have gone up a lot. And patients, even the patients that we are able to send to nursing homes are more complex than they were 10 years ago. And so the nursing homes need to have more resources. I do think the short term answer is they need an investment to get more beds open. Okay. And are those people coming forward at all? I mean, is there any initiative? So I'm not, I'm sure there's people back there. Yeah. We are slowly but steadily making progress on getting our traveler numbers down. And over the first quarter, we were able to hire an additional 80 nurses at the medical center that we don't need travelers for that 80 spots right now. And a number of our floors are fully staffed with people that are permanent employees. So I do think it's slowly but surely. Yeah. Thank you. Appreciate it. Thank you very much for being here and see you. I am our community, which is the house human services committee has been hearing a lot about the homeless population and the folks who are taking care of us throughout our. We've heard from a few different people, some disturbing information that some of our hospitals are discharging because they don't have any more space. Homeless people that are sick, maybe not as sick enough to be need to be in the hospital, but they're discharging them out onto the streets. I'm guessing UVM is not doing that. But when I look at these high numbers and assuming that's partially why your numbers are high, but are you hearing this as well? And we really, we're trying to figure out should we have some high end beds that are homeless that are shelter beds because we were concerned about this happening. So Burlington UV medical center in the county is very fortunate that we have some opportunities for places that discharge people who don't have a home to meet their health care needs. We have Harbor Place and we have some other local partners place where we can put patients for short time. I can tell you this as an ER doctor for sure. If you send somebody out who's still sick and they don't have a mechanism to take care of their medicines or get care. They're coming back and they come back to the ER. It's probably Friday night and they're getting readmitted. So that may look like a good idea in the short term today when you have a real bind. It fails. So I think that we have to make sure that every room honor has a place to be discharged that meets their care needs that time. That's everything from the advanced beds that I care is bringing online. I'm sure you've maybe heard about I'm very hopeful those med beds make some difference for those 40 long stay patients. I know it'll be all 40, but I think it takes some of those patients. And I think we have to have a plan for people who's either doesn't don't have a home. Or the home they have doesn't meet the needs they have when they're discharged to care for them. Otherwise they're coming back. Right. Right. So follow up to that would be are you is UVM health network investing in nursing home. In ways to be helpful here because we're all face facing. So in Vermont UVM health network has order. Helen Porter nursing home as Woodridge. We're doing our very best to keep all those beds open. And our nursing homes also face the same challenges as our private nursing homes across the state, staffing those beds, people there. If you have to staff them with travelers, the business model doesn't really work with the current pay structure. And the other trick is that the way our nursing homes are paid and this is a little beyond my expertise. So there's smart people back there that can do better. I want you to hear that people need more than just the normal. They need to cost our nursing homes more to care for them than the revenue coming in. So we have to fix that. So they want to take more complicated patients. Okay. Okay, thank you. I have one question. Yeah, and I was just going to say we want to make sure that we have time for all of the witnesses. So I think Lori's question will be the last question. What do you have an estimate of the monthly costs to UVM health network for not getting the reimbursements for the people who are there. I mean, I just sent me that this morning. So it's about $3.2 million over the first quarter caring for those people that's unreversed. Great. Thank you very much. Suzanne and not might say this wrong. I apologize and there and there you got it. Welcome. Hi everyone. I let me get my video going. Good morning. You can introduce yourself for the record. I've been trying to use myself for the record Suzanne before she does just I'm Helen layman from the Vermont health care association. I'm her phone a friend. If there's any technical questions. Other than that, it's all Suzanne. Yes. So Laura will be my smart or Helen will be my smart friend in the front of the room not in the back. So thank you. Hi, my name is Suzanne and air. I am a licensed nursing home administrator. I have been licensed in the state of Vermont for over 16 years. Prior to that I was licensed in the state of Massachusetts and I also have been licensed in the state of New York. I have spent my whole career in long term care. I started out as a college student working as a nursing assistant and provided direct care to patients. And then along the way, took on different leadership. So I've done a little bit of everything in the skilled nursing world and the nursing homes. Currently, I have, I was the administrator on record at CLR, which is on the SVMC campus in Bennington, Vermont up until the fall of 2023. Currently, I have transitioned into a position. I'm the executive responsible for CLR. I oversee the operations and the administrator. And I'm also the vice president of business development and marketing for a layer health services in that position right now. I do spend a lot of my time working on hospital relationships, building partnerships, working on discharge, discharges, making sure we're having patients in the right places. So I do work with SVMC. I'm working with Geisinger, Jefferson, UPMC and Penn State. So I do a lot of work in the four states that we operate in. First, I want to say that I'm grateful to be here. I'm