 Good afternoon, everyone. This is the Vermont House Committee on Commerce and Economic Development, along with the House Committee on Health Care. This is a joint hearing to hear Health Care Workforce Strategic Plan report. So first up, stateauditor.offer, and just to let everybody know, this is Friday afternoon, so it's Friday, January 26, 2024 at 1.08 in the afternoon. So with that, Madam Chair, did you want to. No, I appreciate us doing this together. I think the both committees have put a lot in place of the last couple of years. And so it's going to be great to see where it's landed and what else we might need to do. Thank you. So, Mr. auditor, thank you for joining us this afternoon. muted. Can you hear us? Is that better? There you go. Okay, sorry about that. I'll get the visual up to. Thank you for having me today. Is that good? Nope. No visual. Get your voice. I don't use zoom very often we use. Team. There you go. All right. I'm in your neighborhood. Not really. I apologize for being remote, but our building is still shut down. So thank you. Not a problem. So as you know, we did this work because like you, we think it's an important issue. Obviously the community at large needs more nurses. And we wanted to see if the programs who were working the incentive program. So the question is how do you define success in this case? Presumably it's, you know, what are we getting for the investment? How many new nurses are they sticking around and for how long? Unfortunately, we can't answer the question we need data to answer the question and one of the key things we found in looking at the various programs that you have created. There really are no performance or evaluation tools yet. Which makes it impossible for us to do the work. But we did come away with some. Not findings, but some information we can share with you and you probably read the report. It's not terribly long. You know that the incentives as far as we could tell are not coordinated. And that's not a big problem for the state. I don't think but we did learn that there are incentive programs at a number of the hospitals. And I'm not sure that the state programs or the state funded programs really include consideration of those private efforts and how they work together or not. So that's one thing to think about. The other is that, you know, this is a great time to do this as JFO also pointed out, there's a lot of money still on the table. And therefore you can make some changes that could have an effect pretty quickly and influence, you know, the rest of the money that's currently available, let alone new funds that you allocate. And arguably at least as importantly as you know, the hospitals have made some progress in reducing their reliance on traveling nurses, but it is a massive cost and drain on the system. And I'm shocked to learn that in the last three years, the hospitals have spent $357 million on traveling nurses. So every dollar spent to reduce that amount has a direct benefit on the cost of health care. Doug, is that all, is that just hospitals or is that all health care? Just hospitals as far as we know. So we know that there's nursing homes and home health agencies that are having the same issue. The information we got came from the Green Mountain Care Board is, I think, as a part of the hospital budget process. So that's why it's limited to hospital. We, unlike JFO, we focused exclusively on nurses. I know their charge was broader and included other health care professionals. So that's helpful to have that extra data. So as I said, we did not conduct a full blown gag is audit because we just didn't have sufficient performance data to answer the questions. And if we don't do something about getting performance measures and evaluative tools, we'll never be able to do an audit report. I mean, we could wait a year because the programs are so new. That's another issue. But if we don't have data, we can't answer the questions and neither can you. Although we have a number of recommendations on the last page of our report. There was one that I see in the JFO. Brief that's really encouraging and that it echoes hours and it's from a heck. And I'll read it. I'm sure you guys have read it, but I'll read it out loud. It's so good. Consider adding statutory language across workforce development incentive programs that requires the administering entities to establish consistent agreed upon benchmarks, common definitions, annual price measures, process measures, and longitudinal outcome measures without consistent measures, methodologies and common reporting structures. It is challenging to determine program effectiveness relative to the investment and relative to other workforce incentive programs. Here, here, that's that's exactly what's needed. The only thing I would change is the very first word says, consider, I would say, just do it. The sooner the better. Not an easy task, but it's still January. Thank goodness. We had a couple of other things that I think were not addressed by JFO that may have seen in our report. And in addition to aligning all the programs in terms of cutting comparable service year obligations by those who benefit from the program. I think you should seriously consider increasing the service obligation. And here's something to think about and why I think it's so obvious to me. The median hourly wage for an RN is $9 an hour higher than an LPN. So in one year, if a person goes through the process, the additional education and the certification comes out on our end. In the very first year, they're going to make an additional $17,000 on average once they hit the median. If you extend that over the life and career of that person, it is an enormous career changing life changing decision and good for them. And we need them. It's all good. It's a win-win for everybody. But I'm not sure that it's a fair match between what we ask of them in return since it's a career long benefit. We're asking for one year of service for one year of the incentive and I would encourage you to reconsider that. The other is that we learned that there are, you may know this, that there are some nurses who live in Vermont but are licensed and work in a neighboring state. For any number of reasons, probably money is a big part of it, but they represent a possible pool. And there's hundreds of possible pool of people who could be encouraged one way or another to return to Vermont. And they're already certified to return to Vermont. So, you know, as you consider working with the parties, the administrative entities on how to collect more data, not just as they're in the program but longitudinally, I would also consider reaching out to these nurses that are currently working in neighboring states and see what, if anything, could bring them back because they're a great resource, no doubt. So it's really all I had for now. Any questions for Doug? Thank you. Thank you for your information, your report. It's fantastic. I'm just, you know, you mentioned considering the obligation a little bit longer. I specifically remember when we were trying to come up with the length of obligation years served. We were competing with other states who are also scrambling to incentivize nursing programs and we were trying to align the obligation length to them. I'm wondering if you looked at any of our neighboring states in particular, because we do have a lot of residents that work, say in New Hampshire, New York. I'm wondering if you looked at any of their programs that they've put into place to incentivize this career and what their obligation, length of obligation was. We did look at some surrounding states and some of them are two years for one year of incentive. And to me that makes more sense. Obviously, you know, there are going to be people who for any number of understandable reasons, when they complete their education, something may happen. There may be a family emergency, they've got to move to take care of someone, or a spouse gets a job somewhere that they can't turn down. That is complicated. But for those who don't have those complications, you know, one for one, considering it's, as I said, it's a career changing event worth a great deal of money. And again, I would be happy for everybody who benefits, but we're making an investment and ultimately the answer is, where is that sweet spot we don't know, because we have no data. And one of the things I think that a heck and we pointed out is, we would greatly benefit from interviewing everybody who goes through the program in depth. Everybody's different. Everybody has their own family and