 folks. This is a joint meeting House health care committee as well as House the breaches and institutions committee and we had a joint meeting. Long time ago just the first week of the session. He's a long time ago. I was like 4 months ago. Yeah, 4 weeks ago. We're going to continue our that meeting. We had scheduled that that previous meeting to hear from our contractor who provides health care services. In our correctional system, our correctional facilities here in Vermont well packed so entity we contract out. They were on zoom and waiting for us and we just didn't have the time because we spent bulk of our time talking with DOC for folks to get an understanding of how health care services are delivered within a correctional setting, which is a little different community. So we've scheduled today to hear from the contractor that the state contracts with and we're going to start it next to this Titus Titus was a director of health and wellness for the Department of Corrections. And we have just because chairman who is here who's regional vice president. Well that and I don't know if you both want to come up at the same time. How do you want to do this? Okay. Okay. Can't you come on up that table seems so I know my glasses. I know so much. Sorry we're so far away. Are you okay down there? But you're okay. Yeah, that's fine. So if you could introduce yourself Max and give us just what your role is and also the how DOC enters into a contract, what the process is because we have a bidding process and how long the contract is for cost and what is covered. Okay. Yeah, Max Titus I'm the director of health and wellness for the Department of Corrections. I can start with a broad overview and then zoom in or answer questions as needed. So as you know, we are current model for providing health care in corrections is through a contract with an outside vendor. Our current vendor is well path. We are in our seventh month with our contract currently that started in July of last year. And there is an extensive process that we go through so the contract was about 18 months into our process of getting a new vendor. And so that planning process started early in 2022. That process essentially starts with us looking at our current model, looking at the system that we have, looking at the resources and determining if any of the alternatives out there are something we want to pursue. For example, some states and some jurisdictions do a contract model like we do some employee state staff that provide the direct care, some partner with outside systems to come in and provide the care and some do a combination of all of those things. So at that time in January of 2022, the department decided to move forward with our current model, which was to go out to bid for a new contract knowing that we were planning for 18 months in the future. So our team essentially spent a ton of time with our RFP to make sure that it included the expectations of what we were looking for in our system. We view it as our team at DOC builds and sets the expectation of what the system will look like and the vendor is implementing and providing the care as part of that system. So we released the RFP in mid-2022. We received two bids both from private or profit healthcare companies that specialize or specifically provide healthcare and correctional services. Based on a lengthy review of that of both vendors materials, we did interviews of both vendors, did research and media and legal histories on those. We determined that well path was what we were going to move forward with contract negotiations. And then we engaged in the discussion of the details of the scope of the contract, the financial provisions and any conversations about state language that's included in all of the contract. So that process concludes with an agreement between both parties of what we anticipate the contract to look like. And then from there, there's a state review process where it goes through various state agencies for approval. The intent is that the contract started on July 1st, which it did. A WEP transition period work that goes into that actual takeover that happens 90 days and further in advance of the contract itself. So we consider that pre-90 days plus the first three to six months of any contract as transitionary. A new vendor is really common. They're onboarding and training staff. They're recruiting for vacant positions. They're learning the system. They're learning how we do gains and fractures in Vermont. And then they're assessing what needs to be done to improve the system or to bring it to the contract expectations that we have with them. So that brings us about to where we're at now, which is we've just sort of shifted into a phase with WEP. And we've been focusing on a change management plan, which is a requirement of their contract. Essentially, they spent the first six months assessing the current system by a contract requirement and determining where in our system we are meeting those expectations already or what changes may need to happen for us to get to achieve, essentially, our desired state of health system. So that brings us to essentially where we're at and covers the bid process and the contract negotiation process. And I'm happy to talk a little bit about the specific contract structure and then answer some of the questions that were posed in the last testimony about the financial provisions that you guys didn't get into. Do you want me to pause for a minute? Before you go there, I know we have a question for our member. John? When you review the bids, when the two come in, do you keep the price concealed until you've reviewed all their aspects and then look at the price last? So we predetermined criteria for scoring of the materials that are presented as part of their proposal. We don't keep the price confidential until after, but it's scored separately and our financial director is a part of that conversation as well. Essentially, we have a team of individuals that come from mostly the health services team at DOC plus some operational folks, financial folks, and folks in different divisions that come together, review all of the content of the proposal, essentially all the services that the vendors are proposing to provide to meet our requirements. And then we have a separate conversation about the financial aspects, which factors into the decision. And then we have another conversation about the IT components, which is they bring their own network to our facilities. So there's an ADS component too. Did well path appear to have the lowest price? That's a good question. The cost in this, I don't remember the exact numbers. The cost for the two bidders that we got in this last bid was very similar. It's very close. Great. And then Mary, and then we'll continue with your testimony. Thank you. This is coming from nurse healthcare workers. What standards does the Department of Corrections and or well path use? What model of care do you follow? Do you follow national standards like the National Commission on Correctional Health? And did you use minimum standard of care for correctional health care to evaluate well path and to continue to assess quality and safety in an ongoing way? Yes. And actually I was going to speak to that, but I was just going to announce that. So that's good. So our contract is structured around the National Commission on Correctional Health Care Standards. All of it's a requirement of well path to ensure that all of our facilities are accredited. And we have been accredited for many years through multiple contract terms. That is a baseline. What we consider like a minimum standard of care. And we actually, in our contract, although it's structured in the same like title format as NCHC standards, within each of those, we include Vermont specific requirements that go above and beyond the NCHC standard. And then we have an additional section at the front of the contract at the beginning that goes into any Vermont specific requirements that aren't already included, including a minimum like staffing levels in certain areas, human resource requirements, etc. You could share with us. Sure. The contract, you mean? Yeah, electronically. Yeah. Can you make a note? So we