grateful. I am a Vermonter. I am grateful to have a position in Bennington and in Vermont. My husband and I, we raised our family here. We stay here in Vermont and we want to be here. So I'm passionate about what I do. So I appreciate the opportunity to be here in front of you today. You know, as Dr. Leffler talked about, workforce is one of our biggest issues. I'm only going to talk to you today about the issues that we face currently. But I do want to put a little side note in is that there are federal, there's some federal push for us to increase the staffing mandates in the skilled nursing facilities across the country. That will affect Vermont. It'll affect every state in the country. So I just want to put that out there. There's a real possibility there'll be more strength constraints on our organizations in our industry. Currently, right now at CLR, we have, we have not rebounded from COVID. When you look at the agency staff that we use, we have not rebounded. We've actually increased in 2023. And I think we're seeing that on a lot of our facilities across the board. You know, people will say, why haven't you rebounded? There's a lot of reasons we haven't rebounded. So one, you know, there's a lot more opportunities for nursing staff. So for LPNs, there's a lot more opportunities. What we do in skilled nursing, it's hard work. It is very hard work. It's seven days a week. It includes holidays. We have at CLR, we have lost nurses a lot of retirement. We've seen nurses go into medical practice positions where they can work Monday through Friday, no holidays, no weekends. We've also seen an increase in remote work for nurses. So nurses can work remotely and do clinical reimbursement, insurance, workman's comp. There's a lot more opportunity. And that's what we've seen at CLR. We have lost nurses who've not gone to other skilled nursing facilities. They've left skilled nursing. So that is one of the challenges that has we've been presented with. And I pulled some of our numbers. So in 2022, we spent roughly about $41 million in contract staff that does not include our own staff. That is just nursing and nursing assistants to staff our facility. In 2023, this number is actually low and I'll explain to you why. So in 2023, we spent $4.8 million in contracted staff. During COVID, we saw about a 32% agency. We were running about 32% agency per day. Right now, we're up over 40% agency staff for CLR. In 2023, and the reason I want to talk a little bit about the number that I gave you, 4.8, that's actually low. What we did in 2023, we tried to get creative. We tried to keep as much dollars at the facility rather than sending them to out of state agencies, you know, paying staff that don't live in our state. We actually tried to recruit staff from Vermont and pay a little more. You know, they did not reflect on what we actually can pay our staff. But we did see where we would pay staff $45 an hour just to get a six week or eight week contract from them. On average, an LPN can cost anywhere between $45 and $75. A contract RN can cost anywhere from $75 to $125 and a nursing assistant can cost up to $40 to $65 per hour. You know, that is significantly higher than our regular staff are paid. Right now, what we're seeing at CLR, you know, we are right located on the SVMC campus. We are seeing the highest census we have ever had. At one time, CLR was 150 licensed beds. We actually downsized to 130 beds to save money and not pay bed tax. I'm currently today, we opened at 122 patients. So I know we're a little bit different. Some of the access that we're seeing in other facilities, but I do have a referral and a wait list of every day 15 to 20 people. And you know, this is something we have never seen before. Will we get to 130? We will not get to 130. On average, I would say we can get to about 125 to really the reason for that. Why is that? We have patients who need private rooms. You know, we have Medicaid patients who may have an infectious process. We may have patients were actively passing. We want to give them some privacy and dignity to be with their families and not share room with a roommate. So there are reasons that we can't get to 130. The commissioner and the staff at Vermont, they were helpful to CLR during COVID. We had a 20 bed unit that was closed due to staffing. We could not staff it. The commissioner recognized that, you know, having this unit, what we would do is CLR would open the unit. They would help with funding. We would staff at 100% with agency and we would only admit from Vermont hospitals. And that's what we did. You know, we met our mission. We have continued to keep that, that unit open. And it is 100% staff with agency, which again is a challenge. When I talk about admitting just from Vermont hospitals, where we are in Bennington, we do see a fair number of patients and referrals from our community. People from Bennington are going outside of the state for medical care. Albany Med is one that we will see a lot of referrals. We really have not, we've had a significant over 50, 50% decrease in the emissions that we take from Albany Med. It's over that. We are having a hard time servicing our own community. So that's one thing that we have seen change. Dr. Leffler talked about, one thing I do want to mention. So our center, we are 70% Medicaid. We roughly are about 20% Medicare and we're about 10% private and other insurances. We did talk a little bit. Dr. Leffler brought up the acuity of patients and that has significantly changed. Again, I'm fortunate I have the support of the hospital that is, you know, 250 yards away. But the complexity of what we're seeing and the care that we need to give. There's high cost medications that we aren't reimbursed for. Sometimes the medications we need to give our patients, we can't get, you know, we do have pharmacies. We have specific skilled nursing for some pharmacies. We have seen more at CLR Plurix catheters, which is a complexity we have never seen before, but just to treat that patient with medical supplies is over $1,000 on a patient that's $600 a day. We take those patients, but when I look at some of our rural counterparts, I