personal needs. But I think if we did it regularly, we would probably learn a lot that could be helpful to you to help make these kinds of decisions. Because right now we're just guessing. You're welcome. My question is for Doug. Thank you, Doug. I, our auditor, sorry. Okay. I was just wondering if you actually had a number mentioned for monitors who are licensed neighboring states, but you also mentioned in the report about for monitors who have left, but still have a nursing license. I assume here in Vermont. Do you know a number. I have to check with my team. I don't have that in front of me, but I'll be happy to get back to you. Sure. I just curious about how big that universe is. Thank you. By the way, for what it's worth in my work prior to becoming auditor, I occasionally would look at median hourly incomes for a range of occupational titles. I won't surprise you to learn that in nursing as with almost every other profession. Vermont is on the low end of the wage scale. So if you are in your twenties to 30 or any age for that matter, but say you still have education debt. You're trying to build a career. You can make a lot more money going to Boston or York than staying in Vermont. So, you know, we have to find ways to make up the difference, not just with money, which is a challenge. But I wage your unintended pun. I guess that a lot of people who leave do it because they can make so much more other places. And I think, frankly, I wouldn't surprise me if some of the people who worked here and are certified here originally ended up becoming traveling nurses because they make so much more than full time equivalent nurses in the hospitals. It's very significant almost twice as much annually. Having said that, you're not guaranteed full time work, but at those wages, you can afford to take a little time off. Thank you, Mr. Chair auditor Hoffer. I thank you for your report. I found it illuminating as always. I am curious because a just in so frequently when they outsource so many of the essential services that are preferred to Vermonters. They are very insistent on innumerable quantifiable performance measures, both quantitative and qualitative, especially when grant agreements are hammered out with various nonprofits in the social service sector. Does it surprise you that they didn't have these in place these types of performance measures for their own programmatic efforts? Well, yes and no. They're young. The programs are young. But, you know, I know a lot about economic development. That's an area I spent some time on. And I know that during COVID and just before there was a rush to get money out the door. So it wasn't uncommon that the agencies might come before you guys and say, give us the money. We'll design the program and tell you what the performance measures are later. That's dangerous to me. In this case, I was interested that AHS didn't have much to say in response to JFO's report. AHA had a bunch of good recommendations, but not AHS itself. I was a little surprised by that. I don't know why. We did not interview them directly for our work. We're just looking at the records available. But no, I share your little curiosity and confusion about why AHS isn't deeper into this right now. I do. No question about it. Yeah. Thank you. Hi. Hi, Auditor Hopper. This is Representative Cordis. I'm speaking as giving you in the group an update on travel nursing. I currently work both in the state of Vermont as a registered nurse and also have in the last two years have completed a number of projects in Maine and in Virginia and largely or partly because of action taken on the federal level to reduce the amount of, for lack of a better word, graft taken by some of the recruiting agencies in pulling in the extra money. The wages for traveling nurses have gone down considerably. So many, just another area where nurses are undervalued. So it depends on the field that you work if there's an urgent need or if there's a hospital that the union staff are about to go on strike. Then those wages offered by travel agencies will be higher. But right now it's not necessarily a great option anymore. That's interesting to say that I recall hearing recently something about discussion of an agreement amongst all of Vermont hospitals that they won't compete with each other for nurses. Which, on the one hand, might sound good. It wouldn't change the balance of where there are too many or too few. But it'll also mean that those hospitals that pay more or pay less are not going to have to be forced by the market to pay more. I was curious. Have you heard anything about that? So if I can respond to that, I'll just say from the testimony we've had over the last couple years, this is Lori Houghton, sorry, chair of the House Healthcare Committee. It is a common problem that hospitals, designated agencies, home health, we're all, they're all competing against each other for the workforce. And so people are moving if an incentive is better at one versus another. So it is a problem we have in the state. And I assume it's a problem we have in other states as well. And if I can also just comment on something Jonathan, you asked, I just want to remind everyone at the table, we put many of these programs, if not all of them into place. And we are responsible for putting metrics in that would measure the success of them. So that if we're finding that what we did or didn't put into place is not giving us what we need to track this, we need to do that. And we need to remember that going forward. So I would not put the blame on AHS on that. That's fair, Madam Chair. My apologies. No, that's okay. One thought on that as you go forward. Some people undoubtedly might be reluctant to share information about their lives and life choices out a couple of years from the incentive and their certification and their life. So I would encourage you to think about putting something in the grant agreement that requires them to provide at least baseline information that you can also promise not to make public obviously just use it for research purposes. Otherwise, they might say, we'd rather not talk to you. And that would be unfortunate. I think this shows a great need for us to really consider creating a data bank. Thank you very much for joining us this afternoon. We appreciate it. You're very welcome. Thank you for your good work. And I hope these programs continue and you get the data you need. And then we need to measure their success. Thank you. Thank you. Nolan. And do you want to go up to you? There are no chair down here. Record no language office office. I think this might be my first time on commerce. Hopefully it's not the last. Maybe once maybe 10, 12 years ago. Maybe. So I thought I would just briefly just talk about what our role was in this report and then just quickly just say what it's in there and why we did it. And then jump in whenever. As you know, the law of legislation required us to do an inventory. It required us to some funds and then it required. Us to come up with recommendations and work with the collaborators being a HS. BSAC and a heck. So the first two we felt was well within our scope to come up with an inventory, which I think was really useful to myself as well because throughout the years people have asked me all over the place. So I thought it was very useful having the piece about where the money is also well within the scope of what the work we do. So in terms of making recommendations of how you should, how the program should be streamlined. We didn't feel that was within our expertise. We're not in the field. So what we did instead was just put the recommendations and attribute their recommendations to the other collaborators being a heck and BSAC. So that was the approach that took the information about the inventory of existing programs was provided to us by HS. So we tried to highlight where, you know, as required, the amount that was appropriate the source of the fund, whether it was base or one time. And then this where the money was in terms of as of 63023. And then recognizing there'd be questions about what about after that we tried to highlight if that money has since been obligated or program has been created. So any questions you have about status of where money is or whether it's been obligated or out the door, we will defer you to HS. And I think there is someone from HS on the line who will happily write your questions down. I don't know if you want to add anything. Um, no, I don't think so. I mean, thank you to HS and a heck and BSAC for their cooperation and general and for taking lead on