 Good morning today. This is the Vermont House Human Services Committee and this is Friday, January 15th. And while the bulk of the morning's agenda will be sort of focused on getting feedback and testimony from providers and others as it relates to COVID-19 response and impact on elders and people with disabilities. As we begin now and I see that the Commissioner of Dale is here. So if the Commissioner of Dale is here, rather than I was going to have us chat a little bit about the budget adjustment, just know that the budget adjustment has been presented to house appropriations. You can see it on YouTube at 9am and we'll talk about that later this afternoon. Commissioner Hutt, thank you very much. I realize that you needed to be in two places at once. And so, and Representative McFawn, thank you, everyone. And so, let us begin with our testimony and focus on how COVID-19 has impacted our elders and Commissioner Hutt. Good morning, everybody. For the record, Monica Hutt, I'm the Commissioner at the Department of Disabilities, Aging and Independent Living. Happy New Year to all of you. It's lovely to see you. I let Representative McFawn know that I was going to throw him under the bus immediately and blame him for me being late. Well, at least honest with him about that initially, so he knew that that was coming. It's really lovely to see all those of you who are returning and to members of the committee. Hopefully we'll have a chance to touch base and just a quick invite. If it ever is helpful for you to sit with me or any of my staff just to get a little bit of a 101 on the Department of Disabilities, Aging and Independent Living, I'm happy to do that. I even have a PowerPoint all ready to go because I anticipated that that might be necessary. So it is more information than you will ever want. But we are a department that actually has a pretty broad reach and a lot of different populations that we serve and many, many community partners that we connect with and work with. So it might be helpful. The notes that I got as I was hearing what the committee wanted were four different topic areas. So let me tell you what I think I'm talking about and then you can modify. So I understood that you wanted updates on the COVID response and long term care. Wanted me to speak to adult day program specifically a little bit. A little bit about the impact on elder abuse and financial exploitation so I have some data about that that I can share. And then finally, Chairwoman Pugh, I understood that you wanted me to talk a little bit about maybe just give a quick frame about the transfer of ownership issue for nursing homes and how that's working right now so that that can be a conversation into the future. Yes, in terms of how that has impact, you know, that probably needs to be a discussion that this last piece. So yes, on some respects we are focused we are focused for the most part on one of the most vulnerable populations as we explore and think about COVID-19 and how they are being how it is for them and how our service delivery system is impacting that, whether it is a relationship to COVID-19 or whether it is just a coincidence in terms of time. During this same period of time during the past 10 months, there has been what seems to be a significant ownership change in nursing homes and long term care facilities in the state and a lot of transfer of ownership and then in fact one entity owning a bunch. So that's why that is there. So I can certainly at the end of my testimony just talk about how that process works and just give you just a tiny bit of framework for maybe some future conversations. Okay, so let me just jump in then and I'm going to just start and I know I know that many of you were most of you were probably part of the testimony yesterday and so I won't focus so much on the funding amounts and I'm actually kind of terrified to do that with that Sarah Clark to check my numbers. We've been very clear that we need to have a what does she call it a a loadstone of truth around the finances because it's been so fast and furious so well represent I'm sorry Commissioner hot that's sort of why we're having you all and folks here this afternoon this morning we got them we got the numbers and we're the people committee. Thank you. So we want to know how the people are are are are doing perfect and and what what's worked and should continue and what we clearly what are the holes are the what are the opportunities for making changes in the immediate future and long term. Okay, so let me so let me talk to you a little bit about the response particularly long term care. I think I will preface everything that I'm going to say with the fact that we've had a lot of opportunity to hear from other states across the country, you know different different. Some of us have had been in conversations with our counterparts across the country and and I will say that Vermont's response has been strong has been cohesive has been effective. I will tell you without a doubt in my mind that that is not true across the rest of the country. And I think that a lot of people credit that to our size. And I understand that, but we have operated on relationships that have been built across the legislature across the administration across our community partners, and with our facilities. So our size is important, but the relationships that we all have focused on for so long have been much more important. And I just I get a little bit frustrated when people say well it's because you're small. Maybe it's because we're small enough to have spent time on the things that were important. So I think that our ability to act quickly and cohesively across the legislature and the administration. The ability to I was sharing with with Laura Pelosi you know I was making calls at eight o'clock on Tuesday to some long term care facilities and all I had to do is say hey it's Monica, and they were like oh how are you, you know so we have built that kind of a connection in this state. And I think that that's just really powerful. So in terms of our long term care facilities which is kind of where I want to start this conversation. When we think about that we think about those facilities as our skilled nursing facilities, our residential care programs are assisted living facilities, and our therapeutic community residences and the response in Vermont has been across all four of those licensed residential facilities. The states have bifurcated it a little bit differently, and they've looked at nursing homes kind of separate from all of those other residential care facilities. I will tell you that we identified early on that the biggest risks were in those smaller facilities that didn't have the requirements for a medical director or a director of nursing. You know, we saw it hit our nursing homes hard which was not unexpected, but they really had the capacity to address it in a way that a residential care home with 10 residents and five staff didn't have. And then we have still seen some really remarkable responses from that community. So I am incredibly proud of that and incredibly proud of them, and the staff that just hung in there, as well as the communities that created meal trains and check-ins and put signs on their lawns and you know celebrated the workforce. Sorry, that just kept going. I mean really that just kept going. It's unbelievable to me. Sorry, I didn't think that was going to happen. So from a state perspective, I think that what we have done really well is is we did a tremendous amount of preparation work and I know I've already testified to this committee about what we did to get ready in terms of training and technical assistance and surveys with the facilities so that they would have their infection prevention and control procedures in hand. But more recently as we've gotten back into this second level of surge, we have a really aggressive testing strategy that the state is sponsoring and supporting. So in facilities, they are testing two kinds of tests, point of care, so antigen tests, right? So a point of care, it's called a POC test. And then a PCR test. I don't know what that stands for, but that's the test that goes to the laboratory to be screened and determine whether or not there's positivity. So we've been using those two kinds of tests aggressively in facilities. We would love to have more of the point of care antigen tests, but those are limited at a federal level. But part of that really aggressive testing strategy has been enacted in both nursing homes and in all of those other facilities that I talked about, and that has been the way for us to identify cases very early on, and then act, which has been critical, in this response. That is a tremendous amount of work that our facilities took on, and also a tremendous amount of work from the Vermont Department of Health, and frankly from a Dale team, but and I'll talk about that a little bit more. So we've had this aggressive testing strategy and we created this contract through support from the legislature and funding with the with the group that's able CIC Broad, who is an outside lab who's been able to assist with those tests so they have a direct relationship with every facility in the state, enabling them to access that testing capacity. We've had ongoing technical assistance around infection prevention and control measures. So our state survey agency has been able to go in and to do both on site and