don't know how they would do that. That would be extremely difficult with agency staff competencies and then cost. The other thing I see at CLR right now what we're having, and I know this is pretty standard across the board is we are running anywhere between 10% and 15% non-payers. So we have non-payers in our facility. It's not a Medicaid application issue. The Vermont has been wonderful about processing applications. We are seeing an increase in difficulties in having the families help us fill out these applications so we could go without payment for these patients anywhere between three, four or five months. And so you need to somehow make up that difference. So that's very difficult, especially when we're paying as much money as we are for agency staff. The other thing that we're seeing, I'm seeing a lot of more managed products in the marketplace, which does delay the authorizations and getting them over to CLR. The other thing we do see is there's high cost in transportation issues. So at CLR we're fortunate. We have a bus in January. We used the bus to transport. We did 185 transportations. So we did transportations back and forth to medical appointments. And we also did transportations and emissions from our hospital. I see sometimes hospitals are delayed if they don't have partners in the community that can help transport. If they don't qualify for an ambulance, you either rely on families, you have to rely on taxis, which is not safe. Hospitals do not want to put people in an Uber to send them to the nursing home. So that's one thing we have been able to help with in Bennington is we have done those transportations. One of the high cost items that we are not reimbursed for and I do want to bring this up is if a patient comes to us and they need ambulance transportation. If they don't qualify and Medicaid or Medicare sets those rules in these cases, they do not qualify for transportation. We take a patient. They need to be transported across the parking lot for care and even a life sustaining treatment that will cost the facility $3,000. It's $1,500 one way. And that's also, you know, that is not reimbursed. So I do see, I know some of my counterparts in the state have said that is really a problem for them, especially when I look at dialysis patients. It's difficult to have that transportation. I know one of the things I wanted to talk about and I know this is a start and I want to say thank you to the state and the investments that we've made. I want to talk a little bit about the reducing the occupancy occupancy penalty from 90% to 80%. I do think that that will help. And certainly my case, it will help where we're over 90%. The one thing I'm concerned with I don't know if that alone will solve the workforce issues. You know, for patient or for facilities to start at 60% and they got to get to 80% to get an enhanced rate and not be penalized. I'm not sure how they're going to make up that difference. There's a cost associated that there's a workforce issue of cost, you know, associated with that. The workforce is going to drive some of that. So I just I'm not sure that that alone will solve the workforce issues. The last thing I want to talk about is the relationship with our partners, the hospitals we work with, the V&A. It is so important that we have the V&A with us, that we have good relationships, that they have the funding to stabilize their organization. We have to be able to discharge them. We can admit from the hospital as soon as we can get the patient out of the building. So it's pretty much the same with the hospital. There's workflows, there's patient flows that we always need to be working on. We do spend every day at CLR. We look at bed management to make sure that people are in the right place getting the right care and moving them appropriately. I'm open to questions. I don't know how long if I forgot anything I would hand it over to you if there's something that you wanted to bring up. That was wonderful. Thank you. Can I ask a question? Thank you very much for helping us to understand the pressures that you're under. You were just mentioning the proposed changes in the occupancy rule. I'm just wondering, maybe this is maybe more a question for the Department of Disabilities, Aging and Independent Living. But I know that some facilities have reduced their license capacity in order to end up with a higher occupancy rate and to also avoid paying the bed tax. Is it possible to, I guess, have some fluidity in that? So if a facility reduces, I'll just use the example. If they have 100 license capacity, current capacity of 100 license beds, they're only able to be at 60 because of the staffing, the 60% that you were just referring to. Can they temporarily reduce their license capacity and then at some future time, you know, request to reopen their license, you know, increase their license capacity? So I can, you know, based on my knowledge, so at CLR, we gave up 20 beds. We cannot get those back. We won't be able to get those back. I think that the facilities and the concern that we have in the industry and Dr. Lechler talked about is that facilities are choosing not to fill beds. They're still licensed. They're still paying taxes on them. They cannot staff them. Okay. And just to make sure that we're clear that the occupancy county is not based on your current occupancy is historic. So it's based on what your occupancy was in calendar year 2021. Yeah. Based on that for the next four years. So you would have had to have done it five years ago. Yeah, I'm just talking about like, so as you move forward, trying to avoid the, you know, the bed tax and trying to, you know, avoid some of those other triggers, but I think represent Greglar. Can I just, just real quick for my committee or committee health care, this occupancy thing does not fall in our jurisdiction. So I know we probably are like, what are we talking about? We're going to give it on the table for them to deal with. It's interesting because my question, probably you guys know all about, but first I would say like, I mean, I understand the funding part is like, you know, Medicaid's a lot like the