 So I say, you know, back this is with us. Hi, you know, welcome. I'm not joining the committee from inside the committee room today and talking through a mask. So, try to see if you can hear me clearly enough. It is so interesting sitting here with all of us wearing masks watching people who are maskless. I'm feeling jealous. Yes, highly, highly jealous at this point. Yeah. So, So welcome. Our hope is for you to walk us through the governor's recommended initiatives around healthcare workforce development. I'm not going to talk about healthcare workforce development generally, perhaps, but healthcare workforce is of course what we're particularly interested in, and I'm going to turn it over to you to help us with that. We'll entertain questions along the way. Thank you very much for the record in a back as director of health reform in the agency of human services. This presentation is certainly a follow along to the overview that I provided for the healthcare workforce development strategic plan earlier on in the session. I am very happy to have the opportunity to share with you. How the governor's budget proposals on a number of areas create a comprehensive approach to improving nursing healthcare workforce in our state so if I could I'll go ahead and share my screen. That'd be fine. And let me know if you can see the presentation. Oh, okay. Yes. Okay. You can take it to full screen. It's actually easier to, you know, there you go. Yeah, that's good. Thank you. Great. Thank you. So consistent with the. Sorry, I'll just go back here. It really wanted me to give subtitles a try which was making it so I couldn't see my screen. Consistent with the healthcare workforce development strategic plan. The governor has proposed an initiative specific to recruitment retention and training. And the governor proposed a total of 33 million in the FY 22 budget adjustment to support a program of recruitment retention and training for nurses as well as the health and human services providers. In this program, we propose would be a needs based program and would allow employers flexibility and how to propose and allocate funding within the terms and conditions of the program. And that would allow for recruitment or retention bonuses funds to be utilized for training needs to include potentially utilize utilizing funds to support international nurse recruitment or other creative employer identified incentives for recruiting and retaining the workforce. We propose that there would be a program limits so as to so as to provide for a service agreement for those staff who would be receiving retention or recruitment bonuses, and thereby create consistency across the system and minimize system to provide inequities in equities. And this could be for a limited period of time that the service agreement would be in place. Further the governor proposed in the FY 23 budget, $3 million to continue and expand existing scholarships for Vermonters and out of state individuals to attend nursing programs at Vermont colleges and universities would include Norwich University that's been a question that we've heard a number of times, and would this would include students that are pursuing practical nursing certificates associates degrees in nursing or bachelor of science degree in nursing. And students would similarly here agree to work as a nurse in Vermont for a minimum of one year following licensure for each year of the scholarship awarded. And as you're likely familiar this is how the nurse scholarship program does operate today. This is a scholarship program that was established in, I believe, through Act 155 of 2020. And again, this is an expansion of that program with the additional and investment of funds. The governor also proposed an additional $2 million to expand loan repayment for nurses who live in Vermont and are permanently employed by Vermont health care providers and employers. And with this proposal that nurses again would agree to service obligation to live and work in Vermont for each year of loan payment provided. This is certainly a theme in the in the proposal and in the package overall that there is a service component to the programs that are offered or in the case of tax incentives. There is a residency component and a Vermont employer component to that proposal. And here further, the governor's budget proposes a $1,000 refundable income tax credit for nurses as well as nurse educators. And this in total was a $15.4 million estimated investment. The tax credit is available to those nurses and nurse educators that will be living and working as permanent employees for Vermont health provider employers and would include registered nurses, licensed practical nurses, licensed nurse assistants and nurse educators as well. And can we interrupt you with a question. Yeah, I think representative. I have several questions. Yeah, she also she actually just answered it I had never seen anywhere. Because it's not on the slide and hadn't thought to ask but you just now said that the cost of that tax expenditure would be 15.4 million in terms of the budget right set correct. That is my understanding of the estimated the estimated budget impact. Yes. Okay, thank you represent court. Thank you. Can you hear me, you know, I can. Okay. And noticing that we're not talking about advanced practice nurses here. It looks like they're not included in scholarships loan repayment tax incentives. And I think in one of the, I don't have the bill number. I didn't get another program. They were left out of something that was supporting primary care providers. Was there any discussion about including advanced practice nurses and any of these. Let me, let me go back to the team before I answered definitively but in advanced practice nurses, advanced practice registered nurses correct. Yes, advanced, but they're nurse practitioners they. You know, they're, we