have one more question. I am. Mary. And then the other two. Any. So the bid on this highlighted well path is being the getting the contract. Were there certain services they could provide that the other couldn't? Or how did that come about? That's a good question. So obviously I mentioned we had a scoring process with predetermined criteria that was specific to the actual bid materials and what the vendors were able to provide. In that case, it was relatively similar between the two parties. So we really relied heavily on the interview process with the vendor. One of the things that was really important to us as a health services monitoring team was making sure it was really clear what our philosophy was about the care that's provided within our facilities. There's this term. It's commonly called correctional health care. And we actually were upfront and talked in our interviews with our vendors about or with the bidders about our philosophy that we are not providing quote unquote correctional health care. We're providing health care that happens to be in a correctional facility. If that was the core value of our discussion with the bidders was about philosophy and whether the philosophy of the vendor aligned with what we're looking to do. So let's say that was the primary difference. So when you went through this process, does the wellness team or whatever your team is called work with VDH, Department of Health, Department of Mental Health, DEVA, the other agencies within agency of human services that provide and monitor and do insurance for health care. Is there a collaboration there at all? Are they involved at all in the process of selecting a vendor or monitoring and providing oversight of the vendor? Yes. Good questions. So they are involved in the, I would say in general, they're involved in our day-to-day work. We work with the other departments within AHS frequently. For example, it's a requirement that the vendor have a drug formulary that's as closely aligned with the Medicaid preferred drug list. So we are working with the other departments to determine what is the community standard. How do we build that into our contract language to make it clear? During that process, during the process, we try and include a representative from another department and other divisions to have that voice there. And if they're not included in the specific scoring aspects, they're consulted as part of the process. Great. Thank you. We're going to hold. So write it down. We're going to let Max continue. I'm going to continue on because I also realized I didn't answer the CQI portion of your question. So I was going to talk about that anyway. So there is an additional section of the contract that is devoted to how we as a monitoring team oversee the services that are provided and then how we're able to follow up with the vendor to make changes and impact that change process. So WELPAP, as any healthcare entity has their own CQI process, and I'll let Dr. Sherman talk more about that. But we require that our team is a part of that process along with them and that we are able to bring to that discussion any areas of concern that we have. The contract requires us to have a monthly meeting and a committee. And there's a whole process outlined about how that happens. And the contract also ties liquidated damages, which I'll talk about when I get to the financial more. So essentially we can withhold funds if the contractor is not engaging in that process with us as it's outlined. Max, I think it would be important to talk about what the cost of the contract is. Yeah, I guess give us the dollar amount that we pay for it. So to specifically answer that question, there's two answers. There's a per individual, per month rate that we look to. But essentially it comes out for year one, around 34.7 million is the total contract budget. And then for year two, it's 38.1 million. And for year three, it's 40.6 million. And that is based upon during the contract negotiations process, the vendor brings a budget with their proposal of what they propose it will cost to provide the services that we're requesting. That budget is broken down by sections that include everything from staff costs and benefits to pens and pencils. It's broken down and itemized in the way that you would anticipate like a healthcare organization. And so that PIPM is determined during the negotiation process. And we refer to it frequently, but I want to be clear, it's the basis of the negotiated amount that is paid to the vendor. Once it is signed and the contract is done, that per individual, per month rate does not change based on the daily fluctuations that we have with the number of individuals. So during the negotiations, we determined an estimated in-state population would be 1250. And that's how we calculate that PIPM times 1250 is how we get the amount that we pay well on a monthly basis. It is the same amount each month. And it's been determined. It doesn't vary unless we go outside of a range of average daily population. And then we would be negotiating that. Can you tell us what the rate is? So yeah, for year one, it's 2,253.33 cents for year two. And this would be in the document I showed, by the way. So it's 2,476 dollars and 81 cents. And for year three, it's 2,636 dollars and 74 cents. Wayne. So those are pretty substantial increases from year to year. What's driving that? So that's part of the proposed budget. The cost of health care continues to rise. The cost of staff and the reliance on agency staff when you have full-time staff has increased over the years. So we add into that budget. I guess we don't well-packed us, but then we can talk about that during the negotiations. An amount that seems reasonable for what they anticipate the cost of supplies and staff and other increases from year to year. So it seems pretty substantial increase that's projected out future. And you're locked into a contract with that. We are and you have terms that allow us to renegotiate if there's a substantial change in either the service or the conditions of the system. And can I just follow up and if the cost is more? Yes, let me talk about that. And then we'll go to our for your question. We oftentimes, and I think this came up in the last testimony when my colleague was here, get questions or comments about contracting with a for-profit vendor. The question tends to come up about how would that or would it impact care? And if so, how? So our team has considerations when we look at the vendor and the cost model. And so for the last several contracts, we have included language to try and address that issue and to make sure that providing less care does not incentivize additional funding for the vendor. So our contract requires that pre-agreed upon budget and a year and reconciliation every contract year. At the end of each contract year, WELPAP has to provide their actuals broken down and compared and mapped to the budget that was originally agreed upon. If their actuals are less than the budgeted amount for that contract year, the difference is returned to the state and it becomes state funds again, it's used at our discretion. If at the end of that contract year, we actually have spent more in actuals than what the contract was budgeted. There's language that requires like a shared risk. The first 3% of the overage is paid for by WELPAP. The second 3%, so 4% to 6% is paid for by the state. And if we're over 6% over our budget amount, we negotiate based on the circumstance. So essentially, if WELPAP provided less care and didn't spend as much money on it, they don't keep the money comes back to the state. The question was, has that ever happened? Not in this contract or the last one, but in previous contracts, there were times where savings were returned to the state. All right, go ahead. Yeah, when a contractor like WELPAP comes, you know, they came in, walks talking about all I guess to do this work. Do they bring equipment with them, supplies, or do we provide everything that they need to do the work? Is it just people? It's not just people. So we obviously provide the space and we provide equipment to the extent like the beds. For example, DOC pays for the bed. So in infirmaries, when there's