VA where you get a bill for $3,600 and they're like, hey, we'll give you 836 or something and have a nice day and maybe we'll pay in 90 days or whatever. I understand that. But so what my question is, so both the witnesses so far have talked about the higher acuity and more complicated cases, etc. And I think in my head, I go, well, we're much more modern society advanced, etc. So for us that don't deal with health care every day, why in this modern society are cases more acute? Why are you having more like more acuity, more complicated cases? Like, what's the causation? Or is there, and that's probably a big question. I think I'm going to leave that to Dr. Leffler because I think that, you know, honestly, the days of us having the sweet patients, easy patients who had knee replacements and hip replacements and stayed with us for, you know, 50 or 40 days, those days are gone. Why our population has more complexities? I would leave that up to, you know, maybe he has more of a population health answer for that. Okay, I'm going to turn to Dr. Leffler. Yeah, thank you. So the answer is that people are older and sicker and we're doing more amazingly to keep them alive. And so I'm just going to give a quick example. So we can do a procedure now through your skin to replace your aortic valve. It's called the TAVR. And 10 years ago, if you had terrible earwax stenosis, your jaw was closing, and you were too sick to get the operation, you would die over six months. And then you would need to go to a nursing home, you wouldn't be costing any beds, you die, just stare at it. Now, 85 year old, nine year olds come in with this problem. We can fix them that day if they're able to have a place to go, they go home in two or three days and they live for another three years. They're getting a nursing home stay in that three years and now they're really complicated. They have a lot going on. That's one example I could give you 10 like that where we're keeping people alive with new amazing procedures. Okay, thank you. So over the past few years, our funding model has relied on EFR, extraordinary financial relief. What impact does that have on the ability of nursing homes to address the boarding problem that we have in hospitals? Yeah, I think Helen should speak to that because CLR has not received any funding except a short term funding during COVID to open up a closed unit. We have not received any, so I would leave that to Helen to answer. And that's actually a good example of why it hasn't. So EFR comes in when you're on the brink of closure, right? That's the extraordinary and extraordinary financial relief. So even though Suzanne can tell you about all these financial problems that she's facing, she isn't at the place where she can apply yet for EFR. And so that's why we see as you look at the charts, new facilities entering the pool because it's not something to help you get ahead of the problems. It's just something to build a brick once you're at risk of closure or other dramatic downsizing. So it's simply designed to be a stopgap. It's not designed to resolve the problem. And on one hand, from a budgetary perspective, that's great, right? Because you're only giving the barest amount needed to keep facilities open. So it's very conservative in that way, but it also isn't building capacity, getting us ahead of the problem, you know, giving the money to staff up. It's not designed to do that. The only thing I would add to that, to Laura's point, we only have, again, 33 nursing homes and skilled facilities in the state of Vermont and we need every single one of them. So if we had invested that money earlier in the process with the problem we have now? If we were psychic and had known that the workforce was not going to rebound in Vermont, then yes. We really are, when you look at the national statistics on workforce, which is driving this, not only is the skilled nursing sector the slowest to recover from COVID, but Vermont is last in the pack. There was just a health affairs article on this actually in that recovery. So we would have had to have predicted that Vermont would be dead last for any sort of healthcare workforce recovery in any sector to have been able to know that that was going to be an issue, which I was not making. I was working for the FQHCs at that time. Maybe someone, maybe Laura knew that that was going to happen, but it would have taken a lot of questions. Thank you. Great. Thank you both very much. We appreciate all you're doing for Vermonters. Sarah and Jill, you come up to you. Welcome. Thank you. Good morning. I'm Jill Olson and the executive director of the NAs of Vermont. I'm just going to tee it up for a second and then just turn it over to Sarah. So all of you have heard from me many times, so I want you to hear from her. But just to connect some dots that I'm not sure have been connected. So the role we play in the system is to we do a tremendous number of hospital discharges. So it's probably the people who are boarding in hospitals probably aren't appropriate for home health, but almost as many individuals get discharged just skilled home health as to nursing homes. So if we weren't doing our part, that problem would be substantially worse. And if we weren't taking the pressure off of choices for care with at home services, the nursing home beds would also be further impacted. So I just wanted to connect those dots for you before I introduce Sarah. Hi, everyone. I'm Sarah King. I am the CEO at the V&A and Hospice of the Southwest region. I've been with the agency for 23 years prior to my role as CEO of a CFO and COO. Our agency has been around since 1946 starting primarily in Rutland County and then through the early 2000s we've actually expanded our territory down to Bennington County and most recently we are up in Franklin County. Throughout our 78 years though, we pride ourselves on working really closely with our local hospitals, our nursing homes, and with our primary care physicians. I employ 325 employees at various levels that provide care to the residents in our communities. Currently our census for our service area is 1500. 