all know of the primary care providers shortage crisis, in addition to the nurses that we're talking about now so I just want to make sure that advanced practice nurses have opportunity as well. Thank you. I'll, I'll follow up on that point to be sure that I'm clear on on how that is being handled. Thank you. The, we are also promoting Vermont as the best place place to live and work as a nurse and through this is through collaboration between the agency of human services and the agency of commerce and community development. The focus here is to leverage existing platforms and to establish new marketing campaigns that can draw nurses from other states, as well as internationally amplify the full range of incentives for living and working as a nurse in Vermont, including those incentives that I've just provided an overview about the certainly bringing those into the program as well. Scholarships loan repayment tax incentives, further amplifying the fast track to licensure which I believe you had discussion about with the office of professional regulation which does speed path to licensure for nurses coming to work in the state of Vermont and and also utilizes relocation programs to support nurses and and family members coming to live and work in the state of Vermont. So this is very much a cross department and agency initiative to utilize existing resources and expertise and to create a specific a specific campaign directed again at nurses and nurses who would be interested in living and working in our state. Representative just a question. Yes, can you go back to the previous slide and can you explain what the $1,000 refundable income tax credit is is that after you submit your tax information is this for this is for itemizing or how does that actually work. It's, it's a refundable income tax credit for nurses and nurse educators. I'm sure that the, if you're interested in having a deep dive on how it works. I know that the tax department tax department would be happy to do that. But I mean, do you just, is there something that you have to apply for is it is it mean, is it going to be easy for a nurse to apply for $1,000 refund. I mean, like so many of these things. You know, they're not the top of your tax. Is that how it's going to work. I think that's liability. I think comes up 1500 in taxes, I think the thousand go to a CEO 500. I think I have to answer all those questions when you're talking about your taxes, you know, did you do this. So you're, you're itemizing your tax. I think we should probably ask someone who actually understands this answer the question. I guess what I'm asking is something that's really going to work. Well I don't know. And it would be something that would absolutely be evaluated by the means committee who are familiar with refundable tax credits and, you know, it's not a great deal of money but well the total amount that the budget would impact it's estimated $15,000 per person is the amount of money that's being recommended to everybody. Anyways. Okay. Well, I mean, let's let's continue here in this presentation. He got me to it. We're also through this comprehensive initiative to promote nursing in the state of Vermont, launching a marketing campaign to promote enrollment in career and technical education programs. And this campaign would can include an emphasis on health care careers specifically and the trades. Further the budget proposal does does propose continued investment in the successful Vermont housing improvement program, which does help private owners of vacant rental properties to bring units back on to online for housing, and to increase the housing available in the state. We've certainly heard regularly from health care employers that housing is is a is a key barrier for people looking to live and work in Vermont in the health care system. We also propose the, the, the, the governor also proposes investing in a new private home builder program which is focused on creating missing middle housing for moderate income home buyers specifically. And childcare is another area that I know that the committee is familiar with that poses barriers to recruiting and retaining Vermonters to work in the health care workforce. The administration has proposed a comprehensive package of investments to continue investing in the accessibility and affordability of early care and learning pre kindergarten in a mixed delivery system, as well as to enrich after school and summer programs for youth in pre K through grades 12. So that's that is a high level overview of the package of initiatives that do come together through the budget proposal as well as the budget adjustment specifically coming together through those avenues to support the health care workforce in the state of Vermont and as you again are also familiar the health care workforce development strategic plan has a number of initiatives and recommendations within it that are also in play today. So I'm going to give you an update from the Office of Professional Regulation pertaining to the work that they are convening around increasing nurse educators in the state of Vermont increasing the number of slots available for persons to pursue education and training to be nurses and work in the state of Vermont. So I think we have some more questions, if you don't, if you're, yeah, this question is good. Hi, thank you for that. So I have a question. Was the 5 million for the two scholarship program or the scholarship and loan forgiveness it was 15 million for the tax incentives, which I think gets me to 20 million so can you tell me how the rest of the 13 million is split out between the marketing campaign and the other options. The other recommendations. Oh, I want I want to clarify that the 33 million dollars is was was proposed only for the recruitment retention and training initiatives. So, the 33 million that is only for those