telephonic assessments of strategies, and the VDH team even developed sort of a video process where you can have an administrator walk around the building with a camera and show them, this is how we're set up. These are where the doors are. Here's the nurses station. Here's the break room. How do we make this safe and the VDH team just consults literally in real time. We developed this rapid response team and that's a partnership between VDH and Dale. So the VDH Epi program, the epidemiological team and five Dale staff, myself included that consult with every single facility where even a single positive is developed. So those are seven or eight phone calls literally every day of the week where we are sitting with facilities to talk about when did that positive get identified? What's the infectious period? What do you need to get through this? What do you have for PPE? Can we get you some more? What do you need for staffing? What are the gaps? One of the things that was identified really early on is that as soon as there's a positive there is an impact to staffing. Whether that staff that is fearful and doesn't want to come in or staff that are testing positive and can't be coming in or staff that were close contacts of a positive resident or other staff person that need to be excluded while we watch and see. The staffing impact is immediate absolute and it happens right away. It mitigates over the next couple of weeks, but immediately it creates a crisis. And so we have worked with facilities to figure out what resources they have, what contracts they can build with staffing agencies, where they can pull from within their organization. And in the worst case scenarios, we developed an emergency staffing pool. So we've got 40 people on contract through TLC that we deploy at Dale when there is a need. It's a tiny pool. It's been used a lot, but I think it has really saved some facilities who just didn't have the resources to pull. Again, a nursing home has some capacity that a small, tiny rest care isn't going to have and they can't be fussing with not knowing where the person's going to come in to be awake for the night shift. They just need somebody there. And so that staffing pool has been really critical. We also have started using, and I believe that Sarah Clark spoke to it yesterday, we realized with the CRF funds that an ongoing need right now. We've used it to create these little tiny grants to some very small facilities. So again, not necessarily needed for a nursing home, but for a tall facility that immediately gets hit for them to be able to buy catering for them to be able to pay for this because they're one, they're one kitchen staff, a single person is no longer able to come into work. They still need to feed people. And so to be able to pay for that or to buy really expensive masks because as was pointed out yesterday, as soon as the need for PPE became great, every company that produced it just decided to take advantage of that and the costs are obscene. It's critical to be able to buy the supplies that you need. In one instance, a facility bought commode so that everybody could stay in their rooms because part of the prevention strategies is keeping people in their rooms behind a closed door. And that makes a shared bathroom, which is often the case in a residential care facility, impossible. Right, so it's been amazing what we've seen and just sort of that basic need and that grant program has been really, really helpful. Right now we're obviously working on the more hopeful upswing end because of the vaccination process. One of the real aggressive goals and charges from the governor and the secretary was to make sure that all of our long term care facilities could have a first dose of the vaccine in January. So as soon as the program became available to us and we've spent the last couple of weeks with the federal pharmacy partners, the three pharmacies that are partnering with us through the federal government. And they have been amazing about moving up every clinic so that every res care, every nursing home, every assisted living will have their first vaccination clinic by the end of this month. We're still working on the TCRs, there's only about 10 in the state, but we are working to get those moved up as well, but really trying to focus on vaccination aggressively because we know that that's where we need to be. I see that there may be some questions so I'm going to stop for a second. Commissioner. Partly because we have new members I'll blame it on them, but also some of us may have forgotten. You've used some alphabet soup and you just said that's okay and you just said TCL or are and if you could say what they are. Sure. So those are all just different variations of licensing and licensured. So every every level of licensing and licensure has its own requirements so skilled nursing facilities are often hear people talk about them as snips. So nursing home skilled nursing facilities in Vermont they tend to be the same thing it was took me the longest time like what's a sniff. Other than the obvious thing, but so skilled nursing facility SNF. The next is residential care and again again you're always going to hear that called res care different level of licensure. Typically, I always and I know Laura will probably scream when I say this but I just tend to think about the more as our old fashioned boarding houses. They provide so much more than that they actually do get into medical care for for individuals, but they are set up in a way where there are communal meals communal activities. A lot of times there are shared rooms and shared bathrooms, but res care also does take on higher levels of care and can get variances for individuals who actually need nursing home level of care. So they are really a hybrid in the state of Vermont. Assisted living is is a is a kind of a licensure and a kind of a facility that has to be able to guarantee that somebody can live there independently, typically in their own apartment with their own bathroom and sometimes a kitchenette. But assisted living has to be able to meet needs until the end of someone's life. So the variation in the kind of care that they receive or able to provide in the kind of medical clinical capacity they need to have can be really variable depending on who's there. And finally TCR therapeutic community residents. TCRs are typically more short term people are not living in a TCR as a long term it's typically more of a treatment and intervention. There's a clinical component and a goal of care for someone. So those tend to be more short term. Again in Vermont we have looked at all of these as licensed residences and so the same level of risk. You might argue that TCR has more risk if people are moving in and out more frequently. The reality is that we lump them into thinking about long term care and planning for them in the same way. Is that helpful that's really short and I know, not actually that much about it to be honest with you. So what I've just said to you is all I've got in terms of that information. It's great. Thank you commission. Okay. So actually that's the that's really what I wanted to talk about in terms of the response to long term care. I think in terms of the impacts, you know, one of the things that I mentioned yesterday is that movement in that system typically flows pretty freely. People will move from hospital into nursing home for short term stay or rehab. From there they might go to a residential care home for more longer term living. But I think that at all levels of our system, there's a stuckness, you know, it's hard to discharge from a hospital to a nursing home with in the in the COVID environment. You know, you need people to be, you need to be clear if somebody is positive or negative before they're discharging. There's a lot of quarantining that has to happen as you move from one facility to another. But that's been a huge problem. I, and it has made it challenging to move people as fluidly as they should be moving to be at the right level of care. The isolation for folks has been profound and we've all talked about that. I talked with many of you individually about that. I don't know that there's any way to gauge the physical and emotional and mental health impacts of isolation, both in a facility, but then imagine that facility and outbreak goes in and out of even more intensive isolation. So you might have a facility where you're not getting visitors and that's one level of impact. You then look at a facility and outbreak and literally people aren't even mingling within the facility. So folks have been in their rooms in the middle of an outbreak. They are in their rooms to prevent the spread to keep them physically safe at the risk of their emotional and mental health. We are really well aware of that. It's been a terrible algorithm and a terrible risk to assess throughout this pandemic. You know, there are conversations that we have with facilities that are as specific as, okay, you've got 14 residents. Can you keep 12 on your two floors in your room while staff are walking one person at a time out of their room so that they can get some exercise, can get some movement, can get some air that's not, you know, just in their space. It is, it's heartbreaking. And it's heartbreaking for the staff that are watching this happen. You know, I will share with this committee that over the course of this time, my daughter has