putting their report together. Um, as no one said the recommendations are from primarily from BSAC and a heck do not typically provide recommendations partisan staff. We just do what you asked us to do as far as getting information for you to be able to make decisions. And I don't know if you want us wanted us to put the report up or you're good with people just looking at it on their own devices. We generally have you put it up on so everyone can see it, even people that are on watching us on YouTube. If you don't mind, we'd love to have it up on. All right. Yeah, that's right. Yeah, we usually do that moment too. And I assume it's on today's link so that people. Yes, it is. The other thing I also added was or wish that we added was an acronym list. Thank you. Health care. I didn't know what an FLR was either. So, and then also both BSAC and a heck had other recommendations. I wasn't sure whether to include them because it was sort of outside the scope. And then I said, well, you know what? It's, I think it were worthy of still in. So I have a third of an appendix B, which is like suggested edits another type of action because they are the one in the field. And so, even though it wasn't within the specific scope. They have plenty of infant about ways to make the programs better. So I included them as an appendix so that it would be. Technical. We can build this together for 16 years. All right. So here is the report. And you can see. Starts with the language. That directed the work to be done for this was done in last year's appropriations act. In our offices and collaboration with agency human services and certain departments within it. The Vermont student assistance cooperation, what we've been calling BSAC and the office of primary care and area health education centers program at the university of Vermont, our college of medicine, which we've been calling a heck. I think you're going to be chairing from some of them. The report was actually due to the appropriations committees, but obviously a particular interest to your committees. And as no mentioned, it was to include this inventory of existing state programs dealing with healthcare workforce incentives. The summary of the amounts and sources of the funds for each program. And no one mentioned the June 30th 2023 date that is the was the close of fiscal year 2023 so that's why that date was used for the directions and then recommendations for streamlining or restructuring programs. And those are the recommendations from the SAC and a heck. The inventory and no one talked some about how he put that together. We tried to give you the name of the program, the statute if it was codified, which department and state government and who was the outside administrator or grantee. The amount appropriated either now or on an ongoing basis, the source of the funds, whether the funds or base, base funds so built into the funding on an annual, onto the budget on an annual basis or one time, just funding appropriated. One time it would have to be re appropriated for the funding to continue. And then they carry forward if any of unobligated balances as of that date. So, many programs talk through them if you want, but some of them are were only in session law, several of them were in Act 183 of 2022, which was a workforce development bill and other topics from the Commerce Committee. So some of those will look particularly familiar to those view on commerce. So those were codified, put into statute on an ongoing basis, but the funding isn't necessarily built into the budget and less specified. Anything else you want to add on there. And then you'll see that recommendations from the collaborators. So I think we'll be speaking to in your testimony as well as the acronym list. No one mentioned. And the suggested edits and technical directions. So the other thing I would add or end with my thank you to Sarah Clark, who, before she left it, a bunch of the heavy lifting on the inventory to HS for the timeliness of their information because they had to reach down and his crew had to go to multiple agencies to get information. Thank you to Liz Cody from a heck or multiple correction and terminologies of things. Always keeping me straight on the subject. And then to Tom little and his crew would be sat again for their timeliness and the process of getting media information. I have, I have not a question but a potential request. Sorry, no one. Is there any way to structure the spreadsheet by the administrator or grantee. So we have like all a hack together all set together all a jazz or that would be a pain. I forget. I just ordered the way it was there was a very good reason. Oh, I see. It was by year. It was by year. But I can restructure it. That'd be great. I mean, if you can keep both some people might like it this way, but I would love to see if I. Thank you. When you have time. Summer. If I remember right. Two years ago in a budget. We've appropriated dollars. And expecting it to be a two year period. I think. So that we appropriated in the 20. 22 23 budget. That we expected those funds to be expended within a two in a two year periods. We didn't. We didn't put more dollars into them last year. Right. Well, I think you'll see from some of the recommendations there are recommendations regarding carry forward that would. I think make that more systematized and the programs we're creating. Okay. Okay. Thank you both. Thank you. I'm Liz. I'm Liz Cody and I am from the University of Vermont and I represent the program. And. Thank you for inviting me. I'm mostly here to be a resource and to answer your questions, but in hearing some of this conversation, there's so many things like now I want to respond to. Hey, heck is minister educational loan repayment for 27 years. The first visceral response that I have is to the data questions and there are no data or there's a lack of data. I want to say there are a ton of data for these programs. I can tell you almost anything about every applicant. Age, race, ethnicity, gender identity, where they went to high school, where they, they went to help profession student school, what their average debt is, where they work, how many hours a week they work. All kinds of things and then the attributes of those workplaces. So we have a ton of data for our programs. Where we, the problem is, what does it all mean as far as impact program impact, are people staying in their jobs because of these programs. That's something we can't really answer. It's a really complex question because so many different things factor employment decisions. But we do have a system for collecting data, storing it and analyzing it. I also have to respond to a lot of ideas about will we could do this or do that. I encourage you when new programs are initiated or new ideas processes are added. There needs to be payment for our budgeting for administration. And budgeting for program evaluation. So, we're, we administer these educational learning payment programs for almost three decades. And for 26 years of that time, we did not receive any administration funding. We had to raise administration funding from different sources, every dollar we received for these programs were allocated as awards. So, we have to think about those things because none of this can be administered it's it's not free it's really labor intensive in fact and evaluation is labor intensive. So, please as you move forward think about administrative cost and and budget for it. I also have ideas of about it would be nice to talk with everybody who had one of these awards that again we have to think about the administrative burden of that and and is it is a practical. I think it spends a lot of time counseling applicants and recipients of the educational learning payment program. And a lot of time that counseling is, can you really commit to this obligation this time period. Does this fit with what your career goals are, and we work with folks to ensure that they know what they're signing and agreeing to. And the service period is really something that is talked about a lot because the longer the period is the, the more they have to be sure they can stay put in that certain work site for a two year or longer period. We have experimented with multi year contracts. So, we, we have 1 year programs 2 year programs back in 2015 2014, 15, 16, all of our programs are at least 2 years in length. And we learn a lot with all of those decisions. There are consequences. Some we can anticipate and others are surprises. And then we adjust from there. With the nursing programs, we learned that multi year