initiatives, the nurse scholarships loan repayment tax incentives are all additive to the 33 million. And then the dollars proposed, you know, for investing in supporting the agency of commerce and community development in marketing activities are additive to those as well and I don't have. I don't have that number off the top of my head in terms of any investments in the marketing campaign specifically. So if you get that for us or have someone get it to us, that'd be great. Thank you. So, just for my application the 33 million for retention, recruitment and retention that is in the BAA. Is that right. That's correct. Yep. And the others the other, the other dollar amounts are in the FY 23 budget. And the distinction. Yeah. Yeah. So is there. And I apologize. I, it says right here fiscal year 2022. So you know this weekend I made the same mistake and was emailing. Sorry about that. We should read a little bit better. So is there any money in the fiscal year 23 budget for recruitment retention and training. No, the recruitment retention and training is proposed in the FY 22 budget adjustment. Okay, thank you. Okay. Thank you. Maybe take down your slides so we can see that would be wonderful. Oh, are they not down. I'm sorry. I thought I took them down. Stop. There you go. There you go. Thank you. That's great. Thank you so much. I have two questions. My first question is sort of taking off where Mari went. Is there anything in the governor's budget about primary care workforce. So beyond just nurses. What are the options. Can we practice stocks. APRNs to do primary care specifically. The recruitment and retention proposal is a broader proposal than for, for just nurses and that those, that $33 million investment that was proposed is, is broader than for just the nurse workforce and could include. It could include a broader workforce. Certainly there are areas of the system where there is a particular need in terms of home health care skill nursing facility care. Certainly rise to the top as examples of that additional where there could be additional investment in recruitment and retention. So I'm hearing you say that it's, it's really still for nursing and not necessarily it could include primary care but might not. Or I'm just wondering if the governor and you have thought about primary care specifically. It is, it is not exclusive to nursing. It certainly could include mental health substance use disorder home health care providers home independent support providers are some key examples there. And, and so it was, it was not envisioned as a specific program to support primary care. However, it could, it could provide for some primary care support. Great, thank you. And I was also wondering on your slides eight and nine. When you were talking about broader strategies that seemed more general to the workforce and not necessarily focused on nursing if I interpret it right I just wanted to make sure those. Yeah, go ahead. Sorry. Yes, I think I saw those. Yes, the, as we experienced workforce shortage certainly across sectors in the state there are a number of strategies and initiatives that apply and can be applied across sectors and, and we can use our current workforce development tools and expertise, both to support the nurse workforce specifically but also to support workforce development in those other sectors. I think childcare housing are key issues across sectors and are not, and are not separate and distinct, for instance for healthcare workers specifically for for nurses even more specifically. I think that those investments are important for workforce development on the whole. Thank you. You know I have a specific question I think it's in line, maybe with what I was asking but more specific, we, we created and funded, I believe was five primary care scholarships for primary care positions at the learner School of Medicine. I think they're just now. We have three years ago or something along that line and is that so that funding is now we were reported that that there are new medical students receiving that funding is that is that embedded in the base budget somewhere, or is that not get refunded. So I'm confused about whether that's already in place and separate from what we're talking about here today or if it's. I can come back to you with with that information I believe that that was that that scholarship program was also started through or was established through Act 155 of 2020. And that it is. I see Jen, Jen has is shaking your head and she can probably clarify that how the program is ongoing or not. I don't have any problems with that if you have any information or Jennifer Carby Legislative Council, I don't think I can answer whether it's fun I think the funding question would need to be answered, either by the administration or by the appropriations folks, but this was a program that was created in Act 155 is in statute it was amended fairly significantly last year, and scholarships are for up to 10 student medical students annually who commit to practicing in a medical specialty area, and with some other for which for the moment at least is focused on primary care. But the program is, I mean, you've, you've appropriated funds for it in each of the last two budget years so I don't know if it is now somehow embedded in the health department statute or a budget request or if it would need to be a new appropriation. And do you have the figure that was what what the figure was that was appropriated in each of the two years when we did appropriate funds. I can look it up fairly easily but I don't know offhand, searching in last years. Okay, so I, yeah, I can forward Nolan I asked this question over the weekend Nolan sent me the language. Okay, from last year. And you know the, so for last year it was, it was one point a little over 1.2 million and global commitment funds so that's the state federal, you