577 of those patients are under what we call skilled home care. That skilled care is really what Dr. Loeffler was talking about today. That's primarily where our hospital discharges the program that they come into. If we did not have those patients, they would still be in a hospital bed or in a nursing home bed. The other thing that we do by taking care of the patients at home is we prevent heavy admissions. So this is something that we are measured on by CMS and we have worked very hard throughout the years to get that percentage of patients very low. We are below the national standard, which is about 13% and we're at 11%. So we are exceeding ourselves in that. Like all of the other VNAs in the state and as Jill had mentioned, we do community based programs like choices for care, which really is a program to keep nursing home level patients in their home. Right now we have about 480 of those patients on our staff. But let's go back to that skilled nursing. Again, this is primarily the program that we admit from hospital discharges, but there are some requirements with that. In order for us to be able to do that, that patient needs to need skilled nursing. They need to either need physical therapy, occupational therapy or speech therapy. And then on top of that, we do have some regulatory requirements. So if the patient that's waiting for a bed in a hospital is Medicare. And they are waiting, but they're not homebound necessarily, then we can't take that. So there's a homebound requirement on the Medicare side of business on the Medicaid side. Again, it's meeting that concept that care. What we call that is a skilled discipline. The other thing is that we need the support of the primary care physician. We can't go into a patient's home without having physician orders. So if that patients in the emergency department, we can get a referral for a one day, one visit, we can go in one time to do an assessment. But we need to have a physician be able to put eyes on this patient to give us orders physician orders to continue to see this patient over a period of time. So that is one of the hurdles that we are facing with some of our patients will get a referral will go in. But we don't have physician orders to go back in to see these patients. One of the other hurdles that we have is just like Suzanne was talking about and Dr. Lechler staffing. We face all of those issues that Suzanne talked about, you know, we're all competing for that same pool of nurses. But one of the things that I think is different about home health care is I've often said it's a calling, not everyone has cut out to do home health care. You literally get this piece of paper with a referral on it has a name has a very brief, you know, history and physical on it might have the diagnosis it has some of the meds, but you're going into a strange home. You are all alone. You don't know if there's a family member there that may have some mental health issues may have some substance use issues. We go into unsafe situations every single day. They don't have another set of eyes those patients that you've heard about the complexity worth getting patients and I started at home health. We had maybe one or two trade patients were double digits taking care of trade patients. We don't have a trade patient a trade patient is somebody that has the they're integrated. Thank you. Yes. So we have a single nurse going into this home with a very complex patient. She has no one to consult with. You know, we can get a physician on the phone, but they're not there at the bedside with us. So it's it's can be a very scary situation for a nurse that's not extremely confident in their skills. So they have to have a lot of confidence in their skills. They also need to remain very composed in some pretty dangerous situations. And that's a whole nother story for a whole nother day about the situations that our staff put into. And the other point I do want to make is that it has to be a significant energy for that patient to come out of the hospital or to a nursing home to home care. If the patient, we're only intermittent care. We're not in there eight hours a day. We're in there to provide. Well, I'd like to say a couple years ago it was a 45 minute visit. Now we're up to patients homes anywhere from two to three hours, depending on the complexity of that patient. So there's really a need for caregiver to be in the home with a lot of these complex patients. And if there's not a caregiver in the home, then it's not a safe structure. One of the things that is also an issue for us is financial just like the hospitals and the nursing homes. We have financial struggles. Just like everyone else we rely solely. Well, I should say 92% of our revenue comes from Medicare and Medicaid. Medicare is constantly cutting us and has been cutting us and will continue to make cuts to us. But we need to remain competitive with our salaries to we need to we're all again, we're all competing for that same pool of nurses, right? If we can't remain competitive, they're not going to come to home care to provide that last year. It's getting really hard to put a budget together where we can remain competitive. My agency lost $2.3 million last year. And that was $800,000 less than a year before only because we were fortunate enough to be able to cut some travel costs out. This is exactly the situation that happened in Franklin County and why we stepped in up there. They could not sustain a freestanding home health agency because of all of the administrative costs. So we were, we were fortunate enough to be able through the elimination of the Medicaid provider tax and through economies of scale. So we could cut out some of the back office and absorb those in my Rutland office that we were able to maintain the clinical staff in Franklin County and be able to still serve the patients up there. So just to be clear that that agency is in the process of closing. That's, that's what's happening. I walked in there. I think it was actually one year ago today. I walked into that agency and they were not going to be able to make their next payroll. Yeah. I had to get on the phone. Which agency is this? Franklin County Home