contracts were more problematic than the benefit nurses do move around within the state a lot. And we were spending so much time trying to counsel nurses to stay in the same work site for 2 years. And a lot of them wanted to break contracts. So then we were forced either there was a breacher contract or repayment or sometimes they qualify for a job, a transfer. What is the, is there a question? Why would a nurse that signs a contract that basically work in within the state? Why is that a problem if they leave their, say their employment in Northeast kingdom and work in. We receive a contract is for a specific work site within the state because we're trying to stabilize the workforce within each organization. And so somebody signs a contract is to stay put for 1224 months in a certain work site. So that that work site can can know that they have locked in service. And otherwise we're always going to see, we're going to see that migration from some of the counties into Burlington into Chittin County. And so we're trying to like stabilize the work sites around the state. And so it's not a free for all as far as transferring to any site within the state. Longitudinally, we do look at retention after the program. And for that kind of thing we do look at, are they still working in Vermont someplace. So we don't stick with this thing we're saying, but for the duration of a contract it is for a specific work site. Do we have buy-in from the single hospital where the contract is signed? Does that hospital also provide some incentive to keep those nurses there? Yes, so that is another piece of the educational loan repayment program that isn't really talked about in these reports. We work directly with all of the employers. They are co-signers of the service obligation with the recipient. So it's coordinated with them. Not only is the recipient buying into, yes, I'm signing on the dotted line, so is the employer. And so then we're receiving input from both of them as far as, are they delivering that service obligation? Are they still there when funds are dispersed? So it's all very coordinated. And some work sites contribute matching funds to the award from the state. And then we take those in and bundle it into one award and one service obligation. So there's a lot of coordination that goes on. I think that the reports are very high level. And so there are a lot of details that we weren't able to go into, but we did provide five years worth of data as the auditor's office requested for the nursing programs. And we showed for our loan repayment programs, which are focused on retention, a significant majority of those nurses are still here working in Vermont. And so we provided individual level data about those nurses and the ones who left where they went, Virginia, Tennessee, Massachusetts. For some of them, we know more information about why they left. For others, we don't necessarily, but we do try to collect that. And for the majority, the handful who have left, we do know where they are. A lot of these programs are focused on financial incentives and in working with individuals, we hear a lot of reasons why they may want to leave Vermont or leave their work site within the state. And many times it's not a financial reason as to do with the work site. Sometimes it's about career opportunity and compensation improvement. But other times it's about different things, it's family needs, it's due to divorce or sick parents taking care of people. It's about workplace environment and not being able to get through the day at a certain work site. We hear a lot of those gory stories. So it's very complex what guides people to make the decisions. The educational loan repayment program is for licensed, ready to work people, individuals, professionals, they're not trainees anymore. There's an immediate return on the investment because they're locked in for service right away and we can track it. The longitudinal tracking of all of these programs is labor intensive. You have to keep track. Where are they? What are they doing? Where are they working? It takes a lot to know. But I just, I'm AHS and the health department oversees our program. We do have process measures in our grant. We do have performance measures. The question is, are they the right ones? And how can we look at all of these programs globally and compare them as far as which are more effective? Which one should be invested in more? Which ones don't appear as effective? We're working as intended. How can we adjust? So I think that these reports all bring us to really good conversations. And when I read them, when I've read them, I try to think, don't be defensive. But they are sometimes just too surface level to get to the details. And we have a lot of experience and a lot of data to inform these programs. And we do adjust. One of the things that's important in legislation is being clear on the intentions of the legislation or the program, but also allowing some flexibility for some experimentation and adjusting. You know, we try, we tried multi years that didn't seem to work. So we go, we went back to one year. Should we try multi years again? That's what we're doing right now. We're experimenting where the environment changes. So we need a little bit of a wiggle room to respond to those changes. And priorities and legislation are good because priorities help us identify, for instance, certain medical specialties or type of care sites that are priority. But it doesn't eliminate the others that are important that could come to the forefront. So that also gives us something to work with. So there are certain nuances that really make a difference in how a program can be administered and then is overall effectiveness. What questions do you have for me? Yes, thank you very much for your report. So I just want to be clear here, you have actual data, numbers of students who see scholarships, who stayed in Vermont as per Act 183 in 2022, which I know we took a lot of data, a lot of information on where we were in healthcare when we were putting some of this together. So you have that data. No, because that's not the program we administer. We administer educational loan repayment. Right. So only loan repayment. So it's for people who are licensed already. They've already been trained. They're not scholarships. They're already trained and they're able to work. So we have that kind of data for those people, but as far as one to receive scholarships. No, with the exception of one new program that we work in collaboration with besack on and that is the medical student incentive scholarship loan loan forgiveness program. So, because we collaborate on that, we do have internally that data and tracking and sharing data back and forth with besack. But that's the only program where it's students and scholarship related or loan forgiveness related where we have the data. Most of the other scholarship related things are belong to besack and you don't have. Right, we focus on educational loan repayment. Okay. So in the debt for the, for those recipients are from programs from all over the country. It's undergraduate graduate level, it's lenders from all over the country, direct loans, private loans, that kind of thing. It's not just Vermont based because they may have trained in other places. Okay. In all of the debt information that we have everything's verified. We do try to coordinate with the state when it's possible to receive direct information. For instance, one of the things we look at our Medicaid, the Medicaid population served. And we receive data directly from Diva on that because we learned over the years that self reported data were not reliable. We do ask applicants to report if they have other service obligations or scholarships that might be service obligations because sometimes they don't always know or think that scholarship they received had a service obligation attached. We try to pull that out, but they don't always report it and that's when we go back to, if it's a state program, the health department and try to receive that information. The health department works with us on coordinating federal programs, the national health service scholar scholars, national service core. They receive data on that and share that with us so that we can do the crosswalk and make sure there are no double dippers or concurrent service obligations. We're paying for one award, two awards, but one set of time one timeframe. We want to avoid that we want to leverage these dollars. So there is coordination. There just could be more coordination. It could be improved. Another