know, combined amounts. And I can look at the year before it happened in the budget each year. Okay. So if, if there's any way to determine whether that's somehow in base budgeting for the Department of Health, or somewhere else, apart from the initiatives that you've outlined that would be very helpful to understand, or if it's not, we have to understand. There may be confusion as to whether because it was put into statute that it actually therefore became part of a base funding, or whether it has to be separately authorized in each fiscal year. Yeah, the, the, the amount that Jen just referenced last year, it actually says that amount is transferred to the sec in fiscal year 2022. So, my understanding is that was like, that was the carry over that's so that 2022 maybe funded already through that we did need to verify that. But that's the language, the language says fiscal year 2022. Right it was in the FY 22 budget act. This year. Yes, that is the current that is the end in June. Yes, I'm sorry. Yes. Yeah, for the record no language joint fiscal office represent Donnie is correct I sent there the numbers yesterday. So Jen's correct is 2.2 gross million and global commitment. And there was language in the house past BAA that basic that said this funding shall remain available to be second till expended, and if needed, physically neutral adjustments to spending authority shall be included in future budget legislation. I don't know if that translates to base or not. But it's definitely sounds like intent. So I'm still left a little confused. I don't know what the others are not but I am as to, can you translate what you said to, is there money in this in this upcoming, did the BAA put money into the upcoming fiscal year or is that simply to authorize money for the current fiscal year. The BAA money was to authorize that if it's not spent that it doesn't go away that it just keeps carrying forward. So it doesn't get scooped up and use for something else. That's an example of when people ask about carry forward and spend the money what happens so that that creates it as a carry forward, but it doesn't. But it doesn't appropriate new dollars. The BAA isn't appropriating new dollars. So if that was to be, if there was money needed in addition to whatever is carried forward there would that would require an additional appropriation I assume. Yeah, I was getting I asked this question yesterday of some other folks and I was getting mixed signals about whether this was base going forward, or if it's just a single appropriation so I will get clarification for you on that. Okay, so that's that's the question I think we were asking as well whether there was somehow it was in the base and we're not just seeing it. I think that would be very helpful to understand. Yeah. Okay. Yes, I have several questions here. Relocation programs for nurses. What are they are they moving nurses from out of state to Vermont. Are we paying for their moves. Could you explain a little bit about that how much is that has been allocated there. That's specifically that's the relocation program in the agency of commerce and community development that supports relocation for workers coming to Vermont. We would like to see, you know, certainly that program be able to accommodate and include persons who are working in Vermont, or coming to work in Vermont as, as you know, in the in the healthcare field and with healthcare employers. Okay, so it's in the big. It's a broader picture I guess that's not just nurses it's a lot of others okay. And the housing issue. What are the incentives for nurses to get housing. Are we providing some sort of loans for for nurses to purchase homes, and I see where invest in a new private home builder program. Are we subsidizing builders who then sell these homes that are at a lower cost and what they're being paid for you have any information on that and how it affects our nurses are nursing and contracting nurses here, or keeping him here. Again, it certainly is, it is a broader issue but one that is also true for the nurse workforce that housing in in Vermont can be difficult to find. So housing in Vermont can be difficult to find and so these two programs are not exclusive at all for nurses but they are programs that can increase the housing available in the state of Vermont. And certainly nurses could take advantage of those programs, you know, take advantage of the additional housing created by those programs as could any, any other Vermont or take advantage of the additional housing created by those programs. The strategy is certainly to acknowledge or more than acknowledge but to address what is a shortage of available housing, which is certainly a recruitment barrier when when looking to bring more people into the workforce here in the state of Vermont. People are looking, certainly to establish housing as a part of being in the workforce. There are not. There are no specific dollars for nurses to support nurses at housing specifically. It is a broader strategy. This is another, this is one of the broader initiatives rather than a nursing specific initiative, but it certainly could include nurses but it's not, they're not targeted to nurses at this point. But I mean if we're trying to attract nurses chair with, and I'm not arguing with you but I'm just saying I'm just trying to describe what I think he said here. Yeah, yeah, but that'll be our discussion tomorrow. You paint a picture that you know all these incentives for nurses and yet it's, it's broader. It's not specifically designed for the nursing school that I think that's accurate and I think that's what we're hearing. Okay, and then do we know where these, where these homes will be built. Do we have an idea do we have any home builders that we've, you know, started asking for information on designs and qualifications things like that. Those are really