been working in a long term care facility in White River Junction. And just seeing this through her eyes has been incredibly powerful and incredibly profound, just kind of what the staff are up against and what they're trying to do to care for people throughout this and to take care of themselves. I mean, she's 19, she's young, she's resilient. But you know, this is hard. And it's hard in terms of what we've also asked staff to do because they are not sometimes going home to their families. You know, they are staying in hotels if there's an outbreak in their facility, they are camping out on the floor in the facility, they are in trailers in the backyard, because they want to be able to care for their, their residents and they don't want to risk their families. So the impact has been so global. And it's really across residents, staff and the families of residents who are feeling really powerless and really disconnected, and really like they aren't fulfilling their obligations as family members to the people that they love the most. I, you know, I could go, I could talk about this really all day because it's just been incredible to see and to be part of. But, and I don't think I've talked to you about any of the impacts that you already don't know about to be honest with you because you've been talking about this as a committee the whole time. I think Representative Jail is talking or I'm not sure. No, no. Sorry, I'm also at work and I have to attend the lane. So shall I, shall I keep moving through I know you had a few other topic areas for me, but this one I can go on. I feel like I step behind a pulpit when I start talking about this. No, I appreciate that. But yes, to move on. Because we and because I also want to I mean it is not even 1030 but I also want to give enough time to our other witnesses, but I thought it was appropriate to start with you and the commissioner as the commissioner. So let me talk with you just a little bit about adult days and it will be the same kind of rhapsodizing about our community partners. Adult day programs have been in a really unique position throughout this throughout this pandemic and again we talked about it a little bit yesterday, the fact that from a funding perspective, what we realized really early on was that they were going to need support and actually what you all realized early on was that they were going to need support, because in March, we asked them to close down. We realized that the nature of an adult day program as it has typically run is that it is a congregate setting. It provides you know respite supports for families who have individuals living with them at home, but it also provides kind of socialization and connection for their participants. It's a connection to personal care and medical procedures, and it is a full service kind of a facility and adult day program. And considering who was most at risk for a COVID infection and the level of care that's provided an adult day program. There was no way that we could figure out with them and thinking looking at the science and the data how to keep people in those settings safe and how to keep the staff state. So they were asked in March to close down fully. And the healthcare stabilization fund was available to them to apply for, but more specifically, there was money appropriated through the legislature and put into the budget that supported them fully for all of their operational costs to different tranches of funding July through September and October through December. So, so two quarters of full operational funding to enable them to stay closed, but not to lose their staff to be to be there kind of at the end of this to be able to reopen and support individuals when that became safe. We did some planning with them at the very end of the summer, when we thought that they were going to be able to reopen at partially with physical distance and at a reduced census. And just as we were ready to launch that and if you had actually started again, the second wave hit and we realized that we needed to pull back. So they have been closed physically all of this time, but they have been delivering services throughout in terms of of online connection groups I had we had a great presentation or a great conversation with the adult days. Last week and one of the programs was just talking about 40 people in a zoom meeting doing classes and how they had to raid their staff, so that one staff was leading and other staff were paying attention to all of the of the videos and if somebody started to have a offing fit they would go offline and check in with that person on the phone individually checking in for for comprehension and attention and it was it was it was extraordinary what they were able to do online to keep people connected. So from a Dale perspective, you know we worked really hard to make sure that they had flexibility in their billing so that they could bill for telehealth which has been a huge and interesting silver lining to this pandemic that I think we don't want to lose as we go forward, because we've made some progress there with Medicaid, not with Medicare, but with Medicaid at least to really be able to build telehealth which has been great and beyond telehealth to build some of the companionship and activity hours one on one to be able to bill for those as well which has been wonderful. We're also looking at trying to create strategies to bill for those group rates a little bit more effectively so that people can stay connected. None of that replaces the physical care that still needs to happen through adult days and none of it fully replaces the respite that is so critical for families who are caregivers. I'm going to know again we've talked about it in this committee many many times the value and the profound numbers of unpaid caregivers across the state of Vermont is is mind blowing and when you look at the actual numbers and the and the financial impact of those unpaid hours. We you know it's easy to see clearly that the system could never sustain that at a paid level and so it's it's important that we continue to support those unpaid caregivers and that's one of the most significant components of the adult day programs. So I don't I don't know that I have a lot more to say about that I know that you've got a couple of folks on the phone to talk or on the screen to talk later but if there are any questions from a Dale perspective about adult days I can answer those and then pop on to talk a little bit more about abuse and exploitation. Thank you Commissioner. You will continue to be in the room as they say so why don't you move forward. Okay, and then actually committee and I'm sort of like also thinking about the folks who are here to testify. Potentially, if there are brief questions not comments but questions for the commissioner. And then as each person goes and then we may circle back with more questions. Go ahead, Commissioner. Okay. So the next topic is I feel like I'm a little all over the map here but it gives you some grounding. One of the questions that chairwoman pew asked me to just talk very briefly about was the impact of coven 19 on abuse and financial exploitation for our vulnerable Vermonters. So part of the department is our division of licensing and protection, which is our survey and certification unit so those nurses that I talked about as part of the rapid response team. We've been working earlier on our surveyors, but also adult protective services sits in the department. And so we have been obviously paying attention to adult abuse and neglect and exploitation throughout this pandemic. And we knew as this pandemic started ramping up as was true nationally that there was going to be a huge impact on reporting as as as the, as the world kind of locked down. So we anticipated that we would see less reporting. And that is in fact proven true and I have just a little bit of data to share with you. But so we knew that that was a potential that that's a typical response, and that we were worried and we were worried right because people are much more isolated and you don't know what you don't know and if you're not getting those reports. That really puts people at risk. And just as a side note, you know, I think we've all seen the data about domestic abuse, right that really increased through the pandemic but was reported less prosecuted less, because people were stuck in situations and couldn't get out. So you think about domestic abuse and it obviously pertains as well to individuals that might be living with families and situations that are highly stressed and highly fraught and much more problematic than they were when everybody was moving about more normally. So this was something that we were paying attention to and we're really worried about quite frankly. So what we did was just to get prepared for this and it would be great I think in the future to bring licensing and protection in to talk with you a little bit more specifically. I believe that you received either yesterday or today, a report from Adult Protective Services with a whole lot of data points for you to look at and so that might be something worth talking about into the future. We know that nine months of COVID from April through December of 2020. So that's a nine month period. We compared that same nine month period to 2019 and 2018, just to give us a little bit of perspective and a little bit of trend information. So with that