thing I'll mention is that the overall environment is changing at the federal level educational loan programs are popping up all over the place, whether they're employer or federal for all kinds of things. We need to be aware of that we need to understand what they are so that we're leveraging those and that we're not using state dollars and federal dollars can be leveraged public service loan forgiveness. That program get off to a bumpy star, but it is actually happening where we, we need to be aware of that and how does that impact our programs. We need to stay on top of loan cancellation programs that we're hearing about the federal level and how that can influence. There is a pause on federal pay required payments during COVID three year pause when federal direct loan recipients did not have to make payments. How does that affect loan debt as the pinch point for these folks. Are there other things that we could be doing. I have a ton of data. And we provide that to the health department as well. And I'm happy to talk with you anytime about the data questions and how we try to understand what it all means. Thanks for coming in. I want to find out if I heard you right. Did you say that in terms of administrative monies that you don't get any. So, we do starting 2023. So, for 26 years, 27 years did not. We had to raise those resources and the way we raise those dollars were from private foundations as well as contributions from the hospitals from around the state. So we raise those dollars separately. We do it in the last 15 years receive other grant funds from the state separate from those loan payment dollars, but those other grant funds have. Completely different deliverables attached to them. So it's not like those dollars allowed for the administration of this program. Starting with 2023 is the first time we were allowed administrative funds for this program. We pulled off something amazing, but it's not a good business plan and it's not sustainable. Can I just, I want to, oh, sorry, go ahead. Please. I just want to verify a couple of things on the actual programs based on this chart. So it looks like you have the loan repayment for healthcare providers and healthcare education educational loan repayment fund. For an amount of 6667,111 dollars. That amount is available for 2 years. And so the 1st year has been. So, so I'm curious if we've gone through the 2 years and there's $0 or there's still 1 year left of the 667,000. So we have a grant right now that is a 2 year grant that also the new innovation of 2 year grants before they're 1 year at a time. We have a 2 year grant and for each of those 2 years, we have 667,000 that grant ends December 2024. So ends at the end of this year. Okay. So the grant has money for FY 25, which the process is the 24 process. How that's appropriated, I can't say. Okay, so right now you have nothing available. You're waiting for that appropriation for the next. As of July 1st. Right, but technically we have a grant that says that says, okay, so we can, okay, gotcha. And then there's 1 that you do with. BSEC, which you talked about, which is the scholarships for 10, 3rd and 4th year UBM medical students. The program repeals on July 1st, 2027 was at 1 point. Close to 1.5 million. It says there's zero carry forward. So has that money all gone out? Or is there still money available for? I'm going to defer that to BSEC. Okay, that's fine. And then the other one I see is the Vermont healthcare professional loan repayment program for 2 million and then another 500,000. It looks like it was ARPA one time money. So is there any, has that gone out the doors or any money left available? We have a grant for that and that ends December 2024. And the majority of those funds have gone out the door or are encumbered for a year 2 awards. Okay. I believe that we have about $50,000 in that program that is not either dispersed or encumbered. Okay. And then it looks like the nurse faculty loan repayment program. For 500,000 was one time money. And is that at the door and done. No, that also ends at the end of the year, the year 2024 and 175,000 has dispersed. Okay. But there may be your two awards that are encumbered. Great. And we might have you back into healthcare to walk through some of the data that you talked about. And I want to say you've always been very helpful in coming up with data. So we appreciate that. Yeah, but I think it would be nice to know how those programs work. Did they work the way we intended by getting more nurse faculty available so that we could train more nurses quickly or quicker than we do now. So I think it'd be interesting so that we can make recommendations to appropriations of whether or not. We need to continue to fund these programs. One question I had going back to the contracts. So nurses that break their contract. How many about how many of those. How many times does that occur. It occurs less frequently than it used to partly because we have such rigorous counseling that goes on and the one year contracts. You know, it's not good for anybody if somebody is breach of contract. It's not good for the employer. The individual is not good for our programs. It's a lot of work. The counseling is a lot of work. But we try to work through some of the issues with the individuals and with their human resource departments. And there's three of us on a zoom trying to sort out like, how can we make this work for everybody. And so it's for nursing of the five year period that we just reported the auditors. I think there was one breach of contract. That's not, it's not prevalent. It's not, but it doesn't happen on its own. But I'm wondering if there's maybe something to think about. People that are breaking your contract. Make more money somewhere else. Okay, I get that. But if there are other issues that are happening in someone's life. As you described, how, and if. Through your counseling, they can't make it work. Why, why wouldn't we, as long as they're staying in Vermont. Allow them to continue to receive. That loan payment. So in some cases we do. Okay. So you have, you have that. So that is the. The aim is to lock in at a certain work site. So we don't quickly go there because then it defeats the whole. We're not doing what we're saying we're trying to do, but if there are extenuating circumstances, the entire contract talks about extenuating circumstances. I just want to make sure that there was the ability for you to work with with the person and if need be then switch. As long as they stay in Vermont state and there are also clauses in the contract for leaves of absence where they take a pause. And then when they come back, the contract and date is extended to make up for that time. So there's, it's, it's pretty sophisticated. I like you thought a lot about this. Jonathan Leslie and art. Or no art, Jonathan. Thank you. If I might expand on representative McFawn's line of questioning with regards to the indirect. The lack of administrative funding was no. Deminimus offered or preferred to your organization or didn't solicit. An allowance for indirect funds at 5, 10% or whatever and working night. And if you were denied, was there a rationale provided. No, we were denied for many years, but, but we did solicit and over time. We, we got that last year. Okay. But in initially you said there was no funding for administrative. Correct. The, the grants that we would receive would, would be very specific that the dollars had to be used 100% for awards. Thank you. Yeah, it's more for you. I think both of you, there were like, 8 recommendations that came through a heck and just wondering if there's going to be opportunity to discuss them and what the process might be better. So, this is our 1st look at the report and then we'll. Yeah, as with most joint meetings that we've been having, then the chairs will get together and decide next steps. Thank you. Yeah. If you have specific questions on the recommendations, feel free to seem like a lot of consolidation and things around that, which always makes sense to me. So I was just looking forward to a conversation how to make it more efficient effective. Definitely. And I want to follow up on that. Yeah, I think we're going to have a very careful report and probably no one or Jen could chime in with it. This all the scholarship incentive work that we did in the last years is at all here. Yeah, it is. So, there's no other agency that has other, it seems like we were bounced around a lot of place. We put it together and I just want to make sure this is all of it. Related to health care. Right. Correct. Nursing