a hospital bed, DOC purchases those. We provide anything that's property of the state. WELPAP does bring in office furniture and specific medical equipment that they may sell contract with for vendor to provide onsite. And Dr. Sherman can speak to the details of what other equipment they bring in. But they also are bringing in an IT network. So even though they're working in our facilities, they're not using the state's network, they bring their own IT network into the facilities. Their staff are working on their own network. So there's an ADS component to it. They're bringing obviously staff and they're also bringing like subcontract services that might come in as well. And how about like personal gear? All the personal gear is there. All of the medical supplies, medications, anything that's needed for the actual provisions. Yes, there's provide. Okay. All right. Thank you. So we have another question, John. With our contract down in Tallahatchie, does that include healthcare and is a WELPAP play a role down in Mississippi? The contract with WELPAP is just in state. The contract out of state, which is not my area of expertise, does include the healthcare portion of the folks that are out of state. Do you have much more? Are you? I have a couple more financial things I wanted to mention just about the contract. So we also include, I might have mentioned liquidated damages as part of our CQI process. Essentially that is predetermined and agreed upon rate that our team can deduct from any invoice when we have determined that the contractor is not fulfilling the terms of the contract and not engaging in the process to improve. Those liquidated damages are deducted and cannot be recouped at a later time. So if it's, if we deduct from the invoice, the WELPAP doesn't have the opportunity to earn it back. We also have holdbacks, which we can use any time we haven't received all of the documentation or information we need to verify that WELPAPS has complied with the contract. We can hold 5% back from each invoice. On the flip side, we also have payment incentives for a certain performance. So we have a list of performance metrics that depending on the threshold of performance by WELPAP on each of those metrics, they can earn an additional up to additional 3% on top of what we have determined as the year budget. And so those are calculated on a monthly basis and added to the contract when funds are released. So I think that's, those are important aspects. And I need to talk more about that if you want, but just wanted you to be aware. I think generally I'll just say when we're looking at the system in corrections, it's important to consider in context with the larger health system in Vermont, we're just a part of the larger health system. And what we often see in corrections, as commissioners demo and being noted last year in their op-ed, mirrors and magnifies the challenges that are seen in the community. We are seeing generally an older and safer population, people that have a lot of health needs and are challenging to care for. So I think that's important to consider as some stats on, you know, percentages with chronic illnesses, the percentage of M.A.T., you know, things like that, if you want me to speak to us, but I know you have time. So I have a lot more questions here. So we have Mary and Chip and Tristan. Okay, I saw a hand. I think you characterize the process as a negotiation with WellPath in order to forward the process here. My question is, is there a vetting process as well as a negotiation or is that part of a negotiation? Is there a separate vetting process and how might that work? Can you say what you mean by vetting process? Well, I guess look into the practices and history of the potential provider and, Steve, you can recognize anything good or bad about their practices and free? That sort of thing. Okay. Yeah, so the negotiation process is strictly after we've made a decision to move forward and the vetting process happens prior to that during the bid review process. So once we've reviewed the materials, interviewed vendors had internal discussions. We do reference checks. So the vendors providing references to us. We also do other background and research. And I can defer to Isaac, who I think was involved in that process, to look into, you know, media history, legal history. All of those things are required as part of the bid submission for the vendor to provide us their litigation history and essentially that information. And then we do our own checks of that as well. That happens before the negotiations. Then when we make our decision, then we shift into negotiations where we're talking about one with a vendor about the terms of the contract. Does the provider have to be licensed in Vermont in order to obtain this contract? So the contract is really comprehensive services. Each individual who is providing service under that contract is licensed just like any community provider would be. So the medical providers are licensed. Medical providers in Vermont have nurses or registered nurses. Thank you. Tristan, Michelle and Connor. Thank you. It seems to me that there's some reassurance that there's an incentive. There's not incentive to withhold health care. It is the intention of the contract. That seems clear. It doesn't seem clear that there's incentive to get people healthier. And if you looked at performance-based ways of actually asking to give in the many challenges of the population that DOC is serving, what path is serving, to look at population measures like hypertension, diabetes, and try to rein those numbers in to get people healthier? Yeah, that's a good question. So I mentioned very briefly the pay for performance metrics. So we have a pre-determined list of metrics, which are a combination of things that are interested, interest of our monitoring team, as well as metrics that were originated through like HEDIS measures, which is like a you know, a well-known hospital metrics. And then we've also consulted with our VDH, our diva partners, to talk about metrics that might make sense as well. So that is incentive dollars, which is intended to be that if the vendor achieves certain outcomes beyond what's required by the contract, then they are getting additional funding. How much? It's up to 3%. That's the total contract. Thanks. Michelle and then Connor. Yeah, so my question, then we're going to go to WellPass, so we make sure we get to them today. Like that's related to that as well. Actually, you talked about liquided damages and incentives. I'm wondering, it's actually two questions. The first part is how often is that calculated? Do you look quarterly? Do you look annually? How long do you take to look at potential damages or incentives and then figure that things are either going well or not? So that's the first question. The second question is, could you give some examples of what that looks like? You know, are we talking about, you know, fewer heart attacks over a long period or like, just if you could give some examples of what would qualify as an incentive and also particularly like what would qualify as when damages would happen because that feels like a useful thing for us to know. Sure. Yeah. So they're calculated monthly because they're tied to each monthly influence. And I mentioned, I think briefly, but it's worth noting that that liquidated damage is essentially a rate based on the amount of time that like the actual amount of time it takes our team to resolve whatever issue it is that we have. So if our team collectively spends 10 hours in a month to resolve an issue that we're not getting what we need from the vendor, then we would say 10 hours times that pre-negotiated amount, which I don't have off the top of my head. And then that would be deducted from the invoice that month. So that's how it works. So just based on how much time they take to address an issue, not what the outcome is of the issue. That's how much time our team has to spend to resolve the issue. So essentially it's like if we've assigned a timeline and they don't need the timeline and it takes our team four hours of conversations and following up or whatever to get the resolution that we need, then we charge four hours times