good questions. I don't have those answers for you today I can, I can look into that, you know those the details of the, of the program and how, how far in the planning. It is, but certainly the proposal is, is to support those is to support the creation of new housing for moderate income individuals but I can, I can definitely get back to you with some more information about that program. And do we have loan guarantees for nurses, you know want to buy their home and settle in Vermont I mean, here again. Can we say, I mean, your title of your slides here, recruitment retention and training. Healthcare workforce development strategic plan implementation. It just seems very broad and it doesn't really seem to me anyways, to be addressing the issue of trying to get nurses into Vermont and keep them here. We have we have what we have in front of us is what's being proposed by the administration. We are also looking at other initiatives that we may add to this or review these proposals and and see which ones we want to prioritize and support. I have another question, because I, in the, in the healthcare workforce development plan. There was a proposal I believe, specifically to, and I'm not going to get the language quite right because I'm remembering it to house to put a position within the agency human services to help coordinate and have folks access supports through the healthcare workforce. That's the liaison. Yeah, yeah, yeah, is that what that is that that's that's re recommended in the healthcare workforce strategic plan. And my question is, is that position anticipated to be created in the government budget. I think I need to clarify that there is not a position proposed in the in the healthcare workforce development strategic plan to sit within the agency of human services. We did not. Maybe I misunderstood stuff. Okay. Thank you. Yeah, yeah, thanks chair. You know, I see as a retention item with retention bonuses. Is there any plan of foot to to for a broad increase so that someone coming in could see that, you know, we're going to be in a nurse can can make me a little bit of money above what they get now. So just a bonus is maybe a one year shot versus a substantial increase in salary that has a longer lasting. I know it's a bunch of item but to two. We can look at this is saying, you know, this is a very significant rising pay for nursing. We, you're correct that the retention bonus is not a is is not a proposal for an increase in in base pay for nurses the intent of the program is certainly to acknowledge that I given the current workforce challenges and that there is a very, you know, near term need to do what we can certainly promote nurses and others working in the health and human services in Vermont to remain in their positions to incentivize them in the near term to continue on in the workforce, recognizing that longer term strategies likely will also need to be employed for recruitment and retention initiatives. When you develop a plan like this, you have a number in mind of nurses that you hope to attract I mean is there any sort of. I know that's probably very difficult to do but I didn't know if there was any ballpark figure that you maybe would be able to so for intact. What would they be the impact. I think that's a that's a really excellent question in in putting together this proposal certainly there are key objectives to try to again retain those nurses already working in the workforce so that the workforce does not experience additional attrition so to do to provide funding for employers to innovate around retaining employees to reduce additional attrition. And I certainly we propose something that could be flexible for those employers that may not be most concerned about attrition but could be very concerned about bringing, you know, recruiting additional additional staff into roles. We don't have a specific target there, because we have these kind of multi factors at play, but I do think that that is a good question. Thank you. Okay, I have one other question and then I see representative goldenness question, we're going to suggest we stop minutes five minutes. And, but in the course of your analysis of the workforce strategic plan or these workforce initiatives. One of the things I'm always interested in is that we invest our state dollars in efforts that result in workers being in Vermont, as opposed to training people in nursing programs or other programs. So, our initiative with the larner school of medicine is to have people practice in Vermont after they've, as we probably the scholarships as an incentive to work in primary care, and in exchange they work back in Vermont and I think that's part of this initiative that you've talked about. In terms of just generally at this point in time do we have any sense of whether each of the programs like at UVM at Norwich or Castleton or other places. Do we have any good sense of these exist nurses who are being trained now in trained in Vermont. Are they work or do they end up working in Vermont. I've heard various descriptions and how to measure that. I don't know if you had access to any of that information the course of any, any analysis that you were part of that. That is that's an area that we're actively analyzing and looking into and I don't have that I don't have, you know, analysis for you for you across the board for all the nursing programs in the state of Vermont, again, it's an area we're actively looking into and trying to understand, but I can share that for instance, in the programs offered by the Vermont technical center, what I've understood, and what's been reported to me is that most of the graduates, you know, in that program are already working in Vermont and that that program has an 85 to 90% rate of students who stay and work in Vermont as as nurses. That's a Vermont technical college. As opposed to Vermont, I think