Health. I got on the phone with Jill's assistance and we were able to get some contingency funding from the state that allowed us and has carried us through. That money has run out and they are now under our payroll. And Franklin County is a very high Medicaid payor mix. Very high Medicaid payor mix. So that's, I think it's really important to understand that the immediate problem for patients and staff has been solved. But it's, I think from the policy perspective to understand that high percentage of Medicaid in that agency led to a closure. So I'm just going to close by saying, you know, we're all losing money. All of us home health agencies in the state are losing money. And it's really not sustainable. But we know we are the lowest cost option. And, you know, to the healthcare system and we want to work together with our hospitals and our nursing homes to try and keep these patients in home where they where it's studies show they do better in their home. And so that is our goal is to keep our patients in. Good question. And then we'll go to Leslie. You said you need a physician order and you're not getting them. So can you just explain that a little bit more? The shortage of primary care physicians. Okay, you're not getting it because there's no primary care provider for that person. What's happening in some situations is there's such a turnover of low comes that their, their appointments get pushed out, pushed out, pushed out. But if we can't go, we cannot go in, we can't say we can wait for that physician order. We cannot go in if we do not have at least a verbal order to. But they have to be signed in order for us to get paid. So it's, it's a domino effect. And there has to be a face to face visit with the. I was just going to ask, can you use telehealth to set eyes on the face? You can do telehealth through for hospice, but you cannot from here. Yeah. Yeah. Did you, was that your question? Well, my question was also about that. So what solution might you suggest to this problem? Do you have your thought about it in a way that we can think about it? If you don't have a physician, I don't know how to fix it. So first of all, some of this problem is federal. So we really need that telehealth permission for on the home health side. It's just doesn't make any sense. Some agencies are starting to experiment with actually partnerships with the emergency departments. We're seeing in one place where the emergency departments have a really strong incentive to figure out how to keep someone from needing to come to the emergency department. So in, they might be able to actually help with the order that could then allow home health to keep that patient at home. So that is one experiment that's happening, but I think it's much too early to say whether that's something that could work and also in our most rural settings. But that's one of the ideas that's on the table that where's that happening. I believe that's happening at UVM medical center and with UVM. It's a little tricky because the ER doctor can sign the first one and we do it all the time. But then at the end of that period. You can't really stay the ER doctors if they're not your primary care doc. So when they're calling and saying, we want to adjust their blood pressure medicine. Like, I don't want to do that. Yeah. You need a real primary care doctor. They're chronic medications. Yep. I just wanted to clarify if the plan of care, it actually has to be a physician. Doesn't it can't be a PA or a nurse practitioner? So it's it for home care. It has to be a physician or a nurse practitioner acting under a physician. Okay. So if they're primary. The rules are different. Your primary care is a prime is a physician assistant that they have to see a physician. Not actually, though, it could be practitioner. No, it had to be a physician. Yeah. So the nurse practitioner could order a nursing home stay, but not home health, which does not make any sense. Yeah. Yeah. All right, one more question are and then we're going to go to the commissioner. And this may be a question for Dr. Lefler and both of you together. Are there people boarded in hospitals today who would like to go to their home. But can't because of your lack of work workforce. Or can you accept anybody. And now all that qualify. If they qualify. Yeah. We are accepting them. We are not turning away. You're not turning away. Nope. And then from your end of it, folks, I mean, you folks. I hate to say advertise, but but do you kind of push folks toward home that they can go. I mean, how does that dynamic work. It sounds stupid, but everyone to go to the level of care that meets their needs. Most people want to go home. Right. In China County at the medical center, we've helped pay for travelers for our home health and hospice. Okay. We have enough travelers take everybody because when they are short staff, they say, well, this person could go home. Yeah. Have a nurse to see them tomorrow. We've actually paid nursery normal rates and the rates of travelers to have enough nurses. So we want everyone to go to the level that they the lowest level they can that meets their needs and most people prefer home. That's the most efficient. Okay. And cheapest by the way. All right. So, so you're kind of purging your hotel of anyone that can go home and should go. Yes. Yes. Okay. I would also say that it is different in different parts of the state. There is more challenges transferring to home health and in the sort of Dartmouth region than there is in the. Okay. Thank you. Thank you so very much. Thank you. I also invited a guest with me. Welcome. Hi, I'm Began Tierney Ward. I'm the interim commissioner at the Department of Disabilities, Aging and Independent Living. I think we have a written testimony that we shared this morning. We've been uploaded. I don't know if it will appear about right now. No, I probably won't. And the reason is because what I'd like to share today is a little bit of history about what we've done so far. A little snapshot of data. And then Angela Smith Jang, our director of our adult services division is going to share some information about what we're doing now