our rate. And then what about the incentives? And on the incentive, I don't want to quote the specifics, but we have the metrics that we could provide the description and numerator to not bear for you. But is it also about time? Some of them are based on the threshold of meeting timelines that we've expected. Some of them are about discharge planning and the percentage of individuals that are receiving certain elements of discharge planning at release. There's, I think, 26, my case. Yeah. Honor and then John. Thanks very much, Max. A lot of my questions answered already with some of the guardrails in the contract. And I'm just kind of trying to balance in my mind like what's realistic versus what's acceptable, right? And in my mind, having like a private equity firm, chair for people in our custody, still subject to like bottom line objectives and shareholders, I just don't like it. It sits wrong with me. But realistically, I've seen the cost models, right, of how much it would cost to bring in house. I know that like prison healthcare doesn't get great press generally, no matter who's providing it. But at the same time, we're the oversight committee, right? And it's a gnarly Google search well path. It is. It's somebody at Springfield whose license has been suspended in three states. It's inmates getting the wrong medicine. And it's tough, I think, when constituents call, because it feels like there's a level of detachment, you know, when it's a private contract versus more in-house work where it could be more accountable, more oversight to it. So I guess the question is like, you know, I'm looking at the cost analysis and has 204 full time positions for state employees. The first question would be do we have 204 well path employees on the ground right now? And then you kind of mentioned like looking at other models. And I think it's interesting because like the state hospital, some of our state employees do work, but they partner with the tertiary hospital who's providing some of the functions at the top and there. So like, have you considered those models? I wonder like, you know, if you ask Fletcher Allen, hey, here's $40 million. Could we work out a deal or something? Would that be a conversation starter designated agencies with mental health? So I'm just wondering like, so going forward, like it might be acceptable now, but long term, do we want to move in another direction? Yeah, no, I mean, I think I understand your question to be like how, how have we considered other models in the past? And to what extent? So I'll say we, I mentioned before in the bid process, that's always the first step before we decide to put out to go through that process. It takes a lot of time and effort. We consider it. And each time we go through that bid process and then sometimes in addition to that, we do have these conversations. I think the last time, looking to Isaac to make sure I get the number right, but the last time we did an estimate of what it would cost to do it strictly in state, the number was more than double what our annual contract was. Well, this now I think it was upwards of 80 million. And, you know, that is based on all the things that go into employing state staff versus a private entity employing staff, the ability for vendors to get negotiated rates that are lower than what we may be able to get because they're doing large like national scale business, things like that. We do consider that we consider partnerships. The challenges, we experience the same challenges that the community system does with staffing in being able to hire and retain staff. WellPath has a lot of resources in recruitment and being able to hire and onboard staff in ways that would be challenging, I think for our state to do, based on the resources that we have here. So I think there are some operational challenges that we consider as part of it as well. We have approached community health systems and providers and had some of those conversations about the DEVM health system, for example, and none of those conversations have ever resulted in the outside entity wanting to be a partner of ours. And so I think once we do get into detailed conversation, people start to understand how complicated it is and how complex it is and difficult it is to retain, hire and retain staff, and to provide service at this level. Great question. John. Can you follow up on Representative Boslin's question on liquid damages? When you mentioned that my mind immediately went to, okay, for an example, diabetic, it's foot infection, it's not treated properly and it results in hospitalization or worse. From your description, it didn't sound like that was part of the equation. Yeah, it could be. So if we had heard of that and identified based on it that there was a deficiency in care provided that was an issue of the vendors, we would engage them in that CQI process that's outlined in the contract. Essentially, it allows our team to gather as much information as we need to really evaluate the issue and then designate that we've identified a deficiency that needs to be resolved with a plan. If well pack is agreeable and makes the changes necessary, we would not engage liquidated damages. However, if we don't get the response or the change in practice that we're looking for within the timelines that have been set, then we would engage the liquidated damages for that. Okay, thank you. Great. Max, when you send the contract, and which I'm assuming is where the metrics are that you've talked about, if you can point those out, and if you could also include any results to date that you've had with WellPass or if you could just see what the has been and what the oversight is, that would be great. Thank you for your testimony. Thank you, sir. Ready? Jessica, why don't you come on into the hot seat, which has been warmed up. Welcome. And if you could identify yourself for the record, and you've also heard some of the focus of some of the questions, but we'd also like to hear in terms of how WellPass sees delivery of services within a healthcare situation, maybe also explain a day-to-day operation of what occurs in a facility with your medical staff, what they encounter, what they see coming in for services, how it gets resolved, how it doesn't get resolved. That might be helpful for the committee to have a perspective of what's occurring within our facilities. Yeah, of course. Good evening. My name is Dr. Jessica Sherman. I'm the regional vice president for the WellPass contract here in Vermont. Our services, we provide comprehensive medical and dental and psychiatry, behavioral health, nursing. We contract with audiologists, ophthalmologists. We provide physical therapy, radiology. Just about any kind of service we can provide on-site, we will do so. If we are unable to provide that on-site, we contract with community providers to set them up with, say, a specialty care like a cardiologist or endocrine, and then we will follow that plan of care that that provider has set forth for us. Good day. Each site has a medical clinic, so just kind of give you an overview of how each site is run. They have their, each site has their own leadership. They have what's called a health service administrator. That person is the administrative oversight of the clinic. They have a licensure. They may be having licensure or certification in healthcare, but they may also have a degree in healthcare management. Most of our HSAs are nurses, although they don't have the nurses to be in that role. The HSA is the administrative oversight, so they are the liaison for that site between the medical department and their site DOC. They meet daily with the superintendent and other members of the DOC on that site to review medical cases that they need to know about. If somebody is going out for an appointment or maybe there's somebody in the hospital, they would give updates on when they're planning on coming back. Maybe they have a patient in the infirmary, who talk details about when they could be released to go back into their housing unit. The HSA also provides just overall ensuring that the day-to-day for the staff on site is that they can do their job. So providing that support and ensuring that supplies are ordered, ensuring