information looking at the 2020 data. We know that reports through this COVID pandemic have gone down about 13% and the ability to complete investigations has gone down about 32%. So just looking at our intakes in 2019 we had 2879 and in 2020 we had 2516. And we know that we were hearing less from people, but with all of that said the recommendation for substantiations has gone up to 18% from 13% to 18%. So if we look at the data and you can look at data so many different ways, but for us what we really believe is that the most serious abuses were still being reported because the rate of substantiation was so much higher. So we were seeing things that were much more clear. That is my hope. That's my hope that that's what the data means, because anything else is sort of untenable. But so I'd like to believe that we were catching the worst things and people were still reporting them. I will say that we also just in terms of breakout it was abuse was it about 25% neglect was it about 25% and exploitation was about 50% of our of our investigations over that same time period. So again that's a little bit of a shift, but I know we've seen more and more financial exploitation. And so we were the course of the last few years and it's something that we've talked about as a group, a couple of different times to counteract what we knew was going to be a problem with with this reporting through the pandemic. We did have a pretty aggressive approach to outreach. So we worked with inventory, we worked with community partners to make sure that they knew how to report that we were still functioning even if investigators were functioning and investigating the case. We developed a one page outreach outreach document that we distributed throughout that whole provider community to again remind them, just because the status is is working remotely doesn't mean that our investigations aren't still happening doesn't mean that investigators aren't still going out. We got all of our investigators fit tested and got them PPE early on. So when they were going out they looked a little bit like they weren't policemen but they were going out still and interviewing people on their front porches and their front yards, you know, trying to do it as safely as possible but not not neglecting or walking away from that responsibility. We also developed a PSA in conjunction with family services with their child protection registry group, because we, the same sort of an impact in reporting was happening in child abuse prevention. It was a PSA and it got about 550 radio spots throughout the height of the pandemic so that people continue to hear, we want you to still report we're still here to get reports this is really critical. We moved our, our training for abuse, neglect and exploitation reporting online so that we could push it out to more organizations more quickly and they didn't have to physically come in to be trained. We had a lot of community partners and worked with a specific interagency team in the Windsor area. That was part of an elder justice grant. So again, tried to be very aggressive and remind people that we were here. Working, taking calls, and again even now investigators are going out in full PPE to collect reports if that's necessary. So a lot of information again that you should have received a report either yesterday or today I think it was due today. I think we actually got it in yesterday, and that has a lot, a lot more data points in it that actually is based on as you will all recall the older Vermonters Act that was passed last session. The adult abuse registry was required to submit a report for many years, that requirement sunset, we continue to submit a report, but the older Vermonters Act codified that that would be an annual report that the legislature would receive and this was the first newly revised version of that report. So I have just one more topic should I jump right into it and give you a little bit of a framework about transfer of ownership or is this too much for right now. This is enough for right now. How's that. And partially because we do have folks who were in the field who are for representing folks who were in the field to give us some testimony both in terms of what the experience but more what we've learned and if we're going to be there's a we're in the middle of another surge and we it's going to be for a while. So what do we need to keep doing. What do we need to do differently. So, I will move on and thank you if you would stay we would appreciate that. Absolutely. I just want to ask Sean long again the long term care on Bootsman to testify. I want to make sure that there's no question right now from any of the committee members. Okay. Thank you. Thank you, Commissioner. She does. Why can't I see it. Okay, Sean if you could wait for a second. Representative would I did not see your hand. I apologize. That's okay madam chair thank you. Thank you so much. Not only for being here but for the leadership that you've provided with the department and all of your staff. And I totally agree with you when you talk about relationships, meaning everything when you're in a crisis so thank you so much. I just have really one quick question and I did take a look at the the report that we did receive yesterday and thank you for that and I have a lot of questions there but I'm going to leave that for another day for I just wanted to double check on on two things. First I heard you say about the 40 people that are contracted via TLC and it sounded like that that facilities contact you and then you contact TLC and they, they go out, you know, that you're the hub there in terms of getting them out is that right. That's correct. Okay, thank you. Excuse me I'm going to be alphabet soup. That's actually literally their name. I don't know what it stands for the it's a so TLC is a is a non non medical provider essentially they so they are you can contract with them directly to provide home care. They're able to hire RNs and LPNs, although it's challenging to get any RNs and LPNs in the state right now but they have they have travelers actually coming in from other parts of the country that are just here in Vermont and working for them directly. So they are a sort of a staffing agency. Thank you. And then this is unprecedented I might add so you know the fact that the, you know that we're contracting out with non Medicaid providers for these kind of services is creative I had softer seeing a problem and figuring out how to solve it. I think that was was wanting to see how that worked in terms of facilities, then my, my second question really has to do with adult days and I think we'll probably maybe take additional testimony at some further point about that but the payments lasted through December, and we don't have the coverage right now and it seems to be going to be lasting for a while. Um, could, can you describe what kind of assistance the department is providing between now and say June 30. In terms of flexibility and billing or I know that the COVID money right now, the, the cares money has been allocated. We don't exactly know what's going to happen with the second round but so just what kind of flexibility and how are you working with them since we've lost three of them I think today so far. Yes. So, yeah, absolutely. You're absolutely right in that the the CRF funding that was available at this point is that original tranche of dollars is is spent out. I think we're all waiting to see what will happen with the federal government my understanding is that that money that the next round of dollars is not designed in the same way as the original one was in that we might not be able to as a state to decide how to use it and allocate it out. There is a little bit and I'm sure that the folks that are here will testify to it but there is about $150,000 more or less left from what was allocated out to the adult day programs. And to account to us and to give us information about what they've spent about those two tranches of dollars. So there's a little bit left. And I think it's not yet clear if that can be carried forward, but it's just a it's a very small amount, obviously, and then beyond that it's trying to really develop the billing flexibilities that we've talked about so enabling them to bill when they are delivering you know, electronically on the phone over video, trying to build them towards a group rate that they can also access. But that's not that will not sustain them. I mean just to be very direct and candid, that is a portion of what they could do and bill but that will definitely not sustain them fully. And also, I will say that the pandemic, it has its own silver linings and it is pushing ahead, a conversation that we've wanted to have about payment reform with the adult day programs because going into the future, their billing structure is really very fee for service and I don't think that that's something that can be sustained. You know, just imagine any kind of a program where you're sending a family member, but with the dull day if somebody doesn't walk in the door, the adult day cannot bill for that person, even though they are holding their spot. They have staffing available. So when they do open up again. I think that the payment structure is something that we have to look at we've talked about that a lot, but this has really Commissioner, thank you. That is identifying perhaps something that we in fact can