some of the projects that are happening. In regards to the snapshot data you heard this morning about beds. And I'd like to share some data that we've been tracking and really just three points of time. So January of 2022, January of 2023 and January of 2024. We have been tracking the hospital post-acute information that comes from the hospitals through a database called EM resource. And in January, we saw only about 86 people at that point in time. And now there's upwards of 140 people and at any given day. So really that reflects what the hospitals are telling you this morning. So that's about 65% higher over those last two years. The nursing facility bed availability back in January 2022. We had only about 91 beds available at that point in time data. That is 76% occupancy. So all available licensed beds. We were at about 76%. And at that time we had about 15% of all beds offline. So that's a lot of beds. I'm happy to say that the numbers are a little better today for a nursing facility. So we have right now about 170 give or take available beds. We have about roughly 83% occupancy and only about 5% based on the given day of beds offline. And when I say offline, that's really due to staffing. That's what you heard earlier about not officially offline. So they've not asked to reduce their beds, but they are unable to staff those beds. So even with that improvement, there are still beds that are going unused and obviously still people in hospitals unable to find the right placement for their care needs. So this picture that if you have it, and it is a great kind of just demonstrates those lines a bit on that post-acute hospital data, which is blue. And the orange line, which is the nursing facility bed availability. With regards to what's been done so far. So the department has programs that provide the Medicaid reimbursement to folks who come in through our long term care system. So you may have heard it choices for care. That's our one of our biggest programs. And that pays across the system. So that pays for the nursing facility care. It pays for residential care assisted living and it also pays for home and community based services for people who meet that criteria. So that's another key part folks have to meet that the federal requirements for long term care Medicaid and they have to meet the clinical criteria, which is a nursing home level of care to get that service. And so some of the, I caught kind of the levers that we've had over the past couple of years is how we look at rates. You've probably heard that we have in our 25 budget, a rate increase to address some of the nursing facility. Methods to help provide financial stability back in. 2023 we were able to do a retroactive inflationary rate. For nursing facilities, because at that time they were already seeing quite a bit of. Nursing contract staff, which put a huge pressure on them. In 24 on nursing facilities were rebased to their 21 costs. And that just means every 2 years. There's a rebase on that Medicaid rate to capture. The costs in that period for that rebase. And so last year, July 1st, that was based on their 21 costs. We also did with our partners at the department of Vermont health access. A rate review of the methodology in this year. We did that the end of last year looking at where were those pressures meeting with our partners at the healthcare association to figure out where some of those biggest impacts are in the rate method. It's a complicated system. And if you ask me questions, a lot of questions today, I may not be able to answer them, but there are some really important parts of the method that needed to be changed to be able to stabilize the industry. And there's a report available for that. We also have history with residential care and assisted living and home and community based services. So in 23, the legislature provided an 8% increase for home and community based residential care services. We also in 23, we negotiated a collective bargaining agreement with caregivers who self direct. So those are those folks who may want to go home. And if they're able to and have caregivers, they can hire under our program, they can actually do that. We operate our Medicaid rates and our reimbursement through a collective bargaining agreement for that part of the program. We also completed a rate review for residential care, assisted living, home health, non skilled services and adult day. And there's also a legislative report around that. And so that we were very thankful for the legislature to provide some well needed increases in the 24 budget to address some of those and the rates varied, depending on the provider. From 4% to 79%. The 79% being in a rate specific to assistive community care. Those are the residential care homes that are taking folks. And that was a rate that had not been touched for years and years and years and it was right sided, you know, right with that 79%. So you can see we've we've done work over the years with the legislature and with our partners at Department of health access to address some of these rates. We've also throughout the pandemic and even now you heard about EFR extraordinary financial leave. There's other forms of financial relief we provided to state licensed residential care homes. They don't have the same regulatory. Say, sometimes it's a benefit. Sometimes it's not, but they don't have the same structure as nursing facilities. And so they don't have a formal EFR process, but we were fortunate to use healthcare stability funds to help residential care homes. I think that Suzanne mentioned some grant money to help with beds we also use some of those funds to help bring some beds online with facilities that were able and willing to do that. That was to help that direct kind of flow from the hospital. And then adult days, which is another critical part of home and community based services has received some ongoing legislative support to help them through some of their occupancy challenges and their costs because those center based services were at big risk and had to actually close for a period of time during COVID. So we continue to look at emergency financial