that their staff is supported in getting medications ordered. They also do a lot of like peopleing, so if there's conflict between staff then they would help resolve that. Next in line after the HSA, so everybody on the site ultimately reports to that HSA. Next is the director of nursing. Each site has a director of nursing. They're the clinical oversight of the nurses. They focus on orientation, training. They also focus on patient care. They help us with our CQI processes and making sure that it's getting to the frontline staff. So it's not just a meeting that Max and I have. It gets to the HSA and it gets to the DOM to be able to implement at the staff level. They also are clinical, so they may fill in for some of the vacant shifts if necessary. They also are able to resolve conflict amongst team members. They see patients themselves. We also have what's called a health service coordinator. Most of our health service coordinators are LNAs, although you don't have to be an LNA. They are busy usually schooling outside appointments for our incarcerated individuals. So they take what is given to them from our providers and then they put it into our utilization management system for referral and approval and then they set up the appointments for the incarcerated individuals who are welcome to have their appointment. They also help with discharge planning. They can speak clinical of their LNA and help on the floor. I kind of refer to them as the glue that keeps everybody together because they are the ones that kind of also help order the supplies and whatnot to make sure that we have everything we need to be able to do our things. We have nursing. We have medical providers. We have psychiatry. We have mental health at every facility. We have dental chairs at four of the six facilities and the two facilities that don't have dental chairs, they have transports twice a month to what I like to call their sister site. So Marble Valley and Rutland goes to Springfield and Northeast and St. John's Berry goes to Newport. Day-to-day meds are a large part of what our nursing staff does. We deliver about 10,000 medications, 10,000 pills a day in the state to our incarcerated population. So we have nurses that are dedicated to med lines. They help specific times of the day that we do med line at each site. It's based on working with the security side is why every site might not have the same times. It's based on security flow. So we provide meds. The nurses also do what's called sick call. So if a incarcerated individual has an acute complaint, they are able to put in what we call is a sick slip. The sick slip is entered into a centralized location within their dorm and then a nurse comes around and picks them up at midnight. They read them and triage them. If it's an urgent thing, like sometimes people actually put on sick slips, I have chest pain. So in the middle of the night, they will go to that individual and assess their chest pain. But if it's something is, I have hangnail. I have back pain. I want to be seen by the provider. Those things are triaged and the nurse will see them face to face within 24 hours of receipt of that sick call. They will use the well path nursing guidelines to take care of that patient up to the scope of their practice. And then if they are unable to treat them based on their scope, then they would be referred to the onsite provider. Nurses are also very involved in site level on wound care treatments. They do like nebulizer treatments. They're also in our booking area where the intakes come in. They do that medical intake that spoke about that is very lengthy process. They'll do that medical intake. They're also out there with our patients that are coming in and out for quick, if we have people that come in that are actively detoxing or, you know, they're for a short period to sober up, they are monitoring those patients as well. We have for medical providers, we have a majority of a majority mid-level provider. So we have nurse practitioners and physicians assistants. We do have a doctor coming down to Southern in a couple months. We are, once that doctor arrives, we'll be fully staffed with providers. The providers day-to-day, the nursing staff will step them up with a list of patients to see when they were seen last, basically. So the providers are doing what's called an initial health and physical that has to be done within seven days of being admitted into the incarcerated setting. After that, their annual health or periodic health and physical is based on their age. So the older you are, the more frequently we're going to see you. So it might be every year, it might be every two years, every three years based on your age. We also have what's called a CIC, which is a chronic care visit. That is, you know, we've determined in your initial HMP, we realize that you have maybe diabetes or heart disease. We're going to have you have an initial chronic care visit at that time, and then we're going to manage your chronic care condition. They typically, in the beginning, might see them more frequently, but it's usually a 30, 60, or 90-day rotation. Once you're stable with that chronic condition, then they would put them on the 90-day rotation. So they're seeing those patients, and then we're popping in those CIC calls throughout the day as well. If everything is moving, as if we're working with our Department of Corrections counterparts, so as long as patient movement isn't altered, our providers can see anywhere from 15 to 20 individuals a day. We also have dental. Dental follows the same process with initial and periodic reviews, assessments, and CIC call. There's dental CIC call. They have to be seen by a dental provider within 30 days of admission into the incarcerated setting. Typically during the initial health and physical or the nursing upon medical intake, they will do an oral exam to see if there's anything that would require them to be seen quicker. We have psychiatry at all of our sites. Our psychiatric providers are nurse practitioners. We have used remote psychiatry for the majority of our facilities. If you have two facilities, the provider comes in person at least once or twice a week. But our psychiatry is done remotely. We do have folks who will set up the telepsych for the individual and they call them up. They set them up. They wait for them to be done and then they bring the next person out. Mental health is, you know, they have also parameters that we follow based on NCCHC guidelines. Once somebody comes into the facility, they have to be seen within seven days. Once they're put on the mental health list, they also have those periodic reviews that could go 30, 60, 90 days, same with psychiatry based on their med requirements. You want to stop? I do think we have a couple questions. So we're going to start with Art and Mari. Melanie and then Connor and Daisy and me and Leslie. I guess I'm first. How many overall visits do you see, I guess, let's say in a month per year? I mean, how many interactions with patients that are sick or have pride? If you check somebody in when they first get there, I get that. But how many times are people going to the infirmary? I mean, do you have data on that or maybe you don't know? Well, the infirmary is different than our medical suite. So each, so we have like a clinic, like a primary care clinic. So we act as like a primary care, urgent care in our clinic. And then Southern, Northern and Chittenden have an infirmary, which is for a higher level of care. Okay. So clinic, every facility has a clinic? Every facility has a clinic. But every facility doesn't have an infirmary? No. If we have an individual that is got healthcare needs that would be not hospital level care, but not, they aren't able to care for them in their current facility because they need infirmary level care. The DOC transfers them typically to Southern state. Do they have an infirmary? Yeah, to an infirmary. Okay. So how many, so I guess my question would be how many visits to clinics do we see in the fourth of a year, a month or some indices? So we get an idea of volume. We do have a date on that. Yeah. You figure it out. I just wanted to get a sense of what we're talking about here. Yeah. Yeah. Just to give you a context. All right. The monthly average sick calls is about 3,400 sick calls across the state. How many? Can you say 3,400? Yes. 2,400. Monthly. And the average monthly number of provider visits is over 1,000. A little over 1,000. What was that last one? Provider visits. Okay. What's that mean? So provider is medical. Are you just telling medical? So medical provider visits. Okay. So you got 3,400 going to the clinic. And then beyond that, you've got 1,000 that are on, that are being seen by the provider for their HMP or their chronic care visit. Okay. Okay. Is that 1,000 part of the 3,400? No, that's what that's separate. That's what, yeah, that's the nurse. Those sick calls, I don't know. And that is not unique individuals. That could be one person coming in 10 times. Yes. Yeah. All right. Hi. Good to see you. Good to see you. Oh, colleagues in the past. Dr. Allen was called Dr. Allen. Yes. I have 2 questions. 