can do differently or focus on as we move forward. Thank you very much and I'm now going to turn this over to Sean Lonergan who is our long term care on what's been out of legal aid. Thank you. Chairperson and thank you committee for allowing me to come in and speak to you today. And again, I know some people I don't know other people so I guess the first thing I would say was I will be we similar to Commissioner hot we submitted our report to legislature, our annual reports in the 15 so I said, I, I'm going to be kind of going from that report to today, as I'm speaking so if you have that. I guess if you miss anything, you can refer to that. Sean, you don't need to summarize the entire report. Right. One, one, what would be probably helpful is a very brief description as to who and what the long term care on what's been is. And what you have, you know, and then, which is probably in the report, which is on for anyone who was looking it's on our committee's web page, if they want to do that. And we are focused on COVID, not on other kinds of things we're, we're focused on COVID. Okay. Yeah, so the long term care embossment project. We're part of legal aid so I guess the first point I would just want to make is we're not part of the state government. We're independent and each state has their own on long term care embossment project for months, and it can be all different for much different in the sense that we're not part of the state government, we're not legal aid. So DOP is is where advocates and resources for individuals living in long term care facilities, and also individuals get who are participating with choices for care in the community. So we work with nursing home residents, residential care residents, and residents of assisted living facilities. We also in the so that and then we so we work with people long term care facilities, and then also any individuals who are receiving choices for care in the community so those are primarily individuals who work, I mean, work, live in home and get their services, living at home. And we do a number of, of, we have a number of responsibilities and duty, but primarily what we do is if individuals residents that I talked about our choice of the care participants have concerns or issues about the care that they're receiving, we assist those individuals were trying to resolve problems or issues, and we can do that. Generally, I like it more of an informal way in which we just kind of talked to maybe facility at the staff and we could do it more formally by helping residents and participants recipients of choices for care actual file file complaints, you know, and with the state and that would be a complaint to the survey and certification. And that's how potentially get revolved so we do things informally informally but we're resident directed. So we only do things that the resident tells us that they want to be done. Those are kind of a general, general overview of what the VOP is and what we do. And so, I guess I was just, if I'm just going to skip to through the report in the sense of our report talks about complaints and cases, and you can look at those categories. And I guess, the point here, I guess, if when in reading the port. I think there's things that you could focus on during a time of Kobe right. So if I was going to be short and some sink and focus on what you've asked for. First, you might want to look at page seven, because I'm excuse me, section seven which is on page 12 of the report because that kind of describes some of the case work that ombudsman have worked on during this past year. And so that will give you a flavor of some of the things or issues that residents have experienced during this past year. And some of those things will be Kobe related. Some of those things won't be, but it's really hard to kind of tease out, given the fact that COVID has actually impacted everything, but that will give you an idea of what residents and participants are facing over the past or in the sense of describing their experiences. And also in the report, we talk about what we would do is, as we seen the major issues facing residents and CFC participants at this point. And that's in section 12, and it's issues and recommendations and it starts on page 17. And so one of our first issue is that, and Commissioner had mentioned this, in the sense of, you know, cases and deaths in nursing homes, and the degree to which COVID has impacted residents of long term care facilities has been, you know, document and shown in the sense that early on in the pandemic. That was a hot spot. And I would agree with Commissioner Hut that Vermont in comparison to other states. So I, as a state long term care embossment, I participate on calls, nationwide calls, and given the lack of leadership from the federal government is in my view, each state kind of doing their own thing and trying to muddle their way through this. And in comparison to other states. Vermont's the impact on residents of long term care has been better in the sense that while Vermont has obviously had deaths and cases in long term care facilities. I would just say that those numbers, I haven't been as drastic as other states, for example, in neighboring states of New York, Massachusetts, and New Jersey in the spring when the during the first surge. The stories that I was was hearing about nursing homes and long term care facilities was very frightening. And I do agree with Commissioner Hut that if if you're comparing Vermont to other states. Vermont's done the state government has done a very good job with COVID and nursing homes. So I would just want to emphasize the point that we and I think I and I have no indication this is this is going to occur or happen, but we just need to be still like not let our guard down because the epidemiology of COVID, you know, has not changed. As we've seen with the second surge. So, you know, nursing home residents residents of long term care facilities aren't at any less risk. You know, despite the improvements that we've seen in, you know, testing and surveillance and now we have vaccines. We don't want to let our guard down. So that would be one of our issues is just the fact that and Vermont has has been very proactive. And you've seen it with the vaccines in the sense that, you know, a nursing home residents of residents of long term care are within that first phase of getting vaccinations. So we just want, again, not to let our guard down and realize that, you know, it's still a time of great risks for individuals living in long term care facilities. The second issue that we pointed out our report is the staffing shortages at, you know, long term care facilities and home health agencies. And, you know, inadequate staffing has been an issue, even before COVID. And those staffing issues have just become, you know, more magnified and exasperated by COVID. And so, you know, the long term care embossment, we just want to, we would obviously, and why this is important, why staffing is important is because staffing, you know, is directly related to the quality of care and the care of the services that individuals receive. So, you know, when there's inadequate staffing, that means that residents and CFC participants, you know, are going to bear that in the sense of having less services, the quality of care will be less. So, you know, staffing obviously is very, very important. So, you know, Vermont, and I know that the state's working on this and people are very concerned about it, but we need to explore ways to try to, you know, bolsters us staffing and make sure that staffing meets the needs of individuals who are seeking long term care in facilities and through choices of a care. And maybe that's through pay increases, because most people that work in this field, long term care services, particularly AIDS, don't make a good living. They don't get a good wage. So, you know, that would be one area to look at. And, you know, and this has been talked about two before. And I think it would be some way to maybe realign Medicaid payments to providers so that the actual costs of providing services is is is closer to the actual costs Medicaid all traditionally pays at a lower rate. So it just makes things much more difficult for providers to meet the need. So, and again, you can read through the recommendations a number of recommendations. I don't want to take up time going through each one of those. But again, staffing in a kind of static staffing and facilities and in the community. I want to emphasize that in the community. Again, that's been exasperated by by COVID so we've had during the past, you know, once the pandemic, we and during the pandemic. We've heard many, many stories of from reports from recipients that their care plan needs are care service hours when they live in the community just are being filled for various reasons and it usually goes back to staffing. And that's becoming a bigger and bigger problem. The third issue that we identified is socialized isolation and loneliness. And again, this is not something that people aren't saying is the issue. But the fact that and it's very hard to deal with it, given the nature of COVID, and particularly in long-term care residents with a risk is so high. And, you know, if person does get COVID, it's more than likely going to lead to, you know, really bad outcomes. It's really, really hard. There's no easy choices here. But I just do. And I