and medical and any of that. In terms of state. Correct. We'll talk about this lots of federal stuff as well. Right. So this is, this is what we, we handled in the many sessions and that's through. Okay. Thank you. Questions. Thank you very much. Thank you. Thank you. Welcome. Thank you for joining us. Thank you for having me. It's kind of delightful to kind of kick off the session seeing so many, you know, kind of familiar faces after kind of a little bit of a layoff. So that's, this is great. And I think like Liz, I should, you know, my focus predominantly was going to be to be a resource to respond to questions. The one footnote that I wanted to kind of put to the last question about state funding. You know, the scholarship side, but you need to introduce yourself. Oh, I'm sorry. I think I know that you would think, come on. I'm Scott Giles, presidency over the Vermont student assistance corporation. And I'm delighted to be here to respond to questions. All I was going to offer there was that during the pandemic, and not necessarily specific that's structured in the same way. But the conversations are two organizations engaged with you all in past. There was scholarship funding awarded to the state colleges in particular. Oftentimes labeled as critical occupations, but there was a significant amount of money that went to nursing in particular during that period of time. And I mentioned that impartially because that created coordination work that we engaged in with them while those resources were more available. So I'll offer that as an asterisk because that money probably felt a little bit fungible, given the way that it was appropriated and probably fell outside the scope. Um, you know, kind of kind of drawing on some object. You know, I think Liz was shared our role in this predominantly has been on the scholarship side really except for one program that we are there with. And so where the AHA programs, I think as you've articulated them are focused on kind of recruitment and retention. The programs that you asked us to run. Certainly contributed in some ways to that or I think of them predominantly pipeline programs where what we are trying to do is to encourage people who might not otherwise have considered careers in health care. And as the auditor said, these careers in health care are some of the best paying high demand jobs within our community. And there are equity issues embedded in making a decision to support scholarships because it allows us to work with low income students of all ages. Who, you know, would succeed in these in these professions would consider them, but are afraid of the expense associated with them because this training is within an educational context, the most expensive training. You know, by and large that our institutions, you know, offer. And, you know, I'll just make a couple of observations. I'm going to talk briefly just about our nursing program because it's one that we have partnered with you it grew pretty substantially over the course of the last several years. And it always takes I think is, you know, my is Marilyn Cargill when she came in to kind of share information and Marilyn retired sadly for for me and for everyone. So these things normally take a couple of years to really get their feet on the ground and people have to believe they're going to be there over time for the populations that we support to really fully embrace them. This past year we ran out of money with that program within about 30 days of when the application deadline was in place. Can you just because I want to make sure we're all understanding the terminology so which one are you see reverse the Vermont nursing forgivable loan incentive program is correct one point or the 3 million 3 million. Yeah, so we successfully funded 289 applicants. Unfortunately, there were 70 who we were unable to fund because we did not have the resources, and that probably understates the demand. That was in place because once you put a cut off and send word out that there, there's no more funding. You kind of turn that pipeline off. And partly what that reflects is the kind of broad Vermont community understanding the availability of this program. And for particular, you know, working adults, you know, who were kind of previously, you know, eight eligible but who want to career change. The idea that we can offer pretty close to a tuition full tuition scholarship in exchange for your commitment to work, particularly to Vermont State University is a pretty powerful, you know, pretty powerful incentive. So observations I think was shared, you know, we have a fair amount of data. And, you know, we pride ourselves in trying to share that, you know, with the committee. And it would be happy to, you know, work with you over time if there are other things that you're interested in knowing but from an efficiency perspective the other programs that we are administering for you are largely modeled after the nursing program which allowed us to gain some administrative. There's some complexity by eliminating complexity. There are some minor differences in there. It was in part our response working with you to the conversation about consolidation. With the nursing program at this point, 87% of the recipients have fulfilled their obligation through work in Vermont. So it's, you know, continues to prove to be extraordinarily successful over time from that pipeline perspective. We're exploring. Chair Mark is familiar several years ago the committee came to us at one point asking for some additional data about the advancement grant, which is our non degree grant, which also contributes in this space. We did a survey of recipients longer term to start to take a look at some more specific beneficiary specific data on long term outcomes and impact on wages and, you know, other factors and we've been contemplating ourselves. Perhaps not this year, but next year once the expanded program is more mature and we've got more of the more of these newer beneficiaries actually in the workforce whether or not that would be a good time for us to work with you all to design something that would give us more longitudinal longitudinal data. I will pause there I can, I know one question. I think Liz kindly, you know, deferred to us on on that and I panicked for a moment. Is that the one I didn't bring. I did. So if you remember $10,000 a year that we can obligate for that particular program, given the number of years that the program is in place. And we have awarded jointly together enough to. The money left to award for this year for this year, but you have it set for the meeting. So it's in stages. So can I just, can I just go through my list like we did before. So, sorry, let me get my list. Okay. So, and then I think I know there's questions. So, there's one for. $10,000 the nurse faculty forgivable loan program that looks like as of June 30. There was nothing spent yet. Yeah. So we've got about 28 applications in now. In that we are kind of evaluating this points. Our expectation is that we'll start to see disbursements taking place from there. And then the 1.5 million for the mental health professional. We've actually obligated 1.1 million. This is one that what we experienced with the new programs is there's a slow start and then it starts to rule. Particularly as the educational institutions. Really come to understand the availability of the funding and now that our instant, you know, what we are now seeing is just each of the remind institutions that are providing. Gradual level training and mental health counseling are now integrating this into their counseling programs. So, so do we know how many people and that is that 1.1 million? I will give me a minute and I will be able to answer that question because I do have the number of words. And at this point, we received 130 applications and we've awarded 90 of them. Great. Yes, on this 1. Just a little anecdotal. We had conversations with Northeast King of Human Services. A few months ago, they're opening, they're planning on opening up that new house. From Port, yeah. And, you know, I asked the question of whether or not they had sufficient staff to be able to open that up. And they said because of the work that we did here that they have filled all of their vacancies and they're not worried about being able to bring more people on. So it's just working. That's great. I'm thinking we're over a month. Yeah. Yeah. Yeah. Thank you. So then there's the Vermont psychiatric mental health nurse practitioner program. It's a million dollars. Yes. And that 1 was just launched in