1st one is remind me who does the triage when there's a stick slip? The nurse. A nurse. A registered nurse. A registered nurse or an LPN. An LPN is doing the triage and the call and RN has to sign off on it. Okay. And does well path provider do fill facilities? Any of the facilities have point of care testing like EKGs when someone's having chest pain, diagnostic imaging, ultrasound, things that can be transmitted for interpretation by a qualified provider and lab sampling, for example, for acute medication levels. Yeah. We do phlebotomy on site and we send labs out. The labs come back and providers will interpret the results. We do have radiology that comes into the sites when there is a need. And then there is a part of that service is somebody that reads and interprets that. And the provider can also read that. EKGs as well. EKGs. We have an EKG machine in every clinic. And a qualified provider can read that immediately. And then can you give us an update on the progress you're making around the hepatitis C issue? Can you be more specific? So there was a case and I don't know if you want to dive into this one. I'm sorry to put you on the spot, Jess. But there was an issue with hepatitis C levels. I think you might be referring to a settlement agreement that was in place. Yes. To this. Actually, that agreement has ended. I think we're closing out our portion for that agreement. Our policy is the same as what was agreed upon with that, which I think was in 2021. Hasn't changed. The challenge with treatment for C is really around the determining someone's length of stay and the amount of time that's with us for us to be able to do the workup to determine the treatment that's appropriate. And then provide the eight to 12 weeks of actual medication and then monitor applicants. So our policy addresses how we factor in known length of stay into clinical decisions. And then there's specifics in the policy around folks that are treated regardless of length of stay that needs sort of clinical thresholds of disease. So our policy is unchanged. Our monitoring has continued since. The screening. Yep. If it's screen positive there, like any other CIC process that are followed by the health provider, the additional lab work and a workup that's needed to determine treatment occurs. And there's a review of most of them, just part of our policy. And thank the, it did receive, well, certainly after I asked for the contract. So I appreciate that that was, was sent along with a bunch of other documents. So thank you. Melanie, I believe I heard you saying that health service coordinators within the hospital are within the expressions to speak sometimes outsourced to other specialists or sister site. I'm wondering how many times that happens and is the billing for that? Melanie, can you speak up a little bit? Sorry. Is the billing done for that sprues and negotiated contract or is that another and providers get great value? How much we get of that? They're reimbursement. I can't speak to the reimbursement. But the, yes. So we do, we use outside community providers for specialties. And there's data on how many times we have. I can get it. It would be in our utilization management system, but we do send our incarcerated individuals out for specialty service quite often. And then you spoke about psychiatry being done remotely and on telehealth. I'm curious if there is any in-person counseling if you could speak to what happens for mental health here within the facility. Again, Melanie, we need to hear. Yeah, sorry. It's a really long table. You spoke about psychiatry being done remotely and telehealth counseling. And I'm just wondering if you could speak to what it's done within the facility person to person. Yes. So we do have mental health licensed mental health clinicians on site. We also have rostered as well. Oversight is from the licensed folks. So each site has mental health counselors. They do one-on-one sessions with individuals and they do groups. All right. So I have Connor, Daisy, Leslie, Wayne, Tristan, and then we're going to go to Vermont Department of Health. Connor. Thanks, Dr. I have no worries if you don't have it on you. I was hoping you could just maybe provide the committee with some of the staffing numbers, total staff on the ground, administrative versus medical, who's doing telework, how many of Vermonters would be interested. And I was wondering, it's a tough gig, right? We've trouble recruiting COs and we have trouble recruiting healthcare workers. So having somebody provide healthcare in a facility, that's a heavy lift, right? What are some of the strategies for recruitment that you use? So WellPass does have a robust recruitment team. And I would just like to say that we work for WellPass, but we're all Vermonters. So we're all people, we didn't come from some secret WellPass thing. We are all Vermonters. So I'm born and raised here. So we're all Vermonters. We do reach out for the sites that are closer to the borders. We do get to stretch our recruitment strategies out to New Hampshire, into New York. We've even, for Newport, started trying to recruit up in Canada. And there's a, can't remember the town right about that. So we have one, when we first started the contract, we had four recruiters dedicated to Vermont from WellPass. In that time, when we transitioned from VitalCore to WellPass on July 1, we had significant agency usage, travel nurse usage, especially in Newport and in Southern state and Northwest. And China. So four of the six sites has substantial use of agency use. Since their recruitment model has come in, we have been able to, we no longer have agency usage at Chittenden and the women's facility. We are close. We have about four FTEs, three FTEs left at Northwest for nursing to replace agency with about four at Northern as well. And Southern, we have, we were about 80% agency when we switched over. I would say we're probably down to about 60% now at Southern. Recruitment strategies that they have been using when we, you know, tried to trans convert agency staff members that have been here for a long time. Some of the agency that have been working with corrections have been working with corrections in Vermont for years. So getting them to convert to WellPass has certainly been successful with a handful of agency staff that have decided to convert to WellPass. We also, you know, go to students in the nursing programs. So we try to get clinical, clinical placements. Yes, clinical placements. Thank you with nursing students, nurse practitioners, students so that we can recruit from that as well, because that's really where you need to start. They've been doing a lot better job of reaching out to people. They've been doing a better job of, you know, making sure that those posts are on Indeed. And they've been also, our recruitment has also been helping with trying to support the on-site leadership and tactics with interviewing and making sure that we have the right bodies in the right seats. Thank you, Daisy. I apologize. I'll try to be quick. Melanie kind of got at a bit of my question around psychiatry and portion of it being via telehealth versus in person. So I'll try to focus on my questions around quality access and outcome standards. Given that the general population is approximately 