relief in many ways. And then more specifically with regards to this crisis, this, the bed boarding challenge. We've had for the last few years, I think around 2021, then partnering with the health department and their Vermont healthcare emergency preparedness coalition, which brings together the partners, the folks you see in the room, the associations and to look at where the barriers to transitioning out of hospitals and some of the projects that we've worked on, excuse me, have led from that work. And one of them is a new bed boards. We've worked with the health care association over the last couple of years to start a manually based reporting of beds. We've now moved to an online expansion of the department of mental health's bed board. So we're really excited about that. It provides access to hospitals to the information. So it's how do they know where beds are available and what are the distinct characteristics of the nursing homes who are taking people because that's another very important part of the picture. We've also worked with our partners at diva Vermont health access to look at the Medicaid eligibility process. So where are their opportunities for just improving the process, frankly, for long term care Medicaid, which is very heavily federally mandated. And that's always a barrier when someone applies for that Medicare. So. That's what there's four things which is. And it's. Where. So. And they're on the program yet. So we're looking at trying to dig into that a bit more. And then in 2023 with the help of the health department were a series of just root cause analysis. This was just work to engage with hospitals to hear and listen about what were those barriers and we have some information that is leading to a playbook that will be shared with hospitals and care managers who will be able to look at where do they go when there's a need for complex help with complex placements and with turnover that that playbook will be useful. And then you've heard about, excuse me, the specialized care in a nursing facility. This came out of not only that group, but also a healthcare reform group that really was interested in starting and helping to find a place where folks with these complex combination of nursing home level of care. So they need medical. Physical care and also have things like mental health conditions, substance use disorders, or they're in jail. That's a whole another population and discussion. But how do we do that and and. And. They. You know. There's quite a bit more here, so if there's any one or two key things we need to know Yes. Thank you Madam Chair. I would say I support everything that's in our budget with regards to the nursing facility rate method and how to stabilize that. I also support our partners who testified about home and community-based services as well and how do we shore that up and I'd like Angela just to maybe tag on a couple of things that we're doing that Yeah, how do I pull out just those key points? Angela Smith-Jang, Director of Adult Services for the record. We have a team of nurses that are working with the hospitals on some of those complex care discharges. I really want to ensure that that gets called out and they work to build relationships with the hospitals, the nursing homes, the other providers and kind of work on it as a team to find the right placement for folks. We're able to offer special rates in certain situations on an individualized basis for someone who has complex care to support a nursing home in taking them. And then we're doing some pilot work. We have some grants with hospitals to pilot enhanced discharge planning, really looking at supporting that process. We're working with the two hospitals in southern Vermont Brattleboro and Southwest. And then I'm excited to say too that we're using some enhanced F-MAP funding, the ARPA funding, to do a promotional campaign around our direct care workforce as well. Really, we know workforce is a key challenge that is being faced across the continuum of care. And so this marketing campaign will promote the value of this work and support connecting workers to all of our providers across the continuum. So that'll be happening this year as well. And I do want to call it the eye care hospital or facility. I'm not sure what it's called. Not in our committee, but I know that's a long time coming, which is fantastic. Based on everything we've heard here, I'm curious how many hospital patients eye care will take? That's a great question. We've been working with our department of mental health and our department of corrections to track people who might be eligible for their services. And I would say that people who are, it's going to depend because people have to be fully eligible for choices of care. There's that piece. They also have to be able to be served in a nursing home, kind of eligible to live in a nursing home. So it will depend on the actual individual people. So they're looking at that now. They're looking at our list of people that we know about, trying to look at who would be eligible, who would be the highest priority because the beds will be a premium when they first open up. We think there might be about 20 folks from corrections that eventually could be served. So they'll have to balance that between probably I'm estimating about half of those beds for hospitals and half or maybe a little less than half for folks in corrections. And so when you say they, who makes that determination? The determination is made between the state and eye care. So there's a process that each person has to go through to be screened because we have to make sure that this is the least restrictive setting for people when they apply because it's going to be the highest level of care for folks. So the state will screen for that, screen for eligibility, and then eye care will do their required admissions screening as well. Great. I apologize. We've run out of time, but we appreciate all the work from everyone that's in the room today. We know it's a tough situation and we thank you. And everyone who's online, Suzanne, thank you for being here. And healthcare is back in the room for 10-15 start.