December. That was the 1 launched in December. So, we are going through that same process and expectable at the same and the same with dental hygiene too. It was supposed to December launch. Great. Thank you. I'm just taking off of, I was going to ask the same questions representative did about those specific loans, the six, seven, eight nurse faculty, nurse faculty, mental health. And the psychiatric mental health nurse practitioner. You spoke about kind of generally about what caused a delay. Are there more specific administrative or bureaucratic issues that might be helpful for us to be aware of in each of those. Cases. Yeah. And so I want to be, I want to be cautious because we have a great working relationship with AHS. But for new programs, their procurement process does not align with the academic calendar. So when we have a new program. And in this particular case ones were not made available until effectively July 1st of this year. They delayed their willingness to engage in the MOU conversation on these new programs. Until some of their other priorities were kind of worked through. So we weren't able to get the MOUs in place with them, even though we've got models. For doing this until in the fall. In the December launch for those two programs simply look like someone without their friends. And then the facilities, educational entities and. Facilities that would offer. Like UVM medical center that would offer scholarships or programs like this have their own calendar. In an ideal world, I can, you know, step back from our perspective and because of the. Nursing is a great example of this because the program has been around for a while and there's a lot of support. We have more comfort marketing, even though we know that we're not, you know, we won't know what the dollars are until the end. If we are looking at new students, you know, just the student calendar, they're making financial aid, you know, related decisions and kind of made. Yeah, you know, the spring now we navigate that. Our budget cycle, you know, to support that, but we've got a base program or where we've got carry forward authority. No, we have the money. We can, you know, go ahead and navigate that effectively. With these new programs will we run into is students will have already made their decisions and already done their financing for the fall. By the time we are stepping into the by the time we have the MOU in place. And you'll, you know, you'll see that we have made a recommendation, you know, within the language that we entered. We just is not the only place where we've experienced this before. In some cases we solved it with multi year MOUs that, you know, that worked our way through it. In other cases, we worked with the legislature to appropriate the money directly to us. So that we didn't have to go through the MOU process in order to be able to release it because these are global commitment dollars. I think that there are some other strings around. But they're worried the relationship is that there's a process that they go through that. I think that's really helpful and good for us to be aware of. Thank you. My question was about the dates also and why it takes a significant amount long, a significant amount of time to get these up and running. When we, I know from myself, I'm sure others that we always, we feel like this is such a need that would worry that and but the dates I can see now where you're saying the dates are so closely aligned from when he's appropriated. The build up past and in effect, and we're all looking for the start of the calendar year or the or a start of a cycle for for nurses to apply to apply these scholarships to get to school. So we're a little bit off. We're off. I do think that once we have these programs up and running and there's consistent funding like with nursing, we tell everybody the application deadline this February. So we take all those applications and we can actually share with you what we're seeing if there's money related issues emerging at that point. We still won't make an absolute commitment until the budget is far enough along. You know that we see it, but that becomes the ideal world. Now, what I will say these programs have allowed us to do something that we've because we had 3 of them that were to do with your committee and 1 other new program or launching that allows us to leverage our existing partnerships with the colleges and universities. So candidly with these new programs that are coming now I've already had a conversation with all of our school presidents directly and said, I've got money here. You've got students, some of whom you're in risk of now retaining others of whom are starting the spring. I shouldn't have a penny left to think that the spring if you've any of your students that are interested in working in Vermont. You know afterwards and so that's where why we're seeing like with the mental health counseling. So once you get in, you know, as we confirm this move from the president to the individual as the Dean is running that program and or better yet the graduate counselor who is supporting that student. Well now they've got all that material in front of them and you know they're meeting with all of their individual students and kind of putting this, you know, putting the availability of this in front of them. So, we share your sense of urgency. I will say it's a. We do everything within our power to make it as easy as possible for our partners to reach the right conclusion as quickly as possible. Good. Stopping on these loans. Is there when the loan is set up. Is there a rate of interest that's attached to them. Yeah, so for most of these, these are zero interest loans. You know, which is something that is a design choice that we all then we've all made. So. I think when we say most we, there are some other contexts in which there are. Collection related costs that can be added. So. At the point which one of these converts to a loan, there's costs associated with actually collecting on the loan. And in most of the cases now, I think we have the authority to be able to add reasonable collection costs. To that loan in lieu of an interest rate. Just out of curiosity. What is the rate of interest on those loans that have a rate of interest. It's probably under 3% when you take much probably under 3% when you look at collection costs. That's interesting. I mean, I gotta say this. I get a lot of people that call me. About the rate of interest that they have to pay for VSEC. When they go through VSEC. And it's the 3% that they're telling me. Yeah, well, those are different loan product. I know they are kind of different different loan product and those rates. Are structured rule and related to vote. Their risk in the payment terms that they have slept. So our lowest rate is probably about 4.4%. Edie. Thank you. I just wanted to go back to that question about how do we work with with your organization and the administration. We're looking at a little bit more seamlessly a little bit quicker right now we're looking at a nursing shortage. But in five years we could be looking at a different shortage in a different department. And I would love to have any learnings that you come up with that allow us to get money out faster. I understand if the programs in place of course that's going to be easier all of those pieces are set up but as you're. You know these programs it would be incredibly beneficial for us so that we can put better language in new legislation. Thank you I think I mean I think from our first our experience serve in two ways we've handled it. You know 1 is to get. Our partner agency. Comfortable with a multi year. You know kind of MOU. The other way is to appropriate the money directly to us which is also is a instrumentality the state something that is is done with the vast majority of our programs. I think the complication in this context is the source of funding. But that doesn't mean it's not insuperable and we've been engaged in conversations with our partners that Hs about how much latitude. They have because nursing is a great example there's actually mix of global commitment in general fund dollars in there. Scott. If a person is in. Let's say the medical technician. Education loan program. If that person. Goes into the field. I guess what I'm trying to find out is if they were not if they don't want to prove. In the beginning. But they think so they went to school and they pay they had a loan maybe through the exact. Now if they're working and they apply can they get their loan forgiven. So I think this is going to be the division