would say that the state and actually the federal government has has heard and has recognized that social isolation and loneliness due to COVID and the restrictions and the lockdowns are having a impact on residents and have attempted to try to, you know, rectify that problem address that problem as best they can. But I just think that going forward, it needs to be kept in mind. And I'm not saying that no, that people aren't keeping your mind because if you look at the state guidance over time, it's transformed or evolved whereby they've had, you know, where visits are taking place, right? There was a lockdown initially during this late summer, I mean, early summer, late summer, visitation started, outdoor visitation started. And then in October, there was guidance issued from CMS for nursing homes in regard to indoor visitation, which basically said that indoor visitation should take place, unless there's a valid safety or clinical reason for why it shouldn't. And the state of Vermont evolved their guidance to facilities to match that. And then we had a second surge. So, again, I just want to point out that residents are experiencing isolation, there are reporting loneliness, and it has an impact on their mental and health. But it's really, really hard to try to figure out how to go forward. And I guess the best thing from our perspective is that residents need to be heard in terms of their experience. And then hopefully, and I guess it's been my experience based on what I've seen in terms of guidance that, you know, the experts on how to navigate safely residents through this, you know, like through a public health perspective, you know, have listened to that and try to do the best I can, but there's times when, you know, that there has to be lockdowns or there are times when, you know, visitation has to be restricted, and it's kind of a constant pull and push. And I guess the important thing is just to be in a situation or to reevaluate that guidance around visitation, for example, as regularly as possible, and the state has, you know, has done that. And so then the last issue. Excuse me, Sean, I'm, as you are talking, I actually have pulled up the report. And it's a very thorough report. Thank you. As you're talking, and I just want to point this out and maybe we will look at the whole report at another time more closely. You have a very specific recommendation that Vermont should ensure that long term care facilities provide residents know should provide residents with reliable, regular access to communication technology, along with assistance to use whatever technology is available and works best for the resident. And so, I'm thinking that that must be not just phone but also whether it's things like iPads or computers or whatever so that you can have some kind of face to face. Yeah, communication and that may be something that we need to measure. That may be something that needs to be part of a checklist. I mean, so those are the kinds of things to look at as we continue. Right. And facilities. Again, from my experience have been doing the best they can. And like all of us, you know, sometimes we do really good things and sometimes, you know, we don't so facilities have tried. Yeah, so I guess that's I think that's important point to try to get an idea of how much how to degree. This has actually happened across the board. You know what I mean. So, of course, yeah, there's instances where this is happening. And so they're probably doing as best they can, but it would be good to have an actual data to determine. So if these are recommendations, right, the fact that people are doing the best that they can. It's important that we have a picture of what they're actually doing. Correct, right. That's a great way of putting it. And then, so then the last recommendation is just quality of care. And again, you know, COVID, and rightfully so has taken, you know, everybody's preoccupied with, you know, focused on COVID. But other things are still happening. And so, and that's the focus on COVID, you know, does trickle down and impacts, you know, quality of care. And I guess things are probably even more magnified because, you know, friends families and concerned persons haven't had the same access to, for example, residents of long term communities that they have in the past. So there's questions in everybody's mind about the quality of care that individuals are, you know, are receiving we've received enough complaints or calls from either residents or, you know, concerned persons to realize that you know quality of care is an issue. And again, we have specific recommendations around there and I do remember at the beginning to talk about the nursing home oversight committee, which did have, you know, some recommendations, particularly along like enhanced licensing process for transfers of sales of nursing homes. So again, there and there was actually there. I'm sure the committee remembers this the fact that Dale was rewriting the regulations for residential care homes and assisted living residents. So I know everybody's again doing the best they can but there are other things that were going on prior to COVID. And I just don't I guess we put those recommendations in not just so we as a kind of don't forget about those other things that would impact quality of care for residents. So again, those are specific recommendations. And I apologize for talking fast. I know I always talk fast. But I guess those are the points that I think are are important to hit upon at this time. And if anybody ever has any questions about the report, or wants any, you know, follow up, I can certainly do that. Absolutely. Excuse me, and I want to check and see if there are questions right now and ask you if you are able to to stay through the for the next in case there's an ultimate question at the end. Are you able to do that. I can do that. And one of the I just want to say that I agree with Monica in the sense of Vermont, the state's response and I do think, yes, size has helped but it's also reflection of the leadership here in Vermont and it's from my perspective it's been proactive. And it actually has tried to respond, respond in the sense of it's revised, and it's always looking to try to do things better. So I do think that, you know, from leadership and Vermont should be commended for their, you know, efforts with coven. Well, thank you are there. Questions for or Sean. Okay. Thank you very much. I appreciate. I appreciate that. And I, my computer has just lost my agenda. Laura Pelosi is up next, Madam Chair. Thank you. Thank you, Laura. Good morning, Madam Chair. Good morning, Laura Pelosi and I represent the Vermont Health Care Association, which is the trade association for our long term care facilities so for those of you who are new I guess we'll just keep repeating that it's the SNF slash nursing home so skilled nursing facility slash nursing home residential care home and assisted living residences or facilities. Thank you so much for having me here this morning. This has just been an incredible 10 months I think we're in, I think we're in month 10. But certainly the world went topsy turvy back in March, and things have just simply not been the same. And I would say, you know the impact on long term care facility residents and staff has been incredibly significant as you've heard from both Commissioner hot and from from Sean Laundragon. And I will just echo, I meet regularly with my peers across the country and there is little doubt that we have had a very different experience here in Vermont, you know my peers across the country can't just pick up the phone and get the number, you know, immediately can't get to Dr Levine immediately. They don't have organized zoom meetings like we do with representatives from, you know, 200 facilities representatives from Dale representatives from BDH all on a zoom, like raising questions, asking questions, walking through new guidance, getting technical assistance me we are doing that on a very regular basis and that's just not happening in other places. I think that's a real, you know testament and a real key component to the success that we have had, despite some tragedy. I want to give a little bit more nuance to the, the description that the Commissioner gave with respect to the facilities and just to make sure folks understand that at the SNF or nursing home level. One of the big differences there is that they have really two populations that they serve so they provide a traditional long term care service. These days with our choices for care program having been extremely successful and allowing individuals to receive their care at home for as long as possible. The acuity level of a long term care patient in a nursing home is, is quite high. They tend to have multiple medical conditions and comorbidities think somebody who might be on the dialysis, or have COPD just very, very high medically complex folks, but then they also provide a short stay service under Medicare. So that's your 30 or 60 days recovering from a you know that classic knee or hip replacement, or you've had a severe infection or cardiac event and you need some nursing care or you need PT, OT speech and language therapy for some period of time before you can transition home or back to your residential care home or assisted living so that acuity is high and that's been one of the extreme risk factors in particular at the SNF level. I