18 percent of us have been diagnosed with mental illnesses versus I've seen statistics as high as 45 to 50 percent of the incarcerated population being diagnosed with mental illnesses. What can you say about what WellPass is doing to maintain, I guess, parity with the standards of access, quality, and outcomes that we have here in the general population come to expect from our mental health providers? What can we do to maintain that for people who are in the justice system? Yeah, we do have mental health clinicians at each site physically on site who see patients one-on-one. We do a lot of groups that are and we follow curriculum that is approved by Annie at the DOC. So we follow that curriculum when we do groups and one-on-one counseling. We do have at least each site has, depending on the number of folks within that facility, they have a matrix based on what they need for mental health. We have been rooting mental health as just as heavily as we've been trying to recruit for nursing and have made some gains there, same transition as well. As far as the psychiatry goes, it was, and why we do telehealth, it was actually easier for us to recruit and find psychiatrist services remotely than it was for us to find people who are willing to come into the site physically. Thank you very much Leslie Goldman in healthcare. I was a little surprised at 10,000 pills a day. That's a lot of medicine being through the system. And I'm wondering, it seems like a great opportunity for error, not just because I worked in the medical system, so I guess, and I'm just wondering what processes you have for dispensing and preventing error. That's right. And then once errors happens, how do you handle it? Because it's inevitable. So we have an electronic health record that we follow for medication dispensing. We order medications through a vendor called Diamond when they come in that we count and account for. When the incarcerated individuals come up for their medications at the window, we do, you know, name, date of birth, all incarcerated. We have a wristband that we check that with. If they don't have the wristband, they have to go back and get it. So they come to you. They go, you're not going to them. So that's one step. We would go to them if they were in a custody situation that required us to go to them because they're not allowed to leave the area they're in, or if there is a lockdown in the system and we have to go unit to unit. But otherwise they come to us. So using the five, six rights of medication is how nurses would go through that process ensuring that they have the correct man having the correct person in front of them before they distribute it. We do have met errors. I mean, as you said, it's inevitable with 10,000 pills being passed today. We have, with WellPass, what's called a critical event process. So when a met error happens, and actually any kind of critical event that happens goes through this process. So if somebody sent to the ER, if an incarcerated individual injury, if there's a met error, any kind of event like that, it goes through this process that goes straight to our lead CQI people in WellPass at the corporate level who do a lot of reviewing of our charts and such. But it also comes to me, it comes to our regional director of nursing and our medical director as well. So when a met error occurs, once that error is discovered, they have to notify the provider who's there on site. If it's off hours, then they would notify via on call to the provider on site or whoever's covering statewide. If additional monitoring is necessary, we would bring that patient into an area closer to medical if there's no infirmary. So usually booking is right off the medical. They might stay in booking for the night so that we can monitor and work closely or they would be in the infirmary so we can monitor more closely. After they've been deemed safe to go back to their housing unit, they would go back. I notify Max and their team when a met error occurs that requires further monitoring so that they're aware the on site DOC is also aware. Once we get that met error in, we do a root cause analysis of sorts to figure out the reason why that error occurred. Sometimes it's no, five rights weren't followed. Sometimes we realize that maybe there's rushing at the window so we know that we have to slow the process down. Sometimes it's directly related to pharmacy and how they distribute the met. So we would go through that root cause analysis. We would have education with the nurse involved for sure and we would document that education plan. We would also take that as an example and point out the nurse but use it probably as an educational moment in a staff meeting or whatever to say, hey, you know, this situation occurred. These are some things we learned from it to, you know, keep your, to have a learning lesson from it. So how many met errors do you have a month? You can get back to us. Yeah. Yeah. That's a number you don't want to. I'm sure you don't have it on your head. Met errors are a lot of results of culture or reporting of met errors. Many don't, you know, get hidden because people are afraid of consequences. I don't know what your system's like and I know we want to move on, but that's a concern. Yeah. Yeah. We take an educational approach first of all. And when you do those, that breakdown, how many met errors in a month, it might be good to look at which facilities break it down by. Yeah, we get that data through that system, that tracking system. It can be down by facility, time of day. And I think that's just a good reminder that this is, as someone said, I think it's Max said earlier, this is a acute population. They have high healthcare needs. All right. We're going to keep asking questions and may not get to Kelly. Wayne? I'd like to flip the script a little bit. So, we're giving them almost 10 pills a day for every inmate that we have in prison. And it's very convenient to get medical, to go and see someone, like for me, if I have to drive to Burlington or St. Albans, you know, I don't go very often. So it's very convenient to get the services that we've been provided. And it's constant is a good bit north of $2,000 a month for patient for care. So of all these people coming in, I have an aunt, she died some years ago. She was 97 when she died. She was a hypochondriac for her whole life. And what she was doing, she'd go into doctors to get attention. And you can understand, I could see that in prison, you know, your board, how much, you know, might you go and seek services because your board really having a legitimate issue. So do you have any controls on that in any way so that, you know, we're not being taken advantage of? I mean, our providers are certified educated providers. So they do have, you know, autonomy to prescribe how they choose. But they do know the population that they're working with. And can and know people, especially those who have been in the system for a while who are, you know, are coming back and back and back to medical. So I would say that they are, they're not striving for the sake of prescribing. Understatement. Yes. And I just want to reiterate what Jessica just said. I mean, they are licensed healthcare professionals that have to follow the rules. So what's the one my aunt was going to for years and years? Tristan Roberts. A couple related questions about medically assisted treatment. Do our inmates typically think prescribed subutex or suboxone? They're of the monotherapy. So subutex. So do you think there's that? Cost currently. But we have been exploring the other option. I can just, my concern would be that that's not as effective in helping people avoid if they can get high in other narcotics with subutex. And we know a lot of people are transient. So we need you to speak up. Sorry. So subutex, you know, you can still get high in other narcotics with that. So there's a concern that it's less effective. Still can't hear you. Yeah. It's a big room. Okay. Yeah, because if you have to stand up, it's good for it. I'll just go to my next question. Thank you for the encouragement. Do you provide, you know, part of MIT standard of care, I believe, as counseling and recovery support, does well provide