between the two programs so. Not through our program because ours is effectively the forgivable loan program. Is a scholarship with a work requirement and so those commitments are made right at the time. That you apply but I think they had a program which is a loan repayment program would be the program that would then be. The one that would we would encourage them to apply to. So they can. That particular group is a new newly established educational loan repayment program that we are standing up. So, not quite yet, but soon the answer is yes, but that apply. And think about this conversation globally to any any profession if they already have educational debt existing. We're looking to repay it. That's when it comes in. That's when it comes in. That's when it comes in. Versus when they're a student that's the sack. Okay. So med med tax is the newest, the latest new program based on last year's legislation. And we're working to reach those individuals. They're not licensed or registered by the state. So it's been challenging to stand up this program. It's a little bit unlike our other programs. And they don't have to have a college degree. Can I make one other observation? I don't mean to kind of cut anyone off one of. What I did just want to share is that there is some work that we are doing. In two areas, nursing and respiratory therapy that is outside the context of the state funded programs. Although not unrelated to it that I thought I would share in part because it does. I think implicate one of the concerns that the auditor had raised and is kind of report about the relation, you know, what is the relationship between these programs. And some of the hospital recruitment and kind of other programs and I won't be able to speak. To some of the other state Narpa money that the institutions got. But you may be familiar, the Vermont business roundtable got in your mark, you know, through Senator Leahy for. Vermont talent pipeline work. We are actually a core part of that. No activity and we're providing 2 sets of services. But going to the coordination question. And I should stop if you're not familiar with this program. It's an employer based program. We've got some seed money for pilot purposes, but effectively employers are the hospitals are identifying employees that they currently have who they think. Could or and would be interested in successfully upskilling or to fill positions that. They're not currently qualified to fill nursing respiratory therapy being tuned for examples of that. The way they're structuring is they're prepared to put up their own money in the form of a loan similar structure to what we are doing with the Vermont. The nursing forgivable loan program. Visak is administering that program, but there are 2 pieces to it that we're providing 1 is the career and education counseling. So we're got counselors working with them. The 2nd part of our role is really to leave together all of the various financial aid. Opportunities that are available so that at least on the front end, not on the back end, we know there's not duplication. Those that are qualified should take advantage of the state program. Those that don't qualify for the state program may take advantage purely of the full employer based piece. But that allows us to have some window into what the shortage needs at the hospital level are and at the, you know, what their recruitment strategies are right now. There are about 7 Vermont hospitals participating in this based off of the 1st cohort. I guess we're in our 2nd UVM cohort. We've got 4 others that are asking now whether, you know, they can participate. And that's a great example of our trying to weave together both the public investment that you're making with the private investment that the hospitals know they need to make is a way of addressing some of the product concerns that the state auditor identified. Yeah, and I appreciate that because I think we have to remember it can't just be us. And it can't just be them. The crisis is too deep for our workforce challenges. And so working together and having partners like both of you who can bridge it together is really helpful and impactful. So, thank you for bringing that up. Thank you. Yeah, the questions for Scott. Scott, thank you very much. Thank you. Now, thank you for the opportunity and appreciate the chance to talk about the programs and support the work you're doing it. I'll close by saying thank you for the support that you guys have given us through the years. It's exciting to be able to share some of the outcomes because it's making a real difference. And we talked about it at the aggregate level, but at the student level. This is transforming the lives of students who thought they had limited futures. So, would it be appropriate to ask if they might write their testimony for. I don't think there's anything on our websites of what they. So, I think the testimony is the report for now. And then I think we'll discuss. Next steps are okay. It seems to go beyond. I mean, it was more human than I agree that that was the humanity that was nice. It's for taking various vaccination next to set. We try and be everywhere we're going to we're going to try and capture everybody. Thank you and Liz. Thank you both of you for programs that you run and how you help on it. We really appreciate it. Good afternoon. Good afternoon. I apologize. I'm on the Amtrak. So I'm hoping. Clear for you. Okay. Yes, we can. Thank you. I think, you know, I know you're only you're here to answer some questions or if you can't, you're going to take the questions down and get back to us. I appreciate that. So, I guess one question that I have is the preceptor program and, you know, has that been launched yet? If it isn't, when will it be that type of thing? Okay, I could partially hear you. Should I state my name for the record? Sure, that'd be great. My name is Wendy Trafton. I'm the deputy director of health care reform at the agency of human services. And I know the programs we're talking about today, some are through agency of human services central office and some are through the Vermont Department of Health. Be able to speak to this. I apologize that I'm asking you to repeat your questions. I could not hear it. I think I think we're both on on the receiving ends of of audio issues. I think, I think probably the best thing for us to do is we'll get questions down from from our committees and we'll get them to you and then we can have a conversation. You know, in the next few weeks as we start looking at the budget and talking talking to you about those questions. Thank you. I'd look forward to that. Okay. Great. Thank you. Thank you. Thank you for listening in with us this afternoon. We appreciate that. Thank you very much. Bye. Bye bye. So, any more questions committees. I look forward to that conversation. I do have concerns about you were talking about the real life impact. It's amazing impact it has had. I know personally people who could have benefited from the pipeline program. So I do have some of the concerns we've already discussed about why it's taken so long. Yes, it's fully advocated apparently now but it's taken a long time so. I agree. Okay, well, I'm just sorry, Brian, Brian. Hi, I have just a quick comment like in hearing this, it's great to hear that. You know, all the hard work going on around recruitment through these incentives. And just can you hear me okay. Yes. Yes. Okay. Sorry. I think something that I think we need to reflect on more and I'm not sure who we need to hear from to make these decisions is how do we make the working conditions for our health care workers better because as a health care worker. I can say that like it's getting increasingly harder with the acuity and it feels really like extractive. It's like an extractive system for our labor and our energy. So, you know, the just the question is, are there other things we could be doing to make it more of a regenerative system for the workforce. Thank you, Brian. That's a good point. We will, we will keep talking about that committee. Anything else. Okay. Again, thank you. Thank you, Madam chair health care committee for joining us this afternoon. It's been great collaborating with you the last few years to make our health care system better. I think we're starting to see some fruits to that labor. And hopefully we can. We're able to find the dollars to continue on some of these programs that we've found to be working very well so. But it's going to take all of us to to be able to push things through so. Again, and everybody have a good weekend.