would echo the commissioners comments with respect to our concerns from the very beginning about residential care homes and assisted living and their capacity to manage through this pandemic due to the different types of staffing. They have heavy clinical staffing, they have much less staffing they're organized very differently so we've been very concerned about their capacity and as an association and in working with Dale and VDH I think we've done a good job of trying to make sure they have the resources they need, peer support, all of all of those things. If I just back up a little bit to March and I do want to talk about the challenges and some of the gaps that we're seeing because I think you're particularly interested in that and it's very important for us as well but as we go back to March as we were watching what was happening in the state of Washington which is where the very first SNF was really overtaken by this virus. You know facilities in our state started really trying to beef up their stocks of PPE and supplies which was nearly impossible due to the shortage of those supplies and just the exorbitant costs. They also at that time had already begun screening for symptoms for their residents and for their staff. And then at that you know at that point in time there was really no guidance when the governor declared his state of emergency facilities were shut down to visitation to non essential personnel. They continued and beefed up that symptom screening this was before we had testing available. They had to halt communal activities within those facilities I'm talking nursing homes residential care assisted living so that would be anything like communal dining social activities all of that really stopped. You know they moved to to Sean's point visitation remotely via you know zoom WhatsApp FaceTime standard phone call a window visits you know facilities were creating spaces so that you know their loved one could come you know and visit them outside or maybe maybe in the vestibule with the resident in the lobby so that they could see one another really you know depended on the residents abilities to interact and what the best medium was and what the facility had access to. There were some grant funds that facilities applied for and received so that they could, you know, add iPads and Chromebooks to their stockpile. Certainly not, you know, not every resident, he or she is a is a is equipped with one but the facility was able to increase the number of devices that they had so that they could work with families to schedule. Remote visits it's been very challenging and the visitation piece in particular and during the limited window where we started to do outdoor visitation over the summer. You know we pushed as an association really hard to allow that to occur. It was logistically very complicated because you still had to ensure appropriate social distancing masking but the facilities really felt that that was critical to the emotional health of their residents so they worked really hard to get that up and running. And then we for a limited period of time had moved to that indoor visitation which similarly was challenging and very scary on some level for facilities, you know it's this like benefit, this this cost benefit that they're going through all the time where they know how to do it because it's the best thing for the residents and they do everything in their power to make sure that they are controlling that risk of exposure as well so. So I think facilities have worked really hard to maintain that connection in a really challenging time but you know they recognize how incredibly important that is. So the SNFs in particular upgraded as much as they possibly could their ventilation systems because we know that the ventilation within any given space is really challenging. Negative pressure rooms, not so much there's not a lot of capability to do that the infrastructure and the capital costs associated with that was prohibitive. New admissions into a long term care facility have to quarantine for 14 days that's really tough. It's really tough on the staffing it requires even more staff than we normally have to have the amount that the types and the quantities of PPE that facilities are going through is not like you would see in the normal ordinary course of running a long term care facility and the state has been a great partner in making sure that when we have a gap. And we can't get those supplies and that PPE that they come to the plate and they they help us procure that it's been it's been a great partnership. And the testing piece that has evolved with the science and the availability of new types of tests, you know it started where you know testing was only happening in the outbreak scenario back in the spring. Then we really pushed and VDH was phenomenal on this once the first CDC data came out at the end of March about what happened in the state of Washington, and they realized that asymptomatic transmission and long term care facilities was a huge issue. So we started making sure we could get patients being discharged from the hospital to a long term care facility tested before they came to the facility, and that combined with the quarantine requirements, you know really help to reduce the risk of exposure in the building. Now we are up to regular surveillance you know nursing homes are doing daily antigen testing all shifts, plus once a week PCR testing, our residential care homes and assisted living are doing twice a week PCR. And this is it's administratively and logistically incredibly challenging and every single one of those test results gets reported to the federal and state government so just the time it's and the staffing that it takes. But what I will tell you is, they're so committed to it, because that's how they're catching cases, and it's been very effective that way so as much of the, as much as it's adding to that workload they're doing it and they're very committed to it and very passionate about it they get really concerned if we're getting low on testing supplies, you know whatever the scenario is, they get really concerned about making sure they can continue to do that and the state has been a great partner in making sure they have access to what they need to continue to do that testing. And what I would say now is we're deeply into the vaccine deployment phase. Thankfully, there's light at the end of the tunnel I think this is going to take months and months. But I probably spend, you know, I feel like five hours a day. I'm sure the commissioner does more than that just on vaccine deployment these days. But you know the facilities are all signed up for their clinics we're working through a lot of the logistics and I did just want to comment I heard Dr Levine comments to the joint committees the other day about the uptake of vaccines or a vaccine pregnancy with long term care facility staff. I just want to say I think it's too early for any concern anecdotally what I hear, and maybe the commissioner could verify but we're seeing anywhere from like a around 50% to as high as 90% uptake, but we've only had one clinic. We have multiple clinics scheduled facilities made some conscious choices to stagger staff in case of staff reactions so that they didn't have a lot of staff maybe calling out for one or two days because of the staffing problem that we have. And then some staff wanted to wait for that second clinic just to see how their peers might have done who went in the first clinic so so I would say it's too soon to fear that we're not going to have good uptake of the vaccine and long term care facilities. With regard to challenges and opportunities or gaps. What I would say is that the sheer volume of guidance and the rapid rapid pace at which it changes at the CDC level at the VDH level at the day level. That has been an incredible challenge and again thanks to the relationships and our ability to get the people we need to talk to on a zoom with all the facilities answering questions because every time a new guidance comes out they have to modify their policies and their protocols. So that has really helped to at least you know kind of get folks get their heads around the issue and be able to implement and I think that's been key and that has happened always very quickly when new guidance comes out. We get those zooms going you know right away and I think that's been super helpful. And I appreciate both the commissioner and Sean's focus on perhaps one of our if not the biggest challenge staffing staffing staffing and this was our primary issue before the pandemic you know last session we came in having a chair the rural health services workforce task force. We submit a report the legislature took a lot of steps last year to help us in particular with that nursing shortage there are some more things to be done but we knew before the pandemic we were in a terrible situation with staffing and that has been exacerbated facilities need even more staff than they did pre pandemic even with lower numbers of residents in the building and that's because it takes more staff to do all of the things that have to be done in terms of infection control. It takes any staff person much more time to complete a task because they have to don and doff PPE between every activity and every interaction. And you know staff are out because they're either exposed or they're positive themselves fear fatigue is a real