it's just a, yeah, yeah, Vermont technical college nursing program. Okay. Yeah. Okay. But that's, that's a really great question and it's one of the pieces that we're certainly exploring with the nursing education programs as we engage with them along with the Office of Professional Regulation around increasing the number of students educated in Vermont. Right, right. Just for my refresh my memory. Where is the nursing program at VTC located currently. Is it only at one site? Williston and Randall. So, so it's at both sites. Okay. Thank you. And I think the Castleton has program in a separate program. Well, yeah. Representative Goldman. Thank you, Ena. I'm wondering what number of the administration is working with to understand the gap in our nursing workforce. Does the administration sort of how do you doing this job get your head around this problem. I'll do that in a couple of ways. You know, certainly the workforce development strategic plan does emphasize that we need to bring together different sources of healthcare data to be able to better understand and model. You know, certainly supply and demand and to understand gaps and those pieces of data are coming from different areas of state government, for instance, the Department of Labor, the Department of Health in the survey that the Department of Health. In the, in the information that it collects through the, through the relicensure survey. And so we, we recognize that we need a better way to look at these pieces of information in combination as they obviously do inform one another and would inform and better inform our working understanding of gaps and assessments. And that being said, we also are looking at, you know, key indicators that suggest certainly where there are gaps in the workforce, such as the increasing reliance on traveling staff by facilities in the state of Vermont, including hospitals but not exclusive to hospitals by any means also including traveling staff that are working at skilled nursing facilities and maybe working with health providers. So, those are other areas where we look to understand with, you know, certainly the changes in the composition of the healthcare workforce with respect to the proportion of full time employed staff versus traveling staff and I have some information on that front that I can follow up with you. I'll send it along to the committee. I'll send it along to the committee right after this. If I may follow up. I'm just curious, you know, you talk about a lot of different state government sort of agencies being involved, which I understand is totally complex. So, who do you think understands the whole problem, who has the overarching view of what's going on ground state government and throughout the state in terms of the nursing workforce. Well, I, I think it's a collective point of view I mean I think there's different expertise and pieces of information that are coming from, from, you know, different areas and that together that can create the collective that can create the collective view. Coming to where, when you say coming. I'm just wondering who collects it all in one place. It can't be possible. I don't know. I remember this is my first term so I can be ignorant. Well, I think that's exactly the question that the advisory group and discuss the be so there is an advisory group that was established to advise on the healthcare workforce development strategic plan, and a key area of discussion for this advisory is the data that describes the healthcare workforce does live in different places. And so the committee would recommend that those data be brought together in in a healthcare workforce data hub, which I think is consistent with your with your question which is, well if it's all in different places then how is there any one view of it. So, the report does make that recommendation. And, and I think that there's, you know, further consideration that needs to be. And we need to, you know, further consider how to implement such a recommendation but the advisory group again discussed it repeatedly, and, and put forward that that recommendation. The data hub. That is not a proposal. And no, that is not included in it. No. Thank you. So I, I guess that answer right there maybe answers my because I know that the data hub was sort of one piece of it that then there was also a recommendation around do creating the ability to do supply and demand modeling. And I was going to ask if there were any recommendations from the administration on pursuing that or funding but if the data hub isn't being funded I guess we can assume the supply and demand modeling is also not or is that a consideration. The supply and demand modeling. No is also not included. Okay, thank you. Okay. I think we'll stop there. Thank you for spending time with us and helping us understand what is being proposed in the administration's health care workforce initiatives. And, and, and helping us understand where there are some things that were in the strategic plan but are not not included in the funding recommendations at this point in time. It's actually helpful for us to be able to articulate have you are helpless articulate what's, what's there at this point and what is not. It's helpful for us as we look at what we might want to recommend as well. So, thank you so much. And we'll continue to be in touch in your role, which I would just say, we're asking lots of questions and it's time is frustrating because not everything that is available to us. But I want to just express appreciation for the work that you're doing as the director of health health care reform. So, thank you very much. So no one popped up I don't know if you know where you I'm sorry Nolan was there something further that you were wanting to chime in on. Not, not this time. I'll communicate with various committee members. Okay. Great. Thank you. Thank you. Thank you.