that? Yes. And to what extent? We have MAT case managers at every facility. They see the patients under Medication Assistive Treatment one-on-one and they do groups just based on guidelines and curriculum that has been put forth by the Health and Wellness Department of the Vermont DOC. Can you talk about the frequency of those subgroups or forwards? It really depends on, it does depend on space at the facility. And what's allotted to them, but we do try to make sure that there are at least weekly groups happening at every site. Thank you. Brian Sheena, who is on Zoom, so. Thank you. Does well cast have any mechanism to work with community-based providers to continue care when someone becomes incarcerated? For example, if somebody has a long-standing relationship with a psychotherapist and they become incarcerated, is there any way for the person to continue their work with their existing provider? No, no. Thank you. But we can, based on if we get an ROI from that individual, we can touch face with that provider to have their medical records and understand their treatment plan. Are you good, Brian? Yeah, but it sounds like the person can't continue the therapeutic relationship with a provider who's already working for them. They would have to kind of hand their record over to someone else to try to do that treatment. Is that a DOC or a well-passed requirement? That's based on insurance, isn't it? Oh, right, because we can't do Medicaid or Medicare, right? Okay, thank you. Yeah, but well-passed could pay the person. I mean, well-passed could pay the person. The provider might not be able to bill the existing insurance. But anyway, we answered the question, so thank you. I want to make space for others. Thank you. Thanks, Brian. Go ahead, Jean. Yeah, so, Jean, I'll try to represent it. Thank you. I'm just trying to drill down on the 10,000 pills a day. Any of you. I'm just trying to drill down on the 10,000 pills per day. What percentage is that doses per day? Or actual pills? You know, I mean, it's kind of an ambiguous term. And then, so that's not including MAT doses. So those are a sublingual film. So I just wanted to- We don't do films. You don't do the films. So all your subutexes is based on pills. And to kind of dovetail on that, what are the controls that you have in place so that medication isn't being diverted? Well, diversion is really the security side. So there is an officer at the window who will do mouth checks on individuals. Men's that are able to be crushed, we will crush and put into applesauce or water, depending on what the incarcerated individual prefers. All of our MAT meds are crushed. And there is quite an extensive for MAT. Our MAT lines are separated from our general medication line. So that's its own medication line. The medication is crushed. The individual receives it. And then they sit for 10 to 15 minutes to allow dissolving. And there is a correctional officer who is watching that process during that time. So it's an observed frame of ensuring that it melts. And okay, so out of the 10,000 doses per day or pills over slicing that, what percentage of that would you say is MAT doses versus just other medical conditions? I didn't see the numbers today, but we do have about 600 individuals on that. Okay, so that accounts for a lot. And my last question is, if somebody's on a medication that's multiple times a day, what's the control if they forget to come to the window? If they forget to come to the window or if they forget to come to the window, if they come later, we will give them their meds. If they refuse to come to the window, then we have them sign a refusal. Right, but I'm saying more for somebody that it slipped their mind is there's some sort of oversight in the computer system that says, you know, he takes blood pressure medication three times a day and he missed one of his doses simply because he forgot about it. Right, we do have a system in our electronic health record that allows us to apply when somebody has missed three doses of a medication. Thank you. All right, so we have topper and chip and then we're going to have to call it a day. When I'm in prison, when I get out, I'm sure of my sentence, what's the process to make sure that there's a smooth transition from inside to outside? Yep. In terms of the prescriptions I need, so. So we do have, we do, hopefully you're somebody who's sentenced and we know when you're leaving. Yeah, I'm not talking about when a judge says. Right, so if we know you're leaving, it's quite easy actually. We would call providers in the community and set you up with appointments. For your meds, we would provide, so we tell our pharmacy diamond that you're leaving and they send prescriptions to your preferred pharmacy for you to pick up. We would provide 30 days of medication unless it's a mat-med, then we would provide to your next appointment. I wish it was working out that way. It was only then easier. I feel it all right. Chip. So if I'm going to take up the tail end here, I'm going to be a little rough on you. Sorry to say, but to pick up on what Representative Casey had started about, there was certainly skepticism around this table and in our legislative body about private-for-profit prisons and private-for-profit health care. And with some research, we discovered that Well-Path is a subsidiary of a larger private equity company whose sole motivation is to make a profit. And you may or may not be aware of the letter that was drafted by a number of Massachusetts senators and signed on by two of our congressional delegation regarding some of the investigations that they have done regarding your organization. And I'll read from one paragraph that struck me and really disturbed me. And this is Well-Path asserts that it's not cost-cutting measures or that it's cost-cutting measures do not compromise quality of services. Extensive evidence suggests otherwise. Nationwide, the privatization of prison health care has been associated with instances of reduced quality of care, higher death rates, and less transparency. The more recent trend toward private equity firm, such as HIG Capital Purchasing Prison Health Care Providers, along with food, commissary, and telecommunication providers has supercharged the profit incentive to compromise service quality. I found that really disturbing. And from everything else that you read about this, it certainly seems to have merit because a lot of these senators put a lot of time and effort into investigating this. So I guess I would ask you to comment on that, maybe, if you choose to. I mean, I understand it's difficulty and it's more of a comment or a statement than a question, but I just find it really disturbing. I mean, I did prisoners' rights many years ago and certainly health care, when Vermont was providing their own, was the subject of considerable complaints from inmates. But all throughout these articles, it just carries on about various states that have gained judgments and filed lawsuits against well-paths for inadequacy of care, unlawful use of restraints and medical subduing with medical means. And it just doesn't sit well with me, I have to say. And I'm sorry to lay that on you, but you're sitting in the hot seat, as they say. Yeah, I can't speak to anything that's happened with well-paths in any other state. I know well-paths in Vermont. And we are those who are providing direct care to the incarcerated individuals in Vermont are Vermont first. The nurse at the med line is not thinking about cost savings. She's thinking about the patient as proper. And I can say that the regional office in Vermont for well-paths, we advocate for health care to be what Vermont wants, what Vermont requires, what Vermont needs for our individuals. We believe in a community standard of care. And that is something that we will continue to advocate for, regardless of whose name we're working for. Okay, as oversight, we'll be watching. I have to tell you. Thank you. Thank you for your answer. Hey, thank you, Jessica. I just want to say thank you to you and all the nurses and medical staff who are working every day to support this population. So thank you. I hope you know it's that easy. Thank you. Appreciate it. Thank you. Yep, we're done for now.