issue 10, you know, 10 months into this. Excuse me. And then you know you heard the commissioner with respect. I think we all have fatigue. With respect to the impact on staffing in an outbreak. We have relied very heavily, you know pre pandemic on the traveling nurse population. They simply don't exist these days. They exist but they're deployed everywhere else in the country that is experiencing a terrible terrible, you know, outbreak with this virus. To the extent we can get them they're almost cost prohibitive and we've had to work with Dale and you know a couple of facilities just to try to bring some, you know, traveler resources so that they could, you know, take more admissions from hospitals for example. And those costs are real and we've really appreciated the funding that the legislature has made available for these facilities, you know, we nationally, you know the numbers I see is that there's an expectation that 40 to 60% of long term care facilities. You know, might close in this next year because of the impacts of the pandemic. I think because Vermont has done such a good job with trying to provide financial support, and because we've had direct federal funding come into all levels of our long term care facilities hopefully that's not the situation that we will see here in Vermont but it's, it's, you know, it's precarious, I will say, I think the limitations with our infrastructure has been really challenging. These are old buildings that were built, you know, in the 50s 60s and 70s, they were intended to have multi occupancy rooms shared bathrooms, you know, open spaces so if you think about it I don't know how many of you have the opportunity to attend a legislative event that the healthcare providers have done and one of our administrators from Birchwood Terrace in Burlington, who was the second facility to experience an outbreak you know she told the story there they had to move their dietary services their housekeeping services outside so that they could keep different units of the building locked off and then bring the food and other services in through other entry points just to reduce the risk of spreading, you know that virus from an infected area to a non infected area, you know the infrastructure providers have, you know, placed an increased burden on the ability to manage that that virus and that's not an easy fix, right, that's major capital concern that's not an easy fix but it's something that we know in a situation like this is really challenges the facilities ability to respond. We have seen a serious reduction in admissions capacity so the commissioner mentioned patient flow and this I do hope we can do a deeper dive on I think you know maybe we're not ready for a full reflection and series of recommendations on what to do going forward but some of the things that are already becoming quite obvious. The patient flow from the hospital to the nursing home either for that short stay rehab or for a long term stay has been severely impacted you know when a new admission comes in like I mentioned they have to quarantine. So that's taking up all of those rooms for a minimum of 14 days. So that has oftentimes reduced a nursing homes capacity by 20 to 30%. So folks back up in the hospital. Also taking up quarantine space are our residents that frequently have to leave the building to go out for medical appointments, like dialysis three or four times a week a dialysis patient is in quarantine, all the time, because they're high risk and they're in the building. One area that the facilities have noted for future consideration is to have one or two nursing facilities in the state who can do dialysis, so that we can reduce the risk of exposure to a group of patients like that who are probably high risk patients you know they're at risk during transport to the dialysis center they're at risk being in the dialysis center so that's a that's an area where we feel we need to have a conversation and there are a lot of regulatory components to that but also we've been you know challenged with some of the more challenging populations, whether that's folks that have mental health needs or substance abuse needs, you know, managing their needs with the lack of mental health, you know counselors and substance abuse counselors and the ability to bring those services to the to the nursing facility has been a real challenge I think that's an area, you know down the road for some exploration and that's been exacerbated. In this pandemic, dementia patients has it's been incredibly challenging to manage the dementia population because they wander because they don't necessarily have the capacity to wear their mask. So managing the infection control. When it comes to dementia folks they they might need a minimum of one to one one one staff just to consistently, you know monitor and assist that resident to be able to to be in the facility that's been incredibly, incredibly challenging for folks. I think you know what it certainly tells us when I look at some of the challenges that we've had with the admissions piece between the hospitals and the nursing homes in particular. You know we had a backup of roughly 50 patients at UVM Medical Center that were in need of sniff level of care. The commissioner and I and facilities worked pretty hard to try to resolve or at least release some of that pressure. It took money, it took staffing. But I think what it certainly confirms is that there's a very high level of care that hospitals need the nursing facilities to provide and we need to find ways to build that capacity and to do it more effectively going forward. And then similarly, you know, the residential care homes and assisted living there, they kind of, they, you know, really sort of stop taking admissions, they have a much more stable truly longer term care population. So they were very hesitant to take somebody coming out of a nursing home that, you know, could have used a lower level of care out of fear, understandably because again their ability to manage positive situations, you know, was much less than it was even at the nursing home level. So that definitely created some flow issues across across the system. Having said that, you know, again, I think Vermont has done an amazing job with this, I think we are very lucky to have the leadership that we have. And also the partnership and assistance from the legislature so we greatly appreciate that and I'll stop there if anybody has any questions. I'm sure we, I'm sure we have questions. And however, we may be saving those for another day. Happy to return. Thank you because really this is, I feel like I was sitting down to the Thanksgiving dinner and my eyes were bigger than my stomach and there are four people who are clearly not. We need to hear from whether it's today, whether it's this afternoon or another day that we clearly I put too much on the table for. And so, thank you, Laura, and this is to Gail and Susan and Janet and Molly. We have 15 minutes left and that is not at all sufficient for the time to hear from you and I and others who have, whether it is the commissioner or the long term care on Bootsman for Laura the lobbyist, you can hear things to do and isn't this nice that these are on YouTube now so that if you can't be here. You can listen to it on YouTube. I am wondering if Gail Sue, Janet or Molly, if any of you are available. Even this afternoon at 115. We are. So, I can't. Yes, this is Gail I'm available this afternoon. Okay. I'm also available. Thank you Sue. And if Janet and Molly, if are you available and if not, we can do another time. This is Janet and yes I can be. Okay. Yes, I can be as well I do have a, like it's three o'clock commitment though so as long as. Well, I mean this is, I'm going to, as I'm looking to the four of you. We probably have an hour and a half in the afternoon. Because we are, we are, we are leaving at three. We are leaving at three this week, although it says 330. We need to stop at three this Friday, and we also have to have a committee discussion on our principles and so we need some time for that so it's about an hour and a half which would mean. And I don't know how long, I don't want to cut anyone short, but people have up to this point have had a lot to say. So I don't know how many of you like how long you were thinking of speaking. Well, I can tell you that my part is probably about five ish minutes or so, and then we'll take it from there. And Sue, are you 15 minutes, half an hour, what are you, I would think maybe about five to 10 minutes. Oh okay, okay. Janet, what about you. I can't hear you Janet. I'm sorry, I would say about 10 minutes. That's all really. Okay, I could go longer. So, I'm the four of you I appreciate your flexibility if we could pick up with you at 115 this afternoon that would be great. And I realize we may very well want Sean and the commissioner I realized that you can't spend your whole day here. So you can. When we come up, we will certainly circle back to you. And Sean, I'm struck by how even when the, when Laura was speaking, some of what she was talking about are in fact recommendations in your report. We may want to more specifically have you go through each one of those recommendations in terms of what are things we might be able to tackle this year and what we might not be able to. So, it